Textbook Outcome for the Fontan Operation: A Holistic Quality Metric in Congenital Heart Surgery

To develop a holistic measure of congenital heart center performance, we created a composite "textbook outcome" (TO) for the Fontan operation using postoperative endpoints. We hypothesized that achieving the TO would have a positive prognostic and financial impact.

This was a single-center study of primary Fontan operations from 2005 to 2022. TO was defined as freedom from operative mortality, reintervention, 30-day readmission, extracorporeal membrane oxygenation, major thrombotic complication, chylothorax, >75th percentile length of stay, and >75th percentile mechanical ventilation duration. Multivariable logistic regression and Kaplan-Meier survival analysis were used to assess statistical significance.

Overall, 49% of patients (97 of 198) met the TO. Patients who failed to achieve the TO were more likely to have a dominant right ventricle, moderate-severe regurgitation of the systemic atrioventricular valve, and higher pulmonary vascular resistance. In the multivariable analysis, the presence of pulmonary artery (PA) stenosis, higher mean PA pressure, and Norwood as the index operation were independently associated with a lower likelihood of achieving the TO. However, a history of atrial septostomy prior to Fontan was independently associated with a 3-fold higher likelihood of achieving the TO. Patients who met the TO acquired lower median direct hospital costs ($40,800 vs $80,400, P < 0.001) and had higher long-term survival (log rank, P = 0.027).

Fontan TO achievement is associated with increased long-term survival and lower costs and can be predicted by certain risk factors. As outcomes continue to improve within congenital heart surgery, operative mortality alone becomes a less-sensitive metric. The Fontan TO may represent a balanced measure of successful patient care.