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(Circulation. 2008;118:S171-S176.)
© 2008 American Heart Association, Inc.

Surgery for Congenital Heart Disease

Factors Associated With Prolonged Recovery After the Fontan Operation

Joshua W. Salvin, MD, MPH; Mark A. Scheurer, MD; Peter C. Laussen, MBBS; John E. Mayer, Jr, MD; Pedro J. del Nido, MD; Frank A. Pigula, MD; Emile A. Bacha, MD; Ravi R. Thiagarajan, MBBS, MPH

From the Department of Cardiology, Children’s Hospital Boston, and Department of Pediatrics (J.W.S., M.A.S., R.R.T.), Harvard Medical School, Boston, Mass; the Department of Cardiology, Children’s Hospital Boston, and Department of Anesthesia (P.C.L.), Harvard Medical School, Boston, Mass; and the Department of Cardiovascular Surgery, Children’s Hospital, Boston, and Department of Surgery (J.E.M., P.J.d.N., F.A.P., E.A.B.), Harvard Medical School, Boston, Mass.

Correspondence to Joshua W. Salvin, MD, MPH, Department of Cardiology, Cardiac ICU Office, Bader 600, Children’s Hospital Boston, 300 Longwood Avenue, Boston, MA 02115. E-mail joshua.salvin{at}cardio.chboston.org

Background— Mortality and major morbidity after the Fontan operation is low in the current era. However, factors contributing to prolonged postoperative recovery are not clearly understood.

Methods and Results— Data on all patients admitted to the cardiac intensive care unit (CICU) after a Fontan operation between June 2001 and December 2005 were retrospectively analyzed. We excluded all patients who died, required Fontan takedown, or required ECMO. The study cohort was further divided into a prolonged recovery group that included patients with >75%ile for duration of mechanical ventilation or pleural drainage, and a standard recovery group which included all other patients. A multivariable logistic regression model was used to compare demographic, anatomic, and physiological variables between the prolonged and standard recovery groups. There were 226 Fontan operations performed. Of the study population (n=218), the median age was 2.61 years (1.0 to 31.9 years) and weight was 12.45 kg (8.4 to 77.5 kg). The most common diagnosis was hypoplastic left heart syndrome (n=80, 36.7%). A systemic right atrioventricular valve was present in 139 (63.7%). The lateral tunnel fenestrated Fontan was the most common surgery (n=195, 89.4%). Within the study population, 81 (38%) patients meet criteria for prolonged recovery. Univariate risk factors for prolonged recovery included higher preoperative PVR (P=0.033), longer bypass times (P=0.009), higher postbypass lactate level (P=0.017), higher postoperative central venous (P<0.001) common atrial pressure (P=0.042), inotropic score (P<0.001), and need for greater volume resuscitation during the 24 postoperative hours (>75% for the entire group; P<0.001). In a multivariable model, need for greater volume resuscitation (OR 2.81, 95% CI 1.30, 6.05) was the only independent risk factor for prolonged outcome after the Fontan operation.

Conclusions— High volume expansion in the early postoperative period is an independent risk factor for prolonged recovery. The need for high volume expansion may represent the compound effects of multiple risk factors including preoperative hemodynamics and a marked systemic inflammatory response to surgery and cardiopulmonary bypass, which in turn may mediate prolonged recovery.