Tesis

Pengaruh Gradien Tekanan Transpulmonal terhadap Morbiditas Dini Pascaoperasi Fontan Pada Usia Diatas Empat Tahun

Latar belakang: Sebagian besar pasien PJB di Indonesia menjalani operasi Fontan di atas usia ideal dengan kondisi peningkatan resistensi vaskular paru dan penurunan fungsi diastolik jantung. Pengukuran gradien tekanan transpulmonal (GTP) praoperasi pada penyadapan jantung kanan dapat menggambarkan kondisi paru (prakapiler) dan pompa jantung sistemik (pascakapiler). Beberapa penelitian menunjukkan adanya hubungan antara peningkatan GTP dengan morbiditas dini pascaoperasi Fontan. Namun, sampai saat ini belum terdapat nilai cut-off GTP yang secara luas digunakan sebagai kriteria operasi Fontan. Metode: Penelitian ini adalah penelitian kohort retrospektif yang melibatkan pasien PJB berusia di atas 4 tahun yang menjalani operasi Fontan dari Januari 2015 hingga Juli 2023 di Rumah Sakit Pusat Jantung Nasional Harapan Kita (RSPJNHK). Variabel yang dinilai meliputi GTP praoperasi dan kejadian morbiditas dini pascaoperasi seperti aritmia, prolonged ventilator, kejadian tromboemboli, gagal Fontan dini, prolonged efusi pleura, dan kilotoraks. Analisis bivariat dan multivariat dilakukan untuk menilai hubungan GTP dengan kejadian morbiditas dini. Analisis diagnostik dengan receiver operating curve (ROC) dilakukan untuk menentukan nilai area under the curve (AUC). Nilai optimal cutoffdari gradien tekanan transpulmonal diperoleh menggunakan indeks Youden. Hasil: Terdapat 132 subjek yang diikutsertakan dalam penelitian ini. Median usia subjek adalah 6,85 (5-17,89) tahun. Kejadian morbiditas dini dialami oleh 30,3% subjek. Subjek yang mengalami prolonged efusi pleura secara bermakna memiliki GTP yang lebih tinggi dibandingkan subjek yang tidak mengalami prolonged efusi pleura (p=0,006). Nilai area under curve (AUC) GTP untuk kejadian prolonged efusi pleura, yaitu 75,5% (IK 95%: 57,6-93,5%, p=0,005). Nilai cut-offGTP terbaik adalah 5,75 mmHg dengan sensitivitas 66,7% dan spesifisitas 79,7%). IRAP dan durasi CPB merupakan faktor risiko independen terjadinya morbiditas dini aritmia, sementara usia dan rasio McGoon merupakan faktor risiko independen terjadinya morbiditas dini tromboemboli. Kesimpulan: Terdapat pengaruh GTP terhadap kejadian prolonged efusi pleura pascaoperasi Fontan pada pasien PJB yang menjalani operasi di atas usia empat tahun. Terdapat nilai cut-off GTP yang dapat digunakan untuk memperkirakan keluaran morbiditas dini pascaoperasi Fontan.
Kata kunci: gradien tekanan transpulmonal, Fontan, morbiditas dini, prolonged efusi pleura


Background: Most pediatric patients with congenital heart disease (CHD) in Indonesia undergo Fontan operation beyond the optimal age, presenting with increased pulmonary vascular resistance and reduced diastolic heart function. Transpulmonary pressure gradient (TGP) measurement during right heart catheterization can depict the conditions of the lung (precapillary) and systemic ventricular pump (postcapillary). Several studies reported an association between elevated GTP and early morbidity following Fontan surgery. However, a universally accepted GTP cut-off value for Fontan operation criteria is yet to be established. Methods: This study is a retrospective cohort study involving CHD patients aged above 4 years who underwent Fontan operation from January 2015 to July 2023 at the National Cardiovascular Center Harapan Kita. Preoperative TPG data and postoperative incidence of early morbidity such as arrhtyhmia, prolonged ventilation, thromboembolic events, early Fontan failure, pleural effusion, and chylothorax were collected. Bivariate and multivarate analyses were conducted to assess the relationship between TPG and early morbidity events. Diagnostic test using receiver operating characteristic (ROC) curve was also done to obtain the area under the curve (AUC) value. The best cutoff point was determined by Youden's index. Results: A total of 132 subjects were included in this study, with a median age of 6.85 (4,1-17,89) years. Early morbidity occurred in 30,3% of subjects. Subjects who experienced pleural effusion have significantly higher TPG compared to subjects who did not have it (p=0,006). The area under the curve (AUC) values for TPG in predicting prolonged pleural effusion was 75,5% (95% CI: 57,6-93,5%, p=0,005). The optimal cutoff value for TPG and was determined as 5,75 mmHg with a sensitivity of 66,7% and specificity 79,7%. PARi and CPB duration were identified as independent risk factors for arrhythmia, while age and the McGoon ratio were independent risk factors for thromboembolic event. Conclusion: There is an association between TPG values and prolonged pleural effusion following Fontan surgery in CHD patients undergoing Fontan procedure beyond the age of four years. The TPG could be used to predict the occurrence of these postoperative morbidities with a well-defined cut-off. Keywords: transpulmonary pressure gradient, Fontan, early morbidity, prolonged pleural effusion