Rebuttal

Extract

As I had hoped and anticipated, the previous contributions have shown that Len and I are involved in a debate, but not an argument. As I am asked in this rebuttal to respond to some of the very important points that Len has made, I shall do so. I think that he was very accurate in distilling, from the study of outcomes over 15 years in Philadelphia, the message that late attrition was quite low. Of the first cohort in that study, undergoing surgery way back in 1984, less than one-third survived. As those of you who are familiar with the study now, it has improved steadily, so that now at least four-fifths of those undergoing first stage palliations survive. But what is really important is that those children who got out to 5 years usually got out to 10. And nearly all of those that got out to 10 years were alive at 15 years. I have already pointed to evidence that rates of survival with respect to initial surgical palliation are improving steadily at centers throughout the United States of America, and also around the world. So that, were it not for the shortage of donor organs, we could get together again in a decade or two from now and debate the merits of these two forms of therapy based on a comparison of the late morbidities associated with the creation of the Fontan circulation, such as sinus nodal dysfunction, protein losing enteropathy, thromboembolic phenomenons, and so on, to those events occurring at later stages associated with organ replacement, such as graft atherosclerosis, lymphoproliferative disorders, late rejection, and so on.