Original article
Pediatric cardiac
Perioperative Risks and Outcomes of Atrioventricular Valve Surgery in Conjunction With Fontan Procedure

Presented at the Fifty-fifth Annual Meeting of the Southern Thoracic Surgical Association, Austin, TX, Nov 5–8, 2008.
https://doi.org/10.1016/j.athoracsur.2009.02.059Get rights and content

Background

Long-term outcomes of staged single-ventricle palliation can be impaired by atrioventricular valve (AVV) regurgitation. Atrioventricular valve repair or replacement has been shown to improve late outcomes, but little data exist regarding the associated perioperative morbidity. This study aimed to evaluate the additional perioperative risks associated with single-ventricle AVV surgery.

Methods

Two hundred thirty-six consecutive Fontan procedures were retrospectively reviewed. Group 1 (n = 21, with concomitant AVV repair [n = 19] or replacement [n = 2]) was compared with group 2 (n = 215, no AVV surgery) with regard to preoperative characteristics and perioperative outcomes. Atrioventricular valve regurgitation was graded as 1 (none or trivial) to 4 (severe).

Results

Group 1 patients were older (4.3 ± 3.7 versus 3.0 ± 2.6 years; p = 0.04) and had longer cardiopulmonary bypass (118 ± 38 versus 85 ± 28 minutes; p < 0.001) and aortic cross-clamp times (33 ± 32 versus 14 ± 21 minutes; p < 0.001). There were no differences between groups regarding diagnosis, weight, hospital or intensive care unit length of stay, ventilator time, or 12-hour chest tube output. Postoperative complications were similar between groups, including bleeding (0 of 21 versus 8 of 215; p = 0.8), neurologic injury (1 of 21 versus 9 of 215; p = 0.7), arrhythmias (1 of 21 versus 24 of 215; p = 0.6), and operative mortality (0 of 21 versus 1 of 215; p = 0.1). Group 1 AVV regurgitation significantly decreased after surgery (3.0 ± 0.9 preoperatively versus 1.7 ± 0.9 postoperatively; p < 0.001).

Conclusions

Atrioventricular valve surgery has been shown to improve late outcomes for single-ventricle patients. This study demonstrates that AVV surgery performed with the Fontan procedure increased operative times, but did not significantly increase perioperative morbidity or mortality. This information supports appropriate utilization of AVV surgery for single-ventricle patients.

Section snippets

Patients

This study was conducted with the approval of the Emory University institutional review board with a waiver for individual patient consent. From January 2002 until January 2008, 236 modified Fontan procedures were performed for congenital anomalies with single-ventricle physiology. Data were prospectively entered into our institutional congenital cardiac surgery database and were retrospectively reviewed. Among the patients reviewed, 21 (8.9%) were identified who underwent concomitant AVV

Perioperative Variables

Patients undergoing AVV surgery were older (4.3 ± 3.7 versus 3.0 ± 2.6 years; p = 0.04), but there was no difference in mean preoperative weight or sex (Table 2). Total CPB time (118 ± 38 versus 85 ± 28 minutes; p < 0.001) and aortic cross-clamp time (33 ± 32 versus 14 ± 21 minutes; p < 0.001) were significantly longer among those undergoing AVV surgery. There were no differences between groups regarding diagnosis, hospital or intensive care unit length of stay, ventilator time, or 12-hour

Comment

Early outcomes of the modified Fontan procedure for palliation of single-ventricle physiology have vastly improved since it was first introduced more than 30 years ago, as evidenced by the 0.4% operative mortality in this series of 236 patients. These results are consistent with previously published large series, which have demonstrated superb early results with operative mortality of less than 5% [6, 7, 8, 9, 10]. In addition, results of long-term follow-up studies have demonstrated 10-year

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