Results of the modified fontan operation for congenital heart lesions in patients without preoperative sinus rhythm

Preoperative sinus rhythm has been a criterion for the Fontan operation. However, of 297 patients who underwent the Fontan operation between October 1973 and February 1984, 12 (4%) did not have sinus rhythm. The age at operation ranged from 4 to 34 years (median 15). Nine patients had a univentricular heart, two had tricuspid atresia and one had a complex form of transposition. In all 12 patients, 3 to 8 of the 10 proposed criteria for operability were not met. An atrioventricular (AV) conduction abnormality was present in seven patients, six with complete AV block and one with AV dissociation. The patient with complex transposition had complete AV block and atrial fibrillation. Postoperatively, all seven patients continued to have an AV conduction abnormality, and those with complete AV block had a permanent pacemaker implanted. Six of the 12 study patients had atrial flutter or fibrillation refractory to antiarrhythmic medications. Postoperatively, four of the six patients had sinus rhythm. Two of the six patients had complete AV block (including the patient with complex transposition) and both had a permanent pacemaker implanted. Three of the 12 patients died (mortality rate 25%). The nine survivors were followed up for 6 to 55 months; no late deaths occurred. All had marked clinical improvement. This study demonstrates that 1) complete AV block is not a contraindication to the Fontan operation, 2) some patients may not require AV synchrony postoperatively for survival, and 3) postoperative atrial flutter or fibrillation may cease or be easier to control after the Fontan operation.