Long-term outcomes of direct total cavopulmonary connection versus extracardiac conduit in Fontan circulation

Objective

The long-term outcomes of direct total cavopulmonary connection in Fontan circulation have not been reported yet. This study aimed to compare the long-term outcomes of the direct total cavopulmonary connection procedure with the extracardiac conduit procedure in patients undergoing the Fontan.

Methods

From October 2004 to August 2021, 297 patients undergoing the Fontan operation by extracardiac conduit (n = 268) or direct total cavopulmonary connection (n = 29) procedure at our institution were retrospectively reviewed. The propensity score–matching method was used to match the extracardiac conduit and direct total cavopulmonary connection groups in a 1:2 ratio, yielding 23 patients in the direct total cavopulmonary connection group and 40 patients in the extracardiac conduit group.

Results

The in-hospital morbidity and mortality were similar between the 2 groups in both prematched and matched cohorts (P > .05). The estimated transplantation-free survival at 10 years in the matched direct total cavopulmonary connection group was 89.7% ± 7.0%, in contrast to 92.8% ± 5.0% in the matched extracardiac conduit group (P = .55). The estimated 10-year estimated freedom from Fontan failure in the matched direct total cavopulmonary connection group was 85.2% ± 8.0%, also similar to the 85.9% ± 6.7% in the matched extracardiac conduit group (P = .72). The direct total cavopulmonary connection pathways at the follow-up were significantly larger than those before Fontan surgery (P < .05).

Conclusions

The direct total cavopulmonary connection procedure is a feasible and effective strategy for highly selected Fontan candidates who have well-developed pulmonary arteries of adequate length and size. This approach not only allows for the potential growth of direct total cavopulmonary connection pathways but also demonstrates noninferior short-term and long-term outcomes in contrast to the extracardiac conduit strategy.