Impact on clinical outcomes from transcatheter closure of the Fontan fenestration: A systematic review and meta-analysis

BACKGROUND

Meta-analysis of the impact on clinical outcome from transcatheter closure of Fontan fenestration.

METHODS

Cochrane, Embase, MEDLINE, and Open-Gray were searched. Parameters such as changes in oxygen saturation, cavo-pulmonary pressure, maximum heart rate during exercise, exercise duration, and oxygen saturation after fenestration closure were pooled and statistical analysis performed.

RESULTS

Among 922 publications, 12 retrospective observational studies were included. The included studies involved 610 patients, of which 552 patients (90.5%) had a fenestration. Of those patients, 505 patients (91.5%) underwent attempt at trans-catheter closure. When it could be estimated, the pooled overall mean age at trans-catheter fenestration closure was 6.6 ± 7.4 years, and the mean follow-up time was 34.4 ± 10.7 months. There were 32 minor (6.3%) and 20 major (4.0%) complications during or after trans-catheter Fontan fenestration closure. The forest plots demonstrate that following fenestration closure, there was a significant increase in the mean arterial oxygen saturation of 7.9% (95% CI 6.4-9.4%, p < 0.01). There was also a significant increase in the mean cavo-pulmonary pressure of 1.4 mmHg (95% CI 1.0-1.8 mmHg, p < 0.01) following fenestration closure. The exercise parameters reported in 3 studies also favored closing the fenestration as well, yet the exercise duration increase of 1.7 min (95% CI 0.7-2.8 min, p < 0.01) after fenestration closure is probably clinically insignificant.

CONCLUSION

Late closure of a Fontan fenestration has the impact of improving resting oxygen saturation, exercise oxygen saturation, and a modest improvement of exercise duration. These clinical benefits, however, may be at the expense of tolerating slightly higher cavo-pulmonary mean pressures.

Extracardiac Fontan Fenestration Device Closure with Amplatzer Vascular Plug II and Septal Occluder: Procedure Results and Medium-Term Follow-Up

The objective of this study was to determine medium-term morbidity and mortality of patients who have undergone device closure of an extracardiac Fontan fenestration with an Amplatzer Vascular Plug II (AVPII) or Septal Occluder (ASO). A secondary objective was to compare medium-term morbidity and mortality between these patients and other fenestrated Fontan patients. A retrospective chart review was performed on patients who underwent an extracardiac fenestrated Fontan procedure between 1992 and 2015 at Cardinal Glennon Children's Medical Center. Procedural and follow-up data were obtained and compared between those who underwent fenestration closure and those who did not. Additional outcome measures included whether the fenestration had spontaneously closed, morbidity and mortality, oxygen saturations, and hemodynamics pre- and post-closure. Fifty-nine of 118 patients (50%) with a fenestrated Fontan underwent 60 device closures of the fenestration. Thirty-two (53%) of these were with the AVPII and 28 (47%) with the ASO. There was one device embolization. At a median follow-up of 3.9 years, five patients suffered morbidity, including 2 with arrhythmias, 1 with plastic bronchitis, 1 with protein losing enteropathy, and 1 with stroke. There were no cardiopulmonary deaths in this group. Twenty-three of 118 patients (19%) had spontaneous closure. There was no difference in morbidity and mortality between patients who underwent percutaneous fenestration closure and those who either had spontaneous closure or a persistently patent fenestration. Device closure of Fontan fenestrations is a safe and effective procedure with minimal morbidity and mortality comparable to other patients with fenestrations.

Fontan Fenestration Closure Prior to Posterior Spinal Fusion in Patients With Single-Ventricle Heart Disease

STUDY DESIGN

Case series.

OBJECTIVE

To describe transcatheter closure of the Fontan fenestration prior to posterior spinal fusion in two children to prevent paradoxical venous air embolism during the operation.

SUMMARY OF BACKGROUND DATA

Scoliosis is common among patients with single-ventricle congenital heart disease who have undergone Fontan operation and spinal surgery can offer physiologic benefits. Venous air embolism is a rare, but important reported complication during spinal surgery performed in the prone position. Patients with Fontan circulation can have significant right to left shunting via a patent Fontan fenestration that can increase the risk of paradoxical systemic embolization of any entrained venous air.

METHODS

We retrospectively reviewed the charts of two patients with single-ventricle congenital heart disease who had undergone fenestrated Fontan operation and underwent transcatheter fenestration closure prior to spinal fusion.

RESULTS

Two patients with Fontan circulation underwent successful transcatheter fenestration closure with Amplatzer Ductal Occluder II devices. Five to 6 months after closure, both underwent uncomplicated posterior spinal fusion.

CONCLUSION

Transcatheter closure of the Fontan fenestration prior to spinal fusion in two with Fontan circulation and scoliosis is a rare, but important indication for fenestration closure that warrants emphasis.

LEVEL OF EVIDENCE

N/A.