Outcome after the single-stage, nonfenestrated Fontan procedure

Background A completed Fontan circulation is the goal in the management of patients with single-ventricle physiology. To achieve this end, a two-stage rather than a single-stage approach is carried out routinely at many centers. Some groups have advocated baffle fenestration for virtually all patients to minimize post-Fontan complications. Other centers perform single-stage Fontan operations and do not fenestrate. Thus controversies have arisen regarding the indications for the staged procedure versus single stage and for fenestration versus no fenestration. Methods and Results The preoperative risk factors and postoperative course were characterized in 61 consecutive patients (median age, 3.3 years) undergoing a single-stage, nonfenestrated Fontan. The patients were followed for 3.5 +/- 1.9 years. The relationship between preoperative risk factors and mortality and morbidity was assessed. Preoperative risk factors assessed included age < 2 years (n = 18), branch pulmonary artery stenosis (n = 20), elevated mean pulmonary artery pressure > 15 mm Hg (n = 16), atrioventricular valve regurgitation (n = 5), and decreased ventricular function (n = 2). Total caval pulmonary anastomosis was performed in 53 patients. Additional surgery was required at the time of the Fontan in 25 patients (41%). The median duration of mechanical ventilation was 1 day; median chest tube drainage was 5.5 days (range, 1 to 35). Oxygen saturation rose significantly postoperatively, from 83% to 95%. Early mortality was 4.9%; one patient died from pacemaker failure 9 months postoperatively, and one patient underwent successful heart transplant 4 months post-Fontan. One- and 5-year actuarial survival was 93%. No preoperative risk factor was associated with a failed Fontan or significant effusions. Conclusions A single-stage, nonfenestrated Fontan was performed in a large group of patients with excellent surgical results and intermediate outcome. There is no evidence that a two-stage approach and/or baffle fenestration is required for a large cohort of patients who are candidates for a Fontan operation.