From the Section of Pediatric Cardiology (K.D., C.J.P., F.C., D.J.D.),
Section of Biostatistics (K.P.O., J.M.S.), and the Division of Thoracic and
Cardiovascular Surgery (F.J.P., H.V.S., G.K.D.), Mayo Clinic and Mayo
Foundation, Rochester, Minn. Dr Cetta is currently at the Section of Pediatric
Cardiology, Loyola Medical Center, Maywood, Ill.
Correspondence to Co-burn J. Porter, MD, Section of Pediatric Cardiology, Mayo Clinic, 200 First St SW, Rochester, MN 55905.
Methods and Results—The population consisted of all patients who
had any modification of the Fontan operation at the Mayo Clinic between
1985 and 1993. Clinically significant SVTAs were those requiring
initiation or change of antiarrhythmic treatment, and they were divided
into early SVTAs (<30 days after the operation) and late SVTAs (
Conclusions—Postoperative SVTA continues to be a significant
problem. Risk factors for SVTA are AV valve
regurgitation, abnormal AV valve, preoperative SVTA,
and age at operation. Frequency of SVTA does not appear to be related
to type of Fontan procedure except for slightly lower frequency in
patients with atriopulmonary connection with lateral tunnel
compared with those with total cavopulmonary connection.
All operations resulting in total right heart bypass are now included
under the general heading "Fontan operation." Survival has steadily
improved for this operation.9 10 However, the
development of late-onset supraventricular
tachyarrhythmias (SVTAs) continues to be a
problem.11 12 13 Various
investigators8 13 14 15 16 17 have postulated that by
altering the surgical technique one may decrease the incidence of SVTA.
The 2 most popular modifications of the Fontan operation at our
institution recently have been the total cavopulmonary
connection (TCPC)6 8 14 and the
atriopulmonary connection (APC) with lateral tunnel
modification (APC-lat). It has been suggested that TCPC may lower the
incidence of SVTA,8 but other investigators
believe that TCPC provides a substrate for developing atrial
tachyarrhythmias.18
The objectives of the present study were (1) to determine the
frequency of early and late clinically significant SVTA after the
Fontan operation, (2) to compare the frequency of SVTA among the
various modifications of the Fontan operation, and (3) to identify the
risk factors for SVTA after the Fontan operation.
Types of Modifications of the Fontan Operation
Total Cavopulmonary Connection
Atriopulmonary Connection With Lateral Tunnel
Modification
Heterotaxy Group
Intra-atrial Conduit
Others
Data Collection
The types of SVTA included in the analysis were (1) atrial
flutter or atrial tachycardia and (2)
supraventricular tachycardia (including AV
reciprocating tachycardia, atrioventricular
nodal reentry tachycardia, automatic atrial
tachycardia, but not sinus
tachycardia).19 We also identified
the underlying cardiac rhythm from the surface ECG in each patient as
(1) normal sinus rhythm or (2) sinus node dysfunction, which included
sinus bradycardia (below the normal sinus rate expected for
age20 ) and junctional rhythm.
For the purpose of the present study, a clinically significant SVTA
was defined as SVTA for which any of the following treatments were
initiated or changed: (1) antiarrhythmia drug treatment
(digitalis was included only if the primary reason for using it was for
rhythm control), (2) synchronized direct current cardioversion, or (3)
atrial overdrive pacing (transvenous or
transesophageal).
Arrhythmias that occurred within 30 days after the operation
were defined as early postoperative arrhythmias, and
arrhythmias that occurred at or beyond 30 days after the
operation were defined as late postoperative arrhythmias.
Patients who had early SVTA were classified as having late SVTA if they
had an additional documented episode beyond 30 days.
A detailed database for patients who had the modified Fontan operation
at the Mayo Clinic has been maintained and repeatedly
updated.9 10 21 22 23 This database includes
preoperative and postoperative variables of interest for the
present study (Table 1
Data Analysis
One hundred patients are known to have died. Overall early mortality
(<30 days after the operation) was 9% (45 of 499). The 5- and 10-year
mortality rates (excluding early mortality within the first 30 days
after the operation) were 13% and 18%, respectively. Of the 100
deaths, there were 29 patients whose cause of death was classified as
sudden cardiac death, including 1 patient who died during the
operation, 45 patients with nonsudden cardiac death, 19 patients with
noncardiac death, and 7 patients with unknown or another cause of death
not listed above.
Early-Onset Arrhythmia
Early-onset SVTA occurred in 74 (15%) of 498 patients. SVTA included
atrial flutter or atrial tachycardia in 38 patients
(7.6%), supraventricular tachycardia in 23
patients (4.6%), and both in 13 patients (2.6%). The frequency of
early postoperative SVTA was slightly higher in the group that had
intra-atrial conduit (25%) compared with other groups. The type of
Fontan operation was not one of the predictive factors for early-onset
SVTA by univariate or multivariate
analysis.
Table 2
In the multivariate model, 3 predictive factors were
identified: (1) AV valve regurgitation
(P=0.014), (2) preoperative SVTA (P=0.019), and
(3) abnormal AV valve anatomy (P=0.031). The
frequency of early SVTA in 112 patients who had none of these
predictive factors was 8.9%; in 117 patients who had only abnormal AV
valve anatomy, 11.3%; and in 123 patients with only AV valve
regurgitation, 12.4%. However, in the 146 patients
with both abnormal AV valve anatomy and AV valve
regurgitation, the frequency of early SVTA increased to
22.8%.
Late-Onset Arrhythmia
The frequency for late-onset SVTA was 6% at 1 year, 12% at 3 years,
and 17% at 5 years after the operation. Figure 3
Freedom from clinically significant late-onset SVTA relative to the
type of Fontan operation is shown in Figure 4
Table 3
It has been suggested that exclusion of the majority of the right
atrium from elevated systemic venous pressure may reduce the incidence
of atrial tachyarrhythmia.8
Exclusion of all but the lateral wall of the right atrium from the
systemic venous to pulmonary artery pathway ("lateral tunnel
technique") was reported by King et al.5 In
1987, Puga et al6 described a technique whereby
the superior vena cava was divided and the cephalad and cardiac ends
were anastomosed to the right pulmonary artery; a septation
patch within the right atrium parallel to the medial borders of the
venae cavae (lateral tunnel) completed cavocaval continuity (TCPC).
Short to intermediate follow-up has suggested a lower incidence of
late-onset SVTA after TCPC compared with
APC.15 16 Gelatt et al16
reported that the frequency of atrial arrhythmia was 14% after
the lateral tunnel Fontan (TCPC) compared with 29% after the APC.
However, others13 17 have not found any
significant difference in the frequency of late-onset SVTA between the
2 types of Fontan operation. Our data indicate that over a median
follow-up of 6.2 years, there was no difference by
univariate and multivariate
analyses in the frequency of SVTA among patients who had the
various modifications of the Fontan operation. However, when we
analyzed the frequency of late SVTA for the 2 most recently and
widely used modifications of the Fontan operation, we found a
significant difference in the frequency of late SVTA in patients who
had APC-lat (7% at 5 years) compared with patients who had TCPC (17%
at 5 years) (P=0.046). This observation suggests that with
respect to late-onset SVTA, the location of incisions and suture lines
may be important.
Kurer et al25 have reported that intra-atrial
reentry is the most common mechanism of atrial flutter after the
modified Fontan operation. This type of primary atrial
tachycardia has been termed intra-atrial or
"incisional" reentrant tachycardia (IART) by some
authors.26 Rodefeld et
al,18 using an acute dog model, demonstrated IART
after placing sutures in the right atrium from the superior to the
inferior vena cava to simulate the suture lines of a TCPC
Fontan procedure. IART could be induced as a result of anatomic block
of the atrial activation sequence occurring along the free wall segment
of the lateral tunnel suture line corresponding to the site of the
crista terminalis. The atriotomy and the septal portion of the lateral
tunnel suture line had no impact on the normal atrial activation
sequence or IART cycle. There appeared to be a critical isthmus of
atrial tissue between the portion of the suture line on the free wall
of the right atrium and the tricuspid valve anulus that served as a
substrate for the IART.18 Our findings are
supported by this animal research. Patients with the TCPC type of
Fontan repair appear to be at the same risk for early and late SVTA as
patients with other types of Fontan surgery.
Predictive Factors for Early-Onset SVTA
Predictive Factors for Late-Onset SVTA
The association of sinus node dysfunction and atrial
tachyarrhythmia has been a topic of interest for
several years. Kurer et al25 found that 57% of
postoperative Fontan patients had sinus node dysfunction during
intracardiac electrophysiological study. We
found that 11.9% of our patients during the first 30-day postoperative
period and 11.1% of our patients during the late postoperative period
(
Conclusions
Received February 9, 1998;
revision received May 5, 1998;
accepted May 6, 1998.
© 1998 American Heart Association, Inc.
Clinical Investigation and Reports
Predictors of Early- and Late-Onset Supraventricular Tachyarrhythmias After Fontan Operation
Abstract
Top
Abstract
Introduction
Methods
Results
Discussion
References
Background—The objectives of our
study were to determine the frequency of supraventricular
tachyarrhythmias (SVTAs) among modifications of the
Fontan operation and identify risk factors for developing
SVTA. 
30
days after the operation). Clinical histories were reviewed, and health
status questionnaires were sent. Four hundred ninety-nine patients had
various modifications of the Fontan operation. Frequency of early SVTA
was 15%. Risk factors identified by multivariate
analysis for early SVTA were AV valve
regurgitation, abnormal AV valve, and preoperative
SVTA. Frequency of late SVTA was 6% by 1 year, 12% by 3 years, and
17% by 5 years. Risk factors for late SVTA were age at operation (<3
or 10 years) and systemic AV valve replacement. By
univariate and multivariate
analysis, the type of Fontan operation was not a significant
risk factor for late SVTA when all 6 modifications were considered.
However, when we analyzed the frequency of late SVTA for the 2
recently used modifications, we found a lower frequency of late SVTA in
patients with atriopulmonary connection with lateral tunnel
compared with those with total cavopulmonary connection.
Key Words: arrhythmia • Fontan procedure • pediatrics • tachyarrhythmias
Introduction
Top
Abstract
Introduction
Methods
Results
Discussion
References
In 1971, Fontan et
al1 reported the first successful procedure for
total diversion of systemic venous return to the lungs without use of a
ventricle in patients with tricuspid atresia. The concept was that the
right atrium would act as a pump in place of a right ventricle. Early
modifications of this operation included elimination of the Glenn
anastomosis, elimination of valves in the inferior vena
cava, and performing a direct atriopulmonary connection. Later
modifications included closure of the right AV valve, placement of a
baffle in the right atrium, and use of intra-atrial lateral tunnels and
intra-atrial conduits or extracardiac conduits to treat other complex
anomalies.2 3 4 5 6 7 8
Methods
Top
Abstract
Introduction
Methods
Results
Discussion
References
Patient Sample
The patient sample consisted of all patients who had a Fontan
operation at the Mayo Clinic between January 1, 1985, and December 31,
1993. This period was chosen for 2 reasons: (1) it represents a
time during which TCPC, APC with or without lateral tunnel, and other
modifications were being performed concurrently, and (2) it allows at
least 2 full years of follow-up.
Atriopulmonary Connection
APC (Figure 1A
) involves a direct
connection between the atrium and pulmonary arteries, closure
of any atrial septal defect, and, if necessary, patch closure of the
right AV valve.
View larger version (45K):
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Figure 1. Two types of modified Fontan connections are
shown. A, Atriopulmonary connection. B, Total
cavopulmonary connection. See text for description.
(Figure is used with permission of the Mayo Foundation.)
In TCPC (Figure 1B
), the superior vena cava is divided,
and the superior end is anastomosed to the superior aspect of the right
pulmonary artery. The inferior part of the superior
vena cava is anastomosed to the inferior aspect of the
right pulmonary artery. A partial tubelike baffle is formed by
a prosthetic patch attached with a suture line on the free wall
of the right atrium along the crista terminalis and extended superiorly
to the superior vena cava–right atrial junction.
The APC-lat (Figure 2) is a
connection between the systemic venous atrial appendage and the
pulmonary arteries combined with a prosthetic baffle
sutured posteriorly and parallel to the medial border of the venae
cavae. At the superior end, the baffle suture line deviates leftward to
the atrial appendage. The anterior side of the baffle is sutured
anteriorly and away from the crista terminalis on the free wall of the
right atrium. A generous pericardial patch is used to construct the
sides and roof of the connection.
View larger version (34K):
[in a new window]
Figure 2. Surgical technique for APC-lat modification. A,
Incisions in the free wall of right atrium and atrial appendage. B,
Anastomosis of flap of atrial appendage to pulmonary artery. C,
Intra-atrial baffle inserted to direct blood from inferior
vena cava to atrial appendage–pulmonary artery connection. D,
Pericardial patch to complete the connection. (Figure is used with
permission of the Mayo Foundation.)
Heterotaxy surgery was performed for patients who had either
asplenia or polysplenia syndrome and who required extensive rerouting
of systemic venous return, often with the aid of an intra-atrial baffle
or conduit.
For an intra-atrial conduit, a prosthetic (usually
polytetrafluoroethylene) tube is interposed
between the inferior vena cava and the superior vena
cava–right atrial junction or the APC.
Other types of connections included all those not classified
above, such as from the systemic venous atrium to a diminutive
right ventricle.
The presence of SVTA was ascertained from review of the Mayo
Clinic medical history and included correspondence with referring
physicians and patients. ECGs and 24-hour ambulatory ECGs contained in
the Mayo medical record were reviewed. In addition, a detailed
health status questionnaire was sent to each known survivor whose
follow-up data could not be obtained or whose arrhythmia status
could not be ascertained from the Mayo Clinic medical history. A second
questionnaire was sent to any patient who did not return or complete
the first questionnaire. If the second questionnaire was not returned
or completed, the patient or next of kin was contacted by telephone. We
also requested the death certificate for patients whose underlying
cause of death could not be obtained by the above methods. Local
physicians were contacted only if all of the above efforts failed to
identify the status of the patient. ).
View this table:
[in a new window]
Table 1. Demographic and Hemodynamic
Variables, Preoperative and Postoperative (N=499 Patients)
Statistical analysis was performed by Fisher exact
test, 
2 test of association for comparing
proportions, Wilcoxon rank sum test, Kaplan-Meier survival
curve estimates, log-rank tests to compare survival curves, and Cox
proportional hazards model for assessing multivariate
associations between late arrhythmic status and risk factors. All
deaths, regardless of cause, that occurred after the initiation of the
operation were considered in the survival analysis irrespective
of whether they occurred during the operation, during the postoperative
hospitalization, or after hospitalization. Deaths that were not
preceded by evidence of an arrhythmia were censored at the time
of death and not counted as having the SVTA event. We also censored the
follow-up period in any patient whose Fontan connection was taken
down or who underwent cardiac transplantation. The SVTA status
was determined up to this time. In the multivariate
analysis, we used backward elimination for deletion of
nonsignificant variables. Logistic regression was used for
assessing multivariate factors associated with early
SVTA. Two-tailed values of P
0.05 were taken as evidence of
differences not attributable to chance. The SAS statistical software
system was used throughout.
Results
Top
Abstract
Introduction
Methods
Results
Discussion
References
Patient Sample and Follow-up Status
A total of 499 patients had a modified Fontan operation during the
study period. Their ages at operation ranged from 8 months to 39 years
(mean±SD, 10±7.5 years). There were 308 males (61.7%). Of the 399
patients alive at last contact, follow-up ranged from 2 months to 10.6
years (mean, 5.9±2.7 years; median, 6.2 years), with 89.4% of
patients having follow-up for >2 years. There were 316 patients
(63.3%) who had at least 5 years of follow-up. Eleven patients were
lost to follow-up during the 30-day postoperative period. Table 1 shows
the demographic variables and hemodynamic
variables for all 6 types of Fontan operation. Five patients had
preoperative SVTA.
Excluding 1 patient who died during the operation, the underlying
cardiac rhythm in the remaining 498 patients during the early
postoperative period was normal sinus rhythm in 414 patients (83.5%),
sinus bradycardia in 12 patients (2.4%), and junctional rhythm in 44
patients (8.8%); 26 patients (5.2%) required permanent pacemaker
implantation (24 for high-grade second-degree or third-degree AV block,
symptomatic bradycardia, or junctional rhythm and 2 for
placement of antitachycardia pacemaker). shows different types of
congenital heart lesions and frequency of early-onset SVTA.
Univariate risk factors for early SVTA were AV valve
replacement (P=0.002), AV valve
regurgitation (P=0.011), abnormal AV valve
anatomy (AV valve atresia or common AV valve)
(P=0.024), preoperative SVTA (P=0.025), older age
(10 years old) at operation (P=0.038), and direct hepatic
vein drainage to atrium (P=0.049).
View this table:
[in a new window]
Table 2. Risk Factors for Early Postoperative SVTA, Including
Univariate and Multivariate Findings
There were 443 patients (88.8%) who survived the early
postoperative period and were available for follow-up. Normal sinus
rhythm was the underlying cardiac rhythm in 335 patients (75.6%),
sinus bradycardia in 15 patients (3.4%), and junctional rhythm in 27
patients (6.1%). There were 37 patients (8.4%) whose underlying
cardiac rhythm could not be determined from the available data. There
were 6 additional patients who required pacemaker implantation after
the 30-day postoperative period. The total number of patients who
required pacemaker implantation at the time of last follow-up
(excluding deaths and Fontan procedures reversed) was 29 patients
(6.5%). Twenty-five patients had a pacemaker implanted for high-grade
second-degree or third-degree AV block, symptomatic
bradycardia, or junctional rhythm, and 4 patients had an
antitachycardia pacemaker implanted. shows the time course for freedom from
SVTA for all patients during the late postoperative period. Although
the cumulative frequency of late-onset SVTA increased over time, the
annual rate for developing late SVTA, which ranged from 2% to 6%, did
not seem to increase during the first 6 years of follow-up.
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Figure 3. Survival free of clinically significant SVTA (late
onset) for 443 Fontan patients alive 30 days after operation. Time 0
indicates 30 days after Fontan operation. . Patients who had an intra-atrial
conduit type of Fontan operation had the highest frequency of SVTA
(21%) at 5 years. There was no significant difference by
univariate and multivariate
analysis in the frequency of late-onset SVTA among patients who
had various types of Fontan operation. However, when pairwise
comparisons were performed among each group of the Fontan operations,
we found a small but significant difference between the 2 most recently
and widely used types. The patients who had APC-lat had a slightly
lower frequency of late SVTA at the end of 5-year follow-up than did
patients who had TCPC (P=0.046).
View larger version (20K):
[in a new window]
Figure 4. Survival free of clinically significant SVTA (late
onset) for each type of Fontan operation. Time 0 indicates 30 days
after Fontan operation. IAC indicates intra-atrial conduit; lat,
lateral tunnel. shows the results of
analysis of risk factors for late-onset SVTA.
Univariate risk factors for late SVTA were age at operation
of <3 years and 10 years (P=0.001) and early
postoperative SVTA (P=0.05). In a
multivariate model, the strongest risk factor
associated with late-onset SVTA was age at operation of >10 years
(P<0.001). Other significant risk factors were AV valve
replacement (P=0.029) and age at operation <3 years
(P=0.036).
View this table:
[in a new window]
Table 3. Risk Factor Assessment for Late Postoperative SVTA
Discussion
Top
Abstract
Introduction
Methods
Results
Discussion
References
Although early and late mortality have decreased for the modified
Fontan procedure,9 10 the late development of
SVTA has continued to be a problem.11 12 13 14 15 16 17 The
occurrence of SVTA after the modified Fontan operation has been
reported to range from 20% to 37.5% in follow-up periods of up to 15
years.12 24 In the present study, the late
occurrence of SVTA at 5 years after the operation was 17%. The
reported differences in incidence may be explained in part by the
diverse groups of patients operated on in several eras by different
surgeons. Also, the definition of clinically significant
arrhythmia is different across studies. Additionally, patients
in the present study were operated on in a more recent era than
patients in some of the previous studies, and the techniques of
operation were often different.
We found that the most powerful predictive factors for developing
early SVTA were AV valve regurgitation and
abnormal AV valve (AV valve atresia or common AV
valve morphology). If both AV valve regurgitation and
abnormal AV valve were present, frequency of early SVTA increased
to 22.6%. This observation lends support to the theory that atrial
distension from AV valve regurgitation is one of the
factors contributing to SVTA. Acute and chronic atrial distension and
stretch of atrial fibers are known to be factors for developing atrial
arrhythmias in animal models and in humans with other forms of
congenital heart disease.14 27 28 29 Preoperative
SVTA was also one of the predictive factors for early SVTA, as
previously described.16
Although the cumulative frequency for late-onset SVTA increased
over time, the annual rate for those who developed late SVTA, which
ranged from 2% to 6%, did not appear to increase for the first 6
years. Using multivariate analysis, we found
that risk factors for developing late SVTA were age at operation (<3
years or 10 years) and AV valve replacement. Gewillig et
al17 found that older age was a significant
predictive factor for developing late SVTA; this supports the theory
that long-standing atrial distention is one of the key factors for
developing SVTA, as previously noted in other postoperative congenital
heart patients.14 27 28 29 Although, in our series,
the patients' age distribution may be different from those of other
studies, with the large number of patients we believe that this would
provide a large enough patient population to draw valid statistical
conclusions. Previous studies15 16 have suggested
that early-onset SVTA is a predictor for late-onset SVTA; however, in
our review we found that this correlation was significant only by
univariate analysis. 30 days) had an underlying cardiac rhythm other than normal sinus
rhythm (excluding patients with pacemaker or lost to follow-up), which
suggests some degree of sinus node dysfunction. The apparent lower
occurrence of sinus node dysfunction in the present study is
related in part to the fact that we did not use 24-hour ambulatory ECG
monitors for most patients. Clinically obvious sinus node dysfunction
was not predictive for developing SVTA in this review.
At our institution, the overall cumulative frequency of late-onset
SVTA after the modified Fontan operation was 17% by 5 years after
operation. By univariate and multivariate
analysis, the frequency of early- and late-onset SVTA was no
different among the 6 types of Fontan operation. However, when we
analyzed the frequency of late SVTA for the 2 recently used
modifications of the Fontan operation, we found a lower frequency of
late SVTA in patients with APC-lat compared with those with TCPC.
Abnormal AV valve anatomy, AV valve
regurgitation, and preoperative SVTA were significant
risk factors associated with early-onset SVTA. Age at operation of <3
years and 10 years was strongly associated with late-onset SVTA, and
systemic AV valve replacement was also a significant risk factor for
late SVTA.
Acknowledgments
This study was supported by a grant from Mayo Foundation,
Rochester, Minn.
References
Top
Abstract
Introduction
Methods
Results
Discussion
References
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J. Weipert, C. Noebauer, C. Schreiber, M. Kostolny, B. Zrenner, A. Wacker, J. Hess, and R. Lange Occurrence and management of atrial arrhythmia after long-term Fontan circulation J. Thorac. Cardiovasc. Surg., February 1, 2004; 127(2): 457 - 464. [Abstract] [Full Text] [PDF]
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 Y.-T. Lan, R.-K. Chang, and H. Laks Outcome of patients with double-inlet left ventricle or tricuspid atresia with transposed great arteries J. Am. Coll. Cardiol., January 7, 2004; 43(1): 113 - 119. [Abstract] [Full Text] [PDF]
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C. H. Davos, D. P. Francis, M. F.E. Leenarts, S.-C. Yap, W. Li, P. A. Davlouros, R. Wensel, A. J.S. Coats, M. Piepoli, N. Sreeram, et al. Global Impairment of Cardiac Autonomic Nervous Activity Late After the Fontan Operation Circulation, September 9, 2003; 108(90101): II-180 - 185. [Abstract] [Full Text] [PDF]
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Y. Ishii, T. Nitta, S.-i. Sakamoto, S. Tanaka, and G. Asano Incisional atrial reentrant tachycardia: experimental study on the conduction property through the isthmus J. Thorac. Cardiovasc. Surg., July 1, 2003; 126(1): 254 - 262. [Abstract] [Full Text] [PDF]
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H. M. Burkhart, J. A. Dearani, D. D. Mair, C. A. Warnes, C. C. Rowland, H. V. Schaff, F. J. Puga, and G. K. Danielson The modified Fontan procedure: Early and late results in 132 adult patients J. Thorac. Cardiovasc. Surg., June 1, 2003; 125(6): 1252 - 1259. [Abstract] [Full Text] [PDF]
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S. Ovroutski, V. Alexi-Meskishvili, P. Ewert, J.-H. Nurnberg, R. Hetzer, and P.E. Lange Early and medium-term results after modified Fontan operation in adults Eur. J. Cardiothorac. Surg., March 1, 2003; 23(3): 311 - 316. [Abstract] [Full Text] [PDF]
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C. Stamm, I. Friehs, L. F. Duebener, D. Zurakowski, J. E. Mayer Jr, R. A. Jonas, and P. J. del Nido Improving results of the modified Fontan operation in patients with heterotaxy syndrome Ann. Thorac. Surg., December 1, 2002; 74(6): 1967 - 1978. [Abstract] [Full Text] [PDF]
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 W. Anne, H. van Rensburg, J. Adams, H. Ector, F. Van de Werf, and H. Heidbuchel Ablation of post-surgical intra-atrial reentrant tachycardia. Predilection target sites and mapping approach Eur. Heart J., October 2, 2002; 23(20): 1609 - 1616. [Abstract] [Full Text] [PDF]
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H. Ohuchi, S. Hasegawa, K. Yasuda, O. Yamada, Y. Ono, and S. Echigo Severely Impaired Cardiac Autonomic Nervous Activity After the Fontan Operation Circulation, September 25, 2001; 104(13): 1513 - 1518. [Abstract] [Full Text] [PDF]
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W. T. Mahle, J. W. Gaynor, and T. L. Spray Atrioventricular valve replacement in patients with a single ventricle Ann. Thorac. Surg., July 1, 2001; 72(1): 182 - 186. [Abstract] [Full Text] [PDF]
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D. D. Mair, F. J. Puga, and G. K. Danielson The Fontan procedure for tricuspid atresia: early and late results of a 25-year experience with 216 patients J. Am. Coll. Cardiol., March 1, 2001; 37(3): 933 - 939. [Abstract] [Full Text] [PDF]
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A. Ghai, L. Harris, D. A. Harrison, G. D. Webb, and S. C. Siu Outcomes of late atrial tachyarrhythmias in adults after the Fontan operation J. Am. Coll. Cardiol., February 1, 2001; 37(2): 585 - 592. [Abstract] [Full Text] [PDF]
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