Unplanned Readmissions due to Pleural Effusion Following the Fontan Operation

BackgroundThe Fontan operation is the final stage of palliation for single-ventricle patients. While operative survival has improved, pleural effusions remain a common postoperative complication, increasing morbidity and hospitalization. Our aim was to investigate the incidence and risk factors for unplanned readmissions due to post-Fontan pleural effusion.MethodsA retrospective review of all single ventricle patients who underwent the Fontan procedure from 2012-2023 was performed. This case-control study compared post-Fontan patients readmitted to the hospital due to pleural effusion with those who were not. Readmission was defined as rehospitalization for recurrent pleural effusion requiring intravenous diuretics and/or chest tube placement. Demographics, baseline clinical features, pre-Fontan hemodynamics, type of Fontan surgery, presence of fenestration, cardiac medications and doses, perioperative and post-discharge factors were analyzed between groups.ResultsSixty-one patients who were 42 ± 12.4 months of age underwent the Fontan operation. Of these, 31/61 (51%) had a diagnosis of hypoplastic left heart syndrome, 32/61 (52%) underwent extracardiac Fontan surgery, and 33/61 (54%) had a Fontan fenestration. Nine of 66 (14.7%) patients were readmitted for pleural effusion at a median of 7 days (IQR 5-15) post-discharge. Readmitted patients were older at Fontan (50.4 ± 13 vs 40.5 ± 11.8 months, P = .025), had increased chylothorax incidence (33.3% [3/9] vs 5.8% [3/52], P = .04), absent or restrictive fenestration at discharge (88.9% [8/9] vs 44.2% [23/52], P = .03) and were more likely to have pleural effusion at the first postoperative clinic visit (100% [9/9] vs 13.5% [7/52], P < .01). When comparing maximal diuretic usage, the readmitted patients required more diuretics (median 3 vs 2, P = .01). There were no significant differences in race, gender, weight at Fontan, cardiac anatomy, pre-Fontan hemodynamics, Fontan type, initial fenestration status, cardiopulmonary bypass duration time, supplemental oxygen duration, chest tube duration, number and doses of cardiac medications prior to and at Fontan discharge, or length of hospital stay. No patient required catheter-based intervention or surgery within 3 months post-Fontan discharge.ConclusionOlder age at Fontan, chylothorax, absent/restrictive fenestration at discharge, and detection of pleural effusion at the first postoperative clinic visit are risk factors for readmission due to pleural effusion. Earlier Fontan timing, optimizing diuretic management, and ensuring Fontan fenestration patency may reduce readmissions.