Catherine Deshaies1, Robert M Hamilton2, Azadeh Shohoudi3, Helen Trottier1, Nancy Poirier4, Jamil Aboulhosn5, Craig S Broberg6, Scott Cohen7, Stephen Cook8, Annie Dore9, Susan M Fernandes10, Anne Fournier1, Joseph Kay11, Blandine Mondésert9, François-Pierre Mongeon9, Alexander R Opotowsky12, Anna Proietti9, Jennifer Ting13, Ali Zaidi14, Paul Khairy15. 1. Hôpital Sainte-Justine, Université de Montréal, Montreal, Quebec, Canada. 2. The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada. 3. Montreal Health Innovations Coordinating Center, Montreal, Quebec, Canada. 4. Hôpital Sainte-Justine, Université de Montréal, Montreal, Quebec, Canada; Montreal Heart Institute, Université de Montréal, Montreal, Quebec, Canada. 5. Ahmanson/UCLA Adult Congenital Heart Disease Center, University of California, Los Angeles, California. 6. Oregon Health and Science University, Portland, Oregon. 7. The Wisconsin Adult Congenital Heart Program, Medical College of Wisconsin, Milwaukee, Wisconsin. 8. Children's Hospital of Pittsburgh, Pittsburgh, Pennsylvania. 9. Montreal Heart Institute, Université de Montréal, Montreal, Quebec, Canada. 10. Departments of Pediatrics and Medicine, Stanford University, Palo Alto, California. 11. University of Colorado Denver, Aurora, Colorado. 12. Boston Children's Hospital and Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts. 13. Milton S. Hershey Medical Center, Pennsylvania State University, Hershey, Pennsylvania. 14. Nationwide Children's Hospital, Ohio State University, Columbus, Ohio. 15. Montreal Health Innovations Coordinating Center, Montreal, Quebec, Canada; Montreal Heart Institute, Université de Montréal, Montreal, Quebec, Canada. Electronic address: paul.khairy@umontreal.ca.
Abstract
BACKGROUND: Thromboembolic events contribute greatly to morbidity and mortality following Fontan surgery for univentricular hearts. OBJECTIVES: This study sought to evaluate the effect of type of Fontan surgery on thromboembolic risk. METHODS: A North American multicenter retrospective cohort study enrolled 522 patients with Fontan palliation consisting of an atriopulmonary connection (APC) (21.4%), lateral tunnel (LT) (41.8%), or extracardiac conduit (EC) (36.8%). Thromboembolic complications and new-onset atrial arrhythmia were reviewed and classified by a blinded adjudicating committee. Thromboembolic risk across surgical techniques was assessed by multivariable competing-risk survival regression. RESULTS: Over a median follow-up of 11.6 years, 10- and 20-year freedom from Fontan conversion, transplantation, or death was 94.7% and 78.9%, respectively. New-onset atrial arrhythmias occurred in 4.4, 1.2, and 1.0 cases per 100 person-years with APC, LT, and EC, respectively. APC was associated with a 2.82-fold higher risk of developing atrial arrhythmias (p < 0.001), with no difference between LT and EC (p = 0.95). A total of 71 thromboembolic events, 32 systemic and 39 venous, occurred in 12.8% of subjects, for an overall incidence of 1.1%/year. In multivariable analyses, EC was independently associated with a lower risk of systemic (hazard ratio [HR]: 0.20 vs. LT; 95% confidence interval [CI]: 0.04 to 0.97) and combined (HR: 0.34 vs. LT; 95% CI: 0.13 to 0.91) thromboembolic events. A lower incidence of combined thromboembolic events was also observed with antiplatelet agents (HR: 0.54; 95% CI: 0.32 to 0.92) but not anticoagulation (p = 0.53). CONCLUSIONS: The EC Fontan was independently associated with a lower thromboembolic risk after controlling for time-varying effects of atrial arrhythmias and thromboprophylaxis.
BACKGROUND:Thromboembolic events contribute greatly to morbidity and mortality following Fontan surgery for univentricular hearts. OBJECTIVES: This study sought to evaluate the effect of type of Fontan surgery on thromboembolic risk. METHODS: A North American multicenter retrospective cohort study enrolled 522 patients with Fontan palliation consisting of an atriopulmonary connection (APC) (21.4%), lateral tunnel (LT) (41.8%), or extracardiac conduit (EC) (36.8%). Thromboembolic complications and new-onset atrial arrhythmia were reviewed and classified by a blinded adjudicating committee. Thromboembolic risk across surgical techniques was assessed by multivariable competing-risk survival regression. RESULTS: Over a median follow-up of 11.6 years, 10- and 20-year freedom from Fontan conversion, transplantation, or death was 94.7% and 78.9%, respectively. New-onset atrial arrhythmias occurred in 4.4, 1.2, and 1.0 cases per 100 person-years with APC, LT, and EC, respectively. APC was associated with a 2.82-fold higher risk of developing atrial arrhythmias (p < 0.001), with no difference between LT and EC (p = 0.95). A total of 71 thromboembolic events, 32 systemic and 39 venous, occurred in 12.8% of subjects, for an overall incidence of 1.1%/year. In multivariable analyses, EC was independently associated with a lower risk of systemic (hazard ratio [HR]: 0.20 vs. LT; 95% confidence interval [CI]: 0.04 to 0.97) and combined (HR: 0.34 vs. LT; 95% CI: 0.13 to 0.91) thromboembolic events. A lower incidence of combined thromboembolic events was also observed with antiplatelet agents (HR: 0.54; 95% CI: 0.32 to 0.92) but not anticoagulation (p = 0.53). CONCLUSIONS: The EC Fontan was independently associated with a lower thromboembolic risk after controlling for time-varying effects of atrial arrhythmias and thromboprophylaxis.
Authors: John M Kelly; Gabriel J M Mirhaidari; Yu-Chun Chang; Toshiharu Shinoka; Christopher K Breuer; Andrew R Yates; Kan N Hor Journal: Pediatr Cardiol Date: 2020-11-08 Impact factor: 1.655
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Authors: Erica L Schwarz; John M Kelly; Kevin M Blum; Kan N Hor; Andrew R Yates; Jacob C Zbinden; Aekaansh Verma; Stephanie E Lindsey; Abhay B Ramachandra; Jason M Szafron; Jay D Humphrey; Toshiharu Shin'oka; Alison L Marsden; Christopher K Breuer Journal: NPJ Regen Med Date: 2021-07-22