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Rychik J, Atz AM, Celermajer DS, Deal BJ, Gatzoulis MA, Gewillig MH, Hsia TY, Hsu DT, Kovacs AH, McCrindle BW, Newburger JW, Pike NA, Rodefeld M, Rosenthal DN, Schumacher KR, Marino BS, Stout K, Veldtman G, Younoszai AK, d'Udekem Y. Evaluation and Management of the Child and Adult With Fontan Circulation: A Scientific Statement From the American Heart Association. Circulation 2019; 140:e234-e284. [PMID: 31256636 DOI: 10.1161/cir.0000000000000696] [Citation(s) in RCA: 393] [Impact Index Per Article: 78.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
It has been 50 years since Francis Fontan pioneered the operation that today bears his name. Initially designed for patients with tricuspid atresia, this procedure is now offered for a vast array of congenital cardiac lesions when a circulation with 2 ventricles cannot be achieved. As a result of technical advances and improvements in patient selection and perioperative management, survival has steadily increased, and it is estimated that patients operated on today may hope for a 30-year survival of >80%. Up to 70 000 patients may be alive worldwide today with Fontan circulation, and this population is expected to double in the next 20 years. In the absence of a subpulmonary ventricle, Fontan circulation is characterized by chronically elevated systemic venous pressures and decreased cardiac output. The addition of this acquired abnormal circulation to innate abnormalities associated with single-ventricle congenital heart disease exposes these patients to a variety of complications. Circulatory failure, ventricular dysfunction, atrioventricular valve regurgitation, arrhythmia, protein-losing enteropathy, and plastic bronchitis are potential complications of the Fontan circulation. Abnormalities in body composition, bone structure, and growth have been detected. Liver fibrosis and renal dysfunction are common and may progress over time. Cognitive, neuropsychological, and behavioral deficits are highly prevalent. As a testimony to the success of the current strategy of care, the proportion of adults with Fontan circulation is increasing. Healthcare providers are ill-prepared to tackle these challenges, as well as specific needs such as contraception and pregnancy in female patients. The role of therapies such as cardiovascular drugs to prevent and treat complications, heart transplantation, and mechanical circulatory support remains undetermined. There is a clear need for consensus on how best to follow up patients with Fontan circulation and to treat their complications. This American Heart Association statement summarizes the current state of knowledge on the Fontan circulation and its consequences. A proposed surveillance testing toolkit provides recommendations for a range of acceptable approaches to follow-up care for the patient with Fontan circulation. Gaps in knowledge and areas for future focus of investigation are highlighted, with the objective of laying the groundwork for creating a normal quality and duration of life for these unique individuals.
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Dori Y, Keller MS, Rome JJ, Gillespie MJ, Glatz AC, Dodds K, Goldberg DJ, Goldfarb S, Rychik J, Itkin M. Percutaneous Lymphatic Embolization of Abnormal Pulmonary Lymphatic Flow as Treatment of Plastic Bronchitis in Patients With Congenital Heart Disease. Circulation 2016; 133:1160-70. [PMID: 26864093 DOI: 10.1161/circulationaha.115.019710] [Citation(s) in RCA: 188] [Impact Index Per Article: 23.5] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/29/2015] [Accepted: 02/01/2016] [Indexed: 11/16/2022]
Abstract
BACKGROUND Plastic bronchitis is a potentially fatal disorder occurring in children with single-ventricle physiology, and other diseases, as well, such as asthma. In this study, we report findings of abnormal pulmonary lymphatic flow, demonstrated by MRI lymphatic imaging, in patients with plastic bronchitis and percutaneous lymphatic intervention as a treatment for these patients. METHODS AND RESULTS This is a retrospective case series of 18 patients with surgically corrected congenital heart disease and plastic bronchitis who presented for lymphatic imaging and intervention. Lymphatic imaging included heavy T2-weighted MRI and dynamic contrast-enhanced magnetic resonance lymphangiogram. All patients underwent bilateral intranodal lymphangiogram, and most patients underwent percutaneous lymphatic intervention. In 16 of 18 patients, MRI or lymphangiogram or both demonstrated retrograde lymphatic flow from the thoracic duct toward lung parenchyma. Intranodal lymphangiogram and thoracic duct catheterization was successful in all patients. Seventeen of 18 patients underwent either lymphatic embolization procedures or thoracic duct stenting with covered stents to exclude retrograde flow into the lungs. One of the 2 patients who did not have retrograde lymphatic flow did not undergo a lymphatic interventional procedure. A total of 15 of 17(88%) patients who underwent an intervention had significant symptomatic improvement at a median follow-up of 315 days (range, 45-770 days). The most common complication observed was nonspecific transient abdominal pain and transient hypotension. CONCLUSIONS In this study, we demonstrated abnormal pulmonary lymphatic perfusion in most patients with plastic bronchitis. Interruption of the lymphatic flow resulted in significant improvement of symptoms in these patients and, in some cases, at least temporary resolution of cast formation.
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Affiliation(s)
- Yoav Dori
- From Division of Cardiology, Division of Pulmonary Medicine, and Department of Radiology, The Children's Hospital of Philadelphia, PA (Y.D., M.S.K., J.J.R., M.J.G., A.C.G., K.D., D.J.G., S.G., J.R.); and Division of Interventional Radiology, Hospital of the University of Pennsylvania, Philadelphia (M.I.).
| | - Marc S Keller
- From Division of Cardiology, Division of Pulmonary Medicine, and Department of Radiology, The Children's Hospital of Philadelphia, PA (Y.D., M.S.K., J.J.R., M.J.G., A.C.G., K.D., D.J.G., S.G., J.R.); and Division of Interventional Radiology, Hospital of the University of Pennsylvania, Philadelphia (M.I.)
| | - Jonathan J Rome
- From Division of Cardiology, Division of Pulmonary Medicine, and Department of Radiology, The Children's Hospital of Philadelphia, PA (Y.D., M.S.K., J.J.R., M.J.G., A.C.G., K.D., D.J.G., S.G., J.R.); and Division of Interventional Radiology, Hospital of the University of Pennsylvania, Philadelphia (M.I.)
| | - Matthew J Gillespie
- From Division of Cardiology, Division of Pulmonary Medicine, and Department of Radiology, The Children's Hospital of Philadelphia, PA (Y.D., M.S.K., J.J.R., M.J.G., A.C.G., K.D., D.J.G., S.G., J.R.); and Division of Interventional Radiology, Hospital of the University of Pennsylvania, Philadelphia (M.I.)
| | - Andrew C Glatz
- From Division of Cardiology, Division of Pulmonary Medicine, and Department of Radiology, The Children's Hospital of Philadelphia, PA (Y.D., M.S.K., J.J.R., M.J.G., A.C.G., K.D., D.J.G., S.G., J.R.); and Division of Interventional Radiology, Hospital of the University of Pennsylvania, Philadelphia (M.I.)
| | - Kathryn Dodds
- From Division of Cardiology, Division of Pulmonary Medicine, and Department of Radiology, The Children's Hospital of Philadelphia, PA (Y.D., M.S.K., J.J.R., M.J.G., A.C.G., K.D., D.J.G., S.G., J.R.); and Division of Interventional Radiology, Hospital of the University of Pennsylvania, Philadelphia (M.I.)
| | - David J Goldberg
- From Division of Cardiology, Division of Pulmonary Medicine, and Department of Radiology, The Children's Hospital of Philadelphia, PA (Y.D., M.S.K., J.J.R., M.J.G., A.C.G., K.D., D.J.G., S.G., J.R.); and Division of Interventional Radiology, Hospital of the University of Pennsylvania, Philadelphia (M.I.)
| | - Samuel Goldfarb
- From Division of Cardiology, Division of Pulmonary Medicine, and Department of Radiology, The Children's Hospital of Philadelphia, PA (Y.D., M.S.K., J.J.R., M.J.G., A.C.G., K.D., D.J.G., S.G., J.R.); and Division of Interventional Radiology, Hospital of the University of Pennsylvania, Philadelphia (M.I.)
| | - Jack Rychik
- From Division of Cardiology, Division of Pulmonary Medicine, and Department of Radiology, The Children's Hospital of Philadelphia, PA (Y.D., M.S.K., J.J.R., M.J.G., A.C.G., K.D., D.J.G., S.G., J.R.); and Division of Interventional Radiology, Hospital of the University of Pennsylvania, Philadelphia (M.I.)
| | - Maxim Itkin
- From Division of Cardiology, Division of Pulmonary Medicine, and Department of Radiology, The Children's Hospital of Philadelphia, PA (Y.D., M.S.K., J.J.R., M.J.G., A.C.G., K.D., D.J.G., S.G., J.R.); and Division of Interventional Radiology, Hospital of the University of Pennsylvania, Philadelphia (M.I.)
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Schumacher KR, Stringer KA, Donohue JE, Yu S, Shaver A, Caruthers RL, Zikmund-Fisher BJ, Fifer C, Goldberg C, Russell MW. Fontan-associated protein-losing enteropathy and plastic bronchitis. J Pediatr 2015; 166:970-7. [PMID: 25661406 PMCID: PMC4564862 DOI: 10.1016/j.jpeds.2014.12.068] [Citation(s) in RCA: 59] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/17/2014] [Revised: 10/29/2014] [Accepted: 12/22/2014] [Indexed: 12/23/2022]
Abstract
OBJECTIVE To characterize the medical history, disease progression, and treatment of current-era patients with the rare diseases Fontan-associated protein-losing enteropathy (PLE) and plastic bronchitis. STUDY DESIGN A novel survey that queried demographics, medical details, and treatment information was piloted and placed online via a Facebook portal, allowing social media to power the study. Participation regardless of PLE or plastic bronchitis diagnosis was allowed. Case control analyses compared patients with PLE and plastic bronchitis with uncomplicated control patients receiving the Fontan procedure. RESULTS The survey was completed by 671 subjects, including 76 with PLE, 46 with plastic bronchitis, and 7 with both. Median PLE diagnosis was 2.5 years post-Fontan. Hospitalization for PLE occurred in 71% with 41% hospitalized ≥ 3 times. Therapy varied significantly. Patients with PLE more commonly had hypoplastic left ventricle (62% vs 44% control; OR 2.81, 95% CI 1.43-5.53), chylothorax (66% vs 41%; OR 2.96, CI 1.65-5.31), and cardiothoracic surgery in addition to staged palliation (17% vs 5%; OR 4.27, CI 1.63-11.20). Median plastic bronchitis diagnosis was 2 years post-Fontan. Hospitalization for plastic bronchitis occurred in 91% with 61% hospitalized ≥ 3 times. Therapy was very diverse. Patients with plastic bronchitis more commonly had chylothorax at any surgery (72% vs 51%; OR 2.47, CI 1.20-5.08) and seasonal allergies (52% vs 36%; OR 1.98, CI 1.01-3.89). CONCLUSIONS Patient-specific factors are associated with diagnoses of PLE or plastic bronchitis. Treatment strategies are diverse without clear patterns. These results provide a foundation upon which to design future therapeutic studies and identify a clear need for forming consensus approaches to treatment.
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Affiliation(s)
- Kurt R. Schumacher
- University of Michigan Congenital Heart Center, C.S. Mott Children’s Hospital
| | | | - Janet E. Donohue
- University of Michigan Congenital Heart Center, C.S. Mott Children’s Hospital
| | - Sunkyung Yu
- University of Michigan Congenital Heart Center, C.S. Mott Children’s Hospital
| | - Ashley Shaver
- University of Michigan Congenital Heart Center, C.S. Mott Children’s Hospital
| | - Regine L. Caruthers
- University of Michigan Congenital Heart Center, C.S. Mott Children’s Hospital
| | | | - Carlen Fifer
- University of Michigan Congenital Heart Center, C.S. Mott Children’s Hospital
| | - Caren Goldberg
- University of Michigan Congenital Heart Center, C.S. Mott Children’s Hospital
| | - Mark W. Russell
- University of Michigan Congenital Heart Center, C.S. Mott Children’s Hospital
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Avitabile CM, Goldberg DJ, Dodds K, Dori Y, Ravishankar C, Rychik J. A multifaceted approach to the management of plastic bronchitis after cavopulmonary palliation. Ann Thorac Surg 2014; 98:634-40. [PMID: 24841545 DOI: 10.1016/j.athoracsur.2014.04.015] [Citation(s) in RCA: 48] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/06/2014] [Revised: 03/23/2014] [Accepted: 04/01/2014] [Indexed: 11/26/2022]
Abstract
BACKGROUND Plastic bronchitis is a rare, potentially life-threatening complication after Fontan operation. Hemodynamic alterations (elevated central venous pressure and low cardiac output) likely contribute to the formation of tracheobronchial casts composed of inflammatory debris, mucin, and fibrin. Pathologic studies of cast composition support medical treatment with fibrinolytics such as inhaled tissue plasminogen activator (t-PA). METHODS This was a retrospective case series of medical, surgical, and catheter-based treatment of patients with plastic bronchitis after cavopulmonary palliation. RESULTS Included were 14 patients (86% male, 93% white). Median age at Fontan operation was 2.7 years (range, 1.2 to 4.1 years), with median interval to plastic bronchitis presentation of 1.5 years (range, 9 days to 15.4 years). Cast composition was available for 11 patients (79%) and included fibrin deposits in 7. All patients were treated with pulmonary vasodilators, and 13 (93%) were treated with inhaled t-PA. Hemodynamically significant lesions in the Fontan pathway were addressed by catheter-based (n=9) and surgical (n=3) interventions. Three patients (21%) underwent heart transplantation. Median follow-up was 2.7 years (range, 0.6 to 8.7 years). Symptoms improved, such that 6 of 13 patients (46%) were weaned off t-PA. Rare or episodic casts are successfully managed with outpatient t-PA in most of the other patients. Of the 3 patients who underwent heart transplant, 2 are asymptomatic and 1 has recurrent casts in the setting of elevated filling pressures and rejection. CONCLUSIONS A systematic step-wise algorithm that includes optimization of hemodynamics, aggressive pulmonary vasodilation, and inhaled t-PA is an effective treatment strategy for patients with plastic bronchitis after cavopulmonary connection.
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Affiliation(s)
- Catherine M Avitabile
- Division of Cardiology, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania.
| | - David J Goldberg
- Division of Cardiology, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania; Department of Pediatrics, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania
| | - Kathryn Dodds
- Division of Cardiology, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Yoav Dori
- Division of Cardiology, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania; Department of Pediatrics, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania
| | - Chitra Ravishankar
- Division of Cardiology, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania; Department of Pediatrics, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania
| | - Jack Rychik
- Division of Cardiology, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania; Department of Pediatrics, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania
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Schumacher KR, Singh TP, Kuebler J, Aprile K, O'Brien M, Blume ED. Risk factors and outcome of Fontan-associated plastic bronchitis: a case-control study. J Am Heart Assoc 2014; 3:e000865. [PMID: 24755155 PMCID: PMC4187467 DOI: 10.1161/jaha.114.000865] [Citation(s) in RCA: 45] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
Background The onset of plastic bronchitis (PB) can be debilitating in survivors of Fontan surgery. The rarity of this complication makes designing studies to understand risk factors for PB challenging. This 2‐center case‐control study aimed to describe patient outcomes and to assess the association of antecedent patient factors with PB development. Methods and Results Using center registries, PB patients (n=25) were matched 1:2 to non‐PB Fontans (n=43) by date of Fontan surgery and center. The groups were compared for baseline characteristics. Association of patient characteristics with PB was assessed using logistic regression and of potential risk factors with onset of PB using time‐to‐event analyses. The median time from Fontan to PB diagnosis was 2.5 years. Overall, 12/25 PB patients died or underwent heart transplant; the median transplant‐free survival was 8.3 years after diagnosis. Factors associated with developing PB included post‐surgical chylothorax (44% PB versus 10% control; odds ratio [OR] 7.3; P=0.003), chest tube (CT) duration at stage 2 (P=0.04) and Fontan (P=0.004), and postoperative ascites (36% PB versus 12% control; OR 4.2; P=0.003). CT drainage >13 days at Fontan was associated with earlier PB onset (P=0.04). Early‐onset PB was associated with an increased risk of death (OR 5.0; P=0.002). Conclusions PB is a life‐threatening disorder. A longer duration of CT drainage after surgery, chylothorax, and development of ascites are all associated with developing PB. Understanding the pathophysiology of peri‐operative complications in individual patients and using targeted interventions may delay the onset of the PB phenotype.
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