Impact of Pulmonary Artery Index on the Early Hemodynamic and Laboratory Variables after the Total Cavopulmonary Connection

Background: Current research suggests that a small pulmonary artery index (PAI) can cause adverse events and reduce exercise capacity after the Fontan procedure. This study aimed to evaluate the impact of PAI on early hemodynamic and laboratory variables after total cavopulmonary connection (TCPC).

Methods: We reviewed all patients who underwent TCPC between 2012 and 2022 at our institution. PAI before bidirectional cavopulmonary shunt (BCPS) and before TCPC was measured using angiography as described by Nakata and colleagues. According to our early extubation strategy, all patients were extubated approximately 3 hours after admission to the intensive care unit (ICU). Using the digital ICU charts, serial pulmonary artery pressure (PAP), mean arterial pressure (MAP), and serum lactate levels (LAC) were collected at different points in time: At ICU admission, 1 hour before, and 1, 6, and 12 hours after extubation. The impact of PAI on hemodynamic and laboratory variables were analyzed using logistic regression model.

Results: A total of 263 patients were included. Hypoplastic left heart syndrome (36.1%) was the most frequent diagnosis. Median age and weight at TCPC were 2.2 (interquartile ranges [IQR]: 1.8–2.7) years and 11.7 (IQR: 10.7–13.3) kg, respectively. Prior to that, all patients underwent BCPS at a median age of 4.1 (IQR: 3.2–5.8) months. Risk factors for a higher PAP (>17 mmHg) in the univariate model were lower pre-BCPS PAI (p = 0.006, odds ratio [OR] 0.992), lower pre-BCPS right PAI (p = 0.020, OR 0.990), lower pre-BCPS left PAI (p = 0.014, OR 0.986), and lower pre-TCPC left PAI (p = 0.039, OR 0.989). In the multivariable analysis, pre-BCPS PAI (p = 0.017, OR 0.993) was an independent risk factor. As for MAP (<57 mmHg), pre-TCPC right PAI (p = 0.092, OR: 0.994) was a sole risk factor of p-value < 0.1. Regarding higher LAC (>4.5 mg/dL), pre-BCPS PAI (p < 0.001, OR 0.990), pre-BCPS right PAI (p < 0.001, OR 0.982), pre-BCPS left PAI (p = 0.016, OR 0.988), and pre-TCPC PAI (p = 0.041, OR: 0.995) were risk factors in the univariate model. In the multivariable analysis, pre-BCPS right PAI (p < 0.001, OR 0.983) was identified as an independent risk factor.

Conclusion: In our current cohort of staged Fontan palliation, a small PA size before BCPS and TCPC might be a determinant factor associated with early postoperative higher PAP and higher LAC. Our results suggest that a preoperative small PA size might cause unfavorable early postoperative hemodynamic after TCPC.

Publication History

Article published online:
11 February 2025