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Published on: June 26, 2020
Optimizing Referral Timing of Patients With Fontan Circulatory Failure for Heart Transplant
Elaine M Griffeth1, Luke J Burchill2, Joseph A Dearani1
1Department of Cardiovascular Surgery, Mayo Clinic, Rochester, Minnesota.
Insights
Referring Fontan patients for heart transplant earlier, before end-organ damage, improves transplant listing approval. Younger patients with fewer complications had better outcomes.
Area of Science:
- Cardiology
- Transplant Surgery
- Pediatric Cardiology
Background:
- Lack of established criteria for heart transplant referral timing in Fontan patients.
- Limited data on characteristics of Fontan patients who are deferred or declined for transplant listing.
Purpose of the Study:
- To analyze heart transplant evaluations, listing decisions, and outcomes for Fontan patients of all ages.
- To inform and improve referral practices for Fontan patients undergoing transplant evaluation.
Main Methods:
- Retrospective review of 63 Fontan patients evaluated by advanced heart failure service.
- Data collected from transplant selection committee meetings at Mayo Clinic (2006-2021).
- Statistical analysis using Wilcoxon Rank Sum and Fisher's Exact tests.
Main Results:
- 60% of Fontan patients were approved for transplant listing.
- Younger age (<18 years) at evaluation was associated with higher approval rates.
- Approved patients had fewer complications like ascites, cirrhosis, and renal insufficiency compared to deferred/declined patients.
- Deferred/declined patients exhibited significantly lower overall survival.
Conclusions:
- Early referral for heart transplant in Fontan patients, prior to end-organ complications, is linked to higher transplant listing approval rates.
- Timely evaluation and intervention are crucial for improving outcomes in Fontan patients requiring heart transplantation.
Background:
There are no criteria guiding the timing of heart transplant referral for Fontan patients, nor are there any characteristics of those deferred or declined listing reported. This study examines comprehensive transplant evaluations for Fontan patients of all ages, listing decisions, and outcomes to inform referral practices.
Methods:
Retrospective review of 63 Fontan patients formally assessed by the advanced heart failure service and presented at Mayo Clinic transplant selection committee meetings (TSM) January 2006 to April 2021. The study is compliant with the Helsinki Congress and Declaration of Istanbul and included no prisoners. Statistical analysis was performed with Wilcoxon Rank Sum and Fisher's Exact tests.
Results:
Median age at TSM was 26 years (17.5, 36.5). Most were approved (38/63 [60%]); 9 of 63 (14%) were deferred and 16 of 63 (25%) were declined. Approved patients more commonly were <18 years old at TSM (15/38 [40%] vs 1/25 [4%], P = .002) compared with those deferred/declined. Complications of Fontan circulatory failure were less common in approved vs deferred/declined patients: ascites (15/38 [40%] vs 17/25 [68%], P = .039), cirrhosis (16/38 [42%] vs 19/25 [76%], P = .01), and renal insufficiency (6/38 [16%] vs 11/25 [44%], P = .02). Ejection fraction and atrioventricular valve regurgitation did not differ between groups. Pulmonary artery wedge pressure was overall high normal (12 mm Hg [9,16]) but higher in deferred/declined vs approved patients, 14.5 (11, 19) vs 10 (8, 13.5) mm Hg, P = .015. Overall survival was significantly lower in deferred/declined patients (P = .0018).
Conclusion:
Fontan patient referral for heart transplant at younger age and before the onset of end-organ complications is associated with increased approval for transplant listing.
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