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Status and Operative Outcomes of the Fontan Procedure Performed Beyond the First Decade of Life in the United States
Rohit Ganduboina1, Arman Hasanzade2, Sandeep Sainathan3
1Department of Surgery, NRI Institute of Medical Sciences, Visakhapatnam, India.
Insights
The Fontan operation, a heart surgery, is increasingly performed later in life. While late Fontan (LF) patients face higher morbidity, their short-term mortality remains similar to traditional Fontan (TF) patients.
Area of Science:
- Pediatric Cardiology
- Cardiac Surgery
- Health Services Research
Background:
- The Fontan operation is a critical palliative surgery for single-ventricle congenital heart defects.
- Traditionally performed in early childhood (2-5 years), there's a growing trend towards later intervention.
Purpose of the Study:
- To analyze the immediate outcomes of the Fontan operation performed in patients aged 10 years or older (Late Fontan - LF) in the United States.
- To compare the characteristics and outcomes of LF patients with those undergoing the Traditional Fontan (TF) procedure.
Main Methods:
- Utilized large administrative databases: Kids' Inpatient Database (2003-2019) and Nationwide Inpatient Sample (2016-2021).
- Identified 10,245 pediatric patients undergoing the Fontan operation, categorizing them into TF (2-5 years) and LF (≥10 years).
- Assessed demographic, clinical characteristics, and discharge mortality, employing standard statistical tests and multivariate regression analysis.
Main Results:
- Only 3% of Fontan procedures were performed as Late Fontan (LF).
- LF patients exhibited distinct demographics (non-Caucasian, higher socioeconomic status) and a greater comorbidity burden, with heterotaxy syndrome and total anomalous pulmonary venous return being more prevalent.
- LF patients experienced higher postoperative morbidity but similar short-term mortality compared to TF patients.
Conclusions:
- The proportion of Traditional Fontan (TF) procedures has decreased, indicating a shift towards earlier intervention.
- Despite this trend, the absolute number of Late Fontan (LF) procedures has increased, suggesting expanded application of the surgery.
- Late Fontan (LF) patients face increased postoperative morbidity and higher baseline comorbidities, though short-term mortality is comparable to TF patients.
Abstract:
Background: The Fontan operation is typically performed between two and five years-of-age in the United States. In this study, we analyzed the immediate outcomes of the Fontan operation performed beyond the first decade of life in the United States using a large administrative database. Methods: Kids' Inpatient Database (2003-2019) and Nationwide Inpatient Sample (2016-2021) datasets were used; 10,245 pediatric patients undergoing the Fontan operation were identified. The cohort was divided into: Traditional Fontan (TF, 2-5 years-of-age, n = 9,900) and Late Fontan (LF, ≥10 years-of-age, n = 345); Survivor and non-survivor status were based on discharge mortality. Demographic and clinical characteristics were assessed using standard statistical tests. Results: Only 3% of the Fontan procedures (n = 345/10,245) belonged to the LF group. LF was comprised predominantly of non-Caucasian ethnicity, higher socioeconomic class, and had a greater comorbidity burden. Heterotaxy syndrome and total anomalous pulmonary venous return were more common in the LF group as compared with hypoplastic left heart syndrome in the TF group. Patients in the LF group experienced higher postoperative morbidity but similar mortality and often required specialized healthcare post-discharge. Multivariate regression analysis revealed inferior survival among Fontan patients with ECMO use, atrioventricular septal defect, coagulopathy, acute kidney injury, infection, prolonged mechanical ventilation, but not age at Fontan. Conclusion: The proportion of patients undergoing LF compared with TF has decreased over time signalling a move toward earlier timing of the Fontan procedure. However, within the LF group, the number of LF patients has increased over time signifying an extended application of the Fontan operation. The patients in the LF group experienced greater postoperative morbidity with an associated higher baseline comorbidity but not short-term mortality after the Fontan procedure.
