Pediatric Cardiology

, Volume 33, Issue 2, pp 307–315 | Cite as

Heart Rate Variability in Children With Fontan Circulation: Lateral Tunnel and Extracardiac Conduit

  • Jenny Alenius Dahlqvist
  • Marcus Karlsson
  • Urban Wiklund
  • Rolf Hörnsten
  • Eva Strömvall-Larsson
  • Håkan Berggren
  • Katarina Hanseus
  • Sune Johansson
  • Annika RydbergEmail author
Original Article


The technique in Fontan surgery has developed from the lateral tunnel (LT) toward the extracardiac conduit (EC) used to reduce long-term complications such as atrial arrhythmia and sinus node dysfunction. Heart rate variability (HRV) examines cardiac nervous activity controlling the sinus node. This study aimed to investigate HRV in a cohort of children with univentricular hearts, focusing on the relation between HRV and surgical procedure. For 112 children with Fontan circulation, HRV was analyzed using power spectral analysis. Spectral power was determined in three regions: very-low-frequency (VLF), low-frequency (LF), and high-frequency (HF) regions. Patients were compared with 66 healthy controls subject. Patients with LT were compared with patients who had EC. The children with Fontan circulation showed a significantly reduced HRV including total power (P < 0.0001), VLF (P < 0.0001), LF (P < 0.0001), and HF (P = 0.001) compared with the control subjects. The LT and EC patients did not differ significantly. Reduced HRV was found in both the LT and EC patients. In terms of HRV reduction, EC was not superior to LT.


Extracardiac conduit Fontan circulation Heart rate variability Lateral tunnel 



This study was funded by the Swedish Heart-Lung Foundation according to the Agreement on Medical Education and Research, Västerbotten County Council, Sweden.


  1. 1.
    Azakie A, McCrindle BW, Van Arsdell G, Benson LN, Coles J, Hamilton R et al (2001) Extracardiac conduit versus lateral tunnel cavopulmonary connections at a single institution: impact on outcomes. J Thorac Cardiovasc Surg 122:1219–1228PubMedCrossRefGoogle Scholar
  2. 2.
    Bjelakovic B, Ilic S, Chouliaras K, Milovanovic B, Vukomanovic V, Bojic T et al (2010) Heart rate variability in children with exercise-induced idiopathic ventricular arrhythmias. Pediatr Cardiol 31:188–194PubMedCrossRefGoogle Scholar
  3. 3.
    Blaufox AD, Sleeper LA, Bradley DJ, Breitbart RE, Hordof A, Kanter RJ et al (2008) Functional status, heart rate, and rhythm abnormalities in 521 Fontan patients 6 to 18 years of age. J Thorac Cardiovasc Surg 136:100–107 (7 e1)PubMedCrossRefGoogle Scholar
  4. 4.
    Brown JW, Ruzmetov M, Deschner BW, Rodefeld MD, Turrentine MW (2010) Lateral tunnel Fontan in the current era: Is it still a good option? Ann Thorac Surg 89:556–562 (discussion 62–63)PubMedCrossRefGoogle Scholar
  5. 5.
    Butera G, Bonnet D, Iserin L, Sidi D, Kachaner J, Villain E (1999) Total cavopulmonary and atriopulmonary connections are associated with reduced heart rate variability. Heart 82:704–707PubMedGoogle Scholar
  6. 6.
    Cohen MI, Rhodes LA (1998) Sinus node dysfunction and atrial tachycardia after the Fontan procedure: the scope of the problem. Semin Thorac Cardiovasc Surg Pediatr Card Surg Annu 1:41–52PubMedGoogle Scholar
  7. 7.
    Cohen MI, Wernovsky G, Vetter VL, Wieand TS, Gaynor JW, Jacobs ML et al (1998) Sinus node function after a systematically staged Fontan procedure. Circulation 98:II352–II358 (discussion II8–II9)PubMedGoogle Scholar
  8. 8.
    Cohen MI, Bridges ND, Gaynor JW, Hoffman TM, Wernovsky G, Vetter VL et al (2000) Modifications to the cavopulmonary anastomosis do not eliminate early sinus node dysfunction. J Thorac Cardiovasc Surg 120:891–900PubMedCrossRefGoogle Scholar
  9. 9.
    Davos CH, Francis DP, Leenarts MF, Yap SC, Li W, Davlouros PA et al (2003) Global impairment of cardiac autonomic nervous activity late after the Fontan operation. Circulation 108(1):II180–II185PubMedCrossRefGoogle Scholar
  10. 10.
    Deal BJ, Mavroudis C, Backer CL (2007) Arrhythmia management in the Fontan patient. Pediatr Cardiol 28:448–456PubMedCrossRefGoogle Scholar
  11. 11.
    Dilawar M, Bradley SM, Saul JP, Stroud MR, Balaji S (2003) Sinus node dysfunction after intraatrial lateral tunnel and extracardiac conduit Fontan procedures. Pediatr Cardiol 24:284–288PubMedCrossRefGoogle Scholar
  12. 12.
    Fishberger SB, Wernovsky G, Gentles TL, Gauvreau K, Burnett J, Mayer JE Jr et al (1997) Factors that influence the development of atrial flutter after the Fontan operation. J Thorac Cardiovasc Surg 113:80–86PubMedCrossRefGoogle Scholar
  13. 13.
    Folino AF, Buja G, Bauce B, Thiene G, dalla Volta S, Nava A (2002) Heart rate variability in arrhythmogenic right ventricular cardiomyopathy correlation with clinical and prognostic features. Pacing Clin Electrophysiol 25:1285–1292PubMedCrossRefGoogle Scholar
  14. 14.
    Hakacova N, Lakomy M, Kovacikova L (2008) Arrhythmias after Fontan operation: comparison of lateral tunnel and extracardiac conduit. J Electrocardiol 41:173–177PubMedCrossRefGoogle Scholar
  15. 15.
    Kumar SP, Rubinstein CS, Simsic JM, Taylor AB, Saul JP, Bradley SM (2003) Lateral tunnel versus extracardiac conduit Fontan procedure: a concurrent comparison. Ann Thorac Surg 76:1389–1396 (discussion 96–97)PubMedCrossRefGoogle Scholar
  16. 16.
    Lammers A, Kaemmerer H, Hollweck R, Schneider R, Barthel P, Braun S et al (2006) Impaired cardiac autonomic nervous activity predicts sudden cardiac death in patients with operated and unoperated congenital cardiac disease. J Thorac Cardiovasc Surg 132:647–655PubMedCrossRefGoogle Scholar
  17. 17.
    Lee JR, Kwak J, Kim KC, Min SK, Kim WH, Kim YJ et al (2007) Comparison of lateral tunnel and extracardiac conduit Fontan procedure. Interact Cardiovasc Thorac Surg 6:328–330PubMedCrossRefGoogle Scholar
  18. 18.
    Ocello S, Salviato N, Marcelletti CF (2007) Results of 100 consecutive extracardiac conduit Fontan operations. Pediatr Cardiol 28:433–437PubMedCrossRefGoogle Scholar
  19. 19.
    Robbers-Visser D, Miedema M, Nijveld A, Boersma E, Bogers AJ, Haas F et al (2010) Results of staged total cavopulmonary connection for functionally univentricular hearts: comparison of intraatrial lateral tunnel and extracardiac conduit. Eur J Cardiothorac Surg 37:934–941PubMedCrossRefGoogle Scholar
  20. 20.
    Rydberg A, Rask P, Hornsten R, Teien D (2004) Heart rate variability in children with Fontan circulation. Pediatr Cardiol 25:365–369PubMedCrossRefGoogle Scholar
  21. 21.
    Rydberg A, Karlsson M, Hornsten R, Wiklund U (2008) Can analysis of heart rate variability predict arrhythmia in children with Fontan circulation? Pediatr Cardiol 29:50–55PubMedCrossRefGoogle Scholar
  22. 22.
    Singh S, Johnson PI, Lee RE, Orfei E, Lonchyna VA, Sullivan HJ et al (1996) Topography of cardiac ganglia in the adult human heart. J Thorac Cardiovasc Surg 112:943–953PubMedCrossRefGoogle Scholar
  23. 23.
    Tweddell JS, Nersesian M, Mussatto KA, Nugent M, Simpson P, Mitchell ME et al (2009) Fontan palliation in the modern era: factors impacting mortality and morbidity. Ann Thorac Surg 88:1291–1299PubMedCrossRefGoogle Scholar
  24. 24.
    Wiklund U, Hornsten R, Karlsson M, Suhr OB, Jensen SM (2008) Abnormal heart rate variability and subtle atrial arrhythmia in patients with familial amyloidotic polyneuropathy. Ann Noninvasive Electrocardiol 13:249–256PubMedCrossRefGoogle Scholar

Copyright information

© Springer Science+Business Media, LLC 2011

Authors and Affiliations

  • Jenny Alenius Dahlqvist
    • 1
  • Marcus Karlsson
    • 2
  • Urban Wiklund
    • 2
  • Rolf Hörnsten
    • 3
  • Eva Strömvall-Larsson
    • 4
  • Håkan Berggren
    • 5
  • Katarina Hanseus
    • 6
  • Sune Johansson
    • 7
  • Annika Rydberg
    • 1
    Email author
  1. 1.Department of Clinical SciencesUmeå UniversityUmeåSweden
  2. 2.Department of Biomedical Engineering and InformaticsUmeå UniversityUmeåSweden
  3. 3.Department of Surgical and Perioperative Science, Clinical PhysiologyUmeå UniversityUmeåSweden
  4. 4.Division of Cardiology, Department of PaediatricsSahlgrenska University Hospital/Queen Silvia Children’s Hospital, Göteborg UniversityGöteborgSweden
  5. 5.Department of Cardiothoracic SurgerySahlgrenska University Hospital/Queen Silvia Children’s Hospital, Göteborg UniversityGöteborgSweden
  6. 6.Department of PaediatricsChildren’s Hospital, Lund University HospitalLundSweden
  7. 7.Paediatric Cardiac Surgical UnitChildren’s Hospital, Lund University HospitalLundSweden

Personalised recommendations