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Assessment and Evaluation of the High Risk Neonate: The NICU Network Neurobehavioral Scale
Published on: August 25, 2014
High-risk Fontan completion patients achieve low perioperative risk and benefit from cavopulmonary connection 7 years
Gaia Vigano1, Colin J McMahon2, Kevin Walsh2
1Department of Paediatric Cardiothoracic Surgery, Our Lady's Children's Hospital Crumlin, Dublin, Ireland.
Insights
Conventional high-risk criteria did not predict poorer outcomes after Fontan completion in children. This suggests re-evaluating historical selection criteria for this complex cardiac surgery to improve patient selection.
Area of Science:
- Pediatric Cardiology
- Congenital Heart Disease Surgery
Background:
- The Fontan procedure is a complex surgery for single-ventricle congenital heart defects.
- Historically, specific criteria have been used to identify high-risk patients for Fontan completion.
- These criteria aim to minimize complications and improve outcomes.
Purpose of the Study:
- To retrospectively assess if conventional high-risk criteria accurately predict poorer outcomes after Fontan completion.
- To evaluate the efficacy of current selection criteria in identifying patients who may benefit from the procedure.
Main Methods:
- Retrospective analysis of 133 children undergoing extracardiac Fontan completion between 2004-2012.
- Patients were categorized into three groups based on historical risk factors and contraindications.
- Statistical analysis (Fischer's exact test, chi-squared test) was used to compare outcomes between groups.
Main Results:
- No significant differences in postoperative complications (arrhythmias, infection, stroke) or length of stay were observed between high-risk and low-risk groups.
- Long-term outcomes, including arrhythmias, protein-losing enteropathy, and ventricular dysfunction, were similar across groups.
- A notable finding was a higher rate of catheter reinterventions in the high-risk groups.
Conclusions:
- Medium-term benefits of Fontan completion are achievable even in patients previously considered high-risk.
- The study suggests a need to re-examine and potentially revise historical selection criteria for Fontan completion.
- This re-evaluation could lead to broader eligibility for the procedure and improved patient management.
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.
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