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Survival after bidirectional cavopulmonary anastomosis: analysis of preoperative risk factors
Mark A Scheurer1, Elizabeth G Hill, Nagavardhan Vasuki
1Department of Cardiology, Children's Hospital Boston, Boston, Mass 02115, USA. mark.scheurer@cardio.chboston.org
Insights
Survival after bidirectional cavopulmonary anastomosis is high, but preoperative atrioventricular valve regurgitation significantly increases the risk of death or transplantation in single ventricle patients.
Area of Science:
- Pediatric Cardiology
- Congenital Heart Disease Surgery
- Cardiovascular Physiology
Background:
- Single ventricle physiology presents complex surgical challenges.
- Bidirectional cavopulmonary anastomosis (BCPA) is a palliative procedure for single ventricle patients.
- Predicting long-term outcomes after BCPA requires identification of prognostic factors.
Purpose of the Study:
- To identify preoperative risk factors for death or transplantation after BCPA.
- To analyze hemodynamic and echocardiographic data in functionally single ventricle patients.
- To improve risk stratification for patients undergoing BCPA.
Main Methods:
- Retrospective analysis of 167 patients undergoing BCPA before age 5 (1995-2005).
- Review of preoperative echocardiograms and catheterization data.
- Kaplan-Meier survival analysis and Cox proportional hazard modeling.
Main Results:
- One-year and five-year freedom from death or transplantation was 96% and 89%, respectively.
- Atrioventricular valve regurgitation was identified as an independent risk factor for adverse outcomes.
- Hazard ratio for death or transplantation associated with AVVR was 2.8 (95% CI 1.1-7.1, P=.02).
Conclusions:
- High survival rates are achievable after BCPA.
- Preoperative atrioventricular valve regurgitation is a critical predictor of poor outcomes.
- Risk stratification should incorporate AVVR assessment for BCPA candidates.
Objective:
Prognostic factors for survival after bidirectional cavopulmonary anastomosis for functionally single ventricle are not well defined. We analyzed preoperative hemodynamic and echocardiographic data to determine risk factors for death or transplantation at least 1 year after bidirectional cavopulmonary anastomosis.
Methods:
Data for all patients who underwent bidirectional cavopulmonary anastomosis before 5 years of age at our institution from September 1995 through June 2005 were analyzed. Available preoperative echocardiograms and catheterizations were reviewed. Survivors were compared with those who died or underwent transplantation. Bivariable associations between demographic and clinical risk factors and survival status (alive without transplantation vs dead or transplanted) were assessed with Wilcoxon rank sum test and chi2 or Fisher exact tests. Survival functions were constructed with Kaplan-Meier estimates, and event times compared between subgroups with log-rank tests. Cox proportional hazard modeling was used for multivariable modeling of risk of death or transplantation.
Results:
One hundred sixty-seven patients underwent bidirectional cavopulmonary anastomosis with hemi-Fontan (n = 62) or bidirectional Glenn (n = 105) operations. Three patients died before discharge, 11 died later, and 1 has undergone transplantation. Freedom from death or transplantation after bidirectional cavopulmonary anastomosis was 96% at 1 year and 89% at 5 years. Multivariable analysis of preoperative variables showed atrioventricular valve regurgitation to be an independent risk factor for death or transplantation (hazard ratio 2.8, 95% confidence interval 1.1-7.1, P = .02).
Conclusion:
Although survival after bidirectional cavopulmonary anastomosis is high, preoperative atrioventricular valve regurgitation is an important risk factor for death or transplantation.
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