Abstract 17811: Clinical Utility of Routine pre-Fontan Invasive Hemodynamic Assessment for Surgical Risk Stratification
Background: Preoperative cardiac catheterization before Fontan surgery is routinely performed at most institutions. We sought to determine the value of pre-Fontan hemodynamics as predictors of surgical outcomes after accounting for other recognized risk factors.
Methods: A single center review of consecutive Fontan procedures between 2000 and 2010 was conducted with assessment of a composite outcome measure - in-hospital death/transplant, post-operative length of stay (LOS) ≥ 30 days, or readmission within 6 months for a Fontan related complication. Baseline multivariable logistic regression modeling was performed including known risk factors (presence of ventricular dysfunction, systemic right ventricle, > mild AV valve insufficiency and concomitant surgical procedures). Six hemodynamic variables (pulmonary arterial pressure, common atrial pressure, trans-pulmonary gradient, ventricular end diastolic pressure, pulmonary vascular resistance, cardiac index) and a composite hemodynamic risk score were then incorporated to determine if any of these variables improved the model risk prediction based on a ≥ 5% change in the log-likelihood.
Results: The cohort included 114 patients; 38 (52%) male and 46 (40%) with a systemic left ventricle. No patients were excluded from Fontan solely because of catheterization findings. Surgical mortality was 1.8% (n=2). For survivors, median LOS was 10 days (range 4-90); 13% (n=15) had LOS ≥ 30 days and 19% (n=22) required readmission. By univariate analysis, presence of a systemic right ventricle (p=0.03) was associated with the composite outcome measure but no other demographic, surgical or hemodynamic variables were significant. A multivariable model including non-hemodynamic risk factors predicted 95% of positive outcomes but only 20% of negative outcomes. Presence of a systemic right ventricle (OR 3.0, 95% CI 1.2-7.9) was the only significant model covariate. The model was not improved with addition of any individual hemodynamic variable or the composite hemodynamic risk score.
Conclusions: Predicting poor outcomes after Fontan surgery remains difficult. In our experience preoperative catheterization hemodynamics do not add substantively to surgical risk stratification.
- © 2013 by American Heart Association, Inc.