Outcomes of a Physiology-driven Extracardiac Fontan Strategy Incorporating Computational Fluid Dynamics: A...

Area of Science:

• Pediatric Cardiology
• Congenital Heart Surgery
• Cardiovascular Physiology

Background:

• The extracardiac total cavopulmonary connection (EC-TCPC) is a vital palliative procedure for single-ventricle physiology.
• Optimizing surgical techniques and patient selection remains crucial for improving long-term outcomes.

Purpose of the Study:

• To evaluate early and mid-term outcomes following EC-TCPC.
• To compare outcomes across different eras, surgical strategies (fenestration), and conduit sizing methods, including computational fluid dynamics (CFD).

Main Methods:

• A multicentre retrospective cohort study of 788 patients undergoing EC-TCPC (2009-2025).
• Patients were stratified into two eras (Era I: 2009-2016, Era II: 2017-2025) for temporal analysis.
• Survival and adverse events were analyzed using Kaplan-Meier and competing-risk methods.

Main Results:

• Early mortality was 2.4%; 10-year survival was 92.5%.
• Freedom from major adverse events at 10 years was 75.3%, with a 10-year thromboembolism incidence of 6.8%.
• Era II showed reduced pleural drainage duration and effusion rates; CFD-guided sizing improved early hemodynamics but not mid-term clinical events.

Conclusions:

• A physiology-driven EC-TCPC strategy ensures low early mortality and sustained mid-term survival.
• Selective fenestration and geometry-aware sizing support personalized surgical planning.
• CFD-guided optimization serves as a decision-support tool, not a direct outcome determinant.