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Impact of Fontan Fenestration on Adverse Cardiovascular Outcomes: A Multicentre Study
Nabil Dib1, Michelle Samuel1, Sylvie Levesque2
1Montreal Heart Institute, Université de Montréal, Montréal, Québec, Canada.
Insights
Fenestrating a Fontan baffle did not increase long-term adverse cardiovascular events in patients with univentricular hearts. Further research is needed to fully understand potential risks of open fenestrations, such as arrhythmias.
Area of Science:
- Pediatric Cardiology
- Congenital Heart Disease
- Cardiac Surgery
Background:
- Fenestrating a Fontan baffle is linked to better short-term outcomes in univentricular hearts.
- Long-term effects of fenestrated Fontan baffles are not well understood.
- Adverse cardiovascular events are a concern for patients with Fontan circulation.
Purpose of the Study:
- To evaluate the long-term impact of fenestrated Fontan baffles on adverse cardiovascular events.
- To assess risks including mortality, transplantation, arrhythmias, and thromboemboli.
- To clarify the safety profile of fenestrated Fontan baffles.
Main Methods:
- Retrospective cohort study of 407 patients with total cavopulmonary connection.
- Comparison of patients with and without Fontan baffle fenestration.
- Independent adjudication of outcomes and consideration of confounders and competing risks.
Main Results:
- Fenestration closure occurred in 79.9% of patients within 2 years.
- Open fenestration was not associated with increased risk of major adverse cardiovascular events (HR 1.18, P=0.521).
- No significant association found with mortality, transplantation, or arrhythmias, but sensitivity analyses suggested potential risks.
Conclusions:
- This study found no significant long-term association between open Fontan baffle fenestration and major adverse cardiovascular events.
- Further investigation is warranted regarding potential associations with atrial arrhythmias or thromboemboli.
- The findings suggest fenestration is safe in the long term for Fontan patients.
Background:
Fenestrating a Fontan baffle has been associated with improved perioperative outcomes in patients with univentricular hearts. However, longer-term potential adverse effects remain debated. We sought to assess the impact of a fenestrated Fontan baffle on adverse cardiovascular events including all-cause mortality, cardiac transplantation, atrial arrhythmias, and thromboemboli.
Methods:
A multicentre North American retrospective cohort study was conducted on patients with total cavopulmonary connection Fontan baffle, with and without fenestration. All components of the composite outcome were independently adjudicated. Potential static and time-varying confounders were taken into consideration, along with competing risks.
Results:
A total of 407 patients were followed for 10.4 (7.1-14.4) years; 70.0% had fenestration of their Fontan baffle. The fenestration spontaneously closed or was deliberately sealed in 79.9% of patients a median of 2.0 years after Fontan completion. In multivariable analysis in which a persistent fenestration was modelled as a time-dependent variable, an open fenestration did not confer a higher risk of the composite outcome (hazard ratio, 1.18; 95% confidence interval, 0.71-1.97; P = 0.521). In secondary analyses, an open fenestration was not significantly associated with components of the primary outcome: that is, mortality or transplantation, atrial arrhythmias, or thromboemboli. However, sensitivity analyses to assess the possible range of error resulting from imprecise dates for spontaneous fenestration closures could not rule out significant associations between an open fenestration and atrial arrhythmias or thromboemboli.
Conclusions:
In this multicentre study, no significant association was identified between an open fenestration in the Fontan baffle and major adverse cardiovascular events.
