The objective of this study was to compare cardiac transplant operative and postoperative courses of patients with failed Fontan physiology who were initially palliated with a Norwood (FFN) to those without a prior Norwood (FF).

A single-institution retrospective review of all patients with Fontan failure who underwent cardiac transplantation from 2003–2021 was completed—22 underwent prior Norwood (FFN) and 11 did not (FF). Descriptive and inferential statistics were calculated for operative course and patient outcomes.

The operative course of the FFN cohort appeared to be more complex (not statistically significant, but clinically relevant)—this group exclusively experienced sternal re-entry events (3 of 22 patients) and concomitant neo-aortic reconstruction (6 patients), had a longer duration of surgery (median of 682 min vs. 575.5 min), more time on circulatory arrest (median of 25.5 min vs. 12.5 min), and more frequent use of open sternal management [50% of patients (11/22) vs. 27.3% of patients (3/11)]. Postoperatively, these patients underwent more mediastinal explorations [other than sternal closure; 40.9% of patients (9/22) vs. 18.2% of patients (2/11)], spent more time on mechanical ventilation (median of 5 days vs. 2 days), had a longer length of stay (median of 30 days vs. 19 days), and required more catheter-based re-interventions [22.7% of patients (5/22) vs. 9.1% of patients (1/11)].

Although underpowered, our results suggest that the operative course of FFN patients is more challenging, based mostly on neo-aortic arch issues. In turn, this likely leads to a more complex postoperative course. We are currently collaborating with other institutions to increase the cohort size and power of the study.