A preoperative estimate of central venous pressure is associated with early Fontan failure
Objective: Early Fontan failure is a serious complication after total cavopulmonary connection, characterized by high central venous pressure, low cardiac output, and resistance to medical therapy. This study aimed to estimate postoperative central venous pressure in patients with total cavopulmonary connection using data routinely collected during preoperative assessment. We sought to determine if this metric correlated with measured postoperative central venous pressure and if it was associated with early Fontan failure.
Methods: In this retrospective study, central venous pressure in total cavopulmonary connection was estimated in 131 patients undergoing pre–total cavopulmonary connection assessment by cardiac magnetic resonance imaging and central venous pressure measurement under general anesthesia. Postoperative central venous pressure during the fifirst 24 hours in the intensive care unit was collected from electronic patient records in a subset of patients. Early Fontan failure was defifined as death, transplantation, total cavopulmonary connection takedown, or emergency fenestration within the fifirst 30 days.
Results: Estimated central venous pressure in total cavopulmonary connection correlated signifificantly with central venous pressure during the fifirst 24 hours in the intensive care unit (r = 0.26, P = .03), particularly in patients without a fenestration (r = 0.45, P = .01). Central venous pressure in total cavopulmonary connection was signifificantly associated with early Fontan failure (odds ratio, 1.1; 95% confifidence interval, 1.01-1.21; P = .03). A threshold of central venous pressure in total cavopulmonary connection 33 mm Hg or greater was found to have the highest specifificity (90%) and sensitivity (58%) for identifying early Fontan failure (area under receiver operating curve = 0.73; odds ratio, 12.4; 95% confifidence interval, 2.5-62.3; P= .002). This association was stronger in patients with single superior vena cava.
Conclusions: Estimated central venous pressure in total cavopulmonary connection is an easily calculated metric combining preoperative pressure and flflow data. Higher central venous pressure in total cavopulmonary connection is associated with an increased risk of early Fontan failure and is correlated with directly measured post–total cavopulmonary connection pressure. Identifification of patients at risk of early Fontan failure has the potential to guide riskmitigation strategies.