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Hanser A, Hofbeck M, Hofmeister M, Martirosian P, Hornung A, Esser M, Schick F, Kaulitz R, Michel J, Nikolaou K, Schäfer J, Schlensak C, Sieverding L. Thoracic lymphatic anomalies in patients with univentricular hearts: correlation of morphologic findings in isotropic T2-weighted MRI with the outcome after fontan palliation. Front Cardiovasc Med 2023; 10:1145613. [PMID: 37229222 PMCID: PMC10203211 DOI: 10.3389/fcvm.2023.1145613] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2023] [Accepted: 04/19/2023] [Indexed: 05/27/2023] Open
Abstract
Objectives In this study we examined the correlation between the extent of thoracic lymphatic anomalies in patients after surgical palliation by total cavopulmonary connection (TCPC) and their outcome in terms of clinical and laboratory parameters. Materials and methods We prospectively examined 33 patients after TCPC with an isotropic heavily T2-weighted MRI sequence on a 3.0 T scanner. Examinations were performed after a solid meal, slice thickness of 0.6 mm, TR of 2400 ms, TE of 692 ms, FoV of 460 mm, covering thoracic and abdominal regions. Findings of the lymphatic system were correlated with clinical and laboratory parameters obtained at the annual routine check-up. Results Eight patients (group 1) showed type 4 lymphatic abnormalities. Twentyfive patients (group 2) presented less severe anomalies (type 1-3). In the treadmill CPET, group 2 reached step 7.0;6.0/8.0 vs. 6.0;3.5/6.8 in group 1 (p = 0.006*) and a distance of 775;638/854 m vs. 513;315/661 m (p = 0.006*). In the laboratory examinations, group 2 showed significantly lower levels of AST, ALT and stool calprotectin as compared to group 1. There were no significant differences in NT-pro-BNP, total protein, IgG, lymphocytes or platelets, but trends. A history of ascites showed 5/8 patients in group 1 vs. 4/25 patients in group 2 (p = 0.02*), PLE occurred in 4/8 patient in group 1 vs. 1/25 patients in group 2 (p = 0.008*). Conclusion In the long-term follow-up after TCPC, patients with severe thoracic and cervical lymphatic abnormalities showed restrictions in exercise capacity, higher liver enzymes and an increased rate of symptoms of imminent Fontan-failure such as ascites and PLE.
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Affiliation(s)
- Anja Hanser
- Department of Pediatric Cardiology, University Children's Hospital, University of Tübingen, Tübingen, Germany
| | - Michael Hofbeck
- Department of Pediatric Cardiology, University Children's Hospital, University of Tübingen, Tübingen, Germany
| | - Melanie Hofmeister
- Department of Pediatric Cardiology, University Children's Hospital, University of Tübingen, Tübingen, Germany
| | - Petros Martirosian
- Section on Experimental Radiology, University Hospital of Tübingen, Tübingen, Germany
| | - Andreas Hornung
- Department of Pediatric Cardiology, University Children's Hospital, University of Tübingen, Tübingen, Germany
| | - Michael Esser
- Department of Diagnostic and Interventional Radiology, University Hospital of Tübingen, Tübingen, Germany
| | - Fritz Schick
- Section on Experimental Radiology, University Hospital of Tübingen, Tübingen, Germany
| | - Renate Kaulitz
- Department of Pediatric Cardiology, University Children's Hospital, University of Tübingen, Tübingen, Germany
| | - Jörg Michel
- Department of Pediatric Cardiology, University Children's Hospital, University of Tübingen, Tübingen, Germany
| | - Konstantin Nikolaou
- Department of Diagnostic and Interventional Radiology, University Hospital of Tübingen, Tübingen, Germany
| | - Jürgen Schäfer
- Department of Diagnostic and Interventional Radiology, University Hospital of Tübingen, Tübingen, Germany
| | - Christian Schlensak
- Department of Cardiothoracic and Vascular Surgery, University Hospital of Tübingen, Tübingen, Germany
| | - Ludger Sieverding
- Department of Pediatric Cardiology, University Children's Hospital, University of Tübingen, Tübingen, Germany
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Watanabe R, Honda T, Ebato T, Takanashi M, Hirata Y, Miyaji K, Ishikura K. Rhythm-control strategy with oral cilostazol for refractory protein-losing enteropathy and sinus node dysfunction after the Fontan operation: A case report. J Cardiol Cases 2022; 26:272-275. [DOI: 10.1016/j.jccase.2022.05.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2021] [Revised: 05/07/2022] [Accepted: 05/26/2022] [Indexed: 10/17/2022] Open
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Barracano R, Merola A, Fusco F, Scognamiglio G, Sarubbi B. Protein-losing enteropathy in Fontan circulation: Pathophysiology, outcome and treatment options of a complex condition. INTERNATIONAL JOURNAL OF CARDIOLOGY CONGENITAL HEART DISEASE 2022; 7:100322. [PMID: 39712272 PMCID: PMC11658113 DOI: 10.1016/j.ijcchd.2022.100322] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2021] [Revised: 01/01/2022] [Accepted: 01/02/2022] [Indexed: 01/09/2023] Open
Abstract
Protein-losing enteropathy (PLE) represents a rare but severe and potentially life-threatening complication following Fontan operation in patients with a functional single ventricle. PLE is characterized by enteric protein loss, leading to devastating multiorgan involvement with increased morbidity and mortality. In spite of remarkable advances in the care of congenital heart disease in recent years, treatment of PLE is still one of the most challenging tasks due to limited understanding of the underlying mechanisms and lack of high-quality evidence from large scale, controlled studies to test the real efficacy of the several treatment strategies, which have been proposed. For this reason, we herewith aim to discuss the pathogenesis and diagnosis of PLE in Fontan patients as well as provide a comprehensive overview on potential advantages and disadvantages of the currently available therapeutic strategies, in order to propose a stepwise approach for the management of this unique condition.
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Affiliation(s)
| | | | - Flavia Fusco
- Adult Congenital Heart Disease Unit, AO dei Colli, Monaldi Hospital, Naples, Italy
| | | | - Berardo Sarubbi
- Adult Congenital Heart Disease Unit, AO dei Colli, Monaldi Hospital, Naples, Italy
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Abstract
BACKGROUND The incidence of heart failure is increasing within the Fontan population. The use of serological markers, including B-type natriuretic peptide, has been limited in this patient population. METHODS This was a single-centre retrospective study of Fontan patients in acute decompensated heart failure. Fontan patients underwent a 1:2 match with non-Fontan patients for each heart failure hospitalisation for comparative analysis. A univariate logistic regression model was used to assess associations between laboratory and echocardiographic markers and a prolonged length of stay of 7 days or greater. RESULTS B-type natriuretic peptide levels were significantly lower in Fontan patients admitted for heart failure than that in non-Fontan patients [390.9 (±378.7) pg/ml versus 1245.6 (±1160.7) pg/ml, respectively, p < 0.0001] and were higher in Fontan patients with systemic ventricular systolic or diastolic dysfunction than that in Fontan patients with normal systemic ventricular function [833.6 (±1547.2) pg/ml versus 138.6 (±134.0) pg/ml, p = 0.017]. The change from the last known outpatient value was smaller in Fontan patients in comparison with non-Fontan patients [65.7 (±185.7) pg/ml versus 1638.0 (±1444.7) pg/ml, respectively, p < 0.0001]. Low haemoglobin and high blood urea nitrogen levels were associated with a prolonged length of stay. CONCLUSION B-type natriuretic peptide levels do not accurately reflect decompensated heart failure in Fontan patients when compared to non-Fontan heart failure patients and should, therefore, be used with caution in this patient population.
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Rodríguez de Santiago E, Téllez L, Garrido-Lestache Rodríguez-Monte E, Garrido-Gómez E, Aguilera-Castro L, Álvarez-Fuente M, Del Cerro MJ, Albillos A, Romera R, Olavarria A, Martínez J, Sánchez I. Fontan protein-losing enteropathy is associated with advanced liver disease and a proinflammatory intestinal and systemic state. Liver Int 2020; 40:638-645. [PMID: 31912956 DOI: 10.1111/liv.14375] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/30/2019] [Revised: 01/02/2020] [Accepted: 01/03/2020] [Indexed: 02/13/2023]
Abstract
BACKGROUND AND AIMS Protein-losing enteropathy (PLE) after Fontan surgery carries significant morbimortality. Its pathophysiology and association with other Fontan complications are poorly understood. Our aims were to examine whether Fontan-PLE is associated with greater liver damage and to assess the presence of systemic and intestinal inflammation. METHODS Fontan patients with PLE and Fontan controls without PLE matched for age and Fontan surgery procedure were included. Data were prospectively compiled on blood and stool tests, liver imaging, elastography, cardiac-MRI and cardiac catheterization. RESULTS Twenty-nine Fontan patients were enrolled (14 with PLE and 15 controls without PLE). Patients with PLE had more advanced liver disease estimated by non-invasive methods: blunt liver margins on ultrasonography (71.4% vs 26.7%, P = .027), greater median liver stiffness (25.4 vs 14.5 kPa, P = .003) and higher FIB-4 (P = .016). Portal hypertension-related signs were more common in patients with PLE including ascites (P = .035), larger spleen size (P = .005), oesophageal varices/splanchnic collateral shunts (P = .03), higher liver stiffness-spleen size-to-platelet ratio risk score (P < .001) and lower platelet count (P = .01). Systemic proinflammatory cytokines (TNF-α, interleukin-6), biomarkers of intestinal permeability (intestinal fatty-acid binding protein) and faecal calprotectin concentrations were also significantly increased in Fontan-PLE (P < .05). Faecal calprotectin directly correlated with alpha-1 antitrypsin clearance and inversely with cardiac index, total serum proteins and body mass index. CONCLUSION Fontan-PLE is associated with advanced liver disease and increased markers of systemic inflammation and intestinal permeability. Faecal calprotectin is elevated and correlates with Fontan-PLE severity. Liver assessment is mandatory in all Fontan patients, and especially in those with PLE.
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Affiliation(s)
- Enrique Rodríguez de Santiago
- Department of Gastroenterology and Hepatology, Hospital Universitario Ramón y Cajal, University of Alcala, Madrid, Spain.,Instituto Ramón y Cajal de Investigación Biosanitaria, IRYCIS, Madrid, Spain
| | - Luis Téllez
- Department of Gastroenterology and Hepatology, Hospital Universitario Ramón y Cajal, University of Alcala, Madrid, Spain.,Instituto Ramón y Cajal de Investigación Biosanitaria, IRYCIS, Madrid, Spain.,Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBEREHD), Instituto de Salud Carlos III, Madrid, Spain
| | - Elvira Garrido-Lestache Rodríguez-Monte
- Instituto Ramón y Cajal de Investigación Biosanitaria, IRYCIS, Madrid, Spain.,Paediatric Cardiology Department and Grown Up Congenital Heart Disease, Hospital Universitario Ramón y Cajal, University of Alcala, Madrid, Spain
| | - Elena Garrido-Gómez
- Department of Gastroenterology and Hepatology, Hospital Universitario Ramón y Cajal, University of Alcala, Madrid, Spain.,Instituto Ramón y Cajal de Investigación Biosanitaria, IRYCIS, Madrid, Spain
| | - Lara Aguilera-Castro
- Department of Gastroenterology and Hepatology, Hospital Universitario Ramón y Cajal, University of Alcala, Madrid, Spain
| | - María Álvarez-Fuente
- Instituto Ramón y Cajal de Investigación Biosanitaria, IRYCIS, Madrid, Spain.,Paediatric Cardiology Department and Grown Up Congenital Heart Disease, Hospital Universitario Ramón y Cajal, University of Alcala, Madrid, Spain
| | - María Jesús Del Cerro
- Instituto Ramón y Cajal de Investigación Biosanitaria, IRYCIS, Madrid, Spain.,Paediatric Cardiology Department and Grown Up Congenital Heart Disease, Hospital Universitario Ramón y Cajal, University of Alcala, Madrid, Spain
| | - Agustín Albillos
- Department of Gastroenterology and Hepatology, Hospital Universitario Ramón y Cajal, University of Alcala, Madrid, Spain.,Instituto Ramón y Cajal de Investigación Biosanitaria, IRYCIS, Madrid, Spain.,Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBEREHD), Instituto de Salud Carlos III, Madrid, Spain
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Zentner D, Celermajer DS, Gentles T, d’Udekem Y, Ayer J, Blue GM, Bridgman C, Burchill L, Cheung M, Cordina R, Culnane E, Davis A, du Plessis K, Eagleson K, Finucane K, Frank B, Greenway S, Grigg L, Hardikar W, Hornung T, Hynson J, Iyengar AJ, James P, Justo R, Kalman J, Kasparian N, Le B, Marshall K, Mathew J, McGiffin D, McGuire M, Monagle P, Moore B, Neilsen J, O’Connor B, O’Donnell C, Pflaumer A, Rice K, Sholler G, Skinner JR, Sood S, Ward J, Weintraub R, Wilson T, Wilson W, Winlaw D, Wood A. Management of People With a Fontan Circulation: a Cardiac Society of Australia and New Zealand Position statement. Heart Lung Circ 2020; 29:5-39. [DOI: 10.1016/j.hlc.2019.09.010] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2019] [Accepted: 09/16/2019] [Indexed: 02/07/2023]
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