Evolution of the Fontan Procedure: Early and Late Results.

Abstract

This paper reviews the evolution of surgical technique that has occurred with the Fontan procedure since it was first introduced more than 25 years ago. Although there has been recent enthusiasm at some centers for a return to Fontan's original concept of use of a conduit to achieve the Fontan pathway, we continue to believe that the lateral tunnel with double cavopulmonary anastomosis is the preferred approach. The late incidence of arrhythmias with the lateral tunnel at 10 years follow-up is remarkably low. On the other hand conduits present a risk of outgrowth and pseudointima accumulation. Even small gradients, e. g. less than 4mm, will be poorly tolerated over the longer term and may result in an increased incidence of cirrhosis and protein losing enteropathy.Overall there has been a remarkable improvement in the early and late results of the Fontan procedure over the last decade. The role of the bi-directional Glenn shunt as either a staging procedure or definitive palliation when performed in conjunction with supplementary pulmonary blood flow needs to be defined by a prospective randomized study. Likewise the role of the fenestration also needs to be defined by a prospective randomized study including careful studies of late exercise capacity and maximal oxygen consumption. Another issue that needs to be defined by careful prospective randomized study is the importance of anti-coagulation with coumadin versus aspirin in reducing the incidence of thromboembolism.