Extracardiac conduit versus lateral tunnel: Exploring the optimal surgical approach in the EUROFONTAN experience

Objective The Fontan procedure is a crucial surgical intervention for single-ventricle physiology, with the extracardiac conduit (ECC) and lateral tunnel (LT) techniques being the predominant approaches. This study aimed to compare early and late clinical outcomes of ECC and LT, using inverse probability of treatment weighting (IPTW) to ensure robust assessments. Methods A retrospective analysis of 3300 patients from the EUROFONTAN registry was conducted, with data collected from 21 European centers. The cohort included 3010 patients who underwent the ECC technique and 290 patients who underwent the LT technique. IPTW was used to balance baseline characteristics. Primary outcomes were early and late mortality, Fontan failure, and adverse events. Secondary outcomes included postoperative complications and nonsurgical adverse events. Results Propensity-matched analysis showed significantly better outcomes for ECC. Early mortality was lower for ECC (1.2% vs 3.9%, P = .003), whereas late mortality at 20-year follow-up was 8.6% in LT versus 3.2% in ECC after IPTW ( P = .003). Patients who underwent the ECC technique experienced fewer postoperative complications (47% vs 66%, P = .025) and less frequent Fontan failure (12% vs 19%, P = .032). Kidney-related events were more frequent in patients who underwent the LT technique (3% vs 0.6%, P = .004). The development of arrhythmia initially appeared greater in the LT group but equalized after matching. Long-term complications, such as protein-losing enteropathy and hepatic issues, showed no significant differences. Conclusions ECC was associated with better early and intermediate outcomes than LT in this multicenter European registry. However, surgical era and hospital center explain a substantial part of the observed difference. Continued long-term surveillance of the Fontan pathway is essential to optimize lifelong outcomes.