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Preoperative Hemodynamics Impact the Benefit of Fenestration on Fontan Postoperative Length of Stay
Garick D Hill1,2, Danny T Y Wu1,2,3, M Eric Ferguson4
1Division of Cardiology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA.
Insights
Fontan fenestration use varies by center, but it is linked to shorter hospital stays, especially for patients with mean pulmonary artery pressure (mPAP) ≥13 mm Hg. This suggests a potential threshold for its use in Fontan surgery.
Area of Science:
- Pediatric Cardiology
- Congenital Heart Disease Surgery
- Hemodynamics
Background:
- Utilization of Fontan fenestration shows significant variability across different medical centers.
- The decision-making process for Fontan fenestration lacks clear, universally applied guidelines.
Purpose of the Study:
- To investigate factors influencing the use of Fontan fenestration in pediatric patients.
- To determine the impact of Fontan fenestration on postoperative length of stay (LOS) using a multicenter dataset.
Main Methods:
- Analysis of a Pediatric Heart Network dataset including surgical and preoperative hemodynamic data from patients aged 2-6 years undergoing Fontan surgery (2010-2020).
- Multivariable logistic regression to identify factors associated with fenestration use.
- Multivariable linear regression and spline analysis to assess the effect of fenestration on LOS, stratified by hemodynamic variables like mean pulmonary artery pressure (mPAP).
Main Results:
- Fontan fenestration was utilized in 66.2% of 702 patients, with significant center-specific variation (27%-93% use).
- Fenestration use was associated with Fontan type but not with preoperative hemodynamic variables.
- Fenestration was independently associated with a shorter hospital LOS (P = 0.0024), particularly for patients with mPAP ≥13 mm Hg (9 vs 12 days, P = 0.001).
Conclusions:
- Center variability in Fontan fenestration use is not explained by preoperative hemodynamics.
- Fontan fenestration is associated with reduced postoperative hospital LOS.
- A pre-Fontan mPAP threshold of ≥13 mm Hg may indicate patients who benefit most from fenestration, suggesting criteria for its use.
Background:
Utilization of Fontan fenestration varies considerably by center.
Objectives:
Using a multicenter Pediatric Heart Network dataset linking surgical and preoperative hemodynamic variables, the authors evaluated factors associated with use of Fontan fenestration and the impact of fenestration on post-Fontan length of stay (LOS).
Methods:
Patients 2 to 6 years old at Fontan surgery from 2010 to 2020 with catheterization<1 year prior were included. Factors associated with fenestration were evaluated using multivariable logistic regression adjusting for key covariates. Restrictive cubic spline analysis was used to evaluate potential cut-points for hemodynamic variables associated with longer postoperative LOS stratified by fenestration with multivariable linear regression to evaluate the magnitude of effect.
Results:
Fenestration was used in 465 of 702 patients (66.2%). Placement of a fenestration was associated with center (range 27%-93% use, P < 0.0001) and Fontan type (OR: 14.1 for lateral tunnel vs extracardiac conduit, P < 0.0001). No hemodynamic variable was independently associated with fenestration. In a multivariable linear model adjusting for center, a center-fenestration interaction, prematurity, preoperative mean pulmonary artery pressure (mPAP), and cardiac index, fenestration was associated with shorter hospital LOS after Fontan (P = 0.0024). The benefit was most pronounced at mPAP ≥13 mm Hg (median LOS: 9 vs 12 days, P = 0.001).
Conclusions:
There is wide center variability in use of Fontan fenestration that is not explained by preoperative hemodynamics. Fenestration is independently associated with shorter LOS, and those with mPAP ≥13 mm Hg at pre-Fontan catheterization benefit the most. We propose this threshold as minimal criteria for fenestration.
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