Preoperative Hemodynamics Impact the Benefit of Fenestration on Fontan Postoperative Length of Stay

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.