Protein-losing enteropathy and plastic bronchitis after the Fontan procedure

J Thorac Cardiovasc Surg. 2021 Jun;161(6):2158-2165.e4. doi: 10.1016/j.jtcvs.2020.07.107. Epub 2020 Aug 12.


Objectives: Protein losing enteropathy and plastic bronchitis are severe complications in Fontan circulation, with 5-year survival ranging from 46% to 88%. We report risk factors and outcomes of protein losing enteropathy and plastic bronchitis in patients undergoing the Fontan.

Methods: We performed a retrospective analysis of 1561 patients from the Australia New Zealand Fontan Registry. Two end points were death and cardiac transplantation examined with Cox regression (if no competing risks) or cumulative incidence curves and cause-specific Cs regression.

Results: A total of 55 patients with protein losing enteropathy/plastic bronchitis were included. Their median age at the Fontan was 5.7 years, and time to onset after the Fontan for protein losing enteropathy was 5.0 years and plastic bronchitis was 1.7 years. Independent predictors for developing protein losing enteropathy/plastic bronchitis were right-ventricular morphology with hypoplastic left-heart syndrome (hazard ratio, 2.30; confidence interval, 1.12-4.74), older age at Fontan (hazard ratio, 1.13; confidence interval, 1.03-1.23), and pleural effusions after Fontan (hazard ratio, 2.43; confidence interval, 1.09-5.41); left-ventricular morphology was protective (hazard ratio, 0.36; confidence interval, 0.18-0.70). In the protein losing enteropathy/plastic bronchitis population, freedom from death or transplantation after protein losing enteropathy/plastic bronchitis diagnosis at 5, 10, and 15 years was 70% (confidence interval, 58-85), 65% (confidence interval, 51-83), and 43% (confidence interval, 26-73), respectively; only older age (hazard ratio, 1.23; confidence interval, 1.01-1.52) was an independent predictor. Twenty-six surgical interventions were performed in 20 patients, comprising Fontan revisions (n = 5), fenestrations (n = 11), Fontan conversions (n = 5), atrioventricular valve repairs (n = 3), and hepatic vein diversion (n = 2).

Conclusions: Protein losing enteropathy and plastic bronchitis remain severe complications, preferably affecting patients with dominant right single ventricle, with older age at Fontan being a predictor of developing protein losing enteropathy/plastic bronchitis and poorer prognosis. Heart transplantation remains the ultimate treatment, with 30% dying or requiring transplantation within 5 years, and the remaining being stable for long periods.

Keywords: Fontan; plastic bronchitis; protein-losing enteropathy.

MeSH terms

  • Bronchitis* / epidemiology
  • Bronchitis* / etiology
  • Bronchitis* / mortality
  • Child
  • Child, Preschool
  • Female
  • Fontan Procedure* / adverse effects
  • Fontan Procedure* / mortality
  • Heart Transplantation
  • Humans
  • Hypoplastic Left Heart Syndrome
  • Male
  • New Zealand
  • Postoperative Complications* / epidemiology
  • Postoperative Complications* / mortality
  • Protein-Losing Enteropathies* / epidemiology
  • Protein-Losing Enteropathies* / etiology
  • Protein-Losing Enteropathies* / mortality
  • Retrospective Studies
  • Risk Factors