What is the Clinical Utility of Routine Cardiac Catheterization Before a Fontan Operation?

Abstract

Patients with single-ventricle circulation presenting for Fontan completion routinely undergo cardiac catheterization despite ongoing debate concerning its additive value. Increasing interest in noninvasive preoperative evaluation alone led the authors to analyze the utility of routine pre-Fontan catheterization and to determine whether a subset of patients could avoid this invasive procedure. Patients younger than 5 years referred for pre-Fontan evaluation were retrospectively reviewed. Medical records and catheter angiograms were examined, and catheterizations were categorized as “additive” based on predetermined criteria. Associations between precatheterization variables, catheterization findings, and short-term postoperative outcomes were evaluated. Cardiac catheterization was clinically nonadditive for 89 of 175 patients undergoing pre-Fontan evaluation (51%). There were no robust precatheterization predictors of a nonadditive catheterization. Echocardiography did not fully demonstrate the relevant anatomy of 115 patients (66%), most frequently due to inadequate visualization of the pulmonary arteries, and 22 patients had additive catheterizations due to new diagnostic findings alone. Interventions at catheterization were frequent and deemed “important” for 64 patients (37%). Catheterization hemodynamic data were not associated with early postoperative outcomes. Minor catheterization complications occurred for 51 patients (29%) and major complications for 4 patients (2%). Although at least 50% of the patients presenting for Fontan completion may be able to avoid routine catheterization safely, an echocardiography-based imaging strategy alone is insufficient to allow proper identification of those who could be evaluated noninvasively. A more comprehensive imaging strategy not based solely on echocardiography should be considered.

Reduction in Postoperative High-Density Lipoprotein Cholesterol Levels in Children Undergoing the Fontan Operation

“…Yet, despite this practice, predicting the early postoperative course remains difficult, and it is becoming increasingly evident that catheterization hemodynamic data are not consistently associated with early postoperative outcomes [5, 16]. This suggests the existence of other unexplored variables that place Fontan patients at risk for prolonged postoperative recovery despite acceptable hemodynamic criteria.…”

Predicting the pressure of the total cavopulmonary connection: clinical testing of a mathematical equation

“…Moreover, the performance of the Fontan system itself depends on several variables such as a good systolic and diastolic function, the sinus rhythm, low pulmonary pressure and vascular resistances, and good respiratory function. [1][2][3][4][5][6][7][8][9][10][11][12][13][14][15][16][17][18][19][20] It is also debated if the Fontan outcome is influenced by pre-Fontan haemodynamic data. 6,[13][14][15][16][17][18][19][20] In fact, even if some studies underlined that the pre-Fontan haemodynamic data do not affect short-term post-Fontan outcome, [13][14][15] the majority of the authors agree on the importance of performing a pre-Fontan haemodynamic assessment to obtain the valuable data as the need for fenestration and anticipate the need for peri-operative systemic or pulmonary 18 Bridges et al underlined that the pulmonary artery size could not be considered alone as the major determinant of Fontan outcome.…”

Cardiovascular CT for evaluation of single-ventricle heart disease: risks and accuracy compared with interventional findings

“…Echocardiography is insufficient for evaluation of the thoracic vasculature or for reproducible estimation of ventricular function. 4,5 Cardiovascular MRI is commonly performed for these indications, but it requires relatively long imaging times, deep sedation, or anaesthesia in young children. Many older patients have metallic implants with an artefact that degrades MRI quality.…”

“…– 3 These patients need anatomical evaluation between palliative procedures and intermittently throughout their lives. Echocardiography is insufficient for evaluation of the thoracic vasculature or for reproducible estimation of ventricular function 4 5 Cardiovascular MRI is commonly performed for these indications, but it requires relatively long imaging times, deep sedation, or anaesthesia in young children.…”