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Preoperative N-terminal pro-brain natriuretic peptide is associated with Fontan outcomes

Published:December 09, 2021DOI:https://doi.org/10.1016/j.jtcvs.2021.11.082

      Abstract

      Objective

      The role of preoperative N-terminal pro-brain natriuretic peptide level in patient outcomes after the Fontan operation remains unclear.

      Methods

      The medical records of all patients who underwent their first Fontan operation from June 2011 to October 2019 in our tertiary referral pediatric cardiac center were retrospectively reviewed. Preoperative hemodynamic factors and N-terminal pro-brain natriuretic peptide were analyzed to test the association of mortality and morbidity.

      Results

      We enrolled 110 patients (men/women 62/48; median age, 4.1 [3.4, 5.8] years; median follow-up period, 4.28 [2.31, 6.71] years). Almost all operations were extracardiac conduits (98.2%). Primary outcomes of death, Fontan takedown, and heart transplantation were observed in 9 patients (8.2%). Abnormal ventricular contractility, elevated preoperative pulmonary artery pressure, high pulmonary vascular resistance index, and high log10 N-terminal pro-brain natriuretic peptide level were associated with poor outcomes. Secondary outcomes: atrioventricular valve regurgitation moderate or greater, elevated pulmonary artery pressure, high pulmonary vascular resistance index, and high log10 N-terminal pro-brain natriuretic peptide level were associated with rehospitalization due to heart failure. Multivariable Cox regression analysis revealed that log10 N-terminal pro-brain natriuretic peptide was the only significant predictor of all primary and secondary outcomes. A scoring system including factors of pulmonary artery pressure, pulmonary vascular resistance index, and N-terminal pro-brain natriuretic peptide was established, and the risk stratification is associated with outcomes after the Fontan operation.

      Conclusions

      High preoperative N-terminal pro-brain natriuretic peptide was associated with poor outcomes after the Fontan operation.

      Graphical abstract

      Key Words

      Abbreviations and Acronyms:

      AVVR (atrioventricular valve regurgitation), BNP (brain natriuretic peptide), CI (confidence interval), HR (hazard ratio), NT-proBNP (N-terminal pro-brain natriuretic peptide), PAP (pulmonary artery pressure), PVRI (pulmonary vascular resistance index)
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      Linked Article

      • Commentary: A new Fontan commandment
        The Journal of Thoracic and Cardiovascular SurgeryVol. 164Issue 3
        • Preview
          Choussat's Ten Commandments1 delineating the appropriate selection criteria for Fontan palliation are well known and carefully regarded among practicing congenital heart surgeons. While many of the criteria have evolved, ventricular performance and the hemodynamic health of the pulmonary vascular bed remain cornerstones of candidacy. Lin and colleagues2 share important insights in their study, “Preoperative N-terminal pro-brain natriuretic peptide is associated with Fontan outcomes,” and provide compelling data that would suggest adding an 11th commandment to the list.
        • Full-Text
        • PDF
      • Commentary: A new Fontan commandment?
        The Journal of Thoracic and Cardiovascular SurgeryVol. 164Issue 3
        • Preview
          Since its inception in 1971, the Fontan procedure has become the mainstay of surgical palliation of single-ventricle anomalies.1 Over the years, several surgical modifications have been adopted with the aim to address some of the shortcomings associated with the original descriptions of the procedure.2 The Fontan “10 commandments” were first defined by Choussat and colleagues3 in 1978 as the basic criteria that the patient should meet to predict successful Fontan palliation. These commandments served for many years as guidelines for physicians to select patients who will be advanced toward the last stage of palliation: the Fontan procedure.
        • Full-Text
        • PDF