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Impact of Fenestration Patency on Long-Term Fontan Outcomes
Sakura Horie1, Fumiaki Shikata1, Norihiko Oka2
1Department of Cardiac Surgery, The University of Tokyo Hospital, Tokyo 113-8655, Japan.
Insights
Routine fenestration during Fontan completion may improve long-term outcomes, particularly reducing protein-losing enteropathy, despite a higher end-diastolic pressure at one year. This supports the strategy of routine fenestration creation in pediatric cardiac surgery.
Area of Science:
- Pediatric Cardiology
- Congenital Heart Disease Surgery
- Cardiovascular Physiology
Background:
- Routine creation of a fenestration during Fontan completion is a common surgical policy aimed at stabilizing early circulation.
- The long-term impact of fenestration patency on patient outcomes after total cavopulmonary connection remains an area for investigation.
Purpose of the Study:
- To evaluate the validity of routine fenestration creation during Fontan completion.
- To examine the impact of fenestration patency at one year on long-term outcomes, including Fontan-associated liver disease and protein-losing enteropathy.
Main Methods:
- A retrospective analysis of 105 patients who underwent fenestrated total cavopulmonary connection across four institutions was performed.
- Patients were stratified into two groups based on fenestration status at one year: patent (Group F) and closed (Group C).
- Preoperative and one-year catheterization data were compared, along with long-term complications such as Fontan-associated liver disease and protein-losing enteropathy.
Main Results:
- While fenestration patency at one year was associated with higher systemic ventricular end-diastolic pressure (P=0.007), it was also linked to a significantly lower incidence of protein-losing enteropathy (5.0% vs. 27.0%, P=0.038).
- No significant difference was observed in the cumulative incidence of Fontan-associated liver disease between the patent and closed fenestration groups (12.5% vs. 9.7%, P=0.69).
- Preoperative hemodynamics did not differ between the groups.
Conclusions:
- Patent fenestration after Fontan completion, despite potentially increasing early postoperative ventricular pressure, may confer long-term benefits by reducing the incidence of protein-losing enteropathy.
- Given the difficulty in predicting fenestration patency preoperatively, the policy of routine fenestration creation appears to be a valid and beneficial surgical strategy.
Objectives:
Routine creation of a fenestration during Fontan completion is our policy to stabilize early circulation. This study evaluated its validity by examining the impact of fenestration patency at 1 year on long-term outcomes.
Methods:
Among 112 patients who underwent fenestrated total cavopulmonary connection at 4 institutions, 105 with 1-year catheterization and ≥3 years of follow-up were analysed. Patients were classified by fenestration status at 1 year: patent (Group F, n = 43) and closed (Group C, n = 62). Preoperative and 1-year catheter data and long-term complications-Fontan-associated liver disease (FALD), protein-losing enteropathy (PLE), and catheter interventions excluding veno-venous collaterals-were compared.
Results:
The median age at Fontan was 23 months (interquartile range [IQR]: 15-33). Preoperative haemodynamics showed no differences between the groups. At postoperative 1 year, systemic ventricular end-diastolic pressure (SVEDP) was higher in Group F (F: 8 [5-9] vs C: 6 [5-8] mmHg, P = .007). Protein-losing enteropathy was significantly more common in the Group C (F: 5.0% vs C: 27.0%, P = .038). In contrast, there was no significant difference in the cumulative incidence of FALD between the 2 groups (F: 12.5% vs C: 9.7%, P = .69).
Conclusions:
Although patent fenestration was associated with an increased SVEDP at 1 year postoperatively, it may improve long-term outcomes including PLE. As predicting eventual fenestration patency from preoperative data is difficult, our policy of routine fenestration creation appears to be a valid strategy.
Clinical Registration Number:
Kitasato University, No. B23-130; February 7, 2024.
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