A prospective study of risk factors associated with persistent pleural effusion after total cavopulmonary connection with special reference to serum cortisol level
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The Fontan operation is usually followed by significant pleural effusion. We aimed to study the factors associated with persistent pleural effusion with special reference to serum cortisol levels.
Patients and methods
Thirty-eight patients undergoing the Fontan operation between September 2015 and November 2016 were prospectively studied. Parameters studied included age, weight, symptoms, atrio- ventricular valve regurgitation/stenosis/atresia, ventricular function, pulmonary artery pressures, oxygen saturation, aorto-pulmonary, and veno-venous collaterals, type of Fontan, duration of cardiopulmonary bypass, need for inotropes, duration of mechanical ventilation, conduit size, presence or absence of fenestration, and serum cortisol levels. The latter were measured before and after the Fontan operation and the co-relation between pleural effusion and change in serum cortisol levels was studied.
Mean age at operation was 13.1 ± 5.6 years (median 13 years). Mean duration and amount of pleural drainage was 15.76 ± 13.2 days (median 11.5 days) and 9.15 ± 4.6 mL/kg/day (median 9 mL/kg/day) respectively. Statistically significant risk factors for prolonged pleural effusion were higher pulmonary artery (PA) pressures (r = 0.328, p = 0.003, odds ratio 1.30), higher inotropic score (r = 0.4, p = 0.01), lower rise in serum cortisol (p = 0.03),elevated superior caval venous pressure (CVP) at 6 h (r = 0.44, p = 0.005) and 12 h (r = 0.4, p = 0.01) and higher duration of mechanical ventilation (r = 0.45, p = 0.005).
PA pressures > 15 mmHg, higher inotropic score, higher CVP and lower rise in serum cortisol levels following the Fontan operation were associated with persistent pleural effusion.
KeywordsFontan operation Pleural effusion Cortisol
The authors thank Dr Vishnubhatla Sreenivas, Professor of Biostatistics, All India Institute of Medical Sciences, New Delhi, for statistical analysis.
Compliance with ethical standards
Conflict of interest
All Authors declare that they have no conflict of interest and do not receive any research grants from any company, have not received a speaker honorarium from any company, do not own any stock in any company, and are not members of a committee.
Statement of human rights/ethical approval
All procedures performed in this study were in accordance with the ethical standards of the institutional and national research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards. For this study, formal consent was obtained.
Informed consent was obtained from all individual participants included in the study.
- 1.de Vivie ER, Rupprath G. Long-term results after Fontan procedure and its modifications. J Thorac Cardiovasc Surg. 1986;91:690–7.Google Scholar
- 2.Kiziltepe U, Eyileten ZB, Uysalel A, Akalın H. Prolonged pleural effusion following Fontan operation: effective pleurodesis with talc slurry. Int J Cardiol. 2002;85:297–9.Google Scholar
- 3.Mascio CE, Wayment M, Colaizy TT, Mahoney LT, Bukhart HM. The modified Fontan procedure and prolonged pleural effusions. Am Surg. 2009;75:175–7.Google Scholar
- 5.Airan B, Sharma R, Choudhary SK, et al. Univentricular repair: is routine fenestration justified? Ann Thorac Surg. 2000;69:1900–6.Google Scholar
- 6.Gupta A, Daggett C, Behera S. Risk factors for persistent pleural effusions after the extracardiac Fontan procedure. J Thorac Cardiovasc Surg. 2004;127:1664–9.Google Scholar
- 7.Saiki H, Kuwata S, Kurishima C, Iwamoto Y, Ishido H, Masutani S, et al. Aldosterone-cortisol imbalance immediately after Fontan operation with implications for abnormal fluid homeostasis. Am J Cardiol. 2014;114:1578–83.Google Scholar
- 8.Talwar S, Das A, Choudhary SK, Airan B. Diaphragmatic fenestration for resistant pleural effusions after univentricular palliation. World J Pediatr Congenit Heart Surg. 2016;7:146–51.Google Scholar
- 10.Talwar S, Muthukkumaran S, Makhija N, Hasija S, Choudhary SK, Airan B. Extra cardiac Fontan without cardiopulmonary bypass: techniques and results. Indian J Thorac Cardiovasc Surg. 2013;29:174–83.Google Scholar
- 11.Jonas RA. The intra/extracardiac conduit fenestrated Fontan. Semin Thorac Cardiovasc Surg Pediatr Card Surg Annu. 2011;14:11–8.Google Scholar
- 12.Gaies MG, Gurney JG, Yen AH, et al. Vasoactive-inotropic score as a predictor of morbidity and mortality in infants after cardiopulmonary bypass. Pediatr Crit Care Med. 2010;11:234–8.Google Scholar
- 13.Deal BJ, Jacobs ML. Management of the failing Fontan circulation. Heart. 2012;98:1098–104.Google Scholar
- 14.Fontan F, Baudet E. Surgical repair of tricuspid atresia. Thorax. 1971;26:240–8.Google Scholar
- 15.Kreutzer G, Galíndez E, Bono H, De Palma C, Laura JP. An operation for the correction of tricuspid atresia. J Thorac Cardiovasc Surg. 1973;66:613–21.Google Scholar
- 16.Rogers LS, Glatz AC, Ravishankar C, et al. 18 years of the Fontan operation at a single institution: results from 771 consecutive patients. J Am Coll Cardiol. 2012;60:1018–25.Google Scholar
- 17.Talwar S, Agarwala S, Mittal CM, Choudhary SK, Airan B. Pleural effusions in children undergoing cardiac surgery. Ann Pediatr Cardiol. 2010;3:58–64.Google Scholar
- 18.Mendoza A, Albert L, Ruiz E, et al. Fontan operation. Hemodynamic factors associated with postoperative outcomes. Rev Espanola Cardiol Engl Ed. 2012;65:356–62.Google Scholar
- 19.Hirsch JC, Goldberg C, Bove EL, et al. Fontan operation in the current era: a 15-year single institution experience. Ann Surg. 2008;248:402–10.Google Scholar
- 20.Uemura H, Yagihara T, Kawashima Y, et al. What factors affect ventricular performance after a Fontan-type operation? J Thorac Cardiovasc Surg. 1995;110:405–15.Google Scholar
- 21.Fedderly RT, Whitstone BN, Frisbee SJ, Tweddel JS, Litwin SB. Factors related to pleural effusions after fontan procedure in the era of fenestration. Circulation. 2001;104:I-148–51.Google Scholar
- 22.Mascio CE, Austin EH. Pleural effusions following the Fontan procedure. Curr Opin Pulm Med. 2010;16:362–6.Google Scholar
- 23.Yun T-J, Im Y-M, Jung SH, et al. Pulmonary vascular compliance and pleural effusion duration after the Fontan procedure. Int J Cardiol. 2009;133:55–61.Google Scholar
- 24.Bridges ND, Mayer JE, Lock JE, et al. Effect of baffle fenestration on outcome of the modified Fontan operation. Circulation. 1992;86:1762–9.Google Scholar
- 25.Lemler MS, Scott WA, Leonard SR, Stromberg D, Ramaciotti C. Fenestration improves clinical outcome of the Fontan procedure: a prospective, randomized study. Circulation. 2002;105:207–12.Google Scholar
- 26.Garofalo CA, Cabreriza SE, Quinn TA, et al. Ventricular diastolic stiffness predicts perioperative morbidity and duration of pleural effusions after the Fontan operation. Circulation. 2006;114:I56–61.Google Scholar
- 28.Shikata F, Yagihara T, Kagisaki K, et al. Does the off-pump Fontan procedure ameliorate the volume and duration of pleural and peritoneal effusions? Eur J Cardiothorac Surg. 2008;34:570–75.Google Scholar
- 29.Stewart JM, Gewitz MH, Clark BJ, et al. The role of vasopressin and atrial natriuretic factor in postoperative fluid retention after the Fontan procedure. J Thorac Cardiovasc Surg. 1991;102:821–9.Google Scholar
- 30.Mainwaring RD, Lamberti JJ, Moore JW, Billman GF, Nelson JC. Comparison of the hormonal response after bidirectional Glenn and Fontan procedures. Ann Thorac Surg. 1994;57:59–63.Google Scholar