In-Hospital Outcomes in Fontan Completion Surgery According to Age

Ghimire LV, Chou FS, Pundi K, Moon-Grady AJ.Am J Cardiol. 2022 Mar 1;166:81-87. doi: 10.1016/j.amjcard.2021.11.019. Epub 2021 Dec 18.PMID: 34933746 


Take Home Points:

  • Age at Fontan completion does not adversely affect the in-hospital outcomes.

Dr. Shuhua Luo

Commentary from Dr. Shuhua Luo (Chengdu, Sichuan, China), section editor of Congenital Cardiac Surgery Journal Watch:


A total of 6,647 children with median age 3 (interquartile range 2 to 4) years underwent the Fontan completion procedure were retrospectively included in this study. The patients were categorized into 1 of 5 groups according to their age at the time of Fontan completion: <2(n=956, 14.4% ), 2(n=2190, 32.9%), 3(n=1634, 24.6%), 4(n=829, 12.5%), and ≥5 years(n=1039, 15.6%). The in-hospital mortality rate for the whole cohort was 2.1% (n = 139), and 1.8% (n = 117) needed ECMO during the ICU stay. Independent risk factor for mortality in the multivariable logistic regression was a presence of atrioventricular septal defect (AVSD) [OR4.3 (2.4 to 7.9), p <0.001]. Age was not identified as a risk factor in this study.



Age older than 4 years at the time of Fontan is one of the original “Ten Commandments” for case selection. In more recent years, the Fontan operation has been performed in younger patients. However, the impact of patient age on outcome remains unclear. A recent large retrospective study(n=3319) showed a U-shaped relationship between age and in-hospital mortality, with the lowest risk when the procedure was performed at age 3(1). While other authors suggested that age is not significantly associated with postoperative outcomes (2,3). The current study supported the latter finding in a large multi-institutional population. However, one should interpret this result with caution, as the risk of needing ECMO was significantly higher in those that received the Fontan surgery before 2 years of age with an adjusted OR of 3.1 (95% CI 1.4 to 7.0). As expected, home health care resource utilization was the highest in patients who underwent surgery at <2 years of age (13.7%), compared with 5.6% in the 3-year-old group (p <0.001). These results suggested patients with younger ages (<2 years) may have a complicated postoperative recovery. Furthermore, the occurrence of early Fontan failure was not reported in this study. Unfortunately, other important demographic(e,g weight), physiologic (e.g pre-Fontan arterial oxygen saturation), and anatomic(e.g heterotaxy) risk factors were also not included in the multivariable analysis. With the modification of surgical technique and advancement of perioperative management, age might not be as important as we thought in the era of “Ten Commandments”. The clinical decision-making of timing of Fontan completion should be individualized and always balance the associated benefits and risks. A large multicenter prospective longitudinally follow-up study might help us to generate new evidence regarding Fontan patients’ selection.



1. Marathe SP, d’Udekem Y, Winlaw DS. What Is the Ideal Age for the Fontan Operation? Ann Thorac Surg. 2020 Sep;110(3):1095–6.

2. Salvin JW, Scheurer MA, Laussen PC, Mayer JE, Del Nido PJ, Pigula FA, et al. Factors associated with prolonged recovery after the fontan operation. Circulation. 2008 Sep 30;118(14 Suppl):S171-176.

3. Hosein RBM, Clarke AJB, McGuirk SP, Griselli M, Stumper O, De Giovanni JV, et al. Factors influencing early and late outcome following the Fontan procedure in the current era. The “Two Commandments”? Eur J Cardio-Thorac Surg Off J Eur Assoc Cardio-Thorac Surg. 2007 Mar;31(3):344–52; discussion 353.