Congenital Heart Surgery

Predictive factors contributing to prolonged recovery in patients after Fontan operation. Song Y, Wang L, Zhang M, Chen X, Pang Y, Liu J, Xu Z. BMC Pediatr. 2022 Aug 24;22(1):501. doi: 10.1186/s12887-022-03537-2. PMID: 36002809  Take Home Points: Ventilation time, higher inotropic score in postoperative day, and pulmonary hypertension treatment and higher fluid resuscitation within two days were independent risk factors and have a high predictability for Fontan prolonged recovery. Commentary from Dr. Masamichi Ono (Munich, Germany), section editor of Congenital Heart Surgery Journal Watch: Summary: The single center retrospective study included 282 patients who underwent Fontan surgery between 2015 and 2018. Patients with >75%ile cardiac intensive care unit stay in prolonged recovery group (n=70). The others were assigned to the standard recovery group (n=212). Pre- and intra-operative data showed a higher incidence of heterotaxy syndrome, longer cardiopulmonary bypass, and aortic cross-clamp time in the prolonged recovery group. Postoperative information analysis displayed that ventilation time, oxygen index after extubation, hemodynamic data, inotropic score (IS), drainage volume, volume resuscitation, pulmonary hypertension (PH) treatment, and surgical re-intervention were significantly different between the two groups. Higher IS postoperatively, and PH treatment and higher fluid resuscitation within two days were independent predictive factors for prolonged recovery in our multivariate model. C-statistic model showed a high predictive ability in prolonged recovery by using the three factors. Comment: This relatively large retrospective study for Fontan surgery was done at Shanghai Children’s Medical Center, School of Medicine, Shanghai Jiao Tong University. In this study, they aim to make a deep and whole exploration of the predictive factors, including the demographic, perioperative hemodynamic, important procedure and interventions that may contribute to the prolonged recovery on patients after Fontan operation. They excluded patients who experienced Fontan takedown (n=10) or didn’t survival to discharge (n=15). Patients with > 75%ile cardiac intensive care unit (CICU) stay were defined as prolonged postoperative recovery, and the others were assigned to standard recovery. As result, Heterotaxy syndrome (p=0.042) was only the preoperative factor associated with prolonged ICU recovery. As for intraoperative factors, cardiopulmonary bypass time (P = 0.004) and aortic cross-clamp time (P < 0.001) were factors related with the patient’s recovery. As for postoperative factors, prolonged recovery group had longer mechanical ventilation time, and 62.8% patients need more than 24hr mechanical ventilation. The oxygen index (P/F ratio) after extubation was significantly higher in patients with a standard recovery. mPAP (P = 0.002) and Pp/Ps (P < 0.001) were higher and mABP (P < 0.001) was lower in POD 0 in the prolonged recovery group when compared with the standard recovery group. Thus, 81.4% patients with a prolonged recovery needed a PH treatment within two days, which only performed in 59.9% patients in the standard recovery group (P = 0.034). Prolonged recovery patients needed a longer time of chest drainage (P < 0.001), and the volume of drainage (P < 0.001) and resuscitation (P < 0.001) within two days were more than standard recovery group. Otherwise, IS in POD 0 (P < 0.001), POD 1 (P < 0.001) and POD 2 (P < 0.001) was significantly higher in patients with a prolonged recovery. The incidence of hypoxemia (P < 0.001), low cardiac output syndrome (P < 0.001), liver disfunction (P < 0.001) and renal disfunction (P < 0.001) were significantly higher in the prolonged recovery group. Multivariable logistic regression model demonstrated that higher IS in POD 0 (OR 1.031, 95% CI 1.001, 1.061), PH treatment (OR 2.627, 95% CI 1.053, 6.553), higher fluid resuscitation (OR 1.015, 95% CI 1.009, 1.021) within two days after the surgery, mechanical ventilation time (OR 1.051, 95% CI 1.032, 1.071), and fluid resuscitation within two days (OR 1.012, 95% CI 1.006, 1.019) were independent factors in predicting the recovery of Fontan recovery. This study is well written with good statistical methods. The results were not quite new. However, they clearly demonstrated that postoperative inotropic support, high pulmonary artery pressure, and higher fluid resuscitation were the risks for prolonged Fontan recovery. As for the ventilation time, we already reported the importance of early extubation despite the hemodynamic (Ono, et al. ICVTS 2019, Georgiev, et al. Cardiol Young 2017). We clearly demonstrated the data that early extubation is universally applicable following the Fontan operation and improves postoperative hemodynamics and recovery regardless of the initial hemodynamic status. This might improve the postoperative recovery in their institute.