• Michael A Quail, Ignatius Chan, Shiv Sarna, Marina Hughes, and Vivek Muthurangu.
• Centre for Cardiovascular Imaging, UCL Institute of Cardiovascular Science & Great Ormond Street Hospital for Children, London, United Kingdom. Electronic address: m.quail@ucl.ac.uk.
• J. Thorac. Cardiovasc. Surg. 2021 Apr 1; 161 (4): 142614341426-1434.

ObjectiveEarly 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.MethodsIn 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 first 24 hours in the intensive care unit was collected from electronic patient records in a subset of patients. Early Fontan failure was defined as death, transplantation, total cavopulmonary connection takedown, or emergency fenestration within the first 30 days.ResultsEstimated central venous pressure in total cavopulmonary connection correlated significantly with central venous pressure during the first 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 significantly associated with early Fontan failure (odds ratio, 1.1; 95% confidence 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 specificity (90%) and sensitivity (58%) for identifying early Fontan failure (area under receiver operating curve = 0.73; odds ratio, 12.4; 95% confidence interval, 2.5-62.3; P = .002). This association was stronger in patients with single superior vena cava.ConclusionsEstimated central venous pressure in total cavopulmonary connection is an easily calculated metric combining preoperative pressure and flow 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. Identification of patients at risk of early Fontan failure has the potential to guide risk-mitigation strategies.Copyright © 2020 The American Association for Thoracic Surgery. Published by Elsevier Inc. All rights reserved.

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