Pros and Cons of Fontan Fenestration: a Review of the Recent Literature

Purpose of Review: Currently, there is no clear consensus about risk–benefit profile of placing a fenestration in the Fontan circulation, much less if this surgical modification should be done routinely for all patients. In this manuscript, we review the proposed advantages and disadvantages to fenestration of the Fontan operation and evaluate the recent literature on this topic. Recent Findings: Based on several recent meta-analyses, there are few differences in a variety of both physiologic outcomes (mean pulmonary artery pressure and cardiac output) or practical outcomes (length of stay, overall mortality, and morbidity) between fenestrated and non-fenestrated patients. Fontan fenestration does seem to reduce the risk of significant post-operative pleural effusion. There is a clear trend towards lower saturations in both the short and long term in those with fenestrations. There are conflicting results as to if Fontan fenestration increases the risk of stroke or impacts exercise tolerance. Summary: Given the largely equivocal, or even conflicting findings, there is still no clear consensus as to which patients should undergo Fontan fenestration. It does seem that high-risk patients such as younger patients or those with higher pre-operative pulmonary artery pressures do seem to benefit from fenestration. An individualized approach with careful analysis of each patient’s pre-operative risk-factors should help determine the optimal surgical approach for the Fontan procedure. © 2023, The Author(s), under exclusive licence to Springer Nature Switzerland AG.