Abstract 2120: Transplant-free Survival After Bidirectional Cavopulmonary Anastamosis: The Impact of Age at Surgery for High Risk Patients
Background: A bidirectional cavopulmonary anastomosis (BCPA) is a routine intermediary step between stage one palliation (S1P) and the Fontan procedure for infants aged 4 to 6 months with single ventricle heart disease. Although sometimes performed at an earlier age in order to volume unload patients with ventricular dysfunction and/or atrioventricular valve regurgitation (AVVR), it is unknown whether earlier BCPA is associated with improved transplant free survival in these high risk patients.
Methods: All patients at our institution who underwent a BCPA at 9 months or less from May 2001 through 2008 (n=182) after a prior S1P were included for analysis. Each patient was followed until death, loss to follow-up or May 1, 2009.
Results: Median and IQR for age at BCPA for the entire cohort was 5.1 months (4.1– 6.1). Compared to those in the 2nd to 4th quartiles for age (n=139), those undergoing early BCPA (1st quartile, n=43) had similar AVVR [2 (0 – 4) vs. 2 (0 –3.5) (p=0.06)], more ventricular dysfunction [1 (0 – 4) vs. 0 (0 – 4) (p<0.01)]. Hemodynamics at pre-operative catheterization were similar. Early BCPA versus others was associated with a similar duration of ventilation [21 hrs (9 –169) vs. 18 (6 –528), p=0.18] and increased hospital LOS after BCPA [8 days (1–110) vs. 6 (3– 69), p<0.01]. Transplant-free survival after BCPA for the entire cohort was 94.2% at one year and 88.2% at 3 years. In multivariable analysis, only pre-BCPA AVVR greater than mild [hazard ratio (HR) 8.6 (95% CI 3.4 – 21.1)] and BCPA without prior discharge after initial S1P [HR 11.5 (2.5 – 53)] were found to be independent risk factors for death or transplant through the period of Fontan completion, when adjusted for age at BCPA and ventricular dysfunction. When limiting analysis to those with either greater than mild AVVR or ventricular dysfunction (n=48), early BCPA was found to be an independent risk factor for death or transplant, when adjusted for ongoing hospitalization after S1P [HR 3.5 (1.2 – 10.4)].
Conclusion: Ongoing hospitalization after S1P and significant AVVR prior to BCPA are independently associated with death or transplant in midterm follow-up. Early BCPA is not associated with improved longitudinal outcomes for those with significant pre-operative ventricular dysfunction or AVVR.