Outcomes of Patients Undergoing Primary Fontan Operation Beyond First Decade of Life

Pleural Effusions After Congenital Cardiac Surgery Requiring Readmission: A Systematic Review and Meta-analysis

Patients with congenital heart disease (CHD) are surviving longer thanks to improved surgical techniques and increasing knowledge of natural history. Pleural effusions continue to be a complication that affect many surgical patients and are associated with increased morbidity, many times requiring readmission and additional invasive procedures. The risks for development of pleural effusion after hospital discharge are ill-defined, which leads to uncertainty related to strategies for prevention. Our primary objective was to determine, in patients with CHD requiring cardiopulmonary bypass, the prevalence of post-surgical pleural effusions leading to readmission. The secondary objective was to identify risk factors associated with post-surgical pleural effusions requiring readmission. We identified 4417 citations; 10 full-text articles were included in the final review. Of the included studies, eight focused on single-ventricle palliation, one looked at Tetralogy of Fallot patients, and another on pleural effusion in the setting of post-pericardiotomy syndrome. Using a random-effect model, the overall prevalence of pleural effusion requiring readmission was 10.2% (95% CI 4.6; 17.6). Heterogeneity was high (I² = 91%). In a subpopulation of patients after single-ventricle palliation, the prevalence was 13.0% (95% CI 6.0;21.0), whereas it was 3.0% (95% CI 0.4;6.75) in patients mostly with biventricular physiology. We were unable to accurately assess risk factors. A better understanding of this complication with a focus on single-ventricle physiology will allow for improved risk stratification, family counseling, and earlier recognition of pleural effusion in this patient population.

Where are we after 50 years of the Fontan operation?

First introduced in 1971, the Fontan procedure is the final common destination for all patients with a functional single ventricle. The procedure itself has evolved tremendously over the last five decades. This review traces this journey and presents the importance, outcomes and future outlook of the procedure in the current era.

Multisite measurement of regional oxygen saturation in Fontan patients with and without protein-losing enteropathy at rest and during exercise

BACKGROUND

Protein-losing enteropathy (PLE) is a severe complication of Fontan circulation with increased risk of end-organ dysfunction. We evaluated tissue oxygenation via near-infrared spectroscopy (NIRS) at different exercise levels in Fontan patients.

METHODS

Assessment of multisite NIRS during cycle ergometer exercise and daily activities in three groups: Fontan patients with PLE; without PLE; patients with dextro-transposition of the great arteries (d-TGA); comparing univentricular with biventricular circulation and Fontan with/without PLE. Renal threshold analysis (<65%;<55%;<45%) of regional oxygen saturation (rSO2) was performed.

RESULTS

Fontan patients showed reduced rSO2 (p < 0.05) in their quadriceps femoris muscle compared with biventricular d-TGA patients at all time points. rSO2 in renal tissue was reduced at baseline (p = 0.002), exercise (p = 0.0062), and daily activities (p = 0.03) in Fontan patients with PLE. Renal threshold analysis identified critically low renal rSO2 (rSO2 < 65%) in Fontan patients with PLE during exercise (95% of monitoring time below threshold) and daily activities (83.7% time below threshold).

CONCLUSION

Fontan circulation is associated with decreased rSO2 values in skeletal muscle and hypoxemia of renal tissue solely in patients with PLE. Reduced rSO2 already during activities of daily life, might contribute to comorbidities in patients with Fontan circulation, including PLE and renal failure.

Impact of the Fontan Operation on Organ Systems

In patients having undergone the Fontan operation, besides the well discussed changes in the cardiac, pulmonary and gastrointestinal system, alterations of further organ systems including the hematologic, immunologic, endocrinological and metabolic are reported. As a medical adjunct to Fontan surgery, the systematic study of the central role of the liver as a metabolizing and synthesizing organ should allow for a better understanding of the pathomechanism underlying the typical problems in Fontan patients, and in this context, the profiling of endocrinological and metabolic patterns might offer a tool for the optimization of Fontan follow-up, targeted monitoring and specific adjunct treatment.