Abstract 11089: Hepatic Abnormalities are Present Before and Early After the Fontan Operation

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Objectives: Progressive hepatic fibrosis is common after the Fontan operation, but little is known about its onset. We sought to determine if there is non-invasive evidence of hepatic injury prior to the Fontan operation, and if further injury is seen soon after the procedure. Methods: Patients undergoing the Fontan operation at our institution were prospectively enrolled and underwent hepatic ultrasound with Doppler and serum testing immediately before and 3 to 6 months after the operation. Results: Thirty patients were enrolled at a median age at time of the Fontan operation of 3.1 yrs (range: 2.2-8.1 yrs). An extracardiac Fontan operation was performed in 67% and nearly all (97%) underwent fenestration. Three patients (10%) had abnormal hepatic echotexture prior to the Fontan operation. At the post-Fontan study, mean liver length increased (9.9 vs. 10.9 cm, p<0.0001) and mean hepatic artery end diastolic velocity decreased (18.8 vs. 14.5 cm/sec, p=0.03). One patient showed new, abnormal hepatic echotexture after surgery. Among serum indices, mean aspartate aminotransferase (56.7 vs. 60.7 IU, p=0.04), mean alanine transaminase (ALT) (18.9 vs. 33.9 IU, p=0.0002), and mean gamma-glutamyl transferase (GGT) (18.7 vs. 46.1 IU, p=0.002) increased at the post-Fontan assessment compared to the pre-operative values. By linear regression, hospital length of stay and duration with chest tube after Fontan operation were both significantly associated with an increase in GGT (p< 0.001 for both) and ALT (p=0.008, p=0.04) 3 to 6 months after surgery. There were no associations found between change in ultrasound or serum markers of liver function and pre-Fontan hemodynamic variables as measured by echocardiogram, catheterization, and/or magnetic resonance imaging. Conclusions: Hepatic ultrasound abnormalities were seen prior to the Fontan operation in some patients. Early after the Fontan operation, liver length and serum hepatic markers were increased relative to pre-Fontan values. Post-operative morbidity was associated with an increase in these serum markers. In total, these findings suggest that liver insult may occur prior to the Fontan operation and further insult likely begins soon after the Fontan circulation is created.