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Improving outcomes for transplantation in failing Fontan—what is the next target?

Lookup NU author(s): Dr Jonathan Smith, Dr Katrijn Jansen, Fabrizio De Rita, Mohamed Nassar, Dr Louise CoatsORCiD



This work is licensed under a Creative Commons Attribution-NonCommercial-NoDerivatives 4.0 International License (CC BY-NC-ND).


© 2021Objective: To identify the key contributors to postoperative mortality in patients undergoing orthotopic heart transplantation (OHT) for late Fontan failure. Methods: This retrospective review of failing Fontan patients who underwent OHT in our tertiary care center between 2007 and 2019 included adult patients with congenital heart disease and single ventricle physiology who were palliated with a Fontan circulation for >1 year. We excluded patients undergoing combined heart-liver transplantation. Results: The study cohort comprised 31 patients, including 18 males (58.1%), with a mean weight of 58.4 kg, median age at Fontan of 6.9 years (interquartile range [IQR], 2-38 years), and a median age at OHT of 27.1 years (IQR, 16.7-53.3). Almost all (93.5%) of the patients were in New York Heart Association class III-IV, and the majority (74.2%) were in Interagency Registry for Mechanically Assisted Circulatory Support class 3. Overall survival at 30 days, 1 year, and 5 years after OHT was 81%, 71%, and 67%, respectively. Major intraoperative bleeding was associated with increased mortality after OHT (odds ratio, 30; 95% confidence interval, 2.8-322; P = .002). Neither preoperative systemic ventricular function nor the development of primary graft dysfunction (PGD) was significantly associated with postoperative death. Nevertheless, PGD determined significant morbidity of this population. Conclusions: In our cohort, major intraoperative bleeding was the key factor associated with mortality after OHT for late Fontan failure. Novel strategies for the prevention and management of postoperative bleeding will improve outcomes in this group of patients.

Publication metadata

Author(s): Cardoso B, Kelecsenyi A, Smith J, Jansen K, De Rita F, Nassar MS, Coats L

Publication type: Article

Publication status: Published

Journal: JTCVS Open

Year: 2021

Volume: 8

Pages: 565-573

Print publication date: 01/12/2021

Online publication date: 18/12/2021

Acceptance date: 06/08/2021

Date deposited: 19/10/2023

ISSN (electronic): 2666-2736

Publisher: Elsevier Inc.


DOI: 10.1016/j.xjon.2021.08.006


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