Association of Global Longitudinal Strain and Long-Term Transplant-Free Survival in Fontan Patients

Background and Objectives

Patients with single-ventricle physiology undergoing Fontan operations face high morbidity and mortality risks. While classic-pattern dyssynchrony (CPD) and protein-losing enteropathy (PLE) are known predictors of adverse outcomes, the role of global longitudinal strain (GLS) as an independent predictor of heart failure remains unclear.

Methods

A retrospective cohort study of 135 Fontan-operated patients from 2014 to 2015 evaluated the predictive value of GLS alongside PLE and CPD on mortality and transplantation after 9 years. Echocardiographic data, including GLS, were analyzed using speckle tracking strain analysis in 132 patients. The primary endpoint was transplant-free survival.

Results

Among 132 Fontan patients, 15 had classic-pattern dyssynchrony, 29 had protein-losing enteropathy, 37 had moderately reduced global longitudinal strain (GLS ←8% ≥–16%), and 18 had severely reduced GLS (≥–8%). Cox regression analysis showed moderately reduced GLS increased mortality risk (HR 5.8, 95% CI 1.27–26.5, p = 0.023), with severely reduced GLS showing an HR of 10.3 (95% CI 2.18–48.6, p = 0.003). These results were comparable to CPD (HR 11.5, p = 0.002) and PLE (HR 14.9, p < 0.001).

Conclusion

Global longitudinal strain emerged as the best independent factor for predicting long-term transplant-free survival in Fontan patients, highlighting the importance of GLS assessment in routine follow-up to identify high-risk individuals for early intervention.