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Diagnostic assessment before Fontan operation in patients with bidirectional cavopulmonary anastomosis: are
Pamela S Ro1, Jack Rychik, Meryl S Cohen
1Division of Cardiology, The Children's Hospital of Philadelphia, Pennsylvania 19104, USA.
Insights
Cardiac catheterization before the Fontan procedure may be unnecessary for many patients following bidirectional cavopulmonary anastomosis. Noninvasive criteria can identify a "no-cath" group, potentially avoiding invasive procedures without negative outcomes.
Area of Science:
- Pediatric Cardiology
- Congenital Heart Disease Management
Background:
- Cardiac catheterization is a standard pre-Fontan procedure evaluation.
- Management strategies for single-ventricle physiology have evolved, including staged palliation.
- Exclusion from Fontan based solely on catheterization data is now uncommon.
Purpose of the Study:
- To identify a subset of patients undergoing bidirectional cavopulmonary anastomosis (BCPA) for whom pre-Fontan catheterization offers limited benefit.
- To develop noninvasive criteria for a "no-cath" group before Fontan completion.
Main Methods:
- Retrospective review of 99 patients who underwent BCPA between 1992 and 1997.
- Evaluation of clinical and echocardiographic characteristics to define a "no-cath" group.
- Determination of the predictive value and sensitivity of these criteria for adverse outcomes.
Main Results:
- 46 out of 99 patients met criteria for the "no-cath" group.
- Noninvasive criteria correctly stratified all patients who died or did not proceed to Fontan.
- The negative predictive value of the criteria was 93% for identifying patients not needing further intervention.
Conclusions:
- Pre-Fontan catheterization may be safely avoided in a significant proportion of patients.
- Noninvasive assessment can identify suitable candidates for omitting catheterization.
- Prospective studies are needed to validate this strategy.
Objectives:
This study was designed to determine if a subset of patients who have undergone bidirectional cavopulmonary anastomosis could be identified in which catheterization was of little benefit before completion of the Fontan procedure.
Background:
Diagnostic evaluation before Fontan procedure has typically included cardiac catheterization. However, the overall management strategy for patients with functional single ventricle has evolved to include staging bidirectional cavopulmonary anastomosis in most, and it has become uncommon to exclude patients from Fontan based on catheterization data.
Methods:
Patients who underwent bidirectional cavopulmonary anastomosis and had complete echocardiograms and catheterizations within three months of each other between January 1992 and October 1997 were evaluated with a series of clinical and echocardiographic characteristics to identify a subset in whom catheterization was predicted to be of little added value ("no-cath" group). The predictive value and sensitivity of these criteria in excluding patients who required additional intervention, were excluded from Fontan, or died within 30 days of Fontan was determined.
Results:
A total of 99 patients who underwent bidirectional cavopulmonary anastomosis at 6.7 months (range 2.9 months to 14 years) were studied; 46 met criteria for the "no-cath" group. Noninvasive criteria stratified all patients who died (n = 5) or did not proceed to Fontan (n = 1) and 9 of 11 who required additional interventions to the "cath" group. Thus, the negative predictive value of these criteria was 93%.
Conclusions:
Our data suggest that catheterization before Fontan could be avoided in a large percentage of patients without adversely affecting outcome; prospective evaluation of this strategy is warranted.