IMPACT OF FENESTRATION ON POSTOPERATIVE COMPLICATIONS FOLLOWING A FONTAN PROCEDURE: SYSTEMATIC REVIEW AND META-ANALYSIS

Abstract

A systematic review and meta-analysis of studies were performed comparing fenestrated and nonfenestrated Fontan procedures. Medline and Embase were searched with the following strategy: ([Fenestration OR Fenestrated] AND [Fontan OR cavopulmonary connection) from 1990 to 2017. A total of 413 papers were screened by two independent reviewers (IB and BW). The primary endpoint was Fontan failure defined as in-hospital mortality or Fontan take down. Secondary endpoints were in-hospital mortality, reduction in postoperative pulmonary pressure, prolonged chest tube drainage (> 10 days), postoperative saturation, intensive care unit (ICU) and hospital length of stay. Data were pooled using Rev Man 5. A random effect analysis was used when the heterogeneity was more than mild (I2≥ 25%). Seventeen studies with a total of 4769 patients were included. There was a tendency towards a lower Fontan failure rate in the fenestrated group (OR: 0.74 [0.54-1.02], p=0.06, I2=20%). In contrast, the in-hospital mortality was similar between the two groups (OR: 1.10 [0.57-2.12], p=0.78, I2=49%). The postoperative pressures was significantly lower after a fenestrated Fontan (SMD -0.99 [-1.68-0.30] mmHg, p=0.005, I2=95%). In contrast, the postoperative saturation was significantly lower in the fenestrated group (OR: -3.08 [-4.35, -1.82] %, p < 0.001). The incidence of prolonged chest tube drainage was lower in the fenestrated Fontan (OR: 0.41 [0.23-0.75], p=0.004, I2=71%). However, the ICU and hospital length of stay were similar in the two groups (SMD: 0.69 [-0.24-1.62], p=0.14, I2=95% and -0.84 [-5.04-3.36] days, p=0.70, I2=98%; respectively). The fenestrated Fontan reduces postoperative chest tube drainage, is more effective in reducing postoperative pulmonary pressures and may mitigate the risk of Fontan failure. However, fenestration result in a lower postoperative saturation.