Tesis

Pengaruh Usia Tua Saat Operasi terhadap Kesintasan Jangka Panjang Pascaoperasi Fontan = Impact of Older Age at Completion of Fontan Procedure on Long Term Survival.

Latar belakang: Sirkulasi Fontan menimbulkan sejumlah masalah yang diduga berhubungan dengan peningkatan usia operasi dan durasi sirkulasi Fontan tersebut. Usia operasi Fontan terbaik hingga saat ini masih kontroversial. Sejumlah pusat jantung di negara maju menggunakan batasan usia operasi 2-4 tahun. Sebagai negara berkembang, kebanyakan operasi Fontan di Indonesia dikerjakan pada usia tua yaitu 6 tahun (3-22 tahun). Dengan kemajuan teknik operasi saat ini, bagaimana dampak usia tua saat operasi Fontan terhadap kesintasan jangka panjang belum ada datanya. Tujuan: Mengetahui pengaruh usia tua saat operasi Fontan terhadap kesintasan jangka panjang. Metode: Penelitian ini merupakan studi kohort retrospektif dengan analisis kesintasan Kaplan Meier yang dilakukan terhadap 261 pasien pascaoperasi Fontan (1 Januari 2008 – 31 Desember 2019) di Pusat Jantung Nasional Harapan Kita. Pengumpulan data dilakukan dari registri, konferensi bedah, rekam medis, laporan ekokardiografi, laporan kateterisasi, laporan bedah, serta follow-up melalui telepon atau pengiriman surat. Analisis waktu terjadinya event (kematian) dimulai dari titik awal penelitian hingga 1 April 2020. Usia operasi dibagi menjadi usia muda ≤ 6 tahun dan usia tua > 6 tahun. Hasil: Dari total 261 subjek, mayoritas adalah laki-laki (56,7%) dengan median usia 5 tahun (2-24 tahun). Kesintasan menyeluruh yaitu 92,7%. Proporsi menurut usia operasi yaitu 53,3% berusia ≤ 6 tahun dan 46,7% berusia > 6 tahun, dengan masing-masing kesintasan 95,7% dan 89,3%. Pada subanalisis terhadap usia operasi < 4 tahun, 4-6 tahun (usia referensi), 6-8 tahun, 8-10 tahun, 10-18 tahun, dan > 18 tahun didapatkan kesintasan 90,5%, 97,9%, 93,8%, 84,8%, 91,4%, dan 66,7%. Usia operasi 8-10 tahun (HR 6,79; p = 0,022), 10-18 tahun (HR 3,76, p = 0,147), dan >18 tahun (HR 15,30, p = 0,006) memiliki kesintasan yang paling rendah. Berdasarkan analisis cox regression, usia operasi > 6 tahun (HR 3,84, p = 0,020) dan kebutuhan furosemid jangka panjang (HR 3,90, p = 0,036) secara signifikan meningkatkan risiko kematian jangka panjang. Kesimpulan: Usia operasi Fontan > 6 tahun secara signifikan menurunkan kesintasan jangka panjang, dimana usia operasi 8-10 tahun dan > 18 tahun memiliki kesintasan terendah serta memiliki risiko kematian sebesar 6,7 kali dan 15,3 kali dibandingkan usia 4-6 tahun. Usia 4-6 tahun merupakan usia operasi Fontan yang memberikan kesintasan jangka panjang terbaik.
Kata Kunci: kesintasan jangka panjang, operasi Fontan, usia operasi, usia tua


Background: Fontan circulation is associated with high morbidity, which associated with older age at Fontan completion and the duration of Fontan circulation. The optimal age to perform the Fontan procedure is still unknown. Currently, the majority of centres worldwide are performing the procedure between 2 and 4 years of age. Indonesia as a developing country, most of Fontan procedures are performed at 6 years (3-22 years) of age. With the advancement in operating techniques, there is no data regarding the impact of older age at completion of Fontan procedure on long term survival. Objective: To evaluate the impact of older age at Fontan procedure on long term survival. Methods: We conducted a retrospective cohort study with survival analysis, over 12 years of 261 patients underwent Fontan completion (from Januari 1, 2008, to December 31, 2019), at National Cardiovascular Center Harapan Kita Indonesia. A Kaplan Meier analysis was performed. The data was collected from surgical conference, medical records, echocardiography reports, registries, catheterization reports, surgical reports, follow up by phone or mail. Analysis of death event was started from the beginning of the study to the end of the study (April 1, 2020). The age of operation was categorized into two groups: young age (≤ 6 years old) and old age (> 6 years old). Results: Of 261 subjects who were included, 56.7% were male and median age was 5 years (2-24 years). The overall survival rate was 92.7%. The proportion of subjects according to age group: 53.3% subjects aged ≤ 6 years and 46.7% subjects aged > 6 years with survival rate of 95.7% and 89.3%. In subgroup analysis of age at operation < 4 years, 4-6 years (reference age), 6-8 years, 8-10 years, 10-18 years, and > 18 years, the survival rate were 90.5%, 97.9%, 93.8%, 84.8%, 91.4%, and 66.7% respectively. The age of operation 8-10 years (HR 6.79; p = 0.022), 10-18 years (HR 3.76; p = 0.147), and > 18 years (HR 15.30, p = 0.006) had worse survival rate than the others. In cox regression analysis, age of Fontan completion > 6 years old (HR 3.84, p = 0.020) and need for furosemide use (HR 3.90, p = 0.036) increased longterm mortality significantly. Conclusion: The age of operation > 6 years old was significantly reduced long term survival rate, in which the age of 8-10 years old and > 18 years old had the worst survival rate and higher risk of death (6.7 times and 15.3 times) than age of 4-6 years old. The age of 4-6 years was the optimal age to perform Fontan completion that gave better survival rate.
Keywords: age at operation, Fontan procedure, long-term survival, older age