High-risk Fontan completion patients achieve low perioperative risk and benefit from cavopulmonary connection 7 years out†

Abstract

OBJECTIVES: Our unit has pursued Fontan completion in all patients except those with immobility or combined poor ventricular function and high pulmonary artery pressures. We assessed retrospectively whether conventional high-risk criteria would predict patients with a poorer outcome. METHODS: One hundred and thirty-three consecutive children who underwent extracardiac Fontan completion (2004–2012) had their outcomes recorded (mean follow-up of 7 years). Three groups were analysed: those with 1 of 6 historical risk factors (outside 6 commandments), those with 1 of reduced systemic ventricular function or pulmonary artery pressure >15 mmHg (outside 2 commandments) versus those with no contraindications. The Fischer’s exact test examined frequency differences, with the χ2 test to look for outcome associations. RESULTS: There were no differences in postoperative complication rates between the outside 6 commandments (n = 105) or outside 2 commandments (n = 49) versus the low-risk no-contraindication group (n = 28): arrhythmias [18% (P = 0.3) or 18% (P = 0.3) vs 25%], infection [22% (P = 0.6) or 33% (P = 0.2) vs 21%], cerebrovascular accident [6% (P = 0.5) or 10% (P = 0.3) vs 4%], length of stay [20 days (P = 0.4) or 23 days (P = 0.2) vs 21 days] and duration of chest drainage (P = 0.5). There was 1 predischarge mortality in each group. Long term, the majority of patients in each group had suitable haemodynamics for fenestration closure [95% (P = 0.7) or 95% (P = 0.7) vs 92%]. Long term, there was no difference in the rate of arrhythmias [11% (P = 0.5) or 12.5% (P = 0.3) vs 7%], protein-losing enteropathy [1% (P = 0.1) or 2% (P = 0.3) vs 7%] or moderate or more ventricular dysfunction on echocardiography [2% (P = 0.7) or 4% (P = 0.7) vs 4%]. Notably, there was a higher rate of catheter reinterventions in the high-risk groups [22% (P < 0.05) or 24% (P < 0.05) vs 7%]. CONCLUSIONS The medium-term benefits of Fontan completion can be achieved for high-risk patients, suggesting that historical selection criteria should be re-examined.

The effects of Treprostinil in high-risk patients after total cavo-pulmonary connection procedure

“…In our center, intravenous Treprostinil is not a conventional medicine for all patients after total cavopulmonary connection procedure, only high-risk patients are treated to stable hemodynamic state and improve post-operative recovery. There is no consensus on the de nition of a high-risk patients, but most studies de ned it as one of the below conditions: pre-operative mean pulmonary artery pressure ≥ 15 mmHg, heterotaxia syndrome, moderate to severe atrioventricular valve regurgitation, pulmonary vein stenosis (pulmonary vein ow velocity ≥ 1.3 m/s measured by echocardiography) [14,15,16]. Due to the heterogeneity of high-risk condition, we chose the most di cult condition in clinical practice (preoperative mean pulmonary artery pressure ≥ 15 mmHg) to carry out investigate.…”

Fontan procedure in patients with preoperative mean pulmonary artery pressure over 15 mmHg

“…Kreutzer and coworkers reviewed the reflections on five decades of the Fontan Kreutzer procedure and grouped the factors that jeopardize the late outcome into three categories: (i) suboptimal surgical approach, (ii) ventricular dysfunction, and (iii) increases in PVR 47 . On the other hand, Vigano and colleagues suggest that in the modern era of congenital cardiac surgery, either the “ten commandments” of Choussat 7 or the “two commandments” of the Birmingham‐UK group 14 are helpful for identifying the “high risk” candidates for Fontan completion 48 . They report that there is no actual difference in perioperative outcome in a mean of 7 years follow‐up.…”

Fontan Procedure in Patients with Preoperative Mean Pulmonary Artery Pressure Over 15 mmHg

“…increases in pulmonary vascular resistance [47]. On the other hand, Vigano and colleagues suggest that in the modern era of congenital cardiac surgery, either the'ten commandments' of Choussat [7] or the 'two commandments' of the Birmingham-UK group [14] are helpful for identifying the 'high risk' candidates for Fontan completion [48]. They report that there is no actual difference in perioperative outcome in a mean of 7 years follow up.…”