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Ryu YH, Song MK, Lee SY, Kim GB, Kim YJ, Bae EJ. Late development of intra-atrial reentrant tachycardia in lateral tunnel Fontan patients and the preventive role of prophylactic cryoablation. J Thorac Cardiovasc Surg 2024; 168:933-942.e2. [PMID: 37992960 DOI: 10.1016/j.jtcvs.2023.11.028] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/06/2023] [Revised: 11/13/2023] [Accepted: 11/15/2023] [Indexed: 11/24/2023]
Abstract
OBJECTIVE Intra-atrial reentrant tachycardia is an important late-onset complication in patients undergoing the Fontan procedure. However, the protective effects of prophylactic cryoablation against late-onset intra-atrial reentrant tachycardia are unclear. This study investigated the late development of intra-atrial reentrant tachycardia in patients undergoing the lateral tunnel Fontan procedure and the role of prophylactic cryoablation. METHODS This was a single-center retrospective cohort study of patients who underwent the lateral tunnel Fontan procedure between 1988 and 2003. Univariate and multivariable competing risks regression models were used to determine the associations of prophylactic cryoablation and covariates with the outcomes of interest: late-onset intra-atrial reentrant tachycardia, all-cause mortality, and cardiovascular mortality. RESULTS In total, 130 patients who underwent the lateral tunnel Fontan procedure, 30 of whom had undergone prophylactic cryoablation, were included in this study and followed up for a median of 23.6 years (interquartile range, 17.7-26.5). Intra-atrial reentrant tachycardia was identified in 14 patients (10.8%), none of whom underwent prophylactic cryoablation. The median Fontan-to-intra-atrial reentrant tachycardia time was 17.2 years (interquartile range, 11.1-23.1). Prophylactic cryoablation was protective against late-onset intra-atrial reentrant tachycardia (P < .0001) and cardiovascular mortality (P < .0001) in the type 3 test. CONCLUSIONS None of the patients who underwent prophylactic cryoablation developed late-onset intra-atrial reentrant tachycardia during a median follow-up time of 22.9 years. Our study demonstrated that prophylactic cryoablation was effective in preventing late-onset intra-atrial reentrant tachycardia and cardiovascular mortality in patients undergoing the lateral tunnel Fontan.
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Affiliation(s)
- Young Hye Ryu
- Department of Pediatrics, Seoul National University Children's Hospital, Seoul National University College of Medicine, Seoul, South Korea
| | - Mi Kyoung Song
- Department of Pediatrics, Seoul National University Children's Hospital, Seoul National University College of Medicine, Seoul, South Korea
| | - Sang-Yun Lee
- Department of Pediatrics, Seoul National University Children's Hospital, Seoul National University College of Medicine, Seoul, South Korea
| | - Gi Beom Kim
- Department of Pediatrics, Seoul National University Children's Hospital, Seoul National University College of Medicine, Seoul, South Korea
| | - Yong Jin Kim
- Department of Thoracic and Cardiovascular Surgery, Sejong General Hospital, Bucheon, South Korea
| | - Eun-Jung Bae
- Department of Pediatrics, Seoul National University Children's Hospital, Seoul National University College of Medicine, Seoul, South Korea.
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Small AJ, Dai M, Halpern DG, Tan RB. Updates in Arrhythmia Management in Adult Congenital Heart Disease. J Clin Med 2024; 13:4314. [PMID: 39124581 PMCID: PMC11312906 DOI: 10.3390/jcm13154314] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2024] [Revised: 07/11/2024] [Accepted: 07/18/2024] [Indexed: 08/12/2024] Open
Abstract
Arrhythmias are highly prevalent in adults with congenital heart disease. For the clinician caring for this population, an understanding of pathophysiology, diagnosis, and management of arrhythmia is essential. Herein we review the latest updates in diagnostics and treatment of tachyarrhythmias and bradyarrhythmias, all in the context of congenital anatomy, hemodynamics, and standard invasive palliations for congenital heart disease.
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Affiliation(s)
- Adam J. Small
- Medicine NYU Grossman School of Medicine, 530 First Ave, HCC 5, New York, NY 10016, USA; (M.D.); (D.G.H.); (R.B.T.)
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Venkatesh P, Gao H, Abudayyeh I, Pai RG, Varadarajan P. Contemporary Management of the Failing Fontan. J Clin Med 2024; 13:3049. [PMID: 38892760 PMCID: PMC11172880 DOI: 10.3390/jcm13113049] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2024] [Revised: 05/19/2024] [Accepted: 05/21/2024] [Indexed: 06/21/2024] Open
Abstract
Adult patients with congenital heart disease have now surpassed the pediatric population due to advances in surgery and improved survival. One such complex congenital heart disease seen in adult patients is the Fontan circulation. These patients have complex physiology and are at risk for several complications, including thrombosis of the Fontan pathway, pulmonary vascular disease, heart failure, atrial arrhythmias, atrioventricular valve regurgitation, and protein-losing enteropathy. This review discusses the commonly encountered phenotypes of Fontan circulatory failure and their contemporary management.
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Affiliation(s)
- Prashanth Venkatesh
- Smidt Heart Institute, Department of Cardiology, Cedars-Sinai Medical Center, Los Angeles, CA 90048, USA; (P.V.); (H.G.)
| | - Hans Gao
- Smidt Heart Institute, Department of Cardiology, Cedars-Sinai Medical Center, Los Angeles, CA 90048, USA; (P.V.); (H.G.)
| | | | - Ramdas G. Pai
- California University of Science and Medicine, Colton, CA 92324, USA;
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O'Leary E, Valente AM, Tadros T. Tempering the Storm of Arrhythmias in Adults With Congenital Heart Disease. J Am Heart Assoc 2024; 13:e9566. [PMID: 38629434 PMCID: PMC11179894 DOI: 10.1161/jaha.124.034536] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/19/2024] [Accepted: 03/13/2024] [Indexed: 04/21/2024]
Affiliation(s)
- Edward O'Leary
- Department of CardiologyBoston Children’s HospitalBostonMAUSA
- Harvard Medical SchoolBostonMAUSA
| | - Anne Marie Valente
- Department of CardiologyBoston Children’s HospitalBostonMAUSA
- Department of Cardiology MedicineDivision of CardiologyBrigham and Women’s HospitalBostonMAUSA
- Harvard Medical SchoolBostonMAUSA
| | - Thomas Tadros
- Department of Cardiology MedicineDivision of CardiologyBrigham and Women’s HospitalBostonMAUSA
- Harvard Medical SchoolBostonMAUSA
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Bohn C, Schaeffer T, Cuman M, Staehler H, Di Padua C, Heinisch PP, Piber N, Hager A, Ewert P, Hörer J, Ono M. Tachyarrhythmia after the total cavopulmonary connection: incidence, prognosis, and risk factors. Cardiol Young 2024; 34:713-721. [PMID: 37730655 DOI: 10.1017/s1047951123003141] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 09/22/2023]
Abstract
OBJECTIVE The purpose of this study is to evaluate the incidence and outcomes regarding tachyarrhythmia in patients after total cavopulmonary connection. METHODS A retrospective analysis of 620 patients who underwent total cavopulmonary connection between 1994 and 2021 at our institution was performed. Incidence of tachyarrhythmia was depicted, and results after onset of tachyarrhythmia were evaluated. Factors associated with the onset of tachyarrhythmia were identified. RESULTS A total of 52 (8%) patients presented with tachyarrhythmia that required medical therapy. Onset during hospital stay was observed in 27 patients, and onset after hospital discharge was observed in 32 patients. Freedom from late tachyarrhythmia following total cavopulmonary connection at 5, 10, and 15 years was 97, 95, and 91%, respectively. The most prevalent late tachyarrhythmia was atrial flutter (50%), followed by supraventricular tachycardia (25%) and ventricular tachycardia (25%). Direct current cardioversion was required in 12 patients, and 7 patients underwent electrophysiological study. Freedom from Fontan circulatory failure after onset of tachyarrhythmia at 10 and 15 years was 78% and 49%, respectively. Freedom from occurrence of decreased ventricular systolic function after the onset of tachyarrhythmia at 5 years was 85%. Independent factors associated with late tachyarrhythmia were dominant right ventricle (hazard ratio, 2.52, p = 0.02) and weight at total cavopulmonary connection (hazard ratio, 1.03 per kilogram; p = 0.04). Type of total cavopulmonary connection at total cavopulmonary connection was not identified as risk. CONCLUSIONS In our large cohort of 620 patients following total cavopulmonary connection, the incidence of late tachyarrhythmia was low. Patients with dominant right ventricle and late total cavopulmonary connection were at increased risk for late tachyarrhythmia following total cavopulmonary connection.
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Affiliation(s)
- Cornelius Bohn
- Department of Congenital and Pediatric Heart Surgery, German Heart Center Munich, Technische Universität München, Division of Congenital and Pediatric Heart Surgery, University Hospital of Munich, Ludwig-Maximilians-Universität, Munich, Germany
| | - Thibault Schaeffer
- Department of Congenital and Pediatric Heart Surgery, German Heart Center Munich, Technische Universität München, Division of Congenital and Pediatric Heart Surgery, University Hospital of Munich, Ludwig-Maximilians-Universität, Munich, Germany
| | - Magdalena Cuman
- Department of Congenital Heart Disease and Pediatric Cardiology, German Heart Center Munich, Technische Universität München, Munich, Germany
| | - Helena Staehler
- Department of Congenital and Pediatric Heart Surgery, German Heart Center Munich, Technische Universität München, Division of Congenital and Pediatric Heart Surgery, University Hospital of Munich, Ludwig-Maximilians-Universität, Munich, Germany
| | - Chiara Di Padua
- Department of Congenital and Pediatric Heart Surgery, German Heart Center Munich, Technische Universität München, Division of Congenital and Pediatric Heart Surgery, University Hospital of Munich, Ludwig-Maximilians-Universität, Munich, Germany
| | - Paul Philipp Heinisch
- Department of Congenital and Pediatric Heart Surgery, German Heart Center Munich, Technische Universität München, Division of Congenital and Pediatric Heart Surgery, University Hospital of Munich, Ludwig-Maximilians-Universität, Munich, Germany
| | - Nicole Piber
- Department of Cardiovascular Surgery, German Heart Center Munich, Technische Universität München, Munich, Germany
| | - Alfred Hager
- Department of Congenital Heart Disease and Pediatric Cardiology, German Heart Center Munich, Technische Universität München, Munich, Germany
| | - Peter Ewert
- Department of Congenital Heart Disease and Pediatric Cardiology, German Heart Center Munich, Technische Universität München, Munich, Germany
| | - Jürgen Hörer
- Department of Congenital and Pediatric Heart Surgery, German Heart Center Munich, Technische Universität München, Division of Congenital and Pediatric Heart Surgery, University Hospital of Munich, Ludwig-Maximilians-Universität, Munich, Germany
| | - Masamichi Ono
- Department of Congenital and Pediatric Heart Surgery, German Heart Center Munich, Technische Universität München, Division of Congenital and Pediatric Heart Surgery, University Hospital of Munich, Ludwig-Maximilians-Universität, Munich, Germany
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6
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Egbe AC, Connolly HM. Heart Failure Staging and Indications for Advanced Therapies in Adults with Congenital Heart Disease. Heart Fail Clin 2024; 20:147-154. [PMID: 38462319 DOI: 10.1016/j.hfc.2023.12.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/12/2024]
Abstract
Heart failure (HF) is common in adults with congenital heart disease (CHD), and it is the leading cause of death in this population. Adults with CHD presenting with stage D HF have a poor prognosis, and early recognition of signs of advanced HF and referral for advanced therapies for HF offer the best survival as compared with other therapies. The indications for advanced therapies for HF outlined in this article should serve as a guide for clinicians to determine the optimal time for referral. Palliative care should be part of the multidisciplinary care model for HF in patients with CHD.
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Affiliation(s)
- Alexander C Egbe
- Department of Cardiovascular Medicine, Mayo Clinic and Foundation, 200 First Street Southwest, Rochester, MN 55905, USA.
| | - Heidi M Connolly
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN 55905, USA
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Well A, Dawson C, Johnson G, Patt H, Fraser CD, Mery CM, Beckerman Z. Hospitalisations of children and adults with Hypoplastic Left Heart Syndrome in Texas from 2009 to 2019. Cardiol Young 2023; 33:1819-1827. [PMID: 36220311 DOI: 10.1017/s1047951122003146] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
INTRODUCTION Hypoplastic Left Heart Syndrome accounts for a significant proportion of CHD morbidity and mortality, despite improvements in care and improved survival. This study evaluates number of, reasons for, and trends in discharges of patients with hypoplastic left heart syndrome over 11 years in Texas. METHODS The Texas Inpatient Discharge Dataset Public Use File captures almost all discharges in Texas and was reviewed from 2009 to 2019. Discharges of patients ≥5 years of age and diagnosis codes for Hypoplastic Left Heart Syndrome were included. The admitting and principle diagnoses were categorised and all discharges were evaluated for procedures performed. Descriptive and univariate statistical analyses were performed. RESULTS A total of 1024 discharges were identified with a 16.9% annual increase over the study period. Median length of stay was 4 [IQR: 2-8] and there were 17 (1.7%) in-hospital mortalities with no differences across age groups. Seven (17.1%) discharges of patients 25+ years were uninsured, higher than other age groups (p < 0.001). The most common admitting diagnosis was CHD and 224 (21.9%) of discharges included a procedure, including 23 heart transplants. Discharges occurred from 67 different hospitals with 4 (6.0%) representing 71.4% of all discharges. CONCLUSIONS Discharges of Hypoplastic Left Heart Syndrome have increased rapidly, particularly in the older age groups and were spread over a large number of hospitals. Further work is needed to understand the interplay between Hypoplastic Left Heart Syndrome and other conditions and care experiences that occur within the general population, which will become more common as this population ages and grows.
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Affiliation(s)
- Andrew Well
- Texas Center for Pediatric and Congenital Heart Disease, UT Health Austin and Dell Children's Medical Center, Austin, TX, USA
- Department of Surgery and Perioperative Care, University of Texas at Austin Dell Medical School, Austin, TX, USA
| | - Catherine Dawson
- Texas Center for Pediatric and Congenital Heart Disease, UT Health Austin and Dell Children's Medical Center, Austin, TX, USA
- University of Texas at Austin Dell Medical School, Austin, TX, USA
| | - Gregory Johnson
- Texas Center for Pediatric and Congenital Heart Disease, UT Health Austin and Dell Children's Medical Center, Austin, TX, USA
- Department of Pediatrics, University of Texas at Austin Dell Medical School, Austin, TX, USA
| | - Hanoch Patt
- Texas Center for Pediatric and Congenital Heart Disease, UT Health Austin and Dell Children's Medical Center, Austin, TX, USA
- Department of Pediatrics, University of Texas at Austin Dell Medical School, Austin, TX, USA
| | - Charles D Fraser
- Texas Center for Pediatric and Congenital Heart Disease, UT Health Austin and Dell Children's Medical Center, Austin, TX, USA
- Department of Surgery and Perioperative Care, University of Texas at Austin Dell Medical School, Austin, TX, USA
| | - Carlos M Mery
- Texas Center for Pediatric and Congenital Heart Disease, UT Health Austin and Dell Children's Medical Center, Austin, TX, USA
- Department of Surgery and Perioperative Care, University of Texas at Austin Dell Medical School, Austin, TX, USA
| | - Ziv Beckerman
- Texas Center for Pediatric and Congenital Heart Disease, UT Health Austin and Dell Children's Medical Center, Austin, TX, USA
- Department of Surgery and Perioperative Care, University of Texas at Austin Dell Medical School, Austin, TX, USA
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8
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Egbe AC, Miranda WR, Madhavan M, Abozied O, Younis AK, Ahmed MH, Connolly HM, Deshmukh AJ. Right atrial dysfunction is associated with atrial arrhythmias in adults with repaired tetralogy of fallot. Am Heart J 2023; 263:141-150. [PMID: 37271358 DOI: 10.1016/j.ahj.2023.05.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/13/2023] [Revised: 05/26/2023] [Accepted: 05/30/2023] [Indexed: 06/06/2023]
Abstract
BACKGROUND Adults with repaired tetralogy of Fallot (TOF) have right atrial (RA) remodeling and dysfunction, and RA function can be measured using speckle tracking echocardiography. There are limited data about the role of RA strain imaging for risk stratification in this population. We hypothesized that RA reservoir strain can identify TOF patients at risk of developing atrial arrhythmia. To test this hypothesis, we assessed the relationship between RA reservoir strain and atrial arrhythmias in adults with repaired TOF. METHOD Retrospective cohort study of adults with repaired TOF, and no prior history of atrial arrhythmias. Atrial arrhythmia was defined as atrial fibrillation, atrial flutter/atrial tachycardia, and categorized as new-onset versus recurrent atrial arrhythmias. RESULTS We identified 426 patients (age 33 ± 12 years; males 208 (49%)) that met the inclusion criteria. The mean RA reservoir strain, conduit strain, and booster strain were 34 ± 11%, 20 ± 9%, and 15 ± 12%, respectively. Of 426 patients, 73 (17%) developed new-onset atrial arrhythmias (atrial flutter/tachycardia n = 42; atrial fibrillation n = 31); annual incidence 1.9%. RA reservoir strain was associated with new-onset atrial arrhythmias (adjusted HR 0.95, 95% CI 0.93-0.97) after multivariable adjustment. Of 73 patients with new-onset atrial arrhythmia, 41 (56%) had recurrent atrial arrhythmia (atrial flutter/tachycardia n = 18; atrial fibrillation n = 23); annual incidence 11.2%. Similarly, RA reservoir strain was associated with recurrent atrial arrhythmias (adjusted HR 0.92, 95% CI 0.88-0.96) after multivariable adjustment. CONCLUSIONS RA strain indices can identify patients at risk for atrial arrhythmias, and this can in turn, be used to guide the type/intensity of therapy in such patients.
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Affiliation(s)
- Alexander C Egbe
- Department of Cardiovascular Medicine, Mayo Clinic Rochester, Rochester, MN.
| | - William R Miranda
- Department of Cardiovascular Medicine, Mayo Clinic Rochester, Rochester, MN
| | - Malini Madhavan
- Department of Cardiovascular Medicine, Mayo Clinic Rochester, Rochester, MN
| | - Omar Abozied
- Department of Cardiovascular Medicine, Mayo Clinic Rochester, Rochester, MN
| | - Ahmed K Younis
- Department of Cardiovascular Medicine, Mayo Clinic Rochester, Rochester, MN
| | - Marwan H Ahmed
- Department of Cardiovascular Medicine, Mayo Clinic Rochester, Rochester, MN
| | - Heidi M Connolly
- Department of Cardiovascular Medicine, Mayo Clinic Rochester, Rochester, MN
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Kamp A, Moore JP, Khairy P. How to Perform Catheter Ablation of Atrial Tachyarrhythmia after the Fontan Operation. Heart Rhythm 2023:S1547-5271(23)00294-1. [PMID: 36963742 DOI: 10.1016/j.hrthm.2023.03.023] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/16/2023] [Revised: 03/13/2023] [Accepted: 03/16/2023] [Indexed: 03/26/2023]
Affiliation(s)
- Anna Kamp
- Nationwide Children's Hospital, The Ohio State University, Columbus, OH
| | - Jeremy P Moore
- Ahmanson/UCLA Adult Congenital Heart Disease Center, Los Angeles, CA
| | - Paul Khairy
- Montreal Heart Institute, Université de Montréal, Montreal, Canada.
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10
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Kamp AN, Nair K, Fish FA, Khairy P. Catheter ablation of atrial arrhythmias in patients post-Fontan. Can J Cardiol 2022; 38:1036-1047. [PMID: 35240252 DOI: 10.1016/j.cjca.2022.02.023] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2021] [Revised: 02/18/2022] [Accepted: 02/20/2022] [Indexed: 12/25/2022] Open
Abstract
Atrial arrhythmias are highly prevalent in the aging Fontan population and contribute importantly to morbidity and mortality. Although the most common arrhythmia is scar-based intra-atrial re-entrant tachycardia, various other arrhythmias may occur including focal atrial tachycardia, atrioventricular node-dependent tachycardias, and atrial fibrillation. The type and prevalence of atrial arrhythmia is determined, in part, by the underlying congenital defect and variant of Fontan surgery. While the cumulative incidence of atrial tachyarrhythmias has decreased substantially from the atriopulmonary anastomosis to the more recent total cavopulmonary connection Fontan, the burden of atrial arrhythmias remains substantial. Management is often multi-faceted and can include anticoagulation, anti-arrhythmic drug therapy, pacing, and cardioversion. Catheter ablation plays a key role in arrhythmia control. Risks and benefits must be carefully weighed. Among the important considerations are the clinical burden of arrhythmia, ventricular function, hemodynamic stability in tachycardia, suspected arrhythmia mechanisms, risks associated with anaesthesia, venous access, approaches to reaching the pulmonary venous atrium, and accompanying co-morbidities. Careful review of surgical notes, electrocardiographic tracings, and advanced imaging is paramount, with particular attention to anatomic abnormalities such as venous obstructions and displaced conduction systems. Despite numerous challenges, ablation of atrial arrhythmias is effective in improving clinical status. Nevertheless, onset of new arrhythmias is common during long-term follow-up. Advanced technologies such as high-density mapping catheters and remote magnetic guided ablation carry the potential to further improve outcomes. Fontan patients with atrial arrhythmias should be referred to centers with dedicated expertise in congenital heart disease including catheter ablation, anaesthesia support, and advanced imaging.
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Affiliation(s)
- Anna N Kamp
- Nationwide Children's Hospital, Ohio State University, Columbus, OH, USA
| | - Krishnakumar Nair
- University Health Network, Toronto General Hospital, Toronto, Canada
| | - Frank A Fish
- Vanderbilt University Medical Center, Nashville, TN, USA; and
| | - Paul Khairy
- Montreal Heart Institute, Université de Montréal, Montreal, Quebec, Canada.
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11
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Kamsheh AM, O'Connor MJ, Rossano JW. Management of circulatory failure after Fontan surgery. Front Pediatr 2022; 10:1020984. [PMID: 36425396 PMCID: PMC9679629 DOI: 10.3389/fped.2022.1020984] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/16/2022] [Accepted: 10/18/2022] [Indexed: 11/11/2022] Open
Abstract
With improvement in survival after Fontan surgery resulting in an increasing number of older survivors, there are more patients with a Fontan circulation experiencing circulatory failure each year. Fontan circulatory failure may have a number of underlying etiologies. Once Fontan failure manifests, prognosis is poor, with patient freedom from death or transplant at 10 years of only about 40%. Medical treatments used include traditional heart failure medications such as renin-angiotensin-aldosterone system blockers and beta-blockers, diuretics for symptomatic management, antiarrhythmics for rhythm control, and phosphodiesterase-5 inhibitors to decrease PVR and improve preload. These oral medical therapies are typically not very effective and have little data demonstrating benefit; if there are no surgical or catheter-based interventions to improve the Fontan circulation, patients with severe symptoms often require inotropic medications or mechanical circulatory support. Mechanical circulatory support benefits patients with ventricular dysfunction but may not be as useful in patients with other forms of Fontan failure. Transplant remains the definitive treatment for circulatory failure after Fontan, but patients with a Fontan circulation face many challenges both before and after transplant. There remains significant room and urgent need for improvement in the management and outcomes of patients with circulatory failure after Fontan surgery.
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Affiliation(s)
- Alicia M Kamsheh
- Division of Cardiology, Children's Hospital of Philadelphia, United States
| | - Matthew J O'Connor
- Division of Cardiology, Children's Hospital of Philadelphia, United States
| | - Joseph W Rossano
- Division of Cardiology, Children's Hospital of Philadelphia, United States
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12
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Driesen BW, Voskuil M, Grotenhuis HB. Current Treatment Options for the Failing Fontan Circulation. Curr Cardiol Rev 2022; 18:e060122200067. [PMID: 34994331 PMCID: PMC9893132 DOI: 10.2174/1573403x18666220106114518] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/21/2020] [Revised: 10/22/2021] [Accepted: 11/16/2021] [Indexed: 11/22/2022] Open
Abstract
The Fontan operation was introduced in 1968. For congenital malformations, where biventricular repair is unsuitable, the Fontan procedure has provided a long-term palliation strategy with improved outcomes compared to the initially developed procedures. Despite these improvements, several complications merely due to a failing Fontan circulation, including myocardial dysfunction, arrhythmias, increased pulmonary vascular resistance, protein-losing enteropathy, hepatic dysfunction, plastic bronchitis, and thrombo-embolism, may occur, thereby limiting the life-expectancy in this patient cohort. This review provides an overview of the most common complications of Fontan circulation and the currently available treatment options.
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Affiliation(s)
- Bart W. Driesen
- Department of Pediatric Cardiology, Wilhelmina Children’s Hospital, University Medical Center, Utrecht, Utrecht, The Netherlands
- Department of Cardiology, University Medical Center Utrecht, Utrecht, The Netherlands
- Department of Cardiology, Laurentius Ziekenhuis, Roermond, The Netherlands
| | - Michiel Voskuil
- Department of Cardiology, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Heynric B. Grotenhuis
- Department of Pediatric Cardiology, Wilhelmina Children’s Hospital, University Medical Center, Utrecht, Utrecht, The Netherlands
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13
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Villa CR, Lorts A, Morales DLS. Ventricular Assist Device Therapy in the Fontan Circulation. Semin Thorac Cardiovasc Surg Pediatr Card Surg Annu 2021; 24:19-25. [PMID: 34116777 DOI: 10.1053/j.pcsu.2021.01.001] [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: 09/28/2020] [Revised: 01/04/2021] [Accepted: 01/14/2021] [Indexed: 12/25/2022]
Abstract
The number of Fontan patients with circulatory failure and systolic dysfunction is growing rapidly. The last decade has demonstrated that ventricular assist device (VAD) is an effective therapy in properly selected patients. Herein, we discuss the current approach to patient selection, implantation, and patient management.
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Affiliation(s)
- Chet R Villa
- The Heart Institute, Cincinnati Children's Hospital Medical Center, University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - Angela Lorts
- The Heart Institute, Cincinnati Children's Hospital Medical Center, University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - David L S Morales
- The Heart Institute, Cincinnati Children's Hospital Medical Center, University of Cincinnati College of Medicine, Cincinnati, Ohio.
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14
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Egbe AC, Miranda WR, Devara J, Shaik L, Iftikhar M, Goda Sakr A, John A, Cedars A, Rodriguez F, Moore JP, Russell M, Grewal J, Ginde S, Lubert AM, Connolly HM. Recurrent sustained atrial arrhythmias and thromboembolism in Fontan patients with total cavopulmonary connection. IJC HEART & VASCULATURE 2021; 33:100754. [PMID: 33786365 PMCID: PMC7988316 DOI: 10.1016/j.ijcha.2021.100754] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2021] [Revised: 02/25/2021] [Accepted: 02/27/2021] [Indexed: 11/29/2022]
Abstract
Background Total cavopulmonary connection (TCPC) is associated with a lower risk of incident atrial arrhythmias as compared to atriopulmonary Fontan, but the risk of recurrent atrial arrhythmias is unknown in this population. The purpose of this study was to determine the incidence and risk factors for recurrent atrial arrhythmias and thromboembolic complications in patients with TCPC. Methods This is a retrospective multicenter study conducted by the Alliance for Adult Research in Congenital Cardiology (AARCC), 2000-2018. The inclusion criteria were TCPC patients (age > 15 years) with prior history of atrial arrhythmia. Results A total of 103 patients (age 26 ± 7 years; male 58 [56%]) met inclusion criteria. The mean age at initial arrhythmia diagnosis was 13 ± 5 years, and atrial arrhythmias were classified as atrial flutter/tachycardia in 85 (83%) and atrial fibrillation in 18 (17%). The median duration of follow-up from the first episode of atrial arrhythmia was 14.9 (12.1-17.3) years, and during this period 64 (62%) patients had recurrent atrial arrhythmias (atrial flutter/tachycardia 51 [80%] and atrial fibrillation 13 [20%]) with annual incidence of 4.4%. Older age was a risk factor for arrhythmia recurrence while the use of a class III anti-arrhythmic drug was associated with a lower risk of recurrent arrhythmias. The incidence of thromboembolic complication was 0.6% per year, and the cumulative incidence was 4% and 7% at 5 and 10 years respectively from the time of first atrial arrhythmia diagnosis. There were no identifiable risk factors for thromboembolic complications in this cohort. Conclusions Although TCPC provides superior flow dynamics and lower risk of incident atrial arrhythmias, there is a significant risk of recurrent arrhythmias among TCPC patients with a prior history of atrial arrhythmias. These patients may require more intensive arrhythmia surveillance as compared to other TCPC patients.
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Affiliation(s)
- Alexander C Egbe
- Department of Cardiovascular Medicine, Mayo Clinic Rochester, MN, United States
| | - William R Miranda
- Department of Cardiovascular Medicine, Mayo Clinic Rochester, MN, United States
| | - Janaki Devara
- Department of Cardiovascular Medicine, Mayo Clinic Rochester, MN, United States
| | - Likhita Shaik
- Department of Cardiovascular Medicine, Mayo Clinic Rochester, MN, United States
| | - Momina Iftikhar
- Department of Cardiovascular Medicine, Mayo Clinic Rochester, MN, United States
| | - Ahmed Goda Sakr
- Department of Cardiovascular Medicine, Mayo Clinic Rochester, MN, United States
| | - Anitha John
- Children's National Hospital, Washington DC, United States
| | - Ari Cedars
- University of Texas, Southwestern Medical Center, United States
| | - Fred Rodriguez
- Emory University Hospital and Children's Healthcare of Atlanta, GA, United States
| | - Jeremy P Moore
- Ahmanson/UCLA Adult Congenital Heart Disease Center, UCLA Medical Center, Los Angeles, CA, United States
| | - Matthew Russell
- Ahmanson/UCLA Adult Congenital Heart Disease Center, UCLA Medical Center, Los Angeles, CA, United States
| | - Jasmine Grewal
- University of British Columbia, Vancouver, United States
| | - Salil Ginde
- Children's Hospital Wisconsin, United States
| | | | - Heidi M Connolly
- Department of Cardiovascular Medicine, Mayo Clinic Rochester, MN, United States
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Alnoor M, Marshall M, Balaji S. Current Treatment Options of Fontan Arrhythmias: Etiology, Incidence, and Diagnosis. CURRENT TREATMENT OPTIONS IN CARDIOVASCULAR MEDICINE 2020. [DOI: 10.1007/s11936-020-00849-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Abstract
Tricuspid atresia (TA) is a complex congenital heart disease that presents with cyanosis in the neonatal period. It is invariably fatal if left untreated and requires multiple stages of palliation. Early recognition and timely surgical intervention are therefore pivotal in the management of these infants. This literature review considers the pathophysiology, presentation, investigations, and classification of TA. Moreover, it discusses the evidence upon which the latest medical and surgical treatments are based, as well as numerous recent case reports. Further work is needed to elucidate the etiology of TA, clarify the role of pharmacotherapy, and optimize the surgical management that these patients receive.
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Affiliation(s)
- Anoop S Sumal
- School of Clinical Medicine, Addenbrooke's Hospital, University of Cambridge, Cambridge, UK
| | - Harry Kyriacou
- School of Clinical Medicine, Addenbrooke's Hospital, University of Cambridge, Cambridge, UK
| | - Ahmed M H A M Mostafa
- School of Clinical Medicine, Addenbrooke's Hospital, University of Cambridge, Cambridge, UK
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Impact of Inferior Venae Cava Assessment in Tetralogy of Fallot. CJC Open 2020; 2:129-134. [PMID: 32462126 PMCID: PMC7242499 DOI: 10.1016/j.cjco.2020.02.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2019] [Accepted: 02/16/2020] [Indexed: 11/23/2022] Open
Abstract
Background Inferior vena cava (IVC) size and collapsibility provide a noninvasive estimate of right heart filling pressures, an important determinant of right heart hemodynamic performance that is not measured by cardiac magnetic resonance imaging (CMRI). We hypothesized that compared with CMRI risk model alone, a combined CMRI-IVC risk model will have better correlation with disease severity and peak oxygen consumption in patients with tetralogy of Fallot (TOF). Methods We performed a retrospective review of patients with TOF with moderate/severe pulmonary regurgitation who underwent CMRI and echocardiography. A CMRI risk model was constructed using right ventricular (RV) end-diastolic volume index, RV end-systolic volume index, RV ejection fraction, and left ventricular ejection fraction. We added IVC hemodynamic classification to the CMRI indices to create CMRI-IVC risk model, and IVC hemodynamics were modeled as a categorical variable: normal vs mild/moderately abnormal (dilated IVC or reduced collapsibility) vs severely abnormal IVC hemodynamics (dilated IVC and reduced collapsibility). We defined disease severity as atrial arrhythmias, ventricular arrhythmias, and heart failure hospitalization. Results Of 207 patients, 131 (63%), 72 (35%), and 4 (2%) had normal, mild/moderately abnormal, and severely abnormal IVC hemodynamics, respectively. Compared with the CMRI risk model, the CMRI-IVC risk model had a better correlation with disease severity (area under the curve, 0.62; 95% confidence interval, 0.51-0.74 vs area under the curve 0.84, 95% confidence interval, 0.78-0.91, P = 0.006) and peak oxygen consumption (r = 0.35, P = 0.042 vs r = 0.43, P = 0.031, Meng test P = 0.026). Conclusions The combined CMRI-IVC risk model had a better correlation with disease severity compared with CMRI indices alone and can potentially improve risk stratification in the population with TOF.
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Broda CR, Downing TE, John AS. Diagnosis and management of the adult patient with a failing Fontan circulation. Heart Fail Rev 2020; 25:633-646. [DOI: 10.1007/s10741-020-09932-0] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
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van der Ven JPG, Alsaied T, Juggan S, Bossers SSM, van den Bosch E, Kapusta L, Kuipers IM, Kroft LJM, Ten Harkel ADJ, van Iperen GG, Rathod RH, Helbing WA. Atrial function in Fontan patients assessed by CMR: Relation with exercise capacity and long-term outcomes. Int J Cardiol 2020; 312:56-61. [PMID: 32139238 DOI: 10.1016/j.ijcard.2020.02.060] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/28/2019] [Revised: 01/21/2020] [Accepted: 02/23/2020] [Indexed: 12/20/2022]
Abstract
OBJECTIVE To assess the role of atrial function on exercise capacity and clinical events in Fontan patients. DESIGN We included 96 Fontan patients from 6 tertiary centers, aged 12.8 (IQR 10.1-15.6) years, who underwent cardiac magnetic resonance imaging and cardiopulmonary exercise testing within 12 months of each other from 2004 to 2017. Intra-atrial lateral tunnel (ILT) and extracardiac conduit (ECC) patients were matched 1:1 with regard to age, gender and dominant ventricle. The pulmonary venous atrium was manually segmented in all phases and slices. Atrial function was assessed by volume-time curves. Furthermore, atrial longitudinal and circumferential feature tracking strain was assessed. We determined the relation between atrial function and exercise capacity, assessed by peak oxygen uptake and VE/VCO2 slope, and events (mortality, listing for transplant, re-intervention, arrhythmia) during follow-up. RESULTS Atrial maximal and minimal volumes did not differ between ILT and ECC patients. ECC patients had higher reservoir function (21.1 [16.4-28.0]% vs 18.2 [10.9-22.2]%, p = .03), lower conduit function and lower total circumferential strain (13.8 ± 5.1% vs 18.0 ± 8.7%, p = .01), compared to ILT patients. Only for ECC patients, a better late peak circumferential strain rate predicted better VE/VCO2 slope. No other parameter of atrial function predicted peak oxygen uptake or VE/VCO2 slope. During a median follow-up of 6.2 years, 42 patients reached the composite end-point. No atrial function parameters predicted events during follow-up. CONCLUSIONS ECC patients have higher atrial reservoir function and lower conduit function. Atrial function did not predict exercise capacity or events during follow-up.
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Affiliation(s)
- Jelle P G van der Ven
- Department of Pediatrics, Division of Cardiology, Erasmus Medical Centre - Sophia Children's Hospital, Rotterdam, the Netherlands; Netherlands Heart Institute, Utrecht, the Netherlands
| | - Tarek Alsaied
- Department of Cardiology, Boston Children's Hospital and Department of Pediatrics, Harvard Medical School, Boston, MA, USA; Department of Cardiology, Cincinnati Children's Hospital, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Saeed Juggan
- Department of Cardiology, Boston Children's Hospital and Department of Pediatrics, Harvard Medical School, Boston, MA, USA
| | - Sjoerd S M Bossers
- Department of Pediatrics, Division of Cardiology, Erasmus Medical Centre - Sophia Children's Hospital, Rotterdam, the Netherlands
| | - Eva van den Bosch
- Department of Pediatrics, Division of Cardiology, Erasmus Medical Centre - Sophia Children's Hospital, Rotterdam, the Netherlands; Netherlands Heart Institute, Utrecht, the Netherlands
| | - Livia Kapusta
- Department of Pediatrics, Division of Cardiology, Radboud University Nijmegen Medical Centre, Nijmegen, the Netherlands; Pediatric Cardiology Unit, Tel-Aviv Sourasky Medical Center, Tel Aviv University Sackler School of Medicine, Tel Aviv, Israel
| | - Irene M Kuipers
- Department of Pediatrics, Division of Cardiology, Academic Medical Centre, Amsterdam, the Netherlands
| | - Lucia J M Kroft
- Department of Radiology, Leiden University Medical Centre, Leiden, the Netherlands
| | - Arend D J Ten Harkel
- Department of Pediatrics, Division of Cardiology, Leiden University Medical Centre, Leiden, the Netherlands
| | - Gabrielle G van Iperen
- Department of Pediatrics, Division of Cardiology, University Medical Centre Utrecht - Wilhelmina Children's Hospital, Utrecht, the Netherlands
| | - Rahul H Rathod
- Department of Cardiology, Boston Children's Hospital and Department of Pediatrics, Harvard Medical School, Boston, MA, USA
| | - Willem A Helbing
- Department of Pediatrics, Division of Cardiology, Erasmus Medical Centre - Sophia Children's Hospital, Rotterdam, the Netherlands; Department of Radiology, Erasmus Medical Centre, Rotterdam, the Netherlands; Department of Pediatrics, Division of Cardiology, Radboud University Nijmegen Medical Centre, Nijmegen, the Netherlands.
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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: 6.0] [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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Egbe AC, Najam M, Banala K, Vojjini R, Bonnichsen C, Ammash NM, Faizee F, Khalil F, Deshmukh AJ, Connolly HM. Impact of atrial arrhythmia on survival in adults with tetralogy of Fallot. Am Heart J 2019; 218:1-7. [PMID: 31648061 DOI: 10.1016/j.ahj.2019.08.013] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/08/2019] [Accepted: 08/13/2019] [Indexed: 10/26/2022]
Abstract
BACKGROUND Atrial arrhythmia is a late complication after tetralogy of Fallot (TOF) repair, but arrhythmia outcomes data are limited. OBJECTIVES The purpose of the study was to describe atrial arrhythmia presentations, outcomes of antiarrhythmic therapy, and impact of arrhythmia on transplant-free survival. METHODS We reviewed the MACHD (Mayo Adult Congenital Heart Disease) Registry and identified 113 patients (age 49 ± 13 years) with documented arrhythmia, and 302 patients without history of arrhythmia, 1990-2017. We classified arrhythmias into atrial fibrillation and atrial flutter/tachycardia based on the rhythm on the first abnormal electrocardiogram. RESULTS At the time of first documented arrhythmia, 58(51%) had atrial fibrillation while 55(49%) had atrial flutter/tachycardia. Of the 113 patients, 14(12%) received rhythm control with class I/III antiarrhythmic drugs (AAD), 79(70%) had direct current cardioversion, 9(8%) received rate control with class II/IV AAD, and 11(10%) received only anticoagulation. Successful cardioversion occurred in 100(89%) patients, and arrhythmia recurrence rate was 16 per 100 patient-years. The multivariate risk factors for death and/or heart transplant were atrial fibrillation (HR 1.94, CI 1.10-3.15, P = .031) and older age (HR 1.63, CI 1.12-2.43, P = .019) per 5 year increment. CONCLUSIONS Atrial fibrillation, but not atrial flutter, was associated with reduced survival in our repaired TOF cohort. Further studies are required to determine if more aggressive antiarrhythmic therapy will improve survival in patients with atrial fibrillation.
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Egbe AC, Bonnichsen C, Reddy YNV, Anderson JH, Borlaug BA. Pathophysiologic and Prognostic Implications of Right Atrial Hypertension in Adults With Tetralogy of Fallot. J Am Heart Assoc 2019; 8:e014148. [PMID: 31701796 PMCID: PMC6915294 DOI: 10.1161/jaha.119.014148] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/31/2019] [Accepted: 10/14/2019] [Indexed: 12/31/2022]
Abstract
Background Right atrial pressure (RAP), a composite metric of right ventricular diastolic function, volume status, and right heart compliance, is a predictor of mortality in patients with heart failure due to acquired heart disease. Because patients with tetralogy of Fallot (TOF) might have abnormal right atrial and ventricular mechanics caused by myocardial injury and remodeling, we hypothesized that RAP would be associated with disease severity and cardiovascular adverse events in this population. Methods and Results We performed a cohort study of adults with TOF who underwent right heart catheterization at the Mayo Clinic Rochester between 1990 and 2017. The objective was to determine the association between RAP and multiple domains of disease severity in TOF (percentage of predicted peak oxygen consumption, atrial or ventricular arrhythmia, and heart failure hospitalization), as well as cardiovascular adverse events, defined as sustained ventricular tachycardia, resuscitated or aborted sudden death, heart transplantation, or death. Among 225 patients (113 male; mean age: 39±14 years), mean RAP was 10.7±5.2 mm Hg and median was 10 mm Hg (interquartile range: 7-13 mm Hg). Increasing RAP was associated with atrial or ventricular arrhythmias (odds ratio: 5.01; 95% CI, 1.22-23.49; P<0.001), heart failure hospitalization (odds ratio: 1.47; 95% CI, 1.10-2.39; P=0.033) per 5 mm Hg, and worsening exercise capacity (peak oxygen consumption; R2=0.74, r=-0.86, P<0.001). RAP was a predictor of cardiovascular adverse events (hazard ratio: 1.28; 95% CI, 1.10-1.47; P=0.028) per 5 mm Hg. Conclusions In symptomatic patients with TOF, increasing RAP correlates with multiple domains of disease severity (risk stratification) and predicts future cardiovascular events (prognostication). These data have potential clinical implications in the target population of symptomatic TOF patients.
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Rodriguez FH, Book WM. Management of the adult Fontan patient. Heart 2019; 106:105-110. [DOI: 10.1136/heartjnl-2019-314937] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/03/2019] [Revised: 09/11/2019] [Accepted: 09/30/2019] [Indexed: 12/28/2022] Open
Abstract
Adults with congenital heart disease who underwent the Fontan operation to palliate single ventricle heart defects—by direct connection of caval venous return to the pulmonary circulation—have improved survival due to advancements in surgical and interventional techniques. However, cardiac and non-cardiac comorbidities often coexist, complicating management, and contributing to premature morbidity and mortality. Cardiac issues include heart failure symptoms related to systolic and diastolic dysfunction, atrial and ventricular arrhythmias and systemic atrioventricular valve regurgitation. Structural issues may be related to obstruction of the Fontan pathway, or to branch pulmonary artery stenosis, both of which exacerbate symptoms. Non-cardiac complications in adults involve hepatic congestion, fibrosis and cirrhosis, hepatocellular carcinoma, chronic kidney disease, stroke, venous stasis, lymphatic issues and involvement of other organ systems. ‘Fontan failure’ refers to circulatory dysfunction, either cardiac, non-cardiac, or both, diagnosed after exclusion or treatment of reversible contributors such as structural issues and arrhythmias. Counselling about reproductive health, mental health, perioperative management and overall wellness are paramount for patients’ well-being. Fontan patients are typically managed in highly specialised adult congenital heart centres, but may present to cardiologists or other practitioners with cardiac and non-cardiac emergencies or urgencies, sometimes after being out of care. In this review, we discuss the management of the adult Fontan patient, including surveillance, cardiac and non-cardiac complications, reproductive health, and advanced therapies.
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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: 435] [Impact Index Per Article: 87.0] [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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Atrial Fibrillation Therapy and Heart Failure Hospitalization in Adults With Tetralogy of Fallot. JACC Clin Electrophysiol 2019; 5:618-625. [DOI: 10.1016/j.jacep.2019.01.005] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2018] [Revised: 12/20/2018] [Accepted: 01/02/2019] [Indexed: 11/18/2022]
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Akintoye E, Miranda WR, Veldtman GR, Connolly HM, Egbe AC. National trends in Fontan operation and in-hospital outcomes in the USA. Heart 2018; 105:708-714. [DOI: 10.1136/heartjnl-2018-313680] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/01/2018] [Revised: 09/26/2018] [Accepted: 10/01/2018] [Indexed: 01/22/2023] Open
Abstract
BackgroundNational prevalence and outcomes of Fontan operation in the USA is unknown. Study objective was to determine trends (temporal change) in the annual volume of Fontan operations, in-hospital mortality, postoperative complications and type of hospital discharge.MethodsReview of the Nationwide Inpatient Sample for patients that underwent Fontan operation from 2001 to 2014 using the International Classification of Diseases-Ninth Revision, Clinical Modification procedure code for Fontan operation, that is, 35.94. To evaluate for change in patients’ demographics over the years, we divided the patient population into four groups based on procedure year (2001–2004, 2005–2008, 2009–2011 and 2012–2014).ResultsAn estimated 15 934 Fontan operations were performed in the USA from 2001 to 2014. Median (Q1–Q3) age was 3 (2–4) years and 39.8% were female. Hypoplastic left heart syndrome was the most common (29%) congenital heart disease diagnosis. An estimated 1175 procedures were performed in 2001 and 1340 in 2014, but there was no significant change in the number of procedures per year (p=0.47). There was significant decline in in-hospital mortality from 4.5% (53/1175) in 2001 to 1.1% (15/1340) in 2014 (p=0.009). When we compared event rates between 2001–2004 and 2012–2014 periods, there was significant decline in postoperative cardiac complications (12.6% (459/3640) to 8% (378/4706), p=0.007) and respiratory complications (17.1% (623/3640) to 10.2% (481/4706), p<0.001). However, there was increase in the number of patients discharged to home with healthcare assistance or transferred to another acute care facility (5.8% (211/3640) to 9.4% (443/4706), p=0.01) and inflation-adjusted hospitalisation cost (US$46 978 to US$60 383, p<0.001), but no significant change in length of stay (p=0.73).ConclusionOn the average, 1062 Fontan operations are performed annually in the USA with no change in volume of procedures but a decrease in in-hospital mortality and postoperative complications over a 15-year period.
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Moore BM, Anderson R, Nisbet AM, Kalla M, du Plessis K, d’Udekem Y, Bullock A, Cordina RL, Grigg L, Celermajer DS, Kalman J, McGuire MA. Ablation of Atrial Arrhythmias After the Atriopulmonary Fontan Procedure. JACC Clin Electrophysiol 2018; 4:1338-1346. [DOI: 10.1016/j.jacep.2018.08.012] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2018] [Revised: 07/17/2018] [Accepted: 08/13/2018] [Indexed: 10/28/2022]
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Egbe A, Khan AR, Al-Otaibi M, Said SM, Connolly HM. Outcomes of hospitalization in adults with Fontan palliation: The Mayo Clinic experience. Am Heart J 2018; 198:115-122. [PMID: 29653632 DOI: 10.1016/j.ahj.2017.12.012] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/13/2017] [Accepted: 12/17/2017] [Indexed: 01/09/2023]
Abstract
The outcomes of hospitalization in the Fontan population have not been specifically studied. The purpose of this study was to describe outcomes of hospitalization (frequency and indications for hospitalization, and in-hospital mortality) in this population and to determine how these outcomes differ from those of other adults with congenital heart disease (CHD). METHODS This was a retrospective study of adult Fontan patients hospitalized at Mayo Clinic Rochester in 1990-2015. We selected age- and gender-matched control group of patients with repaired CHD and biventricular circulation hospitalized within the study period. RESULTS A total of 367 Fontan patients (age 31±7 years and 259 [71%] with atriopulmonary Fontan) had 853 hospital admissions in 4 years (58 hospitalizations per 100 patient-years). The most common indications were arrhythmia (n=188, 22%), heart failure (n=169, 20%), and cardiac surgery (n=133, 16%). Overall in-hospital mortality was 4% (n=38), and the highest in-hospital mortality occurred in patients hospitalized for cardiac surgery (n=15, 11%) and heart failure (n=13, 8%). In comparison to the repaired CHD and biventricular circulation group, the Fontan group had more frequent hospitalizations (22 vs 58 per 100 patient-years, P<.001) and higher overall in-hospital mortality (1% vs 5%, P<.001), mortality after cardiac surgery (2% vs 11%, P=.01), and mortality for heart failure-related hospitalizations (2% vs 8%, P=.04). CONCLUSIONS Adults with Fontan palliation had more frequent hospitalization and in-hospital mortality compared to the rest of the CHD population. Arrhythmia and heart failure were the most common indications for hospitalization. Perhaps optimal management of heart failure and arrhythmia may improve outcomes in this population.
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Abstract
Fontan-associated liver disease is a hepatic disorder arising from hemodynamic changes and systemic venous congestion following Fontan surgery. The histological changes produced in the liver are similar but not equivalent to those seen in other forms of cardiac liver disease. While the natural history of this form of liver disease is not well established, over time many Fontan patients develop portal hypertension-related complications such as ascites, variceal hemorrhage or encephalopathy. Fontan survivors also show an increased risk of hepatocellular carcinoma. Early diagnosis of advanced liver disease is mandatory for the prevention and treatment of complications such as hepatocellular carcinoma, esophageal varices and malnutrition. This review updates current knowledge of the pathophysiology and management of Fontan-associated liver disease including new diagnostic methods and treatments.
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Affiliation(s)
- Luis Téllez
- Hospital Universitario Ramón y Cajal. Universidad de Alcalá. Servicio de Gastroenterología y Hepatología
| | - Enrique Rodríguez-Santiago
- Hospital Universitario Ramón y Cajal. Universidad de Alcalá. Servicio de Gastroenterología y Hepatología
| | - Agustín Albillos
- Hospital Universitario Ramón y Cajal. Universidad de Alcalá. Servicio de Gastroenterología y Hepatología
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Téllez L, Rodríguez de Santiago E, Albillos A. Fontan-associated Liver Disease. ACTA ACUST UNITED AC 2018; 71:192-202. [PMID: 29433942 DOI: 10.1016/j.rec.2017.10.052] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2017] [Accepted: 10/11/2017] [Indexed: 02/07/2023]
Abstract
Fontan-associated liver disease refers to the disturbance in the liver secondary to hemodynamic changes and systemic venous congestion following Fontan surgery. Although the natural history of this disease has not yet been established, patients with more advanced liver injury develop the complications of portal hypertension, such as ascites, variceal haemorrhage, or encephalopathy. Moreover, patients with Fontan surgery may have an increased risk of hepatocellular carcinoma. Periodic liver monitoring is essential to prevent this disease and provide early treatment of liver complications.
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Affiliation(s)
- Luis Téllez
- Servicio de Gastroenterología y Hepatología, Hospital Universitario Ramón y Cajal, Universidad de Alcalá, Madrid, Spain
| | | | - Agustín Albillos
- Centro de Investigación Biomédica en Red Área de Enfermedades Digestivas (CIBERehd).
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