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Date Published:
01/02/2021
Abstract Views: 190
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Views PDF: 235
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Research Article
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Dai, T. D., Thanh, L. N. ., Van, D. T. H. ., & Tien, D. A. (2021). Yếu tố tiên lượng của thất bại với tuần hoàn fontan giai đoạn sớm: kết quả sau 8 năm triển khai phẫu thuật fontan. The Vietnam Journal of Cardiovascular and Thoracic Surgery, 30, 90-103. https://doi.org/10.47972/vjcts.v30i.479
Yếu tố tiên lượng của thất bại với tuần hoàn fontan giai đoạn sớm: kết quả sau 8 năm triển khai phẫu thuật fontan
Main Article Content
Abstract
Although early postoperative outcomes after Fontan have improved in the modern era, the convincing evidence in the resource-scare setting was sparse. Our study aimed to characterize the incidence of early Fontan failure (EFF) in a contemporary series of palliated patients and to identify its potential risk factors in these patients. A single-center retrospective study was conducted between August 2012 and December 2019 on 145 patients undergoing the Fontan procedure. The primary outcome of interest was EFF, defined as death, Fontan takedown, or listing for heart transplantation prior to hospital discharge or within 30 postoperative days. The incidence and outcomes were summarized with descriptive statistics, and risk factors for EFF were identified with both univariable and multivariate logistic regression. The incidence of EFF was 9.66% (n = 14: thirteen deaths, and one Fontan takedown). In the univariate analysis for pre-operative data, the anatomical diagnosis of unbalanced atrioventricular (AV) septal defect, situs inversus form, AV valve regurgitation, large aorta-pulmonary circulation in Doppler echocardiography, elevated pulmonary artery pressure (PAP), and elevated pulmonary vascular resistance (Rp) were significantly associated with EFF. At the Fontan, four risk factors influencing EFF included pulmonary artery reconstruction, AV valve repair, bleeding, and elevated PAP. Postoperative edema was also significantly associated with EFF. A total of 22 potential independent variables were put into a model with multivariate logistic regression analysis. A final reduced model following utilizing a stepwise backward selection strategy with pvalues <0.2 indicated preoperative elevated PAP (OR: 1.84, 95%CI: 1.12 – 3.00, p=0.016), AV valve repair at Fontan (OR: 65.85, 95%CI: 1.95–2228.14, p=0.020), and postoperative elevated PAP (OR: 1.66, 95%CI: 1.19–2.33, p=0.004) were independent predictors for EFF. In conclusion, EFF is relatively high in our series, and is associated with significant mortality. Patients with a single ventricle physiology undergoing preoperative elevated PAP, AV valve repair at Fontan, and postoperative elevated PAP were identified as independent risk factors to predict EFF following a Fontan operation.
Article Details
Keywords
Predictors, early Fontan failure, Fontan takedown
References
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2. Mayer Jr, J.E., et al., Factors associated with marked reduction in mortality for Fontan operations in patients with single ventricle. The Journal of thoracic and cardiovascular surgery, 1992. 103(3): p. 444-452.
3. Knott-Craig, C.J., et al., The modified Fontan operation: an analysis of risk factors for early postoperative death or takedown in 702 consecutive patients from one institution. The Journal of thoracic and cardiovascular surgery, 1995. 109(6): p. 1237-1243.
4. Gentles, T.L., et al., Fontan operation in five hundred consecutive patients: factors influencing early and late outcome. The Journal of thoracic and cardiovascular surgery, 1997. 114(3): p. 376-391.
5. Hosein, R.B., et al., Factors influencing early and late outcome following the Fontan procedure in the current era. The ‘Two Commandments’? European journal of cardiothoracic surgery, 2007. 31(3): p. 344-353.
6. Stewart, R.D., et al., Contemporary Fontan operation: association between early outcome and type of cavopulmonary connection. The Annals of thoracic surgery, 2012. 93(4): p. 1254-1261.
7. Tweddell, J.S., et al., Fontan palliation in the modern era: factors impacting mortality and morbidity. The Annals of thoracic surgery, 2009. 88(4): p. 1291-1299.
8. Hirsch, J.C., et al., Fontan operation in the current era: a 15-year single institution experience. Annals of surgery, 2008. 248(3): p. 402-410.
9. Hirsch, J., et al., The lateral tunnel Fontan procedure for hypoplastic left heart syndrome: results of 100 consecutive patients. Pediatric cardiology, 2007. 28(6): p. 426-432.
10. Hasaniya, N.W., et al., In situ pericardial extracardiac lateral tunnel Fontan operation: fifteen-year experience. The Journal of thoracic and cardiovascular surgery, 2010. 140(5): p. 1076-1083.
11. Petrossian, E., et al., The extracardiac conduit Fontan operation using minimal approach extracorporeal circulation: early and midterm outcomes. The Journal of thoracic and cardiovascular surgery, 2006. 132(5): p. 1054-1063.
12. Ovroutski, S., et al., Analysis of the risk factors for early failure after extracardiac Fontan operation. The Annals of thoracic surgery, 2013. 95(4): p. 1409-1416.
13. O'Brien Jr, J.E., et al., The nonfenestrated extracardiac Fontan procedure: a cohort of 145 patients. The Annals of thoracic surgery, 2010. 89(6): p. 1815-1820.
14. Iyengar, A.J., et al., The option of taking down the Fontan circulation: the Melbourne experience. Journal of thoracic and cardiovascular surgery (Print), 2010. 139(5): p. 1346-1348.
15. d’Udekem, Y., et al., The Fontan procedure: contemporary techniques have improved long-term outcomes. Circulation, 2007. 116(11_supplement): p. I-157-I-164.
16. Almond, C.S., et al., Outcome after Fontan failure and takedown to an intermediate palliative circulation. The Annals of thoracic surgery, 2007. 84(3): p. 880-887.
17. Rogers, L.S., et al., 18 years of the Fontan operation at a single institution: results from 771 consecutive patients. J Am Coll Cardiol, 2012. 60(11): p. 1018-25.
18. Giannico, S., et al., Clinical outcome of 193 extracardiac Fontan patients: the first 15 years. Journal of the American College of Cardiology, 2006. 47(10): p. 2065-2073.
19. Meyer, D.B., et al., Outcomes of the Fontan procedure using cardiopulmonary bypass with aortic cross-clamping. The Annals of thoracic surgery, 2006. 82(5): p. 1611-1620.
20. Bautista-Hernandez, V., et al., Right ventricle and tricuspid valve function at midterm after the Fontan operation for hypoplastic left heart syndrome: impact of shunt type. Pediatric cardiology, 2011. 32(2): p. 160-166.
21. Robbers-Visser, D., et al., Results of staged total cavopulmonary connection for functionally univentricular hearts; comparison of intra-atrial lateral tunnel and extracardiac conduit. European journal of cardio-thoracic surgery, 2010. 37(4): p. 934-941.
22. Đỗ Anh Tiến, Nghiên cứu ứng dụng phẫu thuật Fontan với ống nối ngoài tim điều trị tim bẩm sinh dạng một tâm thất tại Trung tâm tim mạch - Bệnh viện E. 2017, Đại học Y Hà Nội.
23. Rochelson, E., et al. Identification of risk factors for early Fontan failure. in Seminars in Thoracic and Cardiovascular Surgery. 2020. Elsevier.
24. Murphy, M.O., et al., Management of early Fontan failure: a single-institution experience. European Journal of Cardio-Thoracic Surgery, 2014. 46(3): p. 458-464.
25. Azakie, A., et al., Extracardiac conduit versus lateral tunnel cavopulmonary connections at a single institution: impact on outcomes. The Journal of thoracic and cardiovascular surgery, 2001. 122(6): p. 1219-1228.
26. Pundi, K.N., et al., 40-year follow-up after the Fontan operation: long-term outcomes of 1,052 patients. Journal of the American College of Cardiology, 2015. 66(15): p. 1700-1710.
27. d'Udekem, Y., et al., Predictors of survival after single-ventricle palliation: the impact of right ventricular dominance. Journal of the American College of Cardiology, 2012. 59(13): p. 1178-1185.
28. Diller, G.-P., et al., Predictors of morbidity and mortality in contemporary Fontan patients: results from a multicenter study including cardiopulmonary exercise testing in 321 patients. European heart journal, 2010. 31(24): p. 3073-3083.
29. Giglia, T.M. and T. Humpl, Preoperative pulmonary hemodynamics and assessment of operability: is there a pulmonary vascular resistance that precludes cardiac operation? Pediatric Critical Care Medicine, 2010. 11: p. S57-S69.
30. Chowdhury, U.K., et al., Surgical outcome of staged univentricular-type repairs for patients with univentricular physiology and pulmonary hypertension. Indian Heart Journal, 2004. 56(4): p. 320-327.
31. Kaza, A.K., et al., Pulmonary vascular remodelling after heart transplantation in patients with cavopulmonary connection. European Journal of Cardio-Thoracic Surgery, 2015. 47(3): p. 505-510.
32. Ridderbos, F.-J.S., et al., Adverse pulmonary vascular remodeling in the Fontan circulation. The Journal of Heart and Lung Transplantation, 2015. 34(3): p. 404-413.
33. King, G., et al., Atrioventricular valve failure in Fontan palliation. Journal of the American College of Cardiology, 2019. 73(7): p. 810-822. 34. Schilling, C., et al., The Fontan epidemic: population projections from the Australia and New Zealand Fontan registry. International journal of cardiology, 2016. 219: p. 14-19.
2. Mayer Jr, J.E., et al., Factors associated with marked reduction in mortality for Fontan operations in patients with single ventricle. The Journal of thoracic and cardiovascular surgery, 1992. 103(3): p. 444-452.
3. Knott-Craig, C.J., et al., The modified Fontan operation: an analysis of risk factors for early postoperative death or takedown in 702 consecutive patients from one institution. The Journal of thoracic and cardiovascular surgery, 1995. 109(6): p. 1237-1243.
4. Gentles, T.L., et al., Fontan operation in five hundred consecutive patients: factors influencing early and late outcome. The Journal of thoracic and cardiovascular surgery, 1997. 114(3): p. 376-391.
5. Hosein, R.B., et al., Factors influencing early and late outcome following the Fontan procedure in the current era. The ‘Two Commandments’? European journal of cardiothoracic surgery, 2007. 31(3): p. 344-353.
6. Stewart, R.D., et al., Contemporary Fontan operation: association between early outcome and type of cavopulmonary connection. The Annals of thoracic surgery, 2012. 93(4): p. 1254-1261.
7. Tweddell, J.S., et al., Fontan palliation in the modern era: factors impacting mortality and morbidity. The Annals of thoracic surgery, 2009. 88(4): p. 1291-1299.
8. Hirsch, J.C., et al., Fontan operation in the current era: a 15-year single institution experience. Annals of surgery, 2008. 248(3): p. 402-410.
9. Hirsch, J., et al., The lateral tunnel Fontan procedure for hypoplastic left heart syndrome: results of 100 consecutive patients. Pediatric cardiology, 2007. 28(6): p. 426-432.
10. Hasaniya, N.W., et al., In situ pericardial extracardiac lateral tunnel Fontan operation: fifteen-year experience. The Journal of thoracic and cardiovascular surgery, 2010. 140(5): p. 1076-1083.
11. Petrossian, E., et al., The extracardiac conduit Fontan operation using minimal approach extracorporeal circulation: early and midterm outcomes. The Journal of thoracic and cardiovascular surgery, 2006. 132(5): p. 1054-1063.
12. Ovroutski, S., et al., Analysis of the risk factors for early failure after extracardiac Fontan operation. The Annals of thoracic surgery, 2013. 95(4): p. 1409-1416.
13. O'Brien Jr, J.E., et al., The nonfenestrated extracardiac Fontan procedure: a cohort of 145 patients. The Annals of thoracic surgery, 2010. 89(6): p. 1815-1820.
14. Iyengar, A.J., et al., The option of taking down the Fontan circulation: the Melbourne experience. Journal of thoracic and cardiovascular surgery (Print), 2010. 139(5): p. 1346-1348.
15. d’Udekem, Y., et al., The Fontan procedure: contemporary techniques have improved long-term outcomes. Circulation, 2007. 116(11_supplement): p. I-157-I-164.
16. Almond, C.S., et al., Outcome after Fontan failure and takedown to an intermediate palliative circulation. The Annals of thoracic surgery, 2007. 84(3): p. 880-887.
17. Rogers, L.S., et al., 18 years of the Fontan operation at a single institution: results from 771 consecutive patients. J Am Coll Cardiol, 2012. 60(11): p. 1018-25.
18. Giannico, S., et al., Clinical outcome of 193 extracardiac Fontan patients: the first 15 years. Journal of the American College of Cardiology, 2006. 47(10): p. 2065-2073.
19. Meyer, D.B., et al., Outcomes of the Fontan procedure using cardiopulmonary bypass with aortic cross-clamping. The Annals of thoracic surgery, 2006. 82(5): p. 1611-1620.
20. Bautista-Hernandez, V., et al., Right ventricle and tricuspid valve function at midterm after the Fontan operation for hypoplastic left heart syndrome: impact of shunt type. Pediatric cardiology, 2011. 32(2): p. 160-166.
21. Robbers-Visser, D., et al., Results of staged total cavopulmonary connection for functionally univentricular hearts; comparison of intra-atrial lateral tunnel and extracardiac conduit. European journal of cardio-thoracic surgery, 2010. 37(4): p. 934-941.
22. Đỗ Anh Tiến, Nghiên cứu ứng dụng phẫu thuật Fontan với ống nối ngoài tim điều trị tim bẩm sinh dạng một tâm thất tại Trung tâm tim mạch - Bệnh viện E. 2017, Đại học Y Hà Nội.
23. Rochelson, E., et al. Identification of risk factors for early Fontan failure. in Seminars in Thoracic and Cardiovascular Surgery. 2020. Elsevier.
24. Murphy, M.O., et al., Management of early Fontan failure: a single-institution experience. European Journal of Cardio-Thoracic Surgery, 2014. 46(3): p. 458-464.
25. Azakie, A., et al., Extracardiac conduit versus lateral tunnel cavopulmonary connections at a single institution: impact on outcomes. The Journal of thoracic and cardiovascular surgery, 2001. 122(6): p. 1219-1228.
26. Pundi, K.N., et al., 40-year follow-up after the Fontan operation: long-term outcomes of 1,052 patients. Journal of the American College of Cardiology, 2015. 66(15): p. 1700-1710.
27. d'Udekem, Y., et al., Predictors of survival after single-ventricle palliation: the impact of right ventricular dominance. Journal of the American College of Cardiology, 2012. 59(13): p. 1178-1185.
28. Diller, G.-P., et al., Predictors of morbidity and mortality in contemporary Fontan patients: results from a multicenter study including cardiopulmonary exercise testing in 321 patients. European heart journal, 2010. 31(24): p. 3073-3083.
29. Giglia, T.M. and T. Humpl, Preoperative pulmonary hemodynamics and assessment of operability: is there a pulmonary vascular resistance that precludes cardiac operation? Pediatric Critical Care Medicine, 2010. 11: p. S57-S69.
30. Chowdhury, U.K., et al., Surgical outcome of staged univentricular-type repairs for patients with univentricular physiology and pulmonary hypertension. Indian Heart Journal, 2004. 56(4): p. 320-327.
31. Kaza, A.K., et al., Pulmonary vascular remodelling after heart transplantation in patients with cavopulmonary connection. European Journal of Cardio-Thoracic Surgery, 2015. 47(3): p. 505-510.
32. Ridderbos, F.-J.S., et al., Adverse pulmonary vascular remodeling in the Fontan circulation. The Journal of Heart and Lung Transplantation, 2015. 34(3): p. 404-413.
33. King, G., et al., Atrioventricular valve failure in Fontan palliation. Journal of the American College of Cardiology, 2019. 73(7): p. 810-822. 34. Schilling, C., et al., The Fontan epidemic: population projections from the Australia and New Zealand Fontan registry. International journal of cardiology, 2016. 219: p. 14-19.