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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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2
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Téllez L, Payancé A, Tjwa E, Del Cerro MJ, Idorn L, Ovroutski S, De Bruyne R, Verkade HJ, De Rita F, de Lange C, Angelini A, Paradis V, Rautou PE, García-Pagán JC. EASL-ERN position paper on liver involvement in patients with Fontan-type circulation. J Hepatol 2023; 79:1270-1301. [PMID: 37863545 DOI: 10.1016/j.jhep.2023.07.013] [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] [Received: 07/06/2023] [Accepted: 07/06/2023] [Indexed: 10/22/2023]
Abstract
Fontan-type surgery is the final step in the sequential palliative surgical treatment of infants born with a univentricular heart. The resulting long-term haemodynamic changes promote liver damage, leading to Fontan-associated liver disease (FALD), in virtually all patients with Fontan circulation. Owing to the lack of a uniform definition of FALD and the competitive risk of other complications developed by Fontan patients, the impact of FALD on the prognosis of these patients is currently debatable. However, based on the increasing number of adult Fontan patients and recent research interest, the European Association for The Study of the Liver and the European Reference Network on Rare Liver Diseases thought a position paper timely. The aims of the current paper are: (1) to provide a clear definition and description of FALD, including clinical, analytical, radiological, haemodynamic, and histological features; (2) to facilitate guidance for staging the liver disease; and (3) to provide evidence- and experience-based recommendations for the management of different clinical scenarios.
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Affiliation(s)
- Luis Téllez
- Gastroenterology and Hepatology Department, Hospital Universitario Ramón y Cajal, Madrid, Spain; Instituto Ramón y Cajal de Investigación Sanitaria (IRYCIS), CIBEREHD (Centro de Investigación Biomédica en Red Enfermedades Hepáticas y Digestivas), University of Alcalá, Madrid, Spain
| | - Audrey Payancé
- DHU Unity, Pôle des Maladies de l'Appareil Digestif, Service d'Hépatologie, Hôpital Beaujon, AP-HP, Clichy, France; Université Denis Diderot-Paris 7, Sorbonne Paris Cité, Paris, France
| | - Eric Tjwa
- Department of Gastroenterology and Hepatology, Radboud University Medical Center, Nijmegen, The Netherlands
| | - María Jesús Del Cerro
- Pediatric Cardiology Department, Hospital Universitario Ramón y Cajal, Madrid, Spain; Instituto Ramón y Cajal de Investigación Sanitaria (IRYCIS), University of Alcalá, Madrid, Spain
| | - Lars Idorn
- Department of Pediatrics, Section of Pediatric Cardiology, Rigshospitalet, Copenhagen, Denmark
| | - Stanislav Ovroutski
- Department of Congenital Heart Disease/Pediatric Cardiology, Deutsches Herzzentrum Berlin, Berlin, Germany
| | - Ruth De Bruyne
- Department of Pediatric Gastroenterology, Hepatology and Nutrition, Ghent University Hospital, Belgium
| | - Henkjan J Verkade
- Department of Pediatrics, Beatrix Children's Hospital/University Medical Center Groningen, The Netherlands
| | - Fabrizio De Rita
- Adult Congenital and Paediatric Heart Unit, Freeman Hospital, Newcastle Upon Tyne Hospitals NHS Foundation Trust, Newcastle Upon Tyne, UK
| | - Charlotte de Lange
- Department of Pediatric Radiology, Queen Silvia Childrens' Hospital, Sahlgrenska University Hospital, Behandlingsvagen 7, 41650 Göteborg, Sweden
| | - Annalisa Angelini
- Pathology of Cardiac Transplantation and Regenerative Medicine Unit, Department of Cardiac, Thoracic and Vascular Sciences and Public Health, University of Padua, Padua, Italy
| | - Valérie Paradis
- Centre de recherche sur l'inflammation, INSERM1149, Université Paris Cité, Paris, France; Pathology Department, Beaujon Hospital, APHP.Nord, Clichy, France
| | - Pierre Emmanuel Rautou
- AP-HP, Service d'Hépatologie, Hôpital Beaujon, DMU DIGEST, Centre de Référence des Maladies Vasculaires du Foie, FILFOIE, Clichy, France; Université Paris-Cité, Inserm, Centre de recherche sur l'inflammation, UMR 1149, Paris, France
| | - Juan Carlos García-Pagán
- Barcelona Hepatic Hemodynamic Laboratory, Liver Unit, Hospital Clínic, Institut de Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Departament de Medicina i Ciències de la Salut, University of Barcelona, Barcelona, Spain; CIBEREHD (Centro de Investigación Biomédica en Red Enfermedades Hepáticas y Digestivas), Health Care Provider of the European Reference Network on Rare Liver Disorders (ERN-Liver), Spain.
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Guerrero-Chalela CE, Therrien J, Grossman Y, Guo L, Liu A, Marelli A. Severe Fontan-Associated Liver Disease and Its Association With Mortality. J Am Heart Assoc 2023; 12:e024034. [PMID: 37776221 PMCID: PMC10727255 DOI: 10.1161/jaha.121.024034] [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] [Received: 01/19/2023] [Accepted: 06/06/2023] [Indexed: 10/02/2023]
Abstract
Background Data are rare about the incidence of severe Fontan-associated liver disease (FALD) and its association with mortality. We sought to: (1) estimate the probability of developing severe FALD in patients who undergo the Fontan procedure (Fontan patients), compared with severe liver complications in patients with a ventricular septal defect; (2) assess the severe FALD-mortality association; and (3) identify risk factors for developing severe FALD. Methods and Results Using the Quebec Congenital Heart Disease database, a total of 512 Fontan patients and 10 232 patients with a ventricular septal defect were identified. Kaplan-Meier curves demonstrated significantly higher cumulative risk of severe FALD in Fontan patients (11.95% and 52.24% at 10 and 35 years, respectively), than the risk of severe liver complications in patients with a ventricular septal defect (0.50% and 2.75%, respectively). At 5 years, the cumulative risk of death was 12.60% in patients with severe FALD versus 3.70% in Fontan patients without FALD (log-rank P=0.0171). Cox proportional hazard models identified significant associations between the development of severe FALD and congestive heart failure and supraventricular tachycardia, with hazard ratios (HRs) of 2.36 (95% CI, 1.38-4.02) and 2.45 (95% CI, 1.37-4.39), respectively. More recent Fontan completion was related to reduced risks of severe FALD, with an HR of 0.95 (95% CI, 0.93-0.97) for each more recent year. Conclusions This large-scale population-based study documents that severe FALD in Fontan patients was associated with a >3-fold increase in mortality. The risk of FALD is time-dependent and can reach >50% by 35 years after the Fontan operation. Conditions promoting poor Fontan hemodynamics were associated with severe FALD development.
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Affiliation(s)
- Carlos-Eduardo Guerrero-Chalela
- McGill Adult Unit for Congenital Heart Disease Excellence (MAUDE Unit) McGill University Health Centre Montreal Quebec Canada
- Beth Raby Adult Congenital Heart Disease Clinic, Jewish General Hospital Montreal Quebec Canada
- Fundacion Cardioinfantil-Instituto de Cardiologia Bogota Colombia
| | - Judith Therrien
- McGill Adult Unit for Congenital Heart Disease Excellence (MAUDE Unit) McGill University Health Centre Montreal Quebec Canada
- Beth Raby Adult Congenital Heart Disease Clinic, Jewish General Hospital Montreal Quebec Canada
| | - Yoni Grossman
- McGill Adult Unit for Congenital Heart Disease Excellence (MAUDE Unit) McGill University Health Centre Montreal Quebec Canada
| | - Liming Guo
- McGill Adult Unit for Congenital Heart Disease Excellence (MAUDE Unit) McGill University Health Centre Montreal Quebec Canada
| | - Aihua Liu
- McGill Adult Unit for Congenital Heart Disease Excellence (MAUDE Unit) McGill University Health Centre Montreal Quebec Canada
| | - Ariane Marelli
- McGill Adult Unit for Congenital Heart Disease Excellence (MAUDE Unit) McGill University Health Centre Montreal Quebec Canada
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Gill M, Mudaliar S, Prince D, Than NN, Cordina R, Majumdar A. Poor correlation of 2D shear wave elastography and transient elastography in Fontan-associated liver disease: A head-to-head comparison. JGH Open 2023; 7:690-697. [PMID: 37908293 PMCID: PMC10615175 DOI: 10.1002/jgh3.12967] [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: 03/19/2023] [Revised: 08/10/2023] [Accepted: 08/31/2023] [Indexed: 11/02/2023]
Abstract
Background and Aims Fontan-associated liver disease (FALD) is a long-term complication of the Fontan procedure. Guidelines recommend elastography, but the utility of transient elastography (TE) and two-dimensional shear wave elastography (2D SWE) is unknown. We aimed to evaluate the relationship between TE and 2D SWE in FALD. Methods This prospective cohort study included 25 patients managed in a specialist clinic between January 2018 and August 2021. Trained clinicians performed 2D SWE (GE Logiq-E9) and TE (FibroScan 503 Touch) on the same day under the same conditions. Laboratory, echocardiography, and imaging data were collected. The atrioventricular systolic-to-diastolic duration (AVV S/D ratio) was calculated as a measure of cardiac diastolic function. Results We analyzed 40 paired measurements. Median age was 22 years. Median liver stiffness measurement (LSM) was 15.4 kPa (12.1-19.6) by TE and 8.0 kPa (7.0-10.3) (P = 0.001) by 2D SWE. There was weak correlation between the modalities (r = 0.41, P = 0.004). There was no correlation between time since Fontan and LSM by TE (r = 0.15, P = 0.19) or 2D SWE (r = 0.19, P = 0.13). There was no difference in LSM irrespective of whether sonographic cirrhosis was present or absent by TE (17.4 kPa [15.9-23.6] vs. 14.9 kPa [12.0-19.4], respectively, P = 0.6) or 2D SWE (9.0 kPa [2.8-10.5] vs. 8.0 kPa [6.7-10.1], P = 0.46). There was no correlation between AVV S/D ratio and LSM by TE (r = 0.16, P = 0.18) or 2D SWE (r = 0.02, P = 0.45). Conclusions In FALD, TE and 2D SWE are poorly correlated. LSM by either modality was not associated with known risk factors for liver fibrosis or Fontan function. Based on these data, the role of elastography in FALD is uncertain.
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Affiliation(s)
- Madeleine Gill
- Australian National Liver Transplant UnitRoyal Prince Alfred HospitalSydneyNew South WalesAustralia
- Faculty of Medicine and HealthThe University of SydneySydneyNew South WalesAustralia
- Centenary Institute of Cancer Medicine and Cell BiologySydneyNew South WalesAustralia
| | - Sanjivan Mudaliar
- Australian National Liver Transplant UnitRoyal Prince Alfred HospitalSydneyNew South WalesAustralia
| | - David Prince
- Australian National Liver Transplant UnitRoyal Prince Alfred HospitalSydneyNew South WalesAustralia
- Centenary Institute of Cancer Medicine and Cell BiologySydneyNew South WalesAustralia
| | - Nwe Ni Than
- Department of Gastroenterology and HepatologyUniversity Hospital CoventryCoventryUK
| | - Rachel Cordina
- Faculty of Medicine and HealthThe University of SydneySydneyNew South WalesAustralia
- Department of CardiologyRoyal Prince Alfred HospitalSydneyNew South WalesAustralia
| | - Avik Majumdar
- Faculty of Medicine and HealthThe University of SydneySydneyNew South WalesAustralia
- Victorian Liver Transplant Unit, Austin HospitalHeidelbergVictoriaAustralia
- Division of Medicine, Dentistry and Health ScienceThe University of MelbourneMelbourneVictoriaAustralia
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Taner T, Hilscher MB, Broda CR, Drenth JPH. Issues in multi-organ transplantation of the liver with kidney or heart in polycystic liver-kidney disease or congenital heart disease: Current practices and immunological aspects. J Hepatol 2023; 78:1157-1168. [PMID: 37208103 DOI: 10.1016/j.jhep.2023.02.012] [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: 09/28/2022] [Revised: 02/08/2023] [Accepted: 02/09/2023] [Indexed: 05/21/2023]
Abstract
Solid organ transplantation has become an integral part of the management of patients with end-stage diseases of the kidney, liver, heart and lungs. Most procedures occur in isolation, but multi-organ transplantation of the liver with either the kidney or heart has become an option. As more patients with congenital heart disease and cardiac cirrhosis survive into adulthood, particularly after the Fontan procedure, liver transplant teams are expected to face questions regarding multi-organ (heart-liver) transplantation. Similarly, patients with polycystic kidneys and livers may be managed by multi-organ transplantation. Herein, we review the indications and outcomes of simultaneous liver-kidney transplantation for polycystic liver-kidney disease, and discuss the indications, timing and procedural aspects of combined heart-liver transplantation. We also summarise the evidence for, and potential mechanisms underlying, the immunoprotective impact of liver allografts on the simultaneously transplanted organs.
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Affiliation(s)
- Timucin Taner
- Departments of Surgery & Immunology, Mayo Clinic, Rochester, MN, USA.
| | - Moira B Hilscher
- Division of Gastroenterology and Hepatology, Department of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Christopher R Broda
- Department of Pediatrics, Baylor College of Medicine/Texas Children's Hospital, Houston, TX, USA
| | - Joost P H Drenth
- Department of Gastroenterology and Hepatology, Radboud University, Nijmegen, the Netherlands
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Liver Disease Assessment in Children with Fontan and Glenn Surgeries for Univentricular Hearts—The Role of Elastography and Biochemical Fibrosis Markers. APPLIED SCIENCES-BASEL 2022. [DOI: 10.3390/app12157481] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
Background: Children born with single-ventricle hearts require surgery in order to survive. Liver fibrosis is a known complication of Fontan surgery for univentricular hearts. Methods: In this study on 13 post-Fontan and 21 post-Glenn patients, we used elastography (shearwave and transient elastography) as well as serum biochemical fibrosis markers to evaluate the degree of liver fibrosis in comparison to 32 controls. Results: The mean Emedian and Vmedian values determined by shear wave elastography in the Fontan Group were significantly higher than the controls (4.85 kPa vs. 3.91 kPa and 1.25 m/s vs. 1.12 m/s, respectively). Fontan patients had significantly increased Fibrotest, Actitest, AST-to-Platelet Ratio index, ALT and GammaGT levels compared to controls. For post-Glenn patients, the mean Emedian and Vmedian values were similar to healthy controls, whereas the Fibrotest, Actitest and AST-to-Platelet Ratio index were significantly increased. Using transient elastography, we found significantly higher values for Emedian and Vmedian in Fontan patients compared to Glenn patients. Conclusions: Elastography and biochemical fibrosis markers are valuable non-invasive tools for screening and monitoring liver fibrosis in patients with Fontan and Glenn interventions.
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LeGout JD, Bolan CW, Bowman AW, Caserta MP, Chen FK, Cox KL, Sanyal R, Toskich BB, Lewis JT, Alexander LF. Focal Nodular Hyperplasia and Focal Nodular Hyperplasia-like Lesions. Radiographics 2022; 42:1043-1061. [PMID: 35687520 DOI: 10.1148/rg.210156] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Focal nodular hyperplasia (FNH) is a benign lesion occurring in a background of normal liver. FNH is seen most commonly in young women and can often be accurately diagnosed at imaging, including CT, MRI, or contrast-enhanced US. In the normal liver, FNH frequently must be differentiated from hepatocellular adenoma, which although benign, is managed differently because of the risks of hemorrhage and malignant transformation. When lesions that are histologically identical to FNH occur in a background of abnormal liver, they are termed FNH-like lesions. These lesions can be a source of diagnostic confusion and must be differentiated from malignancies. Radiologists' familiarity with the imaging appearance of FNH-like lesions and knowledge of the conditions that predispose a patient to their formation are critical to minimizing the risks of unnecessary intervention for these lesions, which are rarely symptomatic and carry no risk for malignant transformation. FNH is thought to form secondary to an underlying vascular disturbance, a theory supported by the predilection for formation of FNH-like lesions in patients with a variety of hepatic vascular abnormalities. These include abnormalities of hepatic outflow such as Budd-Chiari syndrome, abnormalities of hepatic inflow such as congenital absence of the portal vein, and hepatic microvascular disturbances, such as those that occur after exposure to certain chemotherapeutic agents. Familiarity with the imaging appearances of these varied conditions and knowledge of their association with formation of FNH-like lesions allow radiologists to identify with confidence these benign lesions that require no intervention. Online supplemental material is available for this article. ©RSNA, 2022.
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Affiliation(s)
- Jordan D LeGout
- From the Department of Radiology (J.D.L., C.W.B., A.W.B., M.P.C., F.K.C., K.L.C., R.S., B.B.T., L.F.A.) and Department of Laboratory Medicine and Pathology (J.T.L.), Mayo Clinic Florida, 4500 San Pablo Rd, Jacksonville, FL 32224
| | - Candice W Bolan
- From the Department of Radiology (J.D.L., C.W.B., A.W.B., M.P.C., F.K.C., K.L.C., R.S., B.B.T., L.F.A.) and Department of Laboratory Medicine and Pathology (J.T.L.), Mayo Clinic Florida, 4500 San Pablo Rd, Jacksonville, FL 32224
| | - Andrew W Bowman
- From the Department of Radiology (J.D.L., C.W.B., A.W.B., M.P.C., F.K.C., K.L.C., R.S., B.B.T., L.F.A.) and Department of Laboratory Medicine and Pathology (J.T.L.), Mayo Clinic Florida, 4500 San Pablo Rd, Jacksonville, FL 32224
| | - Melanie P Caserta
- From the Department of Radiology (J.D.L., C.W.B., A.W.B., M.P.C., F.K.C., K.L.C., R.S., B.B.T., L.F.A.) and Department of Laboratory Medicine and Pathology (J.T.L.), Mayo Clinic Florida, 4500 San Pablo Rd, Jacksonville, FL 32224
| | - Frank K Chen
- From the Department of Radiology (J.D.L., C.W.B., A.W.B., M.P.C., F.K.C., K.L.C., R.S., B.B.T., L.F.A.) and Department of Laboratory Medicine and Pathology (J.T.L.), Mayo Clinic Florida, 4500 San Pablo Rd, Jacksonville, FL 32224
| | - Kelly L Cox
- From the Department of Radiology (J.D.L., C.W.B., A.W.B., M.P.C., F.K.C., K.L.C., R.S., B.B.T., L.F.A.) and Department of Laboratory Medicine and Pathology (J.T.L.), Mayo Clinic Florida, 4500 San Pablo Rd, Jacksonville, FL 32224
| | - Rupan Sanyal
- From the Department of Radiology (J.D.L., C.W.B., A.W.B., M.P.C., F.K.C., K.L.C., R.S., B.B.T., L.F.A.) and Department of Laboratory Medicine and Pathology (J.T.L.), Mayo Clinic Florida, 4500 San Pablo Rd, Jacksonville, FL 32224
| | - Beau B Toskich
- From the Department of Radiology (J.D.L., C.W.B., A.W.B., M.P.C., F.K.C., K.L.C., R.S., B.B.T., L.F.A.) and Department of Laboratory Medicine and Pathology (J.T.L.), Mayo Clinic Florida, 4500 San Pablo Rd, Jacksonville, FL 32224
| | - Jason T Lewis
- From the Department of Radiology (J.D.L., C.W.B., A.W.B., M.P.C., F.K.C., K.L.C., R.S., B.B.T., L.F.A.) and Department of Laboratory Medicine and Pathology (J.T.L.), Mayo Clinic Florida, 4500 San Pablo Rd, Jacksonville, FL 32224
| | - Lauren F Alexander
- From the Department of Radiology (J.D.L., C.W.B., A.W.B., M.P.C., F.K.C., K.L.C., R.S., B.B.T., L.F.A.) and Department of Laboratory Medicine and Pathology (J.T.L.), Mayo Clinic Florida, 4500 San Pablo Rd, Jacksonville, FL 32224
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Meta-Analysis of the Incidence of Liver Cirrhosis Among Patients With a Fontan Circulation. Am J Cardiol 2022; 177:166-167. [DOI: 10.1016/j.amjcard.2022.05.009] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/12/2022] [Accepted: 05/25/2022] [Indexed: 01/03/2023]
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Giannico S, Trezzi M, Cantarutti N, Cafiero G, Ravà L, Adorisio R, Brancaccio G, Albanese S, Drago F, Carotti A, Amodeo A, Galletti L. Late outcome of Extracardiac Fontan Patients: 32 years of follow-up. Eur J Cardiothorac Surg 2022; 62:6584007. [PMID: 35543463 DOI: 10.1093/ejcts/ezac301] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/31/2022] [Revised: 04/13/2022] [Accepted: 05/05/2022] [Indexed: 11/15/2022] Open
Abstract
OBJECTIVES We sought to evaluate the long-term survival and risk factors for morbidity and mortality in our cohort of patients after Extracardiac (EC) Fontan. METHODS We collected and analyzed follow-up data until September 2020 for all patients who underwent EC Fontan operation at our institution from November 1988 to November 2015. RESULTS Out of 406 patients treated with EC Fontan at a mean age of 5.4 ± 4.5 years, 372 (91.6%) were discharged home; 15% were lost to follow-up. The Median follow-up was 14.6 years (IQR 8.7-20.3). Two hundred patients (54%) had a good long-term outcome, with an event-free long-term survival, but late adverse events of any kind needing interventional or surgical reoperations were reported in 128 patients (34%). Forty-four patients (12%) developed late Fontan failure. Thirty-seven survivors (10%) had late arrhythmias, with the need for pacemaker implantation. Obstruction of the cavopulmonary pathway occurred in forty-nine patients (13%), but just 8 pts needed conduit surgical replacement. At 32 years, the survival probability was 84%. The risk of orthotopic heart transplant (HT), considering death as a competing event, (showed as cumulative incidence) was 12.5%. A preoperative diagnosis of hypoplastic left heart syndrome (HLHS) was an independent risk factor for the need for HT. CONCLUSIONS The EC Fontan shows satisfactory long-term survival and low incidence of adverse events and late failure. Conduit replacement is rare, and its longevity may not represent a substantial issue in these patients. However, as with other technical variants, the need for reoperations during long-term follow-up is a significant challenge.
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Affiliation(s)
| | - Matteo Trezzi
- Cardiac Surgery Unit, Department of Pediatric Cardiology and Cardiac Surgery, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
| | - Nicoletta Cantarutti
- Pediatric Cardiology and Cardiac Arrhythmia Unit, Department of Pediatric Cardiology and Cardiac Surgery, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
| | - Giulia Cafiero
- Sports Medicine Unit, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy 12
| | - Lucilla Ravà
- Clinical Epidemiology Unit, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
| | - Rachele Adorisio
- Pediatric Cardiology and Cardiac Arrhythmia Unit, Department of Pediatric Cardiology and Cardiac Surgery, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
| | - Gianluca Brancaccio
- Cardiac Surgery Unit, Department of Pediatric Cardiology and Cardiac Surgery, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
| | - Sonia Albanese
- Cardiac Surgery Unit, Department of Pediatric Cardiology and Cardiac Surgery, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
| | - Fabrizio Drago
- Pediatric Cardiology and Cardiac Arrhythmia Unit, Department of Pediatric Cardiology and Cardiac Surgery, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
| | - Adriano Carotti
- Cardiac Surgery Unit, Department of Pediatric Cardiology and Cardiac Surgery, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
| | - Antonio Amodeo
- Cardiac Surgery Unit, Department of Pediatric Cardiology and Cardiac Surgery, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
| | - Lorenzo Galletti
- Cardiac Surgery Unit, Department of Pediatric Cardiology and Cardiac Surgery, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
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Hilscher MB, Wells ML, Venkatesh SK, Cetta F, Kamath PS. Fontan-associated liver disease. Hepatology 2022; 75:1300-1321. [PMID: 35179797 DOI: 10.1002/hep.32406] [Citation(s) in RCA: 21] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/27/2021] [Revised: 12/21/2021] [Accepted: 12/27/2021] [Indexed: 12/13/2022]
Affiliation(s)
- Moira B Hilscher
- Division of Gastroenterology and HepatologyDepartment of MedicineUniversity of PennsylvaniaPhiladelphiaPennsylvaniaUSA
| | - Michael L Wells
- Division of Abdominal ImagingDepartment of RadiologyMayo ClinicRochesterMinnesotaUSA
| | - Sudhakar K Venkatesh
- Division of Abdominal ImagingDepartment of RadiologyMayo ClinicRochesterMinnesotaUSA
| | - Frank Cetta
- Division of Pediatric CardiologyDepartment of Pediatric and Adolescent MedicineMayo ClinicRochesterMinnesotaUSA
| | - Patrick S Kamath
- Division of Gastroenterology and HepatologyDepartment of MedicineMayo ClinicRochesterMinnesotaUSA
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Sakamori R, Yamada R, Tahata Y, Kodama T, Hikita H, Tatsumi T, Yamada T, Takehara T. The absence of warfarin treatment and situs inversus are associated with the occurrence of hepatocellular carcinoma after Fontan surgery. J Gastroenterol 2022; 57:111-119. [PMID: 35064829 DOI: 10.1007/s00535-021-01842-8] [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: 06/17/2021] [Accepted: 12/05/2021] [Indexed: 02/04/2023]
Abstract
BACKGROUND Hepatocellular carcinoma (HCC) is a long-term complication of Fontan-associated liver disease (FALD). However, risk factors for HCC in patients with FALD remain unclear. This study aimed to identify factors associated with HCC development post-Fontan procedure. METHODS We retrospectively examined 103 post-Fontan patients who underwent hepatic imaging at our institution. HCC incidence and patient characteristics were analyzed. A Cox proportional hazards model was used to identify risk factors for HCC. RESULTS The median interval between Fontan surgery and final hepatic imaging was 19.6 (1.0-37.7) years. Among 103 patients, nine developed HCC. The cumulative incidence rates of HCC at 10, 20, and 30 years postoperatively were 0%, 7%, and 13%, respectively. In the univariate analysis, age at Fontan surgery, situs inversus, and warfarin absence were associated with HCC occurrence. The multivariate analysis identified the warfarin absence (adjusted hazard ratio [aHR], 22.71; 95% confidence interval: 3.29-507.1; p = 0.0005) and situs inversus (aHR, 14.36; 95% confidence interval: 2.75-105.5; p = 0.002) as risk factors. The prevalence of situs inversus and the warfarin absence was 12% and 50%, respectively. The 20- and 30-year incidence rates of HCC among patients who received warfarin were 0% and 7%, respectively, while those among patients who did not receive warfarin were 14% and 21%, respectively. HCC incidence was significantly higher in the non-warfarin group than in the warfarin group (p = 0.006) and among patients with situs inversus than among those with situs solitus (p = 0.004). CONCLUSIONS Warfarin absence and situs inversus were associated with HCC development post-Fontan procedure.
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Affiliation(s)
- Ryotaro Sakamori
- Department of Gastroenterology and Hepatology, Osaka University Graduate School of Medicine, 2-2 Yamadaoka, Suita, Osaka, 565-0871, Japan
| | - Ryoko Yamada
- Department of Gastroenterology and Hepatology, Osaka University Graduate School of Medicine, 2-2 Yamadaoka, Suita, Osaka, 565-0871, Japan
| | - Yuki Tahata
- Department of Gastroenterology and Hepatology, Osaka University Graduate School of Medicine, 2-2 Yamadaoka, Suita, Osaka, 565-0871, Japan
| | - Takahiro Kodama
- Department of Gastroenterology and Hepatology, Osaka University Graduate School of Medicine, 2-2 Yamadaoka, Suita, Osaka, 565-0871, Japan
| | - Hayato Hikita
- Department of Gastroenterology and Hepatology, Osaka University Graduate School of Medicine, 2-2 Yamadaoka, Suita, Osaka, 565-0871, Japan
| | - Tomohide Tatsumi
- Department of Gastroenterology and Hepatology, Osaka University Graduate School of Medicine, 2-2 Yamadaoka, Suita, Osaka, 565-0871, Japan
| | - Tomomi Yamada
- Department of Medical Innovation, Osaka University Hospital, Suita, Osaka, Japan
| | - Tetsuo Takehara
- Department of Gastroenterology and Hepatology, Osaka University Graduate School of Medicine, 2-2 Yamadaoka, Suita, Osaka, 565-0871, Japan.
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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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Choudhry S, Dreyer WJ, Hope KD, Wang Y, Spinner JA, Tunuguntla HP, Cabrera AG, Price JF, Denfield SW. Pediatric heart-liver transplant outcomes in the United States: A 25-year National Cohort Study. Pediatr Transplant 2021; 25:e14066. [PMID: 34120386 DOI: 10.1111/petr.14066] [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: 10/28/2020] [Revised: 03/28/2021] [Accepted: 03/29/2021] [Indexed: 11/30/2022]
Abstract
BACKGROUND Pediatric HLT remains uncommon in the United States and criteria for HLT are unclear. The objectives of this study were to review the indications, and outcomes of pediatric HLT. METHODS Data from the Scientific Registry of Transplant Recipients heart and liver databases were used to identify 9245 pediatric isolated heart transplants (PHT), 14 134 pediatric isolated liver transplant (PLT), and 20 pediatric HLT (16 patients underwent sHLT [same organ donor] and four patients with a history of PHT followed by PLT [different organ donors]; age ≤21 years) between 1992 and 2017. Outcomes included patient survival, and 1-year rates of acute heart and liver rejection. RESULTS The median age for pediatric HLT was 15.6 (IQR: 10.5, 17.9) years, and included 12 males (12/20 = 60%). In the HLT group, the most common indication for HT was CHD (12/20 = 60%), and the most common indication for liver transplant was cirrhosis (9/20 = 45%). The 1, 3, and 5 year actuarial survival rates in pediatric simultaneous HLT recipients (n = 16) were 93%, 93%, and 93%, respectively, and was similar to isolated PHT alone (88%, 81%, and 75.5%, respectively and isolated PLT alone (84%, 82%, and 80%), respectively. There was no heart or liver rejection reported in the HLT group versus 9.9% in heart and 10.6% in liver transplant-only groups, respectively. CONCLUSION Pediatric HLT is an uncommon but acceptable option for recipients with combined end-organ failure, with intermediate survival outcomes comparable to those of single-organ recipients.
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Affiliation(s)
- Swati Choudhry
- Section of Pediatric Cardiology, Department of Pediatrics, Texas Children's Hospital, Baylor College of Medicine, Houston, TX, USA
| | - William J Dreyer
- Section of Pediatric Cardiology, Department of Pediatrics, Texas Children's Hospital, Baylor College of Medicine, Houston, TX, USA
| | - Kyle D Hope
- Section of Pediatric Cardiology, Department of Pediatrics, Texas Children's Hospital, Baylor College of Medicine, Houston, TX, USA
| | - Yunfei Wang
- Section of Pediatric Cardiology, Department of Pediatrics, Texas Children's Hospital, Baylor College of Medicine, Houston, TX, USA
| | - Joseph A Spinner
- Section of Pediatric Cardiology, Department of Pediatrics, Texas Children's Hospital, Baylor College of Medicine, Houston, TX, USA
| | - Hari P Tunuguntla
- Section of Pediatric Cardiology, Department of Pediatrics, Texas Children's Hospital, Baylor College of Medicine, Houston, TX, USA
| | - Antonio G Cabrera
- Section of Pediatric Cardiology, Department of Pediatrics, University of Utah, Salt Lake City, UT, USA
| | - Jack F Price
- Section of Pediatric Cardiology, Department of Pediatrics, Texas Children's Hospital, Baylor College of Medicine, Houston, TX, USA
| | - Susan W Denfield
- Section of Pediatric Cardiology, Department of Pediatrics, Texas Children's Hospital, Baylor College of Medicine, Houston, TX, USA
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14
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Fontan-associated liver disease and hepatocellular carcinoma in adults. Sci Rep 2020; 10:21742. [PMID: 33303924 PMCID: PMC7728791 DOI: 10.1038/s41598-020-78840-y] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2020] [Accepted: 11/20/2020] [Indexed: 02/07/2023] Open
Abstract
The Fontan operation creates a unique circulation, and is a palliative therapy for patients with single-ventricle congenital heart disease. Increased venous pressure and decreased cardiac output and hepatic venous drainage result in sinusoidal dilatation around the central veins. This causes congestion and hypoxia in the liver, leading to Fontan-associated liver disease (FALD). Non-invasive and invasive markers enable diagnosis and evaluation of the fibrosis status in chronic liver disease; however, these markers have not been validated in FALD. Additionally, regenerative nodules such as focal nodular hyperplasia (FNH) are frequently found. The severity of fibrosis correlates with the duration of the Fontan procedure and the central venous pressure. Cirrhosis is a risk factor for hepatocellular carcinoma (HCC), the annual risk of which is 1.5–5.0%. HCC is frequently difficult to diagnose and treat because of cardiac complications, coagulopathy, and congenital abnormalities. The mortality rate of FALD with liver cirrhosis and/or FALD-HCC was increased to ~ 29.4% (5/17 cases) in a nationwide survey. Although there is no consensus on the surveillance of patients with FALD, serial monitoring of the alpha fetoprotein level and imaging at 6-month intervals is required in patients with cirrhosis.
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15
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Borquez AA, Silva-Sepulveda J, Lee JW, Vavinskaya V, Vodkin I, El-Sabrout H, Towbin R, Perry JC, Moore JW, El-Said HG. Transjugular liver biopsy for Fontan associated liver disease surveillance: Technique, outcomes and hemodynamic correlation. Int J Cardiol 2020; 328:83-88. [PMID: 33278420 DOI: 10.1016/j.ijcard.2020.11.037] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/13/2020] [Revised: 09/17/2020] [Accepted: 11/18/2020] [Indexed: 12/17/2022]
Abstract
BACKGROUND Fontan associated liver disease (FALD) is attributed to the limitations of the Fontan circulation, resulting in congestive hepatopathy. The technique and outcomes of transjugular liver biopsies (TJLB) in Fontan patients warrant definition as part of a rigorous FALD surveillance program. METHOD Four year review of patients with Fontan physiology who underwent a TJLB during surveillance catheterizations. Biopsy site, technique, histology, angiography, hemodynamics, and complications were reviewed to assess correlation of biopsy scores with simultaneously obtained catheterization hemodynamics. RESULTS 125 patients with a TJLB from 10/1/14 to 5/1/18. Median age 17 years (2-50.5). Technical success 100% (125/125), all samples diagnostic. 17% (21) accessed via the left internal jugular vein, secondary to right IJ occlusion or Heterotaxy syndrome. No patients had superior compartment obstruction preventing transjugular approach. 3.2% complication rate (4/125). Complications were early in the experience, including capsular perforation (2), renal hematoma (1) and hemobilia (1), all without long-term effect and all avoidable. After standardized entry/exit angiography was adopted, no further complications noted. There is a significant correlation between the newly described modified Ishak congestive hepatic fibrosis (ICHF) score with mean Fontan pressure, time from Fontan and cardiac index. CONCLUSIONS TJLB is an alternate method for obtaining critical FALD surveillance data, with lower complication rates that traditional techniques. Vascular anomalies in Fontan physiology appear common and warrant pre-biopsy assessment. There is a significant correlation between biopsy score, time from Fontan, mean Fontan pressure and cardiac index.
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Affiliation(s)
- Alejandro A Borquez
- San Diego School of Medicine, Department of Pediatrics, Division of Pediatric Cardiology, University of California, USA.
| | - Jose Silva-Sepulveda
- San Diego School of Medicine, Department of Pediatrics, Division of Pediatric Cardiology, University of California, USA
| | - Jesse W Lee
- San Diego School of Medicine, Department of Pediatrics, Division of Pediatric Cardiology, University of California, USA
| | - Vera Vavinskaya
- San Diego School of Medicine, Department of Pathology, University of California, USA
| | - Irine Vodkin
- San Diego School of Medicine, Department of Gastroenterology, University of California, USA
| | - Hannah El-Sabrout
- San Diego School of Medicine, Department of Pediatrics, Division of Pediatric Cardiology, University of California, USA
| | - Richard Towbin
- Department of Radiology, Phoenix Children's Hospital, USA
| | - James C Perry
- San Diego School of Medicine, Department of Pediatrics, Division of Pediatric Cardiology, University of California, USA
| | - John W Moore
- San Diego School of Medicine, Department of Pediatrics, Division of Pediatric Cardiology, University of California, USA
| | - Howaida G El-Said
- San Diego School of Medicine, Department of Pediatrics, Division of Pediatric Cardiology, University of California, USA
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16
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Fontan-associated liver disease: pathophysiology, investigations, predictors of severity and management. Eur J Gastroenterol Hepatol 2020; 32:907-915. [PMID: 31851099 DOI: 10.1097/meg.0000000000001641] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Cardiac hepatopathy is the liver injury resulting from congestion and ischaemia associated with acute or chronic heart failure. The improved longevity of adults with operated congenital heart disease who develop heart failure as an increasingly late event makes this form of liver injury increasingly clinically relevant. Patients with congenital heart disease with a single ventricle anomaly, who require creation of a Fontan circulation, are particularly vulnerable as they have elevated venous filling pressures with chronic liver congestion. Progression to liver fibrosis and eventually cirrhosis may occur, with its associated risks of liver failure and hepatocellular carcinoma. This risk likely increases over the patient's lifetime, related to the duration post-surgical repair and reflects the chronicity of congestion. Liver biopsy is rarely performed due to a higher risk of complications in the setting of elevated venous pressures, and the frequent use of anticoagulation. Non-invasive methods of liver assessment are poorly validated and different factors require consideration compared to other chronic liver diseases. This review discusses the current understanding of cardiac hepatopathy in congenital heart disease patients with a Fontan circulation. This entity has recently been called Fontan Associated Liver Disease in the literature, with the term useful in recognising that the pathophysiology is incompletely understood, and that long-standing venous pressure elevation and hypoxaemia are presumed to play an additional significant role in the pathogenesis of the liver injury.
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17
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Egbe AC, Miranda WR, Veldtman GR, Graham RP, Kamath PS. Hepatic Venous Pressure Gradient in Fontan Physiology Has Limited Diagnostic and Prognostic Significance. CJC Open 2020; 2:360-364. [PMID: 32995721 PMCID: PMC7499375 DOI: 10.1016/j.cjco.2020.04.011] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2020] [Accepted: 04/23/2020] [Indexed: 01/06/2023] Open
Abstract
Background Hepatic venous pressure gradient (HVPG) is measure of portal pressure and a prognostic tool in patients with viral and alcoholic cirrhosis; its utility is unknown in patients with Fontan-associated liver disease (FALD). Limited data suggest that patients with FALD have normal HVPG. On the basis of the available data, we hypothesized that there would be no association between HVPG, liver disease severity, and transplant-free survival in FALD. Methods A retrospective study of Fontan patients who had liver biopsy and HVPG assessment at Mayo Clinic was performed. HVPG was calculated as wedged HVP minus free HVP; liver disease severity was measured by histologic assessment of fibrosis and standard clinical liver disease risk scores. Results Of 56 patients (aged 28 ± 7 years), the mean Fontan pressure was 16 ± 4 and the mean HVPG was 1.4 ± 0.3 mm Hg (range, 0-3). Perisinusoidal fibrosis and periportal fibrosis were present in 56 (100%) and 54 (94%) patients, respectively; 18 (32%) met criteria for cirrhosis. There was no correlation between HVPG and degree of hepatic fibrosis. Similarly, there was no correlation between HVPG and any clinical liver disease risk score. Six (11%) patients died and 2 (4%) underwent heart transplantation during follow-up; HVPG was not associated with transplant-free survival. Conclusions HVPG is not elevated in FALD even in the setting of cirrhosis and does not correlate with liver disease severity or clinical outcomes. These results suggest the limited diagnostic and prognostic role of HVPG in the management of FALD and highlight the potential pitfalls of using HVPG in this population.
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Affiliation(s)
- Alexander C. Egbe
- Department of Cardiovascular Medicine, Mayo Clinic Rochester, Rochester, Minnesota, USA
- Corresponding author: Dr Alexander C. Egbe, Mayo Clinic and Foundation, 200 First Street SW, Rochester, Minnesota 55905, USA. Tel.: +1-507-284-2520; fax: +1-507-266-0103.
| | - William R. Miranda
- Department of Cardiovascular Medicine, Mayo Clinic Rochester, Rochester, Minnesota, USA
| | - Gruschen R. Veldtman
- Department of Cardiology, King Faisal Specialist Hospital and Research Center, Riyadh, Saudi Arabia
| | - Rondell P. Graham
- Department of Laboratory Medicine and Pathology, Mayo Clinic Rochester, Rochester, Minnesota, USA
| | - Patrick S. Kamath
- Divison of Gastroenterology and Hepatology, Mayo Clinic Rochester, Rochester, Minnesota, USA
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18
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Khuong JN, Wilson TG, Grigg LE, Bullock A, Celermajer D, Disney P, Wijesekera VA, Hornung T, Zannino D, Iyengar AJ, d'Udekem Y. Fontan-associated nephropathy: Predictors and outcomes. Int J Cardiol 2020; 306:73-77. [PMID: 31955974 DOI: 10.1016/j.ijcard.2020.01.014] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/19/2019] [Accepted: 01/08/2020] [Indexed: 01/12/2023]
Abstract
BACKGROUND Nephropathy is a known complication of the Fontan circulation, but its determinants have not been identified and patient outcomes are also still unknown. METHODS The Australia and New Zealand Fontan Registry was used to identify those who underwent Fontan operation before and survived beyond 16-years-old with an intact Fontan circulation. Serum creatinine values were collected for each patient between 16 and 25 years and at recent follow-up. The Modification of Diet in Renal Disease (MDRD) equation was used to calculate eGFR. Patient outcomes were obtained from the Registry. Fontan failure was defined as death, transplantation, plastic bronchitis, protein losing enteropathy, Fontan takedown and NYHA class III-IV. RESULTS Serum creatinine measurements were available for 328 patients. Renal dysfunction was defined as eGFR <90 mL/min/1.72m2. Renal dysfunction was present in 67/328 (20%) and 3/328 (1%) patients had an eGFR <60 mL/min/1.72m2. The 10-year survival and 10-year freedom from death and transplantation were the same, 96% (95% CI: 0.9-1) for those with renal dysfunction, and 89% (0.83-0.95; p = 0.1) and 87% (95% CI: 0.81-0.94; p = 0.05) for patients without dysfunction. The 10-year freedom from failure were also similar, 83% (95% CI: 0.70-0.97) for those without renal dysfunction vs 80% (95% CI: 0.74-0.89; p = 0.84). There was no change in mean eGFR for the renal dysfunction group over a mean of 8 ± 5.5 years. CONCLUSION By the time they reach adulthood, 20% of patients with a Fontan circulation have renal dysfunction by eGFR calculation. Over the course of one decade, Fontan-associated nephropathy appears well tolerated.
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Affiliation(s)
- Jacqueline Nguyen Khuong
- Heart Research Group, Murdoch Children's Research Institute, Melbourne, Australia; Department of Paediatrics, Faculty of Medicine, The University of Melbourne, Melbourne, Australia
| | - Thomas G Wilson
- Heart Research Group, Murdoch Children's Research Institute, Melbourne, Australia; Department of Paediatrics, Faculty of Medicine, The University of Melbourne, Melbourne, Australia
| | - Leeanne E Grigg
- Department of Cardiology, The Royal Melbourne Hospital, Melbourne, Australia
| | - Andrew Bullock
- Children's Cardiac Centre, Princess Margaret Hospital for Children, Perth, Australia
| | - David Celermajer
- Department of Cardiology, Royal Prince Alfred Hospital, Sydney, Australia
| | - Patrick Disney
- Department of Cardiology, Women's and Children's Hospital, Adelaide, Australia
| | | | - Tim Hornung
- Green Lane Paediatric and Congenital Cardiac Service, Auckland District Health Board, Auckland, New Zealand
| | - Diana Zannino
- Heart Research Group, Murdoch Children's Research Institute, Melbourne, Australia
| | - Ajay J Iyengar
- Heart Research Group, Murdoch Children's Research Institute, Melbourne, Australia; Department of Paediatrics, Faculty of Medicine, The University of Melbourne, Melbourne, Australia; Department of Cardiac Surgery, The Royal Children's Hospital, Melbourne, Australia
| | - Yves d'Udekem
- Heart Research Group, Murdoch Children's Research Institute, Melbourne, Australia; Department of Paediatrics, Faculty of Medicine, The University of Melbourne, Melbourne, Australia; Department of Cardiac Surgery, The Royal Children's Hospital, Melbourne, Australia.
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19
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Schleiger A, Salzmann M, Kramer P, Danne F, Schubert S, Bassir C, Müller T, Müller HP, Berger F, Ovroutski S. Severity of Fontan-Associated Liver Disease Correlates with Fontan Hemodynamics. Pediatr Cardiol 2020; 41:736-746. [PMID: 32006084 PMCID: PMC7256101 DOI: 10.1007/s00246-020-02291-5] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/28/2019] [Accepted: 01/17/2020] [Indexed: 01/19/2023]
Abstract
Fontan-palliated patients are at risk for the development of Fontan-associated liver disease (FALD). In this study, we performed a detailed hemodynamic and hepatic assessment to analyze the incidence and spectrum of FALD and its association with patients' hemodynamics. From 2017 to 2019, 145 patients underwent a detailed, age-adjusted hepatic examination including laboratory analysis (FibroTest®, n = 101), liver ultrasound (n = 117) and transient elastography (FibroScan®, n = 61). The median patient age was 16.0 years [IQR 14.2], and the median duration of the Fontan circulation was 10.3 years [IQR 14.7]. Hemodynamic assessment was performed using echocardiography, cardiopulmonary exercise capacity testing and cardiac catheterization. Liver ultrasound revealed hepatic parenchymal changes in 83 patients (70.9%). Severe liver cirrhosis was detectable in 20 patients (17.1%). Median liver stiffness measured by FibroScan® was 27.7 kPa [IQR 14.5], and the median Fibrotest® score was 0.5 [IQR 0.3], corresponding to fibrosis stage ≥ 2. Liver stiffness values and Fibrotest® scores correlated significantly with Fontan duration (P1 = 0.013, P2 = 0.012). Exercise performance was significantly impaired in patients with severe liver cirrhosis (P = 0.003). Pulmonary artery pressure and end-diastolic pressure were highly elevated in cirrhotic patients (P1 = 0.008, P2 = 0.003). Multivariable risk factor analysis revealed Fontan duration to be a major risk factor for the development of FALD (P < 0.001, OR 0.77, CI 0.68-0.87). In the majority of patients, hepatic abnormalities suggestive of FALD were detectable by liver ultrasound, transient elastography and laboratory analysis. The severity of FALD correlated significantly with Fontan duration and impaired Fontan hemodynamics. A detailed hepatic assessment is indispensable for long-term surveillance of Fontan patients.
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Affiliation(s)
- Anastasia Schleiger
- Department of Congenital Heart Disease/Pediatric Cardiology, German Heart Center Berlin, Augustenburger Platz 1, 13353, Berlin, Germany.
| | - Madeleine Salzmann
- Department of Congenital Heart Disease/Pediatric Cardiology, German Heart Center Berlin, Augustenburger Platz 1, 13353 Berlin, Germany
| | - Peter Kramer
- Department of Congenital Heart Disease/Pediatric Cardiology, German Heart Center Berlin, Augustenburger Platz 1, 13353 Berlin, Germany
| | - Friederike Danne
- Department of Congenital Heart Disease/Pediatric Cardiology, German Heart Center Berlin, Augustenburger Platz 1, 13353 Berlin, Germany
| | - Stephan Schubert
- Department of Congenital Heart Disease/Pediatric Cardiology, German Heart Center Berlin, Augustenburger Platz 1, 13353 Berlin, Germany
| | - Christian Bassir
- Department of Pediatric Radiology, Charité-Universitätsmedizin Berlin, Berlin, Germany
| | - Tobias Müller
- Department of Gastroenterology and Hepatology, Charité Universitätsmedizin Berlin, Berlin, Germany
| | - Hans-Peter Müller
- Department of Gastroenterology and Hepatology, Charité Universitätsmedizin Berlin, Berlin, Germany
| | - Felix Berger
- Department of Congenital Heart Disease/Pediatric Cardiology, German Heart Center Berlin, Augustenburger Platz 1, 13353 Berlin, Germany ,DZHK (German Center for Cardiovascular Research), Partner Site Berlin, Berlin, Germany ,Division of Cardiology, Department of Pediatrics, Charité Universitätsmedizin Berlin, Berlin, Germany
| | - Stanislav Ovroutski
- Department of Congenital Heart Disease/Pediatric Cardiology, German Heart Center Berlin, Augustenburger Platz 1, 13353 Berlin, Germany
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20
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Trusty PM, Wei ZA, Rychik J, Graham A, Russo PA, Surrey LF, Goldberg DJ, Yoganathan AP, Fogel MA. Cardiac Magnetic Resonance-Derived Metrics Are Predictive of Liver Fibrosis in Fontan Patients. Ann Thorac Surg 2019; 109:1904-1911. [PMID: 31734244 DOI: 10.1016/j.athoracsur.2019.09.070] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/10/2019] [Revised: 09/12/2019] [Accepted: 09/23/2019] [Indexed: 01/06/2023]
Abstract
BACKGROUND Liver fibrosis is a serious complication of single ventricle Fontan survivors. Its causes are of great interest, and potential solutions to halt or delay progression are needed. The purpose of this study is to investigate if prior hemodynamics and anatomy can predict liver fibrosis severity in these patients. METHODS Twenty-one Fontan patients with cardiac magnetic resonance (CMR) data obtained greater than 1 year before liver biopsy data were included. Computational fluid dynamic simulations were performed to quantify total cavopulmonary connection (TCPC) flow dynamics using patient-specific anatomies and blood flow waveforms reconstructed from CMR data. Collagen deposition (a measure of liver fibrosis) was quantified by digital image analysis of Sirius red-stained slides. Statistical analyses were performed to investigate potential relationships between Fontan hemodynamics and liver fibrosis. RESULTS With an average time of 6.7 ± 2.9 years (range, 2-11 years) between CMR and biopsy, TCPC resistance and left pulmonary artery stenosis showed significant, positive correlations with magnitude of liver fibrosis (r = 0.54, P = .026; and r = 0.55, P = .028, respectively). The change in inferior vena cava flow rate over time also showed a significant positive correlation with magnitude of liver fibrosis (r = 0.91, P = .001). CONCLUSIONS TCPC resistance, left pulmonary artery stenosis, and increased inferior vena cava flow are positively associated with liver fibrosis after Fontan operation and hold promise as important predictors of hepatic decline. These findings encourage preprocedural planning and interventional strategies to improve TCPC performance and reduce vessel stenosis. Further investigation is warranted to design the ideal Fontan circulation and optimize flow dynamics to reduce the risk of liver fibrosis.
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Affiliation(s)
- Phillip M Trusty
- Wallace H. Coulter Department of Biomedical Engineering, Georgia Institute of Technology and Emory University, Atlanta, Georgia
| | - Zhenglun Alan Wei
- Wallace H. Coulter Department of Biomedical Engineering, Georgia Institute of Technology and Emory University, Atlanta, Georgia
| | - Jack Rychik
- Division of Cardiology, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Alexa Graham
- Wallace H. Coulter Department of Biomedical Engineering, Georgia Institute of Technology and Emory University, Atlanta, Georgia
| | - Pierre A Russo
- Department of Pathology and Laboratory Medicine, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Lea F Surrey
- Department of Pathology and Laboratory Medicine, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - David J Goldberg
- Division of Cardiology, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Ajit P Yoganathan
- Wallace H. Coulter Department of Biomedical Engineering, Georgia Institute of Technology and Emory University, Atlanta, Georgia.
| | - Mark A Fogel
- Division of Cardiology, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
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21
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Nagdyman N, Mebus S, Kügel J, Zachoval R, Clevert DA, Braun SL, Haverkämper G, Opgen-Rhein B, Berger F, Horster S, Schoetzau J, Salvador CP, Bauer U, Hess J, Ewert P, Kaemmerer H. Non-invasive assessment of liver alterations in Senning and Mustard patients. Cardiovasc Diagn Ther 2019; 9:S198-S208. [PMID: 31737528 DOI: 10.21037/cdt.2019.07.10] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
Background Adults with congenital heart disease and ventricular dysfunction are prone to liver congestion, leading to fibrosis or cirrhosis but little is known about the prevalence of liver disease in atrial switch patients. Liver impairment may develop due to increased systemic venous pressures. This prospective study aimed to assess non-invasively hepatic abnormalities in adults who underwent Senning or Mustard procedures. Methods Hepatic involvement was assessed non-invasively clinically by laboratory analysis, hepatic fibrotic markers, sonography, and liver stiffness measurements [transient elastography (TE) and acoustic radiation force impulse imaging (ARFI)]. Results Overall, 24 adults who had undergone atrial switch operation (13 Senning, 11 Mustard; four female; median age 27.8 years; range 24-45 years) were enrolled. In liver stiffness measurements, only three patients had values within the normal reference. All other patients showed mild, moderate or severe liver fibrosis or cirrhosis, respectively. Using imaging and laboratory analysis, 71% of the subjects had signs of liver fibrosis (46%) or cirrhosis (25%). Conclusions Non-invasive screening for liver congestion, fibrosis or cirrhosis could be meaningful in targeted screening for hepatic impairment in patients with TGA-ASO. As expert knowledge is essential, patients should be regularly controlled in highly specialised centres with cooperations between congenital cardiologists and hepatologists.
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Affiliation(s)
- Nicole Nagdyman
- Department of Pediatric Cardiology and Congenital Heart Disease, German Heart Centre Munich, Technical University of Munich (TUM), Munich, Germany
| | - Siegrun Mebus
- Department of Pediatric Cardiology and Congenital Heart Disease, German Heart Centre Munich, Technical University of Munich (TUM), Munich, Germany
| | - Johanna Kügel
- Department of Pediatric Cardiology and Congenital Heart Disease, German Heart Centre Munich, Technical University of Munich (TUM), Munich, Germany
| | - Reinhart Zachoval
- Department of Gastroenterology and Hepatology, Ludwig-Maximilians-University Munich, Munich, Germany
| | - Dirk-André Clevert
- Department of Interdisciplinary Ultrasound Center, Ludwig-Maximilians-University Munich, Munich, Germany
| | - Siegmund Lorenz Braun
- Institute of Laboratory Medicine, German Heart Centre Munich, Technical University of Munich (TUM), Munich, Germany
| | - Guido Haverkämper
- Department of Congenital Heart Defects and Pediatric Cardiology, German Heart Centre Berlin and Charité Universitätsmedizin Berlin, Berlin, Germany
| | - Bernd Opgen-Rhein
- Department of Congenital Heart Defects and Pediatric Cardiology, German Heart Centre Berlin and Charité Universitätsmedizin Berlin, Berlin, Germany
| | - Felix Berger
- Department of Congenital Heart Defects and Pediatric Cardiology, German Heart Centre Berlin and Charité Universitätsmedizin Berlin, Berlin, Germany.,DZHK (German Cardiovascular Research Centre), partner site Berlin, Berlin, Germany
| | - Sophia Horster
- Department of Gastroenterology and Hepatology, Ludwig-Maximilians-University Munich, Munich, Germany
| | - Jörg Schoetzau
- Department of Pediatric Cardiology and Congenital Heart Disease, German Heart Centre Munich, Technical University of Munich (TUM), Munich, Germany
| | - Claudia Pujol Salvador
- Department of Pediatric Cardiology and Congenital Heart Disease, German Heart Centre Munich, Technical University of Munich (TUM), Munich, Germany
| | - Ulrike Bauer
- Competence Network for Congenital Heart Defects, Berlin, Germany
| | - John Hess
- Department of Pediatric Cardiology and Congenital Heart Disease, German Heart Centre Munich, Technical University of Munich (TUM), Munich, Germany
| | - Peter Ewert
- Department of Pediatric Cardiology and Congenital Heart Disease, German Heart Centre Munich, Technical University of Munich (TUM), Munich, Germany.,DZHK (German Cardiovascular Research Centre), Munich Heart Alliance, Munich, Germany
| | - Harald Kaemmerer
- Department of Pediatric Cardiology and Congenital Heart Disease, German Heart Centre Munich, Technical University of Munich (TUM), Munich, Germany
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22
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Saraf A, Book WM, Nelson TJ, Xu C. Hypoplastic left heart syndrome: From bedside to bench and back. J Mol Cell Cardiol 2019; 135:109-118. [PMID: 31419439 PMCID: PMC10831616 DOI: 10.1016/j.yjmcc.2019.08.005] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/23/2019] [Revised: 08/07/2019] [Accepted: 08/12/2019] [Indexed: 02/09/2023]
Abstract
Hypoplastic Left Heart Syndrome (HLHS) is a complex Congenital Heart Disease (CHD) that was almost universally fatal until the advent of the Norwood operation in 1981. Children with HLHS who largely succumbed to the disease within the first year of life, are now surviving to adulthood. However, this survival is associated with multiple comorbidities and HLHS infants have a higher mortality rate as compared to other non-HLHS single ventricle patients. In this review we (a) discuss current clinical challenges associated in the care of HLHS patients, (b) explore the use of systems biology in understanding the molecular framework of this disease, (c) evaluate induced pluripotent stem cells as a translational model to understand molecular mechanisms and manipulate them to improve outcomes, and (d) investigate cell therapy, gene therapy, and tissue engineering as a potential tool to regenerate hypoplastic cardiac structures and improve outcomes.
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Affiliation(s)
- Anita Saraf
- Division of Cardiology, Emory University School of Medicine, Atlanta, GA 30322, USA.
| | - Wendy M Book
- Division of Cardiology, Emory University School of Medicine, Atlanta, GA 30322, USA
| | - Timothy J Nelson
- Division of General Internal Medicine, Center for Regenerative Medicine, Pediatric Cardiothoracic Surgery, Division of Cardiovascular Diseases, Transplant Center, Division of Biomedical Statistics and Informatics, Division of Pediatric Cardiology, Department of Molecular Pharmacology and Experimental Therapeutics, Mayo Clinic, Rochester, MN 55905, USA
| | - Chunhui Xu
- Division of Pediatric Cardiology, Department of Pediatrics, Emory University School of Medicine and Children's Healthcare of Atlanta, Atlanta, GA 30322, USA; Wallace H. Coulter Department of Biomedical Engineering, Georgia Institute of Technology and Emory University, Atlanta, GA 30322, USA
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23
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Komatsu H, Inui A, Kishiki K, Kawai H, Yoshio S, Osawa Y, Kanto T, Fujisawa T. Liver disease secondary to congenital heart disease in children. Expert Rev Gastroenterol Hepatol 2019; 13:651-666. [PMID: 31131680 DOI: 10.1080/17474124.2019.1621746] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Introduction: Hepatic fibrosis and hepatocellular carcinoma (HCC) can develop in children with congenital heart disease. Although hepatic fibrosis and HCC are prone to develop after the Fontan operation, they can also develop in patients suffering from congenital heart disease who have not undergone Fontan operation. Area covered: The history of cardiac hepatopathy including Fontan-associated liver disease is described. Patient characteristics, liver histology, imaging examinations and blood tests are reviewed to elucidate the mechanism of cardiac hepatopathy. In addition, a flowchart for the follow-up management of cardiac hepatopathy in children with congenital heart disease is proposed. Expert opinion: Congestion and low cardiac output are the main causes of cardiac hepatopathy. Advanced hepatic fibrosis is presumed to be associated with HCC. HCC can develop in both adolescents and young adults. Regardless of whether the Fontan operation is performed, children with a functional single ventricle and chronic heart failure should be regularly examined for cardiac hepatopathy. There is no single reliable laboratory parameter to accurately detect cardiac hepatopathy; hepatic fibrosis indices and elastography have shown inconsistent results for detection of this disease. Further studies using liver specimen-confirmed patients and standardization of evaluation protocols are required to clarify the pathogenesis of cardiac hepatopathy.
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Affiliation(s)
- Haruki Komatsu
- a Department of Pediatrics , Toho University, Sakura Medical Center , Chiba , Japan
| | - Ayano Inui
- b Department of Pediatric Hepatology and Gastroenterology , Eastern Yokohama Hospital , Kanagawa , Japan
| | - Kanako Kishiki
- c Department of Pediatric Cardiology , Sakakibara Heart Institute , Tokyo , Japan
| | - Hironari Kawai
- d Research Center for Hepatitis and Immunology, National Center for Global Health and Medicine , Chiba , Japan
| | - Sachiyo Yoshio
- d Research Center for Hepatitis and Immunology, National Center for Global Health and Medicine , Chiba , Japan
| | - Yosuke Osawa
- d Research Center for Hepatitis and Immunology, National Center for Global Health and Medicine , Chiba , Japan
| | - Tatsuya Kanto
- d Research Center for Hepatitis and Immunology, National Center for Global Health and Medicine , Chiba , Japan
| | - Tomoo Fujisawa
- b Department of Pediatric Hepatology and Gastroenterology , Eastern Yokohama Hospital , Kanagawa , Japan
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24
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Michel M, Zlamy M, Entenmann A, Pichler K, Scholl-Bürgi S, Karall D, Geiger R, Salvador C, Niederwanger C, Ohuchi H. Impact of the Fontan Operation on Organ Systems. Cardiovasc Hematol Disord Drug Targets 2019; 19:205-214. [PMID: 30747084 DOI: 10.2174/1871529x19666190211165124] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2018] [Revised: 01/09/2019] [Accepted: 01/29/2019] [Indexed: 02/06/2023]
Abstract
In patients having undergone the Fontan operation, besides the well discussed changes in the cardiac, pulmonary and gastrointestinal system, alterations of further organ systems including the hematologic, immunologic, endocrinological and metabolic are reported. As a medical adjunct to Fontan surgery, the systematic study of the central role of the liver as a metabolizing and synthesizing organ should allow for a better understanding of the pathomechanism underlying the typical problems in Fontan patients, and in this context, the profiling of endocrinological and metabolic patterns might offer a tool for the optimization of Fontan follow-up, targeted monitoring and specific adjunct treatment.
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Affiliation(s)
- Miriam Michel
- Department of Pediatrics III, Division of Cardiology, Pulmology, Allergology, and Cystic Fibrosis, Innsbruck Medical University, Anichstraße 35, 6020 Innsbruck, Austria
| | - Manuela Zlamy
- Department of Pediatrics I, Innsbruck Medical University, Anichstraße 35, 6020 Innsbruck, Austria
| | - Andreas Entenmann
- Department of Pediatrics I, Innsbruck Medical University, Anichstraße 35, 6020 Innsbruck, Austria
| | - Karin Pichler
- Department of Pediatrics, Vienna Medical University, Währinger Gürtel 16, 1090 Vienna, Austria
| | - Sabine Scholl-Bürgi
- Department of Pediatrics I, Innsbruck Medical University, Anichstraße 35, 6020 Innsbruck, Austria
| | - Daniela Karall
- Department of Pediatrics I, Innsbruck Medical University, Anichstraße 35, 6020 Innsbruck, Austria
| | - Ralf Geiger
- Department of Pediatrics III, Division of Cardiology, Pulmology, Allergology, and Cystic Fibrosis, Innsbruck Medical University, Anichstraße 35, 6020 Innsbruck, Austria
| | - Christina Salvador
- Department of Pediatrics I, Innsbruck Medical University, Anichstraße 35, 6020 Innsbruck, Austria
| | - Christian Niederwanger
- Department of Pediatrics I, Innsbruck Medical University, Anichstraße 35, 6020 Innsbruck, Austria
| | - Hideo Ohuchi
- Department for Pediatric Cardiology, National Cerebral and Cardiovascular Center, 5-7-1 Fujishiro-dai, Suita, Osaka 565-8565, Japan
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25
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Hepatic and renal end-organ damage in the Fontan circulation: A report from the Australian and New Zealand Fontan Registry. Int J Cardiol 2018; 273:100-107. [DOI: 10.1016/j.ijcard.2018.07.118] [Citation(s) in RCA: 45] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/05/2018] [Revised: 07/21/2018] [Accepted: 07/23/2018] [Indexed: 11/23/2022]
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26
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Hepatic Changes in the Fontan Circulation: Identification of Liver Dysfunction and an Attempt to Streamline Follow-up Screening. Pediatr Cardiol 2018; 39:1604-1613. [PMID: 30032312 DOI: 10.1007/s00246-018-1937-1] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/30/2017] [Accepted: 07/05/2018] [Indexed: 12/27/2022]
Abstract
We tried to identify structural and functional liver aberrances in a palliated Fontan population and sought to determine useful screening modalities, in order to propose a screening protocol to detect patients at risk. Twenty nine patients, median age 23.7 years (interquartile range (IQR) 20.5-27.2) and median Fontan interval 19.7 years (IQR 4.5-21.4), were prospectively studied with echocardiography, blood analysis (including serum fibrosis scores Forns, APRI and FIB4), liver imaging (ultrasound (US), Doppler), and shear wave elastography to determine liver stiffness (LS). Laboratory tests predominantly showed abnormal values for gamma-glutamyltransferase. Forns index indicated moderate fibrosis in 29% of patients and correlated with Fontan interval (p = 0.034). US liver morphology was deviant in 46% of patients, with surface nodularity in 21% and nodular hyperplasia in 29%. Doppler assessment of flow velocities was within normal ranges for most patients. LS (mean 10.4 ± 3.7 kPa) was elevated in 96% of our population and higher LS values were significantly related to longer Fontan interval (p = 0.018). Adolescent and adult Fontan patients show moderate signs of liver dysfunction. Usefulness of serum parameters and fibrosis scores in post-Fontan screening remains ambiguous. The high percentage of morphologic liver changes in palliated patients supports the use of US in periodic follow-up. LS likely overestimates fibrosis due to liver congestion, arguing for the need of validation through sequential measurements. Screening should minimally encompass US assessment in combination with selective liver fibrosis scores. The role of LS measurement in Fontan follow-up and liver screening needs to be further elucidated.
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27
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Munsterman ID, Duijnhouwer AL, Kendall TJ, Bronkhorst CM, Ronot M, van Wettere M, van Dijk APJ, Drenth JPH, Tjwa ETTL, van Dijk APJ, Drenth JPH, Duijnhouwer AL, van Kimmenade RRJ, van Koeverden SW, Munsterman ID, Tanke RB, Tjwa ETTL, Udink ten Cate FEA. The clinical spectrum of Fontan-associated liver disease: results from a prospective multimodality screening cohort. Eur Heart J 2018; 40:1057-1068. [DOI: 10.1093/eurheartj/ehy620] [Citation(s) in RCA: 62] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/16/2018] [Revised: 07/04/2018] [Accepted: 09/14/2018] [Indexed: 12/13/2022] Open
Affiliation(s)
- Isabelle D Munsterman
- Department of Gastroenterology and Hepatology, Radboud University Medical Centre, Postbus 9101, Geert Grooteplein Zuid 10, HB Nijmegen, the Netherlands
| | - Anthonie L Duijnhouwer
- Department of Cardiology, Radboud University Medical Centre, Geert Grooteplein Zuid 10, HB Nijmegen, the Netherlands
| | - Timothy J Kendall
- Department of Pathology, Division of Pathology, University of Edinburgh, Douth Bridge, Edinburgh, UK
| | - Carolien M Bronkhorst
- Department of Pathology, Jeroen Bosch Hospital, Henri Dunantstraat 15223 GZ ‘s-Hertogenbosch, the Netherlands
| | - Maxime Ronot
- Department of Radiology, University Hospitals Paris Nord Val de Seine, Beaujon, 100 Boulevard du Général Leclerc, Clichy, France
| | - Morgane van Wettere
- Department of Radiology, University Hospitals Paris Nord Val de Seine, Beaujon, 100 Boulevard du Général Leclerc, Clichy, France
| | - Arie P J van Dijk
- Department of Cardiology, Radboud University Medical Centre, Geert Grooteplein Zuid 10, HB Nijmegen, the Netherlands
| | - Joost P H Drenth
- Department of Gastroenterology and Hepatology, Radboud University Medical Centre, Postbus 9101, Geert Grooteplein Zuid 10, HB Nijmegen, the Netherlands
| | - Eric T T L Tjwa
- Department of Gastroenterology and Hepatology, Radboud University Medical Centre, Postbus 9101, Geert Grooteplein Zuid 10, HB Nijmegen, the Netherlands
| | - Arie P J van Dijk
- Department of Cardiology, Radboud University Medical Centre, Nijmegen, the Netherlands
| | - Joost P H Drenth
- Department of Gastroenterology and Hepatology, Radboud University Medical Centre, Nijmegen, the Netherlands
| | | | - R R J van Kimmenade
- Department of Cardiology, Radboud University Medical Centre, Nijmegen, the Netherlands
| | - S W van Koeverden
- Department of Radiology, Radboud University Medical Centre, Nijmegen, the Netherlands
| | - Isabelle D Munsterman
- Department of Gastroenterology and Hepatology, Radboud University Medical Centre, Nijmegen, the Netherlands
| | - R B Tanke
- Department of Pediatric Cardiology, Radboud University Medical Centre, Nijmegen, the Netherlands
| | - Eric T T L Tjwa
- Department of Gastroenterology and Hepatology, Radboud University Medical Centre, Nijmegen, the Netherlands
| | - F E A Udink ten Cate
- Department of Pediatric Cardiology, Radboud University Medical Centre, Nijmegen, the Netherlands
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28
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Song J, Kim K, Huh J, Kang IS, Kim SH, Yang JH, Jun TG, Kim JH. Imaging Assessment of Hepatic Changes after Fontan Surgery. Int Heart J 2018; 59:1008-1014. [PMID: 30158375 DOI: 10.1536/ihj.17-349] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
The aim of this study was to evaluate hepatic dysfunction over 10 years following Fontan surgery. We assessed the clinical usefulness of diagnostic tools for the detection and follow-up of hepatic dysfunction in patients with Fontan circulation.A total of 26 post-Fontan patients (median age 13 years, range 10-35 years; median duration from Fontan procedure 10.5 years, range 4-17 years) were enrolled in this study. Hepatic assessment was performed by ultrasonography, computed tomography (CT), and transient elastography (TE) with biochemical tests, echocardiography, and cardiac catheterization. Related parameters were compared on the basis of different findings in liver sonography, CT, and TE.Liver CT and TE showed abnormal findings in all patients. Liver ultrasonography revealed abnormal results in 24 patients (92.3%). However, liver function test was normal and did not correlate with imaging studies. C-reactive protein was significantly correlated with severity of CT findings. White blood cell, platelet count, and N-terminal pro-brain natriuretic peptide were correlated with severity on TE. Post-Fontan high pulmonary vascular resistance (P = 0.046) and high mean pulmonary artery pressure (P = 0.046) correlated with hepatic changes on liver CT.Changes in the liver post-Fontan surgery are common and occur even after 10 years the procedure. Liver imaging is more sensitive, and CT seems to be more useful for differentiation of severe hepatic changes.
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Affiliation(s)
- Jinyoung Song
- Department of Pediatrics, Heart Vascular Stroke Institute, Samsung Medical Center, Sungkyunkwan University School of Medicine
| | - Kyunghee Kim
- Department of Pediatrics, Hongseong Medical Center
| | - June Huh
- Department of Pediatrics, Heart Vascular Stroke Institute, Samsung Medical Center, Sungkyunkwan University School of Medicine
| | - I-Seok Kang
- Department of Pediatrics, Heart Vascular Stroke Institute, Samsung Medical Center, Sungkyunkwan University School of Medicine
| | - Sung Hoon Kim
- Department of Pediatrics, Samsung Changwon Hospital, Sungkyunkwan University School of Medicine
| | - Ji-Hyuk Yang
- Department of Thoracic Surgery, Heart Vascular Stroke Institute, Samsung Medical Center, Sungkyunkwan University School of Medicine
| | - Tae Gook Jun
- Department of Thoracic Surgery, Heart Vascular Stroke Institute, Samsung Medical Center, Sungkyunkwan University School of Medicine
| | - Ji Hye Kim
- Department of Radiology and Center for Imaging Science, Samsung Medical Center, Sungkyunkwan University School of Medicine
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29
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Tikhonov IN, Zharkova MS, Maevskaya MV, Zozulya VN, Nekrasova TP, Arslanyan MG, Musina NP, Tatarkina MA, Rzaev RT, Puzakov KB, Ivashkin VT, Malikova MS. Differential diagnosis of ascites in internal medicine: clinical case. TERAPEVT ARKH 2018; 90:74-80. [PMID: 30701950 DOI: 10.26442/terarkh201890874-80] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
Ascites and hydrothorax may be the symptoms of congestive heart failure and do not always reflects presense of the decompensated liver cirrhosis. Clinical examination of patient with chronic hepatitis C which cyanosis of the lips, cervival veins pulsation, a triple heart rhythm indicated on pathology of the heart (constrictive pericarditis), which was confirmed by instrumental methods. Congestive heart failure has lead to the congestive liver in a young female patient. Regression of all the symptoms of heart failure occurred after surgical treatment (pericardectomy).
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Affiliation(s)
- I N Tikhonov
- Scientific Research Department of Innovative Therapy of the Scientific and Technological Park of Biomedicine, I.M. Sechenov First Moscow State Medical University, Ministry of Health of Russia (Sechenov University), Moscow, Russia.,V.H. Vasilenko Clinic of Propaedeutics of Internal Diseases, Gastroenterology and Hepatology, I.M. Sechenov First Moscow State Medical University, Ministry of Health of Russia (Sechenov University), Moscow, Russia
| | - M S Zharkova
- V.H. Vasilenko Clinic of Propaedeutics of Internal Diseases, Gastroenterology and Hepatology, I.M. Sechenov First Moscow State Medical University, Ministry of Health of Russia (Sechenov University), Moscow, Russia
| | - M V Maevskaya
- The Department of Propaedeutics of Internal Medicine of the Faculty of Physiology, I.M. Sechenov First Moscow State Medical University, Ministry of Health of Russia (Sechenov University), Moscow, Russia
| | - V N Zozulya
- The Department of Propaedeutics of Internal Medicine of the Faculty of Physiology, I.M. Sechenov First Moscow State Medical University, Ministry of Health of Russia (Sechenov University), Moscow, Russia
| | - T P Nekrasova
- Acad. A.I. Strukov Department of Pathological Anatomy, I.M. Sechenov First Moscow State Medical University, Ministry of Health of Russia (Sechenov University), Moscow, Russia
| | - M G Arslanyan
- V.H. Vasilenko Clinic of Propaedeutics of Internal Diseases, Gastroenterology and Hepatology, I.M. Sechenov First Moscow State Medical University, Ministry of Health of Russia (Sechenov University), Moscow, Russia
| | - N P Musina
- V.H. Vasilenko Clinic of Propaedeutics of Internal Diseases, Gastroenterology and Hepatology, I.M. Sechenov First Moscow State Medical University, Ministry of Health of Russia (Sechenov University), Moscow, Russia
| | - M A Tatarkina
- V.H. Vasilenko Clinic of Propaedeutics of Internal Diseases, Gastroenterology and Hepatology, I.M. Sechenov First Moscow State Medical University, Ministry of Health of Russia (Sechenov University), Moscow, Russia
| | - R T Rzaev
- V.H. Vasilenko Clinic of Propaedeutics of Internal Diseases, Gastroenterology and Hepatology, I.M. Sechenov First Moscow State Medical University, Ministry of Health of Russia (Sechenov University), Moscow, Russia
| | - K B Puzakov
- V.H. Vasilenko Clinic of Propaedeutics of Internal Diseases, Gastroenterology and Hepatology, I.M. Sechenov First Moscow State Medical University, Ministry of Health of Russia (Sechenov University), Moscow, Russia
| | - V T Ivashkin
- Scientific Research Department of Innovative Therapy of the Scientific and Technological Park of Biomedicine, I.M. Sechenov First Moscow State Medical University, Ministry of Health of Russia (Sechenov University), Moscow, Russia.,V.H. Vasilenko Clinic of Propaedeutics of Internal Diseases, Gastroenterology and Hepatology, I.M. Sechenov First Moscow State Medical University, Ministry of Health of Russia (Sechenov University), Moscow, Russia.,The Department of Propaedeutics of Internal Medicine of the Faculty of Physiology, I.M. Sechenov First Moscow State Medical University, Ministry of Health of Russia (Sechenov University), Moscow, Russia
| | - M S Malikova
- B.V. Petrovsky Russian Scientific Center of Surgery, Moscow, Russia
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30
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Schachter JL, Patel M, Horton SR, Mike Devane A, Ewing A, Abrams GA. FibroSURE and elastography poorly predict the severity of liver fibrosis in Fontan-associated liver disease. CONGENIT HEART DIS 2018; 13:764-770. [PMID: 30101472 DOI: 10.1111/chd.12650] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/11/2018] [Revised: 05/24/2018] [Accepted: 06/10/2018] [Indexed: 12/17/2022]
Abstract
OBJECTIVE As the population of patients with Fontan circulation surviving into adulthood increases, hepatic cirrhosis has grown to be a significant cause of morbidity and mortality. Early detection of advanced hepatic fibrosis is imperative for proper intervention and consideration for heart or combined heart/liver transplantation. Noninvasive biomarkers and elastography have been evaluated for their diagnostic utility with variable results in the Fontan population. DESIGN The cohort included 14 patients age 26.4 SD 7.5 who underwent Fontan surgery. All patients were evaluated with FibroSURE, shear wave elastography (SWE), hepatic duplex sonography, and liver biopsy. Liver fibrosis on biopsy was evaluated according to the congestive hepatic fibrosis system. RESULTS In our cohort, 100% of patients had fibrosis with 36% demonstrating advanced fibrosis. FibroSURE agreed with liver biopsy in only 5 out of 14 cases (36%): underestimating in 7 and overestimating in 2 individuals. SWE agreed with liver biopsy in 0% of cases: overestimating in 10 and underestimating in 4 cases. None of the duplex sonography indices predicted the presence or severity of liver fibrosis. CONCLUSION This study demonstrates that children who have undergone a Fontan procedure universally develop some hepatic fibrosis and a significant number have advanced fibrosis by adulthood. The FibroSURE blood test, SWE, and hepatic duplex sonography were unable to accurately predict the presence or severity of hepatic fibrosis when compared with liver biopsy. Further studies are needed to investigate novel noninvasive methods and/or biomarkers that can adequately detect advanced hepatic fibrosis before the development of cirrhosis and hepatic decompensation.
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Affiliation(s)
- Jessica L Schachter
- Department of Medicine, Greenville Memorial Hospital, Greenville, South Carolina
| | - Manisha Patel
- Department of Cardiology, Greenville Memorial Hospital, Greenville, South Carolina
| | - Samuel R Horton
- Department of Pathology, Greenville Memorial Hospital, Greenville, South Carolina
| | - A Mike Devane
- Department of Radiology, Greenville Memorial Hospital, Greenville, South Carolina
| | - Alex Ewing
- Department of Quality, Greenville Memorial Hospital, Greenville, South Carolina
| | - Gary A Abrams
- Department of Gastroenterology, Greenville Memorial Hospital, Greenville, South Carolina
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31
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Trusty PM, Wei Z, Rychik J, Russo PA, Surrey LF, Goldberg DJ, Fogel MA, Yoganathan AP. Impact of hemodynamics and fluid energetics on liver fibrosis after Fontan operation. J Thorac Cardiovasc Surg 2018; 156:267-275. [DOI: 10.1016/j.jtcvs.2018.02.078] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/12/2017] [Revised: 11/29/2017] [Accepted: 02/04/2018] [Indexed: 10/17/2022]
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32
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Egbe A, Miranda WR, Connolly HM, Khan AR, Al-Otaibi M, Venkatesh SK, Simonetto D, Kamath P, Warnes C. Temporal changes in liver stiffness after Fontan operation: Results of serial magnetic resonance elastography. Int J Cardiol 2018; 258:299-304. [DOI: 10.1016/j.ijcard.2018.01.108] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/18/2017] [Revised: 12/17/2017] [Accepted: 01/22/2018] [Indexed: 12/27/2022]
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33
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Kim TH, Yang HK, Jang HJ, Yoo SJ, Khalili K, Kim TK. Abdominal imaging findings in adult patients with Fontan circulation. Insights Imaging 2018; 9:357-367. [PMID: 29623675 PMCID: PMC5991003 DOI: 10.1007/s13244-018-0609-2] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2017] [Revised: 02/04/2018] [Accepted: 02/12/2018] [Indexed: 12/12/2022] Open
Abstract
Abstract The Fontan procedures, designed to treat paediatric patients with functional single ventricles, have markedly improved the patient’s survival into adulthood. The physiology of the Fontan circuit inevitably increases systemic venous pressure, which may lead to multi-system organ failure in the long-term follow-up. Fontan-associated liver disease (FALD) can progress to liver cirrhosis with signs of portal hypertension. Focal nodular hyperplasia-like nodules commonly develop in FALD. Imaging surveillance is often performed to monitor the progression of FALD and to detect hepatocellular carcinoma, which infrequently develops in FALD. Other abdominal abnormalities in post-Fontan patients include protein losing enteropathy and pheochromocytoma/paraganglioma. Given that these abdominal abnormalities are critical for patient management, it is important for radiologists to become familiar with the abdominal abnormalities that are common in post-Fontan patients on cross-sectional imaging. Teaching points • Fontan procedure for functional single ventricle has improved patient survival into adulthood. • Radiologists should be familiar with unique imaging findings of Fontan-associated liver disease. • Focal nodular hyperplasia-like nodules commonly develop in Fontan-associated liver disease. • Hepatocellular carcinoma, protein-losing enteropathy, pheochromocytoma/paraganglioma may develop. Electronic supplementary material The online version of this article (10.1007/s13244-018-0609-2) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Tae-Hyung Kim
- Department of Radiology, Seoul National University Hospital, 101 Daehak-ro, Jongno-gu, Seoul, 03080, South Korea.,Department of Radiology, Seoul National University College of Medicine, 103 Daehak-ro, Jongnogu, Seoul, 03080, South Korea
| | - Hyun Kyung Yang
- Department of Medical Imaging, Toronto General Hospital, 585 University Avenue, Toronto, ON, M5G 2N2, Canada
| | - Hyun-Jung Jang
- Department of Medical Imaging, Toronto General Hospital, 585 University Avenue, Toronto, ON, M5G 2N2, Canada
| | - Shi-Joon Yoo
- Department of Diagnostic Imaging, Hospital for Sick Children, 555 University Avenue, Toronto, ON, M5J2L4, Canada
| | - Korosh Khalili
- Department of Medical Imaging, Toronto General Hospital, 585 University Avenue, Toronto, ON, M5G 2N2, Canada
| | - Tae Kyoung Kim
- Department of Medical Imaging, Toronto General Hospital, 585 University Avenue, Toronto, ON, M5G 2N2, Canada.
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Nandwana SB, Olaiya B, Cox K, Sahu A, Mittal P. Abdominal Imaging Surveillance in Adult Patients After Fontan Procedure: Risk of Chronic Liver Disease and Hepatocellular Carcinoma. Curr Probl Diagn Radiol 2018; 47:19-22. [DOI: 10.1067/j.cpradiol.2017.04.002] [Citation(s) in RCA: 40] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2017] [Revised: 03/20/2017] [Accepted: 04/06/2017] [Indexed: 01/24/2023]
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Kovacikova L, Krasnanova V, Skrak P, Zahorec M, Kantorova A, Semberova J, Bacharova L. Immune Abnormalities in Patients With Single Ventricle Circulation Precede the Fontan Procedure. World J Pediatr Congenit Heart Surg 2017; 8:672-682. [PMID: 29187105 DOI: 10.1177/2150135117732529] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
BACKGROUND Immune abnormalities are common in Fontan patients with protein-losing enteropathy. Limited data exist on immune function of other patients with single ventricle circulation. METHODS This prospective cohort study evaluated immunologic characteristics of children with single ventricle circulation from neonatal age up to early post-Fontan period. RESULTS Low leukocyte counts were observed in half of the patients prior to bidirectional Glenn and Fontan surgery. Total lymphocyte counts were below normal range in 36% to 63% of patients across all groups except patients following Fontan procedure who had normal counts. Typical lymphocyte subpopulation patterns were (1) high counts of total and helper T lymphocytes (CD3+ and CD4+ cells), low B lymphocytes (CD19+ cells), and increased CD4/CD8 ratio in neonates and (2) low T lymphocytes (CD3+, CD4+, CD8+ cells) with high natural killer cells (CD16+) and B lymphocytes (CD19+ cells) in other groups. Low preoperative total lymphocyte counts were associated with longer intensive care unit stay in patients after bidirectional Glenn and Fontan procedure ( P = .03 and P = .01, respectively) and low leukocyte counts with higher incidence of pleural effusions and chylothorax after Fontan procedure ( P = .005 and P = .002, respectively). CONCLUSIONS Single ventricle patients display several immunological abnormalities. Beyond the neonatal age, an immune pattern includes CD3+, CD4+, CD8+ lymphopenia, and CD16+ and CD19+ lymphocytosis. B-cell lymphocytosis compensates T-cell lymphopenia, producing normal total lymphocyte counts in patients early after Fontan surgery. Low preoperative total lymphocyte counts may be associated with longer postoperative intensive care unit stay in patients with bidirectional Glenn and Fontan procedure and leukopenia with pleural effusions in Fontan patients.
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Affiliation(s)
- Lubica Kovacikova
- 1 Pediatric Cardiac Intensive Care Unit, National Institute of Cardiovascular Diseases, Limbova 1, Bratislava, Slovakia
| | - Veronika Krasnanova
- 1 Pediatric Cardiac Intensive Care Unit, National Institute of Cardiovascular Diseases, Limbova 1, Bratislava, Slovakia
| | - Peter Skrak
- 1 Pediatric Cardiac Intensive Care Unit, National Institute of Cardiovascular Diseases, Limbova 1, Bratislava, Slovakia
| | - Martin Zahorec
- 1 Pediatric Cardiac Intensive Care Unit, National Institute of Cardiovascular Diseases, Limbova 1, Bratislava, Slovakia
| | - Andrea Kantorova
- 2 Department of Pediatric Cardiac Surgery, National Institute of Cardiovascular Diseases, Limbova 1, Bratislava, Slovakia
| | - Jana Semberova
- 3 Department of Laboratory Medicine, Children Faculty Hospital, Limbova 1, Bratislava, Slovakia
| | - Ljuba Bacharova
- 4 Department of Biophotonics, International Laser Center Bratislava, Ilkovičova 3, Bratislava, Slovakia
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Agarwal A, Cunnington C, Sabanayagam A, Zier L, McCulloch CE, Harris IS, Foster E, Atkinson D, Bryan A, Jenkins P, Dua J, Parker MJ, Karunaratne D, Moore JA, Meadows J, Clarke B, Hoschtitzky JA, Mahadevan VS. Cardiopulmonary exercise testing in the evaluation of liver disease in adults who have had the Fontan operation. Arch Cardiovasc Dis 2017; 111:276-284. [PMID: 29198937 DOI: 10.1016/j.acvd.2017.09.001] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/16/2017] [Revised: 09/08/2017] [Accepted: 09/13/2017] [Indexed: 10/18/2022]
Abstract
BACKGROUND Liver disease (LD) is a long-term complication in patients with a single ventricle who have had the Fontan operation. A decline in cardiopulmonary exercise testing (CPET) variables is associated with increased risk of hospitalization, but its association with LD is unknown. AIM To determine the association between CPET variables and LD in adults who have had the Fontan operation. METHODS We retrospectively reviewed the medical records from two tertiary institutions. RESULTS We identified 114 adults (≥18 years; mean 30.9±7.4 years) who had undergone the Fontan operation: 56% were women; 63% had total cavopulmonary connection; 66% had New York Heart Association (NYHA) class I status; 42% had arrhythmias; 22% had systemic right ventricle; and 35% had ventricular dysfunction. Of 81 patients with liver-imaging data, 41% had LD (i.e. imaging evidence of cirrhosis, with or without portal hypertension, splenomegaly or varices). There were no differences in clinical or echocardiographic variables between those with and without LD. Among the 58 patients with CPET data, mean peak oxygen consumption (VO2) was 18.6±5.7mL/kg/min, per-cent-predicted peak VO2 was 53.9±15.5%, peak oxygen pulse was 9.3±2.9mL/beat and per-cent-predicted peak oxygen pulse was 82.6±21.5%. Of the 44 patients with liver and CPET data, each standard deviation decrease in per-cent-predicted peak VO2 (16%) and per-cent-predicted peak oxygen pulse (22%) was associated with a 2.3-fold increase in the odds of LD, after adjusting for NYHA, institution and Fontan type (P=0.04). Similarly, each standard deviation decrease in per-cent-predicted peak VO2 and oxygen pulse was associated with an estimated 5.9-year and 4.9-year earlier onset of LD, respectively (P>0.05). CONCLUSIONS Decline in per-cent-predicted peak VO2 and oxygen pulse was associated with increased odds of LD in adults who had undergone the Fontan operation. Our study supports more rapid hepatic evaluation among patients with abnormal or worsening CPET variables.
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Affiliation(s)
| | - Colin Cunnington
- Manchester Royal Infirmary, Central Manchester University Hospitals NHS Trust, Manchester, United Kingdom
| | | | - Lucas Zier
- University of California San Francisco, San Francisco, CA, USA
| | | | - Ian S Harris
- University of California San Francisco, San Francisco, CA, USA
| | - Elyse Foster
- University of California San Francisco, San Francisco, CA, USA
| | - Dougal Atkinson
- Manchester Royal Infirmary, Central Manchester University Hospitals NHS Trust, Manchester, United Kingdom
| | - Angela Bryan
- Manchester Royal Infirmary, Central Manchester University Hospitals NHS Trust, Manchester, United Kingdom
| | - Petra Jenkins
- Manchester Royal Infirmary, Central Manchester University Hospitals NHS Trust, Manchester, United Kingdom
| | - Jaspal Dua
- Manchester Royal Infirmary, Central Manchester University Hospitals NHS Trust, Manchester, United Kingdom
| | - Michael J Parker
- Manchester Royal Infirmary, Central Manchester University Hospitals NHS Trust, Manchester, United Kingdom
| | - Devinda Karunaratne
- Manchester Royal Infirmary, Central Manchester University Hospitals NHS Trust, Manchester, United Kingdom
| | - John A Moore
- Manchester Royal Infirmary, Central Manchester University Hospitals NHS Trust, Manchester, United Kingdom
| | - Jeffrey Meadows
- University of California San Francisco, San Francisco, CA, USA
| | - Bernard Clarke
- Manchester Royal Infirmary, Central Manchester University Hospitals NHS Trust, Manchester, United Kingdom
| | - J Andreas Hoschtitzky
- Manchester Royal Infirmary, Central Manchester University Hospitals NHS Trust, Manchester, United Kingdom
| | - Vaikom S Mahadevan
- University of California San Francisco, San Francisco, CA, USA; Manchester Royal Infirmary, Central Manchester University Hospitals NHS Trust, Manchester, United Kingdom.
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Daniels CJ, Bradley EA, Landzberg MJ, Aboulhosn J, Beekman RH, Book W, Gurvitz M, John A, John B, Marelli A, Marino BS, Minich LL, Poterucha JJ, Rand EB, Veldtman GR. Fontan-Associated Liver Disease. J Am Coll Cardiol 2017; 70:3173-3194. [DOI: 10.1016/j.jacc.2017.10.045] [Citation(s) in RCA: 110] [Impact Index Per Article: 15.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
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Diagnosis and Management of Noncardiac Complications in Adults With Congenital Heart Disease: A Scientific Statement From the American Heart Association. Circulation 2017; 136:e348-e392. [DOI: 10.1161/cir.0000000000000535] [Citation(s) in RCA: 106] [Impact Index Per Article: 15.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
Life expectancy and quality of life for those born with congenital heart disease (CHD) have greatly improved over the past 3 decades. While representing a great advance for these patients, who have been able to move from childhood to successful adult lives in increasing numbers, this development has resulted in an epidemiological shift and a generation of patients who are at risk of developing chronic multisystem disease in adulthood. Noncardiac complications significantly contribute to the morbidity and mortality of adults with CHD. Reduced survival has been documented in patients with CHD with renal dysfunction, restrictive lung disease, anemia, and cirrhosis. Furthermore, as this population ages, atherosclerotic cardiovascular disease and its risk factors are becoming increasingly prevalent. Disorders of psychosocial and cognitive development are key factors affecting the quality of life of these individuals. It is incumbent on physicians who care for patients with CHD to be mindful of the effects that disease of organs other than the heart may have on the well-being of adults with CHD. Further research is needed to understand how these noncardiac complications may affect the long-term outcome in these patients and what modifiable factors can be targeted for preventive intervention.
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Buendía-Fuentes F, Melero-Ferrer JL, Plaza-López D, Rueda-Soriano J, Osa-Saez A, Aguero J, Calvillo-Batllés P, Fonfria-Esparcia C, Ballesta-Cuñat A, Martí-Bonmatí L, Martínez-Dolz L. Noninvasive Liver Assessment in Adult Patients With Fontan Circulation Using Acoustic Radiation Force Impulse Elastography and Hepatic Magnetic Resonance Imaging. World J Pediatr Congenit Heart Surg 2017; 9:22-30. [PMID: 29103357 DOI: 10.1177/2150135117732674] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Abstract
BACKGROUND Patients who have undergone the Fontan procedure are at risk of developing hepatic dysfunction. However, broad recommendations regarding liver monitoring are limited. The purpose of this study was to characterize the frequency of liver disease in adult Fontan patients using multimodality imaging (hepatic magnetic resonance imaging [MRI], acoustic radiation force impulse [ARFI] elastography, or hepatic ultrasound). METHODS In a prospective cross-sectional analysis of adult patients palliated with a Fontan procedure, hepatic MRI, ARFI, and hepatic ultrasound were used to assess for liver disease. The protocol compared (1) varying prevalence of liver disease based on each imaging technique, (2) agreement between different techniques, and (3) association between noninvasive imaging diagnosis of liver disease and clinical variables, including specific liver disease biomarkers. RESULTS Thirty-seven patients were enrolled. The ARFI results showed high wave propagation velocity in 35 patients (94.6%). All patients had some abnormality in the hepatic MRI. Specifically, 8 patients (21.6%) showed signs of chronic liver disease, 10 patients (27%) had significant liver fibrosis, and 27 patients (73%) had congestion. No correlation was found between liver stiffness measured as propagation velocity and hepatic MRI findings. Only 7 patients had an abnormal hepatic ultrasound study. CONCLUSIONS There is an inherent liver injury in adult Fontan patients. Signs of liver disease were observed in most patients by both hepatic MRI and ARFI elastography but not by ultrasound imaging. Increased liver stiffness did not identify specific disease patterns from MRI, supporting the need for multimodality imaging to characterize liver disease in Fontan patients.
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Affiliation(s)
- F Buendía-Fuentes
- 1 Department of Cardiology, Arnau de Vilanova Hospital, Valencia, Spain
| | - J L Melero-Ferrer
- 2 Adult Congenital Heart Disease Unit, Department of Cardiology, La Fe University Hospital, Valencia, Spain
| | - D Plaza-López
- 2 Adult Congenital Heart Disease Unit, Department of Cardiology, La Fe University Hospital, Valencia, Spain
| | - J Rueda-Soriano
- 2 Adult Congenital Heart Disease Unit, Department of Cardiology, La Fe University Hospital, Valencia, Spain
| | - A Osa-Saez
- 2 Adult Congenital Heart Disease Unit, Department of Cardiology, La Fe University Hospital, Valencia, Spain
| | - J Aguero
- 2 Adult Congenital Heart Disease Unit, Department of Cardiology, La Fe University Hospital, Valencia, Spain
| | | | | | - A Ballesta-Cuñat
- 4 Department of Hepatology, La Fe University Hospital, Valencia, Spain
| | - L Martí-Bonmatí
- 3 Department of Radiology, La Fe University Hospital, Valencia, Spain
| | - L Martínez-Dolz
- 2 Adult Congenital Heart Disease Unit, Department of Cardiology, La Fe University Hospital, Valencia, Spain
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Choudhry S, Dharnidharka VR, Castleberry CD, Goss CW, Simpson KE, Schechtman KB, Canter CE. End-stage renal disease after pediatric heart transplantation: A 25-year national cohort study. J Heart Lung Transplant 2017; 37:S1053-2498(17)32042-9. [PMID: 29055603 PMCID: PMC5880747 DOI: 10.1016/j.healun.2017.09.027] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2017] [Revised: 07/23/2017] [Accepted: 09/26/2017] [Indexed: 01/11/2023] Open
Abstract
BACKGROUND End-stage renal disease (ESRD), defined as the need for chronic dialysis and/or kidney transplantation (KTx), is a known complication after heart transplant (HTx). However, factors associated with ESRD are not well elucidated. The objectives of this study were to determine the prevalence, risk factors, and outcomes associated with ESRD after pediatric HTx. METHODS Scientific Registry of Transplant Recipients data were linked, using direct identifiers, to the United States Renal Data System to identify patients (aged ≤ 18 years) who underwent primary HTx between 1989 and 2013. Risk factors for ESRD and death were analyzed using Cox regression analysis. RESULTS Combining the above 2 databases identified ~25% additional HTx patients who developed ESRD that were not captured by either database alone. During a median follow-up of 11.8 years, ESRD developed in 276 of 6,901 patients (4%). The actuarial risk of developing ESRD after HTx was 3% at 10 years and 16% at 20 years. Age at HTx > 1 year, African-American race, year of HTx before 2000, hypertension, diabetes mellitus, re-HTx, acute dialysis, graft failure, and hospitalized infection were significant risk factors for ESRD development. Those who remained on chronic dialysis had higher risk of death than those who received KTx (hazard ratio, 31.4; 95% confidence interval, 20.8-48.4; p < 0.0001). CONCLUSIONS ESRD after pediatric HTx is more prevalent in HTx survivors than documented by a transplant database alone. A number of factors develop at or after HTx that increase the risk for developing ESRD. Use of KTx in post-HTx ESRD is associated with improved survival.
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Affiliation(s)
- Swati Choudhry
- Department of Pediatrics, Washington University in St. Louis School of Medicine, St. Louis, Missouri
| | - Vikas R Dharnidharka
- Department of Pediatrics, Washington University in St. Louis School of Medicine, St. Louis, Missouri
| | - Chesney D Castleberry
- Department of Pediatrics, Washington University in St. Louis School of Medicine, St. Louis, Missouri
| | - Charles W Goss
- Department of Biostatistics, Washington University in St. Louis School of Medicine, St. Louis, Missouri
| | - Kathleen E Simpson
- Department of Pediatrics, Washington University in St. Louis School of Medicine, St. Louis, Missouri
| | - Kenneth B Schechtman
- Department of Biostatistics, Washington University in St. Louis School of Medicine, St. Louis, Missouri
| | - Charles E Canter
- Department of Pediatrics, Washington University in St. Louis School of Medicine, St. Louis, Missouri.
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Martínez-Quintana E, Rodríguez-González F. Imagen hepática de pacientes con cirugía de Fontan. Rev Esp Cardiol 2017. [DOI: 10.1016/j.recesp.2016.12.016] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
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Hilscher MB, Johnson JN, Cetta F, Driscoll DJ, Poterucha JJ, Sanchez W, Connolly HM, Kamath PS. Surveillance for liver complications after the Fontan procedure. CONGENIT HEART DIS 2017; 12:124-132. [DOI: 10.1111/chd.12446] [Citation(s) in RCA: 48] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/26/2016] [Revised: 11/01/2016] [Accepted: 12/26/2016] [Indexed: 12/30/2022]
Affiliation(s)
- Moira B. Hilscher
- Department of Medicine/Division of Gastroenterology and Hepatology; Mayo Clinic; Rochester Minnesota USA
| | - Jonathan N. Johnson
- Department of Pediatrics and Adolescent Medicine/Division of Pediatric Cardiology; Mayo Clinic; Rochester Minnesota USA
- Department of Cardiovascular Diseases; Mayo Clinic; Rochester Minnesota USA
| | - Frank Cetta
- Department of Pediatrics and Adolescent Medicine/Division of Pediatric Cardiology; Mayo Clinic; Rochester Minnesota USA
- Department of Cardiovascular Diseases; Mayo Clinic; Rochester Minnesota USA
| | - David J. Driscoll
- Department of Pediatrics and Adolescent Medicine/Division of Pediatric Cardiology; Mayo Clinic; Rochester Minnesota USA
- Department of Cardiovascular Diseases; Mayo Clinic; Rochester Minnesota USA
| | - John J. Poterucha
- Department of Medicine/Division of Gastroenterology and Hepatology; Mayo Clinic; Rochester Minnesota USA
| | - William Sanchez
- Department of Medicine/Division of Gastroenterology and Hepatology; Mayo Clinic; Rochester Minnesota USA
| | - Heidi M. Connolly
- Department of Cardiovascular Diseases; Mayo Clinic; Rochester Minnesota USA
| | - Patrick S. Kamath
- Department of Medicine/Division of Gastroenterology and Hepatology; Mayo Clinic; Rochester Minnesota USA
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Martínez-Quintana E, Rodríguez-González F. Liver Imaging in Patients With Fontan Circulation. ACTA ACUST UNITED AC 2017; 70:517-518. [PMID: 28109852 DOI: 10.1016/j.rec.2016.12.030] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2016] [Accepted: 12/07/2016] [Indexed: 11/19/2022]
Affiliation(s)
- Efrén Martínez-Quintana
- Servicio de Cardiología, Complejo Hospitalario Universitario Insular-Materno Infantil, Las Palmas de Gran Canaria, Spain; Departamento de Ciencias Médicas y Quirúrgicas, Facultad de Ciencias de la Salud, Universidad de Las Palmas de Gran Canaria, Las Palmas de Gran Canaria, Spain.
| | - Fayna Rodríguez-González
- Servicio de Oftalmología, Hospital Universitario de Gran Canaria Doctor Negrín, Las Palmas de Gran Canaria, Spain
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The Long-Term Management of Children and Adults with a Fontan Circulation: A Systematic Review and Survey of Current Practice in Australia and New Zealand. Pediatr Cardiol 2017; 38:56-69. [PMID: 27787594 DOI: 10.1007/s00246-016-1484-6] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/03/2016] [Accepted: 10/15/2016] [Indexed: 01/28/2023]
Abstract
Although long-term survival is now the norm, Fontan patients face significant morbidity and premature mortality. Wide variation exists in long-term Fontan management. With an aim of improving their long-term management, we conducted a systematic review to identify best available evidence and gaps in knowledge for future research focus. We also surveyed cardiologists in Australia and New Zealand managing Fontan patients, to determine the alignment of current local practice with best available evidence. A systematic review was conducted using strict search criteria (PRISMA guidelines), pertaining to long-term Fontan management. All adult congenital and paediatric cardiologists registered with The Australia and New Zealand Fontan Registry were invited to respond to an online survey. Reasonable quality evidence exists for non-inferiority of aspirin over warfarin for thromboprophylaxis in standard-risk Fontan patients. No strong evidence is currently available for the routine use of ACE inhibitors, beta blockers or pulmonary vasodilators. Little evidence exists regarding optimal arrhythmia treatment, exercise restriction/prescription, routine fenestration closure, elective Fontan conversion and screening/management of liver abnormalities. Although pregnancy is generally well tolerated, there are high rates of miscarriage and premature delivery. Thirty-nine out of 78 (50 %) cardiologists responded to the survey. Heterogeneity in response was demonstrated with regard to long-term anti-coagulation, other medication use, fenestration closure and pregnancy and contraception counselling. Substantial gaps in our knowledge remain with regard to the long-term management of Fontan patients. This is reflected in the survey of cardiologists managing these patients. We have identified a number of key areas for future research.
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46
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Lewis MJ, Hecht E, Ginns J, Benton J, Prince M, Rosenbaum MS. Serial cardiac MRIs in adult Fontan patients detect progressive hepatic enlargement and congestion. CONGENIT HEART DIS 2016; 12:153-158. [DOI: 10.1111/chd.12422] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/26/2016] [Revised: 09/22/2016] [Accepted: 10/03/2016] [Indexed: 01/03/2023]
Affiliation(s)
- Matthew J. Lewis
- Division of Cardiology, Department of Medicine, Schneeweiss Adult Congenital Heart Center; Columbia University Medical Center; New York New York USA
| | - Elizabeth Hecht
- Division of Abdominal Imaging, Department of Radiology; Columbia University Medical Center; New York New York USA
| | - Jonathan Ginns
- Division of Cardiology, Department of Medicine, Schneeweiss Adult Congenital Heart Center; Columbia University Medical Center; New York New York USA
| | - Joshua Benton
- Division of Abdominal Imaging, Department of Radiology; Columbia University Medical Center; New York New York USA
| | - Martin Prince
- Division of Abdominal Imaging, Department of Radiology; Columbia University Medical Center; New York New York USA
| | - Marlon S. Rosenbaum
- Division of Cardiology, Department of Medicine, Schneeweiss Adult Congenital Heart Center; Columbia University Medical Center; New York New York USA
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Hebson C, Book W, Elder RW, Ford R, Jokhadar M, Kanter K, Kogon B, Kovacs AH, Levit RD, Lloyd M, Maher K, Reshamwala P, Rodriguez F, Romero R, Tejada T, Marie Valente A, Veldtman G, McConnell M. “Frontiers in Fontan failure: A summary of conference proceedings”. CONGENIT HEART DIS 2016; 12:6-16. [DOI: 10.1111/chd.12407] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/20/2016] [Accepted: 07/24/2016] [Indexed: 12/16/2022]
Affiliation(s)
- Camden Hebson
- Division of Cardiology; Department of Medicine, Emory University; Atlanta GA
- Division of Pediatric Cardiology; Department of Pediatrics, Emory University; Atlanta GA
| | - Wendy Book
- Division of Cardiology; Department of Medicine, Emory University; Atlanta GA
| | - Robert W. Elder
- Division of Cardiology; Department of Medicine, Yale University; New Haven CT
| | - Ryan Ford
- Division of Gastroenterology; Department of Medicine, Emory University; Atlanta GA
| | - Maan Jokhadar
- Division of Cardiology; Department of Medicine, Emory University; Atlanta GA
| | - Kirk Kanter
- Division of Cardiothoracic Surgery; Department of Surgery, Emory University; Atlanta GA
| | - Brian Kogon
- Division of Cardiothoracic Surgery; Department of Surgery, Emory University; Atlanta GA
| | - Adrienne H. Kovacs
- Division of Cardiology; Department of Medicine, Oregon Health and Science University; Portland OR
| | - Rebecca D. Levit
- Division of Cardiology; Department of Medicine, Emory University; Atlanta GA
| | - Michael Lloyd
- Division of Cardiology; Department of Medicine, Emory University; Atlanta GA
| | - Kevin Maher
- Division of Pediatric Cardiology; Department of Pediatrics, Emory University; Atlanta GA
| | - Preeti Reshamwala
- Division of Gastroenterology; Department of Medicine, Emory University; Atlanta GA
| | - Fred Rodriguez
- Division of Cardiology; Department of Medicine, Emory University; Atlanta GA
- Division of Pediatric Cardiology; Department of Pediatrics, Emory University; Atlanta GA
| | - Rene Romero
- Division of Pediatric Gastroenterology; Department of Pediatrics, Emory University; Atlanta GA
| | - Thor Tejada
- Division of Cardiology; Department of Medicine, Emory University; Atlanta GA
| | - Anne Marie Valente
- Division of Cardiology; Department of Medicine, Harvard University; Boston MA
| | - Gruschen Veldtman
- Division of Pediatric Cardiology; Department of Pediatrics, University of Cincinnati; Cincinnati OH
| | - Michael McConnell
- Division of Cardiology; Department of Medicine, Emory University; Atlanta GA
- Division of Pediatric Cardiology; Department of Pediatrics, Emory University; Atlanta GA
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Surrey LF, Russo P, Rychik J, Goldberg DJ, Dodds K, O'Byrne ML, Glatz AC, Rand EB, Lin HC. Prevalence and characterization of fibrosis in surveillance liver biopsies of patients with Fontan circulation. Hum Pathol 2016; 57:106-115. [PMID: 27476041 DOI: 10.1016/j.humpath.2016.07.006] [Citation(s) in RCA: 73] [Impact Index Per Article: 9.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/15/2016] [Revised: 06/30/2016] [Accepted: 07/03/2016] [Indexed: 12/26/2022]
Abstract
The Fontan operation is a widely used palliative procedure in patients with single-ventricle anatomy that results in liver injury. As timely identification of liver fibrosis may result in management changes to Fontan patients, the aim of our study was to identify clinically meaningful semi quantitative/quantitative pathologic parameters for biopsy assessment. We performed a retrospective review of 74 liver needle biopsies from Fontan patients. Fibrosis was assessed using quantitative % collagen deposition by Sirius red image analysis, METAVIR, congestive hepatic fibrosis score, sinusoidal fibrosis score, and sinusoidal dilation score. Contemporaneous laboratory, hemodynamic, and ultrasound data were collected. Centrilobular and peri sinusoidal fibrosis was observed in all cases, with 39.2% high grade. Portal fibrosis was observed in 93.2%, with 36.2% high-grade (METAVIR F3-F4). Cirrhosis was observed in 5.4%. % Collagen deposition was increased over control tissue (P < .001) and correlated with time from Fontan (r = 0.3, P = .009) and prothrombin time (r = 0.25, P = .034). Mildly elevated prothrombin time/international normalized ratio was the only measure of liver function consistently associated with multiple high-grade fibrosis scores (METAVIR P = .046, sinusoidal fibrosis P = .018). Abnormal liver echotexture on ultrasound was associated with high-grade congestive hepatic fibrosis score (P = .03). Pathologic gradings and %CD correlated with each other (r = 0.48-0.8, P < .001). Hepatic fibrosis in Fontan patients in our study is universally present, appears to be time dependent, and correlates with few laboratory measurements of liver function. Careful assessment of needle liver biopsies lends a more meaningful measure of liver fibrosis in the Fontan patient than clinical and laboratory data, allowing for appropriate changes to patient management.
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Affiliation(s)
- Lea F Surrey
- Department of Pathology and Laboratory Medicine, Children's Hospital of Philadelphia, Philadelphia, PA 19104.
| | - Pierre Russo
- Department of Pathology and Laboratory Medicine, Children's Hospital of Philadelphia, Philadelphia, PA 19104
| | - Jack Rychik
- Division of Cardiology, Department of Pediatrics, Children's Hospital of Philadelphia, Philadelphia, PA 19104
| | - David J Goldberg
- Division of Cardiology, Department of Pediatrics, Children's Hospital of Philadelphia, Philadelphia, PA 19104
| | - Kathryn Dodds
- Division of Cardiology, Department of Pediatrics, Children's Hospital of Philadelphia, Philadelphia, PA 19104
| | - Michael L O'Byrne
- Division of Cardiology, Department of Pediatrics, Children's National Medical Center, Washington, DC 20010
| | - Andrew C Glatz
- Division of Cardiology, Department of Pediatrics, Children's Hospital of Philadelphia, Philadelphia, PA 19104
| | - Elizabeth B Rand
- Division of Gastroenterology, Department of Pediatrics, Children's Hospital of Philadelphia, Philadelphia, PA 19104
| | - Henry C Lin
- Division of Gastroenterology, Department of Pediatrics, Children's Hospital of Philadelphia, Philadelphia, PA 19104
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Fujimoto Y, Urashima T, Shimura D, Ito R, Kawachi S, Kajimura I, Akaike T, Kusakari Y, Fujiwara M, Ogawa K, Goda N, Ida H, Minamisawa S. Low Cardiac Output Leads Hepatic Fibrosis in Right Heart Failure Model Rats. PLoS One 2016; 11:e0148666. [PMID: 26863419 PMCID: PMC4749189 DOI: 10.1371/journal.pone.0148666] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2015] [Accepted: 01/21/2016] [Indexed: 12/11/2022] Open
Abstract
Background Hepatic fibrosis progresses with right heart failure, and becomes cardiac cirrhosis in a severe case. Although its causal factor still remains unclear. Here we evaluated the progression of hepatic fibrosis using a pulmonary artery banding (PAB)-induced right heart failure model and investigated whether cardiac output (CO) is responsible for the progression of hepatic fibrosis. Methods and Results Five-week-old Sprague-Dawley rats divided into the PAB and sham-operated control groups. After 4 weeks from operation, we measured CO by echocardiography, and hepatic fibrosis ratio by pathological examination using a color analyzer. In the PAB group, CO was significantly lower by 48% than that in the control group (78.2±27.6 and 150.1±31.2 ml/min, P<0.01). Hepatic fibrosis ratio and serum hyaluronic acid, an index of hepatic fibrosis, were significantly increased in the PAB group than those in the control group (7.8±1.7 and 1.0±0.2%, P<0.01, 76.2±27.5 and 32.7±7.5 ng/ml, P<0.01). Notably, the degree of hepatic fibrosis significantly correlated a decrease in CO. Immunohistological analysis revealed that hepatic stellate cells were markedly activated in hypoxic areas, and HIF-1α positive hepatic cells were increased in the PAB group. Furthermore, by real-time PCR analyses, transcripts of profibrotic and fibrotic factors (TGF-β1, CTGF, procollargen I, procollargen III, MMP 2, MMP 9, TIMP 1, TIMP 2) were significantly increased in the PAB group. In addition, western blot analyses revealed that the protein level of HIF-1α was significantly increased in the PAB group than that in the control group (2.31±0.84 and 1.0±0.18 arbitrary units, P<0.05). Conclusions Our study demonstrated that low CO and tissue hypoxia were responsible for hepatic fibrosis in right failure heart model rats.
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Affiliation(s)
- Yoshitaka Fujimoto
- Department of Cell Physiology, The Jikei University School of Medicine, Tokyo, Japan
- Department of Pediatrics, The Jikei University School of Medicine, Tokyo, Japan
| | - Takashi Urashima
- Department of Pediatrics, The Jikei University School of Medicine, Tokyo, Japan
- * E-mail:
| | - Daisuke Shimura
- Department of Cell Physiology, The Jikei University School of Medicine, Tokyo, Japan
| | - Reiji Ito
- Department of Pediatrics, The Jikei University School of Medicine, Tokyo, Japan
| | - Sadataka Kawachi
- Division of Cardiology, Saitama Children’s Medical Center, Saitama, Japan
| | - Ichige Kajimura
- Department of Cell Physiology, The Jikei University School of Medicine, Tokyo, Japan
| | - Toru Akaike
- Department of Cell Physiology, The Jikei University School of Medicine, Tokyo, Japan
| | - Yoichiro Kusakari
- Department of Cell Physiology, The Jikei University School of Medicine, Tokyo, Japan
| | - Masako Fujiwara
- Department of Pediatrics, The Jikei University School of Medicine, Tokyo, Japan
| | - Kiyoshi Ogawa
- Division of Cardiology, Saitama Children’s Medical Center, Saitama, Japan
| | - Nobuhito Goda
- Department of Life Science and Medical Bioscience, Waseda University, Tokyo, Japan
| | - Hiroyuki Ida
- Department of Pediatrics, The Jikei University School of Medicine, Tokyo, Japan
| | - Susumu Minamisawa
- Department of Cell Physiology, The Jikei University School of Medicine, Tokyo, Japan
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