Original article
Congenital heart surgery
Patients With Systemic Right Ventricle Are at Higher Risk of Chylothorax After Cavopulmonary Connections

Presented at the Poster Session of the Fifty-fourth Annual Meeting of The Society of Thoracic Surgeons, Fort Lauderdale, FL, Jan 27–31, 2018.
https://doi.org/10.1016/j.athoracsur.2018.06.077Get rights and content

Background

Chylothorax is a rare but severe complication after pediatric cardiac surgical procedures and is related to significant morbidity and mortality. It is suspected to be more frequent after single-ventricle staged palliation procedures, but focused studies on chylothorax in patients with univentricular heart physiology are scarce.

Methods

From January 2008 to December 2016, a total of 289 patients underwent 376 cavopulmonary connection (CPC) procedures over 9 years (superior cavopulmonary connection [SCPC], 199; Fontan completion, 177). Patients were classified according to whether they had a chylothorax (group 1) or not (group 2). Chylothorax was confirmed on a pleural fluid test.

Results

The rate of chylothorax after a CPC procedure was 19.7% (74 of 376): 15.6% after SCPC and 24.3% after Fontan completion. Mean follow-up was 4.3 ± 0.1 years. Systemic right ventricle was more frequent in group 1 than in group 2 (64.9% vs 46%, respectively; p = 0.003). Chylothorax was associated with a higher rate of early reoperation (p = 0.001) and late failure of the CPC (p < 0.001). Late mortality was also more frequent in group 1 than in group 2 (17.6% vs 4.3%; p < 0.001). By multivariate analysis, having a systemic right ventricle was the only identified predictor for the development of chylothorax (odds ratio, 2.49; 95% confidence interval, 1.4 to 4.7; p = 0.004).

Conclusions

The incidence of chylothorax in patients undergoing the univentricular pathway procedure is higher than previously suggested. Having a systemic right ventricle is a significant risk factor for developing a chylothorax after a CPC.

Section snippets

Patients and Methods

The records of consecutive patients who underwent a superior cavopulmonary connection (SCPC) and a primary Fontan completion in our institution from January 2008 to December 2016 were reviewed. Patients older than 18 years of age or who underwent previous or further cardiac procedures in other institutions were excluded (n = 62). The study was approved by the Human Research Ethics Committee of The Royal Children’s Hospital Melbourne in Australia. Patients’ characteristics are reported in Table 1

Results

The rate of chylothorax after a CPC procedure was 19.7% (74 of 376): 15.6% (31 of 199) after SCPC and 24.3% (43 of 177) after Fontan completion. SCPC and Fontan completion were performed at a median age of 3.5 months (3.0 to 6.1 months) and 4.9 years (4.2 to 5.6 years), respectively. There were seven (2.4%) early deaths and 26 (9%) late deaths. Mean follow-up was 4.3 ± 0.1 years.

Comment

The mechanisms of failure of the Fontan circulation have not yet been clearly explained. In recent years, better imaging of the lymphatic circulation and improved understanding of the physiology of the thoracic duct have emphasized the lymphatic system abnormalities in patients with a Fontan circulation 12, 13. In the wake of these discoveries, it has been demonstrated that outcomes in patients undergoing Fontan completion were worse if chylothorax developed in the early postoperative period [9]

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