Risk Factors Associated with Prolonged Recovery after Fontan Operation_Chinese Journal of Clinical Thoracic and Cardiovascular Surgery

Authors：

ZHANGYa-juan ,  YANJun , LIShou-jun , WANGQiang , YANPeng , JIANGRui

Department of Cardiac Surgery, Beijing Fu Wai Hospital, Chinese Academy of Medical Science and Peking Union Medical College, Beijing 100037, P. R. China;

Corresponding author：

YANJun, Email: yanjun.1112@aliyun.com

Keywords：

Fontan operation; Prolonged recovery; Risk factor

DOI：

10.7507/1007-4848.20140088

Video：

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Objective To analyze risk factors contributing to prolonged postoperative recovery after Fontan operation. Methods Clinical data of 60 patients undergoing Fontan operation between January 2012 and June 2013 in Beijing Fu Wai Hospital were retrospectively analyzed, including their demographic data, preoperative angiography and echocardiogram, and preoperative, intraoperative and postoperative hemodynamic data and blood test results. According to different length of hospital stay (LOS), all the 60 patients were divided into 2 groups. In the normal recovery group, there were 45 patients including 33 males and 12 females with their age of 5.7±1.7 years, whose LOS was shorter than 32.5 days. In the prolonged recovery group, there were 15 patients including 10 males and 5 females with their age of 4.9±1.6 years, whose LOS was longer than 32.5 days (over 75th percentile of LOS). LOS of the 60 patients ranged from 12 to 53 days, and 75th percentile of LOS was 32.5 days. Clinical results were compared between the 2 groups, and risk factors for prolonged postoperative recovery were analyzed. Results Preoperatively, their oxygen saturation by pulse oximetry was 80.5%±7.4%, ejection fraction (EF)was 64.1%±6.6%, Nakata index was 370.6±234.2 mm²/m², Mcgoon ratio was 2.2±0.7, and pulmonary arterial pressure (PAP)was 12.4±4.0 mm Hg. Twenty-seven patients (45.0%)received Glenn procedure before Fontan operation at the age of 0.9-4.0 years, and the duration from Glenn procedure to Fontan operation was 1.0-5.1 years. Two patients (3.3%)died after Fontan operation. Cardiopulmonary bypass time of 55 patients who received Fontan operation under parallel circulation was 112.0±52.4 minutes. Aortic cross-clamping time of 5 patients who received concomitant repair of intracardiac anomalies under circulatory arrest was 44.8±9.2 minutes. The duration of mechanical ventilation was 18.8±6.4 hours, and ICU stay was 5.1±2.1 days. Univariate analysis showed that risk factors for prolonged postoperative recovery included higher preoperative PAP (P < 0.05), lower preoperative EF (P < 0.05), right ventricle as functional single ventricle (P < 0.05), previous Glenn procedure history (P < 0.05), concomitant total anomalous venous connection (P < 0.05), higher postoperative lactate level (P < 0.05), higher postoperative central venous pressure (P < 0.05), the need for greater volume of fluid resuscitation during the first 24 hours postoperatively (P < 0.05), long duration of chest drainage (P < 0.05)and postoperative infection (P < 0.05). Conclusion Short-term clinical results of Fontan operation for the treatment of functional single ventricle are satisfactory. Careful assessment and appropriate management of risk factors are helpful to improve postoperative recovery after Fontan operation.

Citation： ZHANGYa-juan, YANJun, LIShou-jun, WANGQiang, YANPeng, JIANGRui. Risk Factors Associated with Prolonged Recovery after Fontan Operation. Chinese Journal of Clinical Thoracic and Cardiovascular Surgery, 2014, 21(3): 312-317. doi: 10.7507/1007-4848.20140088 Copy

1.	Gewillig M. The Fontan circulation. Heart, 2005, 91 (6):839-846.
2.	郭少先, 吕小东, 刘迎龙, 等.改良Fontan手术治疗复杂先天性心脏病.中国胸心血管外科临床杂志, 2007, 14 (2):89-92.
3.	Khambadkone S. The Fontan pathway:What's down the road? Ann Pediatic Cardiol, 2008, 1 (2):83-92.
4.	Khairy P, Fernandes SM, Mayer JE, et al. Long-term survival, modes of death, and predictors of mortality in patients with Fontan surgery. Circulation, 2008, 117 (1):85-92.
5.	Almond CS, Mayer JE, Thiagarajan RR, et al. Outcome after Fontan failure and takedown to an intermediate palliative circulation. Ann Thorac Surg, 2007, 84 (3):880-887.
6.	Salvin JW, Scheurer MA, Laussen PC, et al. Factors associated with prolonged recovery after the Fontan operation. Circulation, 2008, l18 (Suppl 1):S171-S176.
7.	Diller GP, Giardini A, Dimopoulos K, et al. Predictors of morbidity and mortality in contemporary Fontan patients:results from a multi-center study including cardiopulmonary exercise testing in 321 patients. Eur Heart J, 2010, 31 (24):3073-3083.
8.	Graham TP, Johns JA. Pre-operative assessment of ventricular function in patients considered for Fontan procedure. Herz, 1992, 17 (4):213-219.
9.	Gewilig M, Brown SC, Eyskens B, et al. The Fontan circulation:who controls cardiac output? Interact Cardioavasc Thorac Surg, 2010, 10 (3):428-433.
10.	Hosein R, Clarke A, Mcguirk S, et al. Factors influencing early and late outcome following the Fontan procedure in the current era. The Two Commandments? Eur J Cardiothorac Surg, 2007, 31 (3):344-353.
11.	Gentles TL, Mayer JE, Gauvreau K, et al. Fontan operation in five hundred consecutive patients:factors influencing early and late outcome. J Thorac Cardiovasc Surg, 1997, 114 (3):376-391.
12.	Maarslet L, Møller MB, Dall R, et al. Lactate levels predict mortality and need for peritoneal dialysis in children undergoing congenital heart surgery. Acta Anaesthesiol Scand, 2012, 56 (4):459-464.
13.	方敏华, 汪曾炜, 张仁福, 等.改良Fontan手术的危险因素分析.中华胸心血管外科杂志, 2002, 18 (4):193-195.
14.	Yamauchi H, Imura H, Maruyama Yuji, et al. Evolution of staged approach for Fontan operation. J Nippon Med Sch, 2002, 69 (2):154-159.
15.	Tanoue Y, Kado H, Boku N, et al. Three hundred and thirty-three experiences with the bidirectional Glenn procedure in a single institute. Interact Cardiovasc Thorac Surg, 2007, 6 (1):97-101.
16.	郑景浩, 徐志伟, 苏肇伉, 等.二期Fontan术治疗小儿复杂先天性心脏病.中华胸心血管外科杂志, 2007, 23 (2):97-99.
17.	Lemler MS, Scott WA, Leonard SR, et al. Fenestration improves clinical outcome of the fontan procedure:a prospective, randomized study. Circulation, 2002, 105 (2):207-212.
18.	朱宏斌, 郑景浩, 刘锦纷, 等. Fontan术后顽固性胸腔积液相关因素分析及处理.中华胸心血管外科杂志, 2005, 21 (3):173-174.
19.	杨克明, 李守军, 张岩, 等.全腔静脉-肺动脉连接术早期临床结果.中国胸心血管外科临床杂志, 2012, 19 (1):15-18.
20.	Grosse-Wortmann L, Drolet C, Dragulescu A, et al. Aortopulmonary collateral flow volume affects early postoperative outcome after Fontan completion:a multimodality study. J Thorac Cardiovasc Surg, 2012, 144 (6):1329-1336.
21.	Kitano M, Yazaki S, Kagisaki K. Aggressive coil embolization for connected aortopulmonary collateral arteries with large shunts devel-oped after diaphragmatic plication performed after cavopulmonary connection to facilitate Fontan circulation. Catheter Cardiovasc Interv, 2013, 82 (5):E694-E703.
22.	Gaynor JW, Collins MH, Rychik J, et al. Long-term outcome of infants with single ventricle and total anomalous pulmonary venous connection. J Thorac Cardiovasc Surg, 1999, 117 (3):506-514.
23.	Bartz PJ, Driscoll DJ, Dearani JA, et al. Early and late results of the modified fontan operation for heterotaxy syndrome 30 years of experience in 142 patients. J Am Coll Cardiol, 2006, 48 (11):2301-2305.
24.	Schreiber C, Hörer J, Vogt M, et al. Nonfenestrated extracardiac total cavopulmonary connection in 132 consecutive patients. Ann Thorac Surg, 2007, 84 (3):894-899.
25.	Stamm C, Anderson RH, Ho SY. The morphologically tricuspid valve in hypoplastic left heart syndrome. Eur J Cardiothorac Surg, 1997, 12 (4):587-592.

1. Gewillig M. The Fontan circulation. Heart, 2005, 91 (6):839-846.
2. 郭少先, 吕小东, 刘迎龙, 等.改良Fontan手术治疗复杂先天性心脏病.中国胸心血管外科临床杂志, 2007, 14 (2):89-92.
3. Khambadkone S. The Fontan pathway:What's down the road? Ann Pediatic Cardiol, 2008, 1 (2):83-92.
4. Khairy P, Fernandes SM, Mayer JE, et al. Long-term survival, modes of death, and predictors of mortality in patients with Fontan surgery. Circulation, 2008, 117 (1):85-92.
5. Almond CS, Mayer JE, Thiagarajan RR, et al. Outcome after Fontan failure and takedown to an intermediate palliative circulation. Ann Thorac Surg, 2007, 84 (3):880-887.
6. Salvin JW, Scheurer MA, Laussen PC, et al. Factors associated with prolonged recovery after the Fontan operation. Circulation, 2008, l18 (Suppl 1):S171-S176.
7. Diller GP, Giardini A, Dimopoulos K, et al. Predictors of morbidity and mortality in contemporary Fontan patients:results from a multi-center study including cardiopulmonary exercise testing in 321 patients. Eur Heart J, 2010, 31 (24):3073-3083.
8. Graham TP, Johns JA. Pre-operative assessment of ventricular function in patients considered for Fontan procedure. Herz, 1992, 17 (4):213-219.
9. Gewilig M, Brown SC, Eyskens B, et al. The Fontan circulation:who controls cardiac output? Interact Cardioavasc Thorac Surg, 2010, 10 (3):428-433.
10. Hosein R, Clarke A, Mcguirk S, et al. Factors influencing early and late outcome following the Fontan procedure in the current era. The Two Commandments? Eur J Cardiothorac Surg, 2007, 31 (3):344-353.
11. Gentles TL, Mayer JE, Gauvreau K, et al. Fontan operation in five hundred consecutive patients:factors influencing early and late outcome. J Thorac Cardiovasc Surg, 1997, 114 (3):376-391.
12. Maarslet L, Møller MB, Dall R, et al. Lactate levels predict mortality and need for peritoneal dialysis in children undergoing congenital heart surgery. Acta Anaesthesiol Scand, 2012, 56 (4):459-464.
13. 方敏华, 汪曾炜, 张仁福, 等.改良Fontan手术的危险因素分析.中华胸心血管外科杂志, 2002, 18 (4):193-195.
14. Yamauchi H, Imura H, Maruyama Yuji, et al. Evolution of staged approach for Fontan operation. J Nippon Med Sch, 2002, 69 (2):154-159.
15. Tanoue Y, Kado H, Boku N, et al. Three hundred and thirty-three experiences with the bidirectional Glenn procedure in a single institute. Interact Cardiovasc Thorac Surg, 2007, 6 (1):97-101.
16. 郑景浩, 徐志伟, 苏肇伉, 等.二期Fontan术治疗小儿复杂先天性心脏病.中华胸心血管外科杂志, 2007, 23 (2):97-99.
17. Lemler MS, Scott WA, Leonard SR, et al. Fenestration improves clinical outcome of the fontan procedure:a prospective, randomized study. Circulation, 2002, 105 (2):207-212.
18. 朱宏斌, 郑景浩, 刘锦纷, 等. Fontan术后顽固性胸腔积液相关因素分析及处理.中华胸心血管外科杂志, 2005, 21 (3):173-174.
19. 杨克明, 李守军, 张岩, 等.全腔静脉-肺动脉连接术早期临床结果.中国胸心血管外科临床杂志, 2012, 19 (1):15-18.
20. Grosse-Wortmann L, Drolet C, Dragulescu A, et al. Aortopulmonary collateral flow volume affects early postoperative outcome after Fontan completion:a multimodality study. J Thorac Cardiovasc Surg, 2012, 144 (6):1329-1336.
21. Kitano M, Yazaki S, Kagisaki K. Aggressive coil embolization for connected aortopulmonary collateral arteries with large shunts devel-oped after diaphragmatic plication performed after cavopulmonary connection to facilitate Fontan circulation. Catheter Cardiovasc Interv, 2013, 82 (5):E694-E703.
22. Gaynor JW, Collins MH, Rychik J, et al. Long-term outcome of infants with single ventricle and total anomalous pulmonary venous connection. J Thorac Cardiovasc Surg, 1999, 117 (3):506-514.
23. Bartz PJ, Driscoll DJ, Dearani JA, et al. Early and late results of the modified fontan operation for heterotaxy syndrome 30 years of experience in 142 patients. J Am Coll Cardiol, 2006, 48 (11):2301-2305.
24. Schreiber C, Hörer J, Vogt M, et al. Nonfenestrated extracardiac total cavopulmonary connection in 132 consecutive patients. Ann Thorac Surg, 2007, 84 (3):894-899.
25. Stamm C, Anderson RH, Ho SY. The morphologically tricuspid valve in hypoplastic left heart syndrome. Eur J Cardiothorac Surg, 1997, 12 (4):587-592.

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