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Published on: May 2, 2025
Factors affecting Fontan length of stay: Results from the Single Ventricle Reconstruction trial
Chitra Ravishankar1, Eric Gerstenberger2, Lynn A Sleeper2
1Department of Pediatrics, Children's Hospital of Philadelphia, Philadelphia, Pa.
Insights
The type of Norwood shunt used in infants with hypoplastic left heart syndrome (HLHS) did not impact length of stay after the Fontan operation. Earlier medical complexity, not shunt type, predicts longer hospital stays post-Fontan.
Area of Science:
- Pediatric Cardiology
- Congenital Heart Disease Surgery
- Outcomes Research
Background:
- Hypoplastic left heart syndrome (HLHS) requires staged surgical palliation.
- The Single Ventricle Reconstruction trial compared right-ventricle-to-pulmonary-artery shunt (RVPAS) and modified Blalock-Taussig shunt (MBTS) in HLHS infants.
- RVPAS showed lower early mortality but more complications at 14 months compared to MBTS.
Purpose of the Study:
- To investigate the impact of initial shunt type on postoperative length of stay (LOS) after the Fontan operation.
- To identify patient, medical, and surgical factors influencing LOS following the Fontan procedure in HLHS patients.
- To analyze the association between pre-Fontan characteristics and outcomes after the Fontan operation.
Main Methods:
- Retrospective analysis of medical records for patients undergoing the Fontan operation.
- Cox proportional hazards modeling to determine factors associated with postoperative LOS.
- Inclusion of variables such as shunt type, age at surgery, pre-Fontan complications, and echocardiographic findings.
Main Results:
- No significant difference in Fontan LOS between RVPAS and MBTS groups (median 11 vs. 10 days).
- Independent predictors of longer LOS included treatment center, LOS at stage II, and pre-Fontan complications.
- Deep hypothermic circulatory arrest during Fontan was associated with shorter LOS; moderate tricuspid regurgitation predicted longer LOS.
Conclusions:
- The type of Norwood shunt (RVPAS vs. MBTS) does not influence postoperative length of stay after the Fontan operation.
- Pre-existing medical complexity and earlier surgical stage LOS are key determinants of longer hospital stays post-Fontan.
- These findings emphasize the importance of comprehensive pre-operative patient status in predicting Fontan outcomes.
Background:
In the Single Ventricle Reconstruction trial, infants with hypoplastic left heart syndrome (HLHS) who received a right-ventricle-to-pulmonary-artery shunt (RVPAS) versus a modified Blalock-Taussig shunt (MBTS) had lower early postoperative mortality, but more complications at 14 months. We explored the effect of shunt type and other patient, medical, and surgical factors on postoperative length of stay (LOS) after the Fontan operation.
Methods:
Fontan postoperative course was ascertained from medical record review. Cox proportional hazards modeling was used to identify factors associated with LOS.
Results:
Of 327 subjects who underwent Fontan, 323 were analyzed (1 death, 1 biventricular repair, 2 with missing data). Median age and weight at Fontan were 2.8 years (interquartile range [IQR]: 2.3, 3.4) and 12.7 kg (IQR: 11.4, 14.1), respectively. Fontan type was extracardiac in 55% and lateral tunnel in 45%; 87% were fenestrated. The RVPAS and MBTS subjects had similar LOS (median 11 days [IQR: 9, 18] vs 10 days [IQR: 9, 13]; P = .23). Independent risk factors for longer LOS were treatment center (P < .01), LOS at stage II (hazard ratio [HR] 1.02 for each additional day; P < .01), and pre-Fontan complications (HR 1.03 for each additional complication; P = .04). Use of deep hypothermic circulatory arrest at Fontan (HR 0.64; P = .02) was independently associated with shorter LOS. When center was excluded from the model, pre-Fontan complications and use of circulatory arrest were no longer significant; instead, older age at stage II (HR 1.08 for each additional month; P = .01) predicted longer LOS. In 254 subjects who had a pre-Fontan echocardiogram, at least moderate tricuspid regurgitation was independently associated with longer LOS, both with center (HR 1.72; P < .01) and without center in the model (HR 1.49; P = .02).
Conclusions:
In this multicenter prospective cohort of subjects with HLHS, Norwood shunt type was not associated with Fontan LOS. Rather, global measures of earlier medical complexity indicate greater likelihood of longer LOS after the Fontan operation.
