Thromboembolic Risk After Atriopulmonary, Lateral Tunnel, and Extracardiac Conduit Fontan Surgery

• Published in: Journal of the American College of Cardiology Vol. 74; no. 8; pp. 1071 - 1081
• Main Authors: Deshaies, Catherine, Hamilton, Robert M., Shohoudi, Azadeh, Trottier, Helen, Poirier, Nancy, Aboulhosn, Jamil, Broberg, Craig S., Cohen, Scott, Cook, Stephen, Dore, Annie, Fernandes, Susan M., Fournier, Anne, Kay, Joseph, Mondésert, Blandine, Mongeon, François-Pierre, Opotowsky, Alexander R., Proietti, Anna, Ting, Jennifer, Zaidi, Ali, Khairy, Paul
• Format: Journal Article
• Language: English
• Published: United States Elsevier Inc 27.08.2019; Elsevier Limited
• Subjects: Adolescent; Adult; Anticoagulants; Arrhythmia; Arrhythmias, Cardiac - diagnosis; Arrhythmias, Cardiac - epidemiology; Arrhythmias, Cardiac - surgery; atrial arrhythmia; Cardiac arrhythmia; Cardiology; Cardiovascular; Child; Child, Preschool; Cohort Studies; Congenital diseases; Data collection; Female; Follow-Up Studies; Fontan procedure; Fontan Procedure - adverse effects; Fontan Procedure - trends; Heart Defects, Congenital - diagnosis; Heart Defects, Congenital - epidemiology; Heart Defects, Congenital - surgery; Heart failure; Heart surgery; Humans; Hypertension; Male; Morbidity; Palliation; Patients; Postoperative Complications - diagnosis; Postoperative Complications - epidemiology; Pulmonary arteries; Quality control; Retrospective Studies; Risk Factors; single ventricle; Surgery; Thromboembolism; thromboprophylaxis univentricular heart; Transplantation; Treatment Outcome; Univentricular Heart - diagnosis; Univentricular Heart - epidemiology; Univentricular Heart - surgery; Venous Thromboembolism - diagnosis; Venous Thromboembolism - epidemiology; Young Adult; atrial arrhythmia; Fontan procedure; thromboembolism; APC; single ventricle; CI; LT; HR; thromboprophylaxis univentricular heart; EC; extracardiac conduit; atriopulmonary connection; hazard ratio; confidence interval; lateral tunnel
• ISSN: 0735-1097; 1558-3597; 1558-3597
• DOI: 10.1016/j.jacc.2019.06.051

Thromboembolic events contribute greatly to morbidity and mortality following Fontan surgery for univentricular hearts. This study sought to evaluate the effect of type of Fontan surgery on thromboembolic risk. A North American multicenter retrospective cohort study enrolled 522 patients with Fontan palliation consisting of an atriopulmonary connection (APC) (21.4%), lateral tunnel (LT) (41.8%), or extracardiac conduit (EC) (36.8%). Thromboembolic complications and new-onset atrial arrhythmia were reviewed and classified by a blinded adjudicating committee. Thromboembolic risk across surgical techniques was assessed by multivariable competing-risk survival regression. Over a median follow-up of 11.6 years, 10- and 20-year freedom from Fontan conversion, transplantation, or death was 94.7% and 78.9%, respectively. New-onset atrial arrhythmias occurred in 4.4, 1.2, and 1.0 cases per 100 person-years with APC, LT, and EC, respectively. APC was associated with a 2.82-fold higher risk of developing atrial arrhythmias (p < 0.001), with no difference between LT and EC (p = 0.95). A total of 71 thromboembolic events, 32 systemic and 39 venous, occurred in 12.8% of subjects, for an overall incidence of 1.1%/year. In multivariable analyses, EC was independently associated with a lower risk of systemic (hazard ratio [HR]: 0.20 vs. LT; 95% confidence interval [CI]: 0.04 to 0.97) and combined (HR: 0.34 vs. LT; 95% CI: 0.13 to 0.91) thromboembolic events. A lower incidence of combined thromboembolic events was also observed with antiplatelet agents (HR: 0.54; 95% CI: 0.32 to 0.92) but not anticoagulation (p = 0.53). The EC Fontan was independently associated with a lower thromboembolic risk after controlling for time-varying effects of atrial arrhythmias and thromboprophylaxis. [Display omitted]