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A preoperative estimate of central venous pressure is associated with early Fontan failure

      Abstract

      Objective

      Early Fontan failure is a serious complication after total cavopulmonary connection, characterized by high central venous pressure, low cardiac output, and resistance to medical therapy. This study aimed to estimate postoperative central venous pressure in patients with total cavopulmonary connection using data routinely collected during preoperative assessment. We sought to determine if this metric correlated with measured postoperative central venous pressure and if it was associated with early Fontan failure.

      Methods

      In this retrospective study, central venous pressure in total cavopulmonary connection was estimated in 131 patients undergoing pre–total cavopulmonary connection assessment by cardiac magnetic resonance imaging and central venous pressure measurement under general anesthesia. Postoperative central venous pressure during the first 24 hours in the intensive care unit was collected from electronic patient records in a subset of patients. Early Fontan failure was defined as death, transplantation, total cavopulmonary connection takedown, or emergency fenestration within the first 30 days.

      Results

      Estimated central venous pressure in total cavopulmonary connection correlated significantly with central venous pressure during the first 24 hours in the intensive care unit (r = 0.26, P = .03), particularly in patients without a fenestration (r = 0.45, P = .01). Central venous pressure in total cavopulmonary connection was significantly associated with early Fontan failure (odds ratio, 1.1; 95% confidence interval, 1.01-1.21; P = .03). A threshold of central venous pressure in total cavopulmonary connection 33 mm Hg or greater was found to have the highest specificity (90%) and sensitivity (58%) for identifying early Fontan failure (area under receiver operating curve = 0.73; odds ratio, 12.4; 95% confidence interval, 2.5-62.3; P = .002). This association was stronger in patients with single superior vena cava.

      Conclusions

      Estimated central venous pressure in total cavopulmonary connection is an easily calculated metric combining preoperative pressure and flow data. Higher central venous pressure in total cavopulmonary connection is associated with an increased risk of early Fontan failure and is correlated with directly measured post–total cavopulmonary connection pressure. Identification of patients at risk of early Fontan failure has the potential to guide risk-mitigation strategies.

      Graphical abstract

      Key Words

      Abbreviations and Acronyms:

      AUC (area under the curve), BCPC (bidirectional cavopulmonary connection), CI (confidence interval), CMR (cardiac magnetic resonance), CVP (central venous pressure), EFF (early Fontan failure), ICU (intensive care unit), IVC (inferior vena cava), OR (odds ratio), PA (pulmonary artery), PVR (pulmonary vascular resistance), Qp (pulmonary blood flow), ROC (receiver operating characteristic), SPC (systemic to pulmonary collaterals), SVC (superior vena cava), TCPC (total cavopulmonary connection)
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      Linked Article

      • Commentary: If only we knew when we would fail
        The Journal of Thoracic and Cardiovascular SurgeryVol. 161Issue 4
        • Preview
          Approximately 5 decades ago, Fontan and colleagues1 gave a new lease on life to patients with single ventricle physiology by introducing a novel surgical procedure. Soon after the total cavopulmonary connection (TCPC) surgery was designed, it was realized that patient selection was critical for the success of the procedure; thus, the commandments of the Fontan procedure were introduced.2 As the procedure underwent several modifications and perioperative management improved, contraindications of the procedure were liberalized.
        • Full-Text
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      • Commentary: How to avoid early Fontan failure?
        The Journal of Thoracic and Cardiovascular SurgeryVol. 161Issue 4
        • Preview
          We congratulate Quail and colleagues1 for their article in this issue of the Journal and their efforts to advance this complex field of single-ventricle palliation. Currently, the Fontan procedure, or total cavopulmonary connection (TCPC), serves as the last step of palliation for several single-ventricle congenital heart conditions.2 It allows for the entire systemic venous return to passively flow to the pulmonary arterial tree without an interposed pump.3 Several requirements must be met for TCPC to be successful (some well-known, others still being explored), necessitating extensive and meticulous evaluation of pre-Fontan patients.
        • Full-Text
        • PDF