A Preoperative Estimate of Central Venous Pressure Is Associated with Early Fontan Failure

Abstract

Objective Early Fontan Failure (EFF) is a serious complication following total cavopulmonary connection (TCPC), characterised by high central venous pressure (CVP), low cardiac output and resistance to medical therapy. This study aimed to estimate post-operative CVP in TCPC patients (CVPTCPC) using data routinely collected during pre-operative assessment. We sought to determine if this metric correlated with measured post-operative CVP and if it was associated with EFF. Methods In this retrospective study, CVPTCPC was estimated in 131 patients undergoing pre-TCPC assessment by cardiac magnetic resonance imaging and CVP measurement under general anaesthesia. Post-operative CVP during the first 24hours in ICU was collected from electronic patient records in a subset of patients. EFF was defined as death, transplantation, TCPC takedown or emergency fenestration within the first 30days. Results Estimated CVPTCPC correlated significantly with CVPICU (r=0.26, p=0.03), particularly in patients without a fenestration (r=0.45, p=0.01). CVPTCPC was significantly associated with EFF (Odds Ratio [OR] 1.12 (1.02-1.24), p=0.02). A threshold of CVPTCPC ≥33mmHg was found to have the highest specificity (90%) and sensitivity (67%) for identifying EFF (area under receiver operating curve, AUC = 0.79), OR 18.8 (3.1-114), p=0.001. This association was stronger in patients with single SVCs. Conclusions Estimated CVPTCPC is an easily calculated metric combining pre-operative pressure and flow data. Higher CVPTCPC is associated with an increased risk of EFF and is correlated with directly measured post-TCPC pressure. Identification of patients at risk of EFF has the potential to guide risk mitigation strategies.

Association between central venous pressure measurement and outcomes in critically ill patients with severe coma

“…For example, Chen et al found in a meta-analysis that a higher CVP value was associated with higher mortality (odds ratio [OR] 1.65) and a greater risk of AKI (OR, 2.09). Quail et al found that a higher CVP is associated with a higher risk of early Fontan failure after total cavopulmonary connections [10]. Liu et al also found that a controlled lower CVP could reduce blood loss during hepatectomy and recommended the promotion of CVP use in clinical settings [12].…”

“…Many clinical studies have reported that higher CVP values may be associated with patients' poor outcomes in different conditions, such as patients undergoing cardiac surgery [11], early Fontan failure [10], acute kidney injury (AKI) [8,9], patients undergoing cardiopulmonary bypass surgery [9], and critically ill patients [2]. A controlled lower CVP can also reduce blood loss during hepatectomy [12].…”

Commentary: How to avoid early Fontan failure?

“…Manan H. Desai, MD, and Can Yerebakan, MD Approximately 5 decades ago, Fontan and colleagues 1 gave a new lease on life to patients with single ventricle physiology by introducing a novel surgical procedure. Soon after the total cavopulmonary connection (TCPC) surgery was designed, it was realized that patient selection was critical for the success of the procedure; thus, the commandments of the Fontan procedure were introduced.…”

“…We congratulate Quail and colleagues 1 for their article in this issue of the Journal and their efforts to advance this complex field of single-ventricle palliation. Currently, the Fontan procedure, or total cavopulmonary connection (TCPC), serves as the last step of palliation for several single-ventricle congenital heart conditions.…”