O1021: Evolution of Outcomes in Patients Undergoing Fontan Procedure in an Enhanced Recovery After Cardiac Surgery Program

Background: Enhanced Recovery After Surgery (ERAS) is a comprehensive perioperative approach targeting improved perioperative outcomes and value. We sought to evaluate the impact of a newly implemented ERAS Cardiac program on postoperative outcomes, length of stay, complications, and readmissions after the Fontan procedure.

Methods: An ERAS Cardiac program was implemented in 2018 for elective patients undergoing low-risk repair of congenital heart disease in a quaternary pediatric institution. All patients undergoing Fontan palliation in the ERAS Cardiac program were included. Patients with a staged approach towards biventricular repair transitioned to single ventricle palliation, patients with Heterotaxy syndrome, pulmonary hypertension or pulmonary vein disease, and Fontan revisions were excluded. Program metrics were compared for year 1, 2, and 3 after program inception. Chi-Square test and Kruskal-Wallis were used to compare categorical and continuous non-parametric variables, respectively.

Results: Seventy-eight patients underwent Fontan procedure in the ERAS program over 3 years (10/2018 – 09/2021), representing 7% of the procedures in the ERAS Cardiac program. The median age was 2.9 years (IQR 2.5 - 3.3). Forty-one percent (32/78) were extracardiac Fontan, 38% (30/78) had a lateral tunnel Fontan (LTF) and 15% had a combined procedure including a valvular repair. There was an increase in extubation in the operative room (15%, 50%, and 42%, years 1,2, and 3 respectively, P=0.01), and in early postoperative extubation (P < 0.01, Table 1). There was no statistical difference in total opioids at 96hrs (Table 1). ICU and hospital length of stay (LOS) were not statistically different: ICU LOS median 50.7-hrs Y1, median 47.7-hrs Y2, median 49.3 Y3, p=0.07; Hospital LOS median 8-d Y1, median 6.9-d Y2, and 7.9-d [IQR 6.8 – 12.3] Y3, p=0.43 (Table 1). Major complications, operations, and 30-d readmissions are low in all 3 years (Table 1). There was no mortality.

Conclusion: Patients undergoing Fontan palliation in ERAS Cardiac program are increasingly extubated in the operative room or early after arrival in the ICU. They have excellent perioperative outcomes, short ICU LOS and hospitalization, low complications, and readmissions. Further adherence to fluid restriction protocols may improve LOS.