Impact on clinical outcomes from transcatheter closure of the Fontan fenestration: A systematic review and meta-analysis

Abstract

BackgroundMeta-analysis of the impact on clinical outcome from transcatheter closure of Fontan fenestration.MethodsCochrane, Embase, MEDLINE, and Open-Gray were searched. Parameters such as changes in oxygen saturation, cavo-pulmonary pressure, maximum heart rate during exercise, exercise duration, and oxygen saturation after fenestration closure were pooled and statistical analysis performed.ResultsAmong 922 publications, 12 retrospective observational studies were included. The included studies involved 610 patients, of which 552 patients (90.5%) had a fenestration. Of those patients, 505 patients (91.5%) underwent attempt at trans-catheter closure. When it could be estimated, the pooled overall mean age at trans-catheter fenestration closure was 6.6 ± 7.4 years, and the mean follow-up time was 34.4 ± 10.7 months. There were 32 minor (6.3%) and 20 major (4.0%) complications during or after trans-catheter Fontan fenestration closure. The forest plots demonstrate that following fenestration closure, there was a significant increase in the mean arterial oxygen saturation of 7.9% (95% CI 6.4–9.4%, p < 0.01). There was also a significant increase in the mean cavo-pulmonary pressure of 1.4 mmHg (95% CI 1.0–1.8 mmHg, p < 0.01) following fenestration closure. The exercise parameters reported in 3 studies also favored closing the fenestration as well, yet the exercise duration increase of 1.7 min (95% CI 0.7–2.8 min, p < 0.01) after fenestration closure is probably clinically insignificant.ConclusionLate closure of a Fontan fenestration has the impact of improving resting oxygen saturation, exercise oxygen saturation, and a modest improvement of exercise duration. These clinical benefits, however, may be at the expense of tolerating slightly higher cavo-pulmonary mean pressures.

Narrative review of single ventricle: where are we after 40 years?

“…While two systematic literature reviews and meta-analyses on the early outcomes of a Fontan fenestration demonstrated mixed benefit in the immediate post-operative period ( 173 , 174 ), our meta-analyses on later outcomes showed patients required either late closure or creation/reopening of a fenestration made at the time of Fontan completion ( 175 ).…”

The pendulum of Fontan fenestration

“…Two systematic literature reviews and meta-analysis have focused upon the early outcomes of a Fontan fenestration, demonstrating a mix benefit in the immediate period, with reduced amount of chest drains and subsequent shorter stay in hospital as the only positive aspects ( 15 , 16 ). Our meta-analysis instead focused on late outcomes, with patients requiring either late closure or creation and/or reopening of a fenestration made at the time of Fontan completion ( 17 ). We found that, following fenestration closure, there was a significant increase in the mean arterial oxygen saturation of 7.9% [95% confidence interval (CI): 6.4–9.4%, P<0.01], at expense of a significant increase in the mean cavo-pulmonary pressure of 1.4 mmHg (95% CI: 1.0–1.8 mmHg, P<0.01) ( 17 ).…”

“…Our meta-analysis instead focused on late outcomes, with patients requiring either late closure or creation and/or reopening of a fenestration made at the time of Fontan completion ( 17 ). We found that, following fenestration closure, there was a significant increase in the mean arterial oxygen saturation of 7.9% [95% confidence interval (CI): 6.4–9.4%, P<0.01], at expense of a significant increase in the mean cavo-pulmonary pressure of 1.4 mmHg (95% CI: 1.0–1.8 mmHg, P<0.01) ( 17 ). The literature data for fenestration creation and/or reopening didn’t allow any meaningful conclusion ( 17 ).…”

“…As illustrated by the varying pattern of fenestration use, there is a substantial lack of high-quality scientific evidence supporting any therapeutic decision ( 17 , 25 ). Thus, in clinical practice, the decision to perform a fenestration and its size is based on the personal and institutional experience in relationship to the morphologic and pathophysiologic characteristics of a specific patient.…”

“…Our metaanalysis instead focused on late outcomes, with patients requiring either late closure or creation and/or reopening of a fenestration made at the time of Fontan completion (17). We found that, following fenestration closure, there was a significant increase in the mean arterial oxygen saturation of 7.9% [95% confidence interval (CI): 6.4-9.4%, P<0.01], at expense of a significant increase in the mean cavo-pulmonary pressure of 1.4 mmHg (95% CI: 1.0-1.8 mmHg, P<0.01) (17). The literature data for fenestration creation and/or reopening didn't allow any meaningful conclusion (17).…”