Factors At Bidirectional Cavopulmonary Anastomosis Associated With Failure To Reach Fontan Circulation
Anna Olds, MD1, Hampton Gray, MD2, Carly Weaver1, John Cleveland, MD1, Michael Bowdish, MD1, Winfield Wells, MD1, Vaughn A. Starnes, MD1, S. Ram Kumar, MD PhD1.
1University of Southern California, Los Angeles, CA, USA, 2University of Alabama, Los Angeles, CA, USA.
OBJECTIVES: Despite better survival, some single ventricle patients fail to reach final stage palliation. This study attempts to identify risk factors before/at bidirectional cavopulmonary anastomosis (BCDA) that predict failure to reach final stage to better manage high-risk patients.
METHODS: All BDCA patients from 2007-2018 were retrospectively reviewed. Successful palliation was considered post-Fontan hospital survival or conversion to 1.5- or two-ventricle circulation. Failed palliation was considered mortality before/at final stage, or cardiac transplantation.
RESULTS: 575 patients underwent BDCA (Table 1). 505(87.8%) patients have had successful palliation with 467(82.1%) Fontans, 6(1%) biventricular repairs, and 27(4.7%) 1.5 ventricle repairs. Median time from BDCA to final stage was 3.4(3-4.1) years. 12(2.1%) are awaiting Fontan, and 30(5.2%) were lost to follow-up. 32(5.6%) had failed palliation, with 5(0.9%) in-hospital BDCA mortalities, 19(3.3%) interstage mortalities, 5(0.9%) in-hospital final stage mortalities, and 3(0.5%) heart transplants. Freedom from failed palliation at 12, 24, and 36 months after BDCA were 96%, 94% and 92%. On time-varying conditional analysis, failed palliation risk factors were Down's Syndrome [hazard ratio (HR)=6.42, 95%CI 1.7-31.1], dominant RV (HR=2.9, 95%CI 1.2-6.5), and lower weight-for-age Z-score at BDCA (HR=0.74, 95%CI 0.45-0.96).
CONCLUSIONS: With improvement in management, most single ventricle patients can be successfully palliated. Our large data demonstrate that factors at BDCA associated with ultimate failure are non-modifiable. Efforts should be directed at identifying alternative strategies to better manage this high-risk cohort.
|MedianAge (months)||6.9 (5.5-8.8)|
|Primary BDCA (n,%)||54 (9.4%)|
|Heterotaxy (n,%)||78 (13.6%)|
|Down syndrome (n,%)||9 (1.5%)|
|Dominant RV (n,%)||240 (41.7%)|
|Mean PA pressure (mmHg)||13 (11-15)|
|Pulmonary vasular resistance (Woods Units)||1.7 (1.3-2.2)|
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