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Chen S, Shezad MF, Lorts A, McCormick AD, Mao CY, Simpson KE, O'Connor MJ, Barnes A, Lubert AM, Castleberry C, Schmidt J, Schroeder K, Joong A, Bearl DW, Lal AK, Mokshagundam D, Conway J, Cedars A, Schumacher KR. Outcomes after initial heart failure consultation in Fontan patients. Cardiol Young 2023:1-8. [PMID: 38014551 DOI: 10.1017/s1047951123003852] [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] [Indexed: 11/29/2023]
Abstract
BACKGROUND Patients with Fontan failure are high-risk candidates for heart transplantation and other advanced therapies. Understanding the outcomes following initial heart failure consultation can help define appropriate timing of referral for advanced heart failure care. METHODS This is a survey study of heart failure providers seeing any Fontan patient for initial heart failure care. Part 1 of the survey captured data on clinical characteristics at the time of heart failure consultation, and Part 2, completed 30 days later, captured outcomes (death, transplant evaluation outcome, and other interventions). Patients were classified as "too late" (death or declined for transplant due to being too sick) and/or "care escalation" (ventricular assist device implanted, inotrope initiated, and/or listed for transplant), within 30 days. "Late referral" was defined as those referred too late and/or had care escalation. RESULTS Between 7/2020 and 7/2022, 77 Fontan patients (52% inpatient) had an initial heart failure consultation. Ten per cent were referred too late (6 were too sick for heart transplantation with one subsequent death, and two others died without heart transplantation evaluation, within 30 days), and 36% had care escalation (21 listed ± 5 ventricular assist device implanted ± 6 inotrope initiated). Overall, 42% were late referrals. Heart failure consultation < 1 year after Fontan surgery was strongly associated with late referral (OR 6.2, 95% CI 1.8-21.5, p=0.004). CONCLUSIONS Over 40% of Fontan patients seen for an initial heart failure consultation were late referrals, with 10% dying or being declined for transplant within a month of consultation. Earlier referral, particularly for those with heart failure soon after Fontan surgery, should be encouraged.
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Affiliation(s)
- Sharon Chen
- Lucile Packard Children's Hospital at Stanford, Palo Alto, CA, USA
| | | | - Angela Lorts
- Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | | | - Chad Y Mao
- Children's Healthcare of Atlanta, Atlanta, GA, USA
| | | | | | | | - Adam M Lubert
- Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | | | - Julie Schmidt
- Lucile Packard Children's Hospital at Stanford, Palo Alto, CA, USA
| | | | - Anna Joong
- Ann and Robert H. Lurie Children's Hospital of Chicago, Chicago, IL, USA
| | - David W Bearl
- Monroe Carell Jr. Children's Hospital at Vanderbilt, Nashville, TN, USA
| | - Ashwin K Lal
- Primary Children's Hospital, Salt Lake City, UT, USA
| | | | | | - Ari Cedars
- Johns Hopkins Hospital, Baltimore, MD, USA
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2
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Weisert M, Menteer J, Durazo-Arvizu R, Wood J, Su J. EARLY PREDICTION OF FAILURE TO PROGRESS IN SINGLE VENTRICLE PALLIATION: A STEP TOWARD PERSONALIZING CARE FOR SEVERE CONGENITAL HEART DISEASE. J Heart Lung Transplant 2022; 41:1268-1276. [DOI: 10.1016/j.healun.2022.06.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2021] [Revised: 04/29/2022] [Accepted: 06/02/2022] [Indexed: 10/18/2022] Open
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3
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Heart transplant indications, considerations and outcomes in Fontan patients: Age-related nuances, transplant listing and disease-specific indications. THE CANADIAN JOURNAL OF CARDIOLOGY 2022; 38:1072-1085. [PMID: 35240250 DOI: 10.1016/j.cjca.2022.02.019] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Subscribe] [Scholar Register] [Received: 12/20/2021] [Revised: 02/09/2022] [Accepted: 02/21/2022] [Indexed: 11/23/2022]
Abstract
In the current era, 5-10% of Fontan patients die or need a transplant in childhood, and approximately 50% will experience the same fate by age 40 years. Heart transplant (HTx) can be successful for selected children and adults with Fontan circulatory failure (FCF) of any mechanism, with a 1-year post-transplant survival approaching 90% in children and 80% in the largest single-centre adult Fontan HTx experience. Protein losing enteropathy and plastic bronchitis can be expected to resolve post-transplant and limited data suggests patients with FALD who survive HTx can expect improvement in liver health. Early Fontan failure, within 12 months of Fontan completion, is not easily rescued by HTx and late referrals / failure to refer adult patients remains problematic. Very little is known about the numbers of patients not referred, turned down following assessment for HTx, or dying on the waiting list which are needed to understand the complete picture of HTx in the Fontan population and to identify where best to focus quality improvement efforts. Recent revisions to listing prioritization in Canada with considerations specific to the Fontan population aim to mitigate the fact that the status listing criteria are not tailored to the congenital heart population. Transplanting high-risk children prior to Fontan completion, developing ACHD transplant centres of expertise which can also offer combined heart-liver transplant when appropriate, and improving single ventricle mechanical support options and criteria for both adults and children may help mitigate the early post-listing mortality.
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4
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Reid CS, Kaiser HA, Heinisch PP, Bruelisauer T, Michel S, Siepe M. Ventricular assist device for Fontan: who, when and why? Curr Opin Anaesthesiol 2022; 35:12-17. [PMID: 34812751 DOI: 10.1097/aco.0000000000001078] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
PURPOSE OF REVIEW Since the advent of the Fontan palliation, survival of patients with univentricular congenital heart disease has increased significantly. These patients will, however, ultimately develop heart failure requiring advanced therapies such as heart transplantation. As wait times are long, mechanical circulatory support (MCS) is an attractive therapy, both for bridge to transplantation and destination therapy in patients not suitable for transplantation. This review aims to summarize current thinking about how to determine which patients would benefit from a ventricular assist device (VAD), the optimal time for implantation and which device should be considered. RECENT FINDINGS VAD implantation in end-stage Fontan is still in its infancy; however, case reports and research interest have increased extensively in the past few years. Mortality is significantly higher than in noncongenital heart disease patients. Implantation in patients with primarily systolic dysfunction is indicated, whereas patients with increased transpulmonary gradient may not benefit from a single-VAD solution. When possible, implantation should occur prior to clinical decompensation with evidence of end-organ damage, as outcomes at this point are worse. SUMMARY Fontan patients demonstrating signs of heart failure should be evaluated early and often for feasibility and optimal timing of VAD implantation. The frequency of this procedure will likely increase significantly in the future.
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Affiliation(s)
- Catherine S Reid
- Department of Anaesthesiology and Pain Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Heiko A Kaiser
- Department of Anaesthesiology and Pain Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
- Centre for Anaesthesiology and Intensive Care Medicine, Hirslanden Klinik Aarau, Hirslanden Group, Aarau, Switzerland
| | - Paul Philipp Heinisch
- Department of Congenital and Pediatric Heart Surgery, German Heart Center Munich, Technische Universität München, Germany
- Division of Congenital and Pediatric Heart Surgery, University Hospital of Munich, Ludwig-Maximilians-Universität, Munich, Germany
| | - Thomas Bruelisauer
- German Heart Center Berlin, Department of Cardiac Anesthesiology and Intensive Care Medicine, Berlin, Germany
| | - Sebastian Michel
- Department of Congenital and Pediatric Heart Surgery, German Heart Center Munich, Technische Universität München, Germany
- Division of Congenital and Pediatric Heart Surgery, University Hospital of Munich, Ludwig-Maximilians-Universität, Munich, Germany
| | - Matthias Siepe
- Department of Cardiovascular Surgery, Heart Center University Freiburg - Bad Krozingen, Bad Krozingen, Germany
- Faculty of Medicine, University of Freiburg, Freiburg, Germany
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5
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Márquez-González H, Hernández-Vásquez JG, Del Valle-Lom M, Yáñez-Gutiérrez L, Klünder-Klünder M, Almeida-Gutiérrez E, Koretzky SG. Failures of the Fontan System in Univentricular Hearts and Mortality Risk in Heart Transplantation: A Systematic Review and Meta-Analysis. Life (Basel) 2021; 11:1363. [PMID: 34947894 PMCID: PMC8709145 DOI: 10.3390/life11121363] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2021] [Revised: 11/12/2021] [Accepted: 11/13/2021] [Indexed: 02/07/2023] Open
Abstract
The Fontan procedure (FP) is the standard surgical treatment for Univentricular heart diseases. Over time, the Fontan system fails, leading to pathologies such as protein-losing enteropathy (PLE), plastic bronchitis (PB), and heart failure (HF). FP should be considered as a transitional step to the final treatment: heart transplantation (HT). This systematic review and meta-analysis aims to establish the risk of death following HT according to the presence of FP complications. There was a total of 691 transplanted patients in the 18 articles, immediate survival 88% (n = 448), survival from 1 to 5 years of 78% (n = 427) and survival from 5.1 to 10 years of 69% (n = 208), >10 years 61% (n = 109). The relative risk (RR) was 1.12 for PLE (95% confidence interval [CI] = 0.89-1.40, p = 0.34), 1.03 for HF (0.7-1.51, p = 0.88), 0.70 for Arrhythmias (0.39-1.24, p = 0.22), 0.46 for PB (0.08-2.72, p = 0.39), and 5.81 for CKD (1.70-19.88, p = 0.005). In patients with two or more failures, the RR was 1.94 (0.99-3.81, p = 0.05). After FP, the risk of death after HT is associated with CKD and with the presence of two or more failures.
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Affiliation(s)
- Horacio Márquez-González
- Department of Clinical Research, Federico Gómez Children’s Hospital, Mexico City 06720, Mexico; (H.M.-G.); (J.G.H.-V.); (M.D.V.-L.); (M.K.-K.)
- Centro Médico Nacional Siglo XXI, IMSS, Department Congenital Heart Diseases, Mexico City 06720, Mexico; (L.Y.-G.); (E.A.-G.)
| | - Jose Gustavo Hernández-Vásquez
- Department of Clinical Research, Federico Gómez Children’s Hospital, Mexico City 06720, Mexico; (H.M.-G.); (J.G.H.-V.); (M.D.V.-L.); (M.K.-K.)
| | - Montserrat Del Valle-Lom
- Department of Clinical Research, Federico Gómez Children’s Hospital, Mexico City 06720, Mexico; (H.M.-G.); (J.G.H.-V.); (M.D.V.-L.); (M.K.-K.)
| | - Lucelli Yáñez-Gutiérrez
- Centro Médico Nacional Siglo XXI, IMSS, Department Congenital Heart Diseases, Mexico City 06720, Mexico; (L.Y.-G.); (E.A.-G.)
| | - Miguel Klünder-Klünder
- Department of Clinical Research, Federico Gómez Children’s Hospital, Mexico City 06720, Mexico; (H.M.-G.); (J.G.H.-V.); (M.D.V.-L.); (M.K.-K.)
| | - Eduardo Almeida-Gutiérrez
- Centro Médico Nacional Siglo XXI, IMSS, Department Congenital Heart Diseases, Mexico City 06720, Mexico; (L.Y.-G.); (E.A.-G.)
| | - Solange Gabriela Koretzky
- Department of Clinical Research, Nacional de Cardiología “Ignacio Chávez”, Mexico City 14080, Mexico
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6
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Exception-Status Listing: A Critical Pathway to Heart Transplantation for Adults With Congenital Heart Diseases. J Card Fail 2021; 28:415-421. [PMID: 34670174 DOI: 10.1016/j.cardfail.2021.10.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2021] [Revised: 09/30/2021] [Accepted: 10/02/2021] [Indexed: 11/23/2022]
Abstract
Adults with congenital heart diseases may not be candidates for conventional therapies to control ventricular systolic dysfunction, including mechanical circulatory support, which moves potential heart-transplantation recipients to a listing status of higher priority. This results in longer waitlist times and greater mortality rates. Exception-status listing allows a pathway for this complex and anatomically heterogenous group of patients to be listed for heart transplantation at appropriately high listing status. Our study queried the United Network for Organ Sharing registry to evaluate trends in the use of exception-status listing among adults with congenital heart diseases awaiting heart transplantation. Uptrend in the use of exception-status listing precedes the new allocation system, but it has been greatest since changes were made in the allocation system. It continues to remain a vital pathway for adults with congenital heart disease (whose waitlist mortality rates are often not characterized adequately by using the waitlist-status criteria) timely access to heart transplantation.
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Riggs KW, Broderick JT, Price N, Chin C, Zafar F, Morales DLS. Transplantation for Congenital Heart Disease: Focus on the Impact of Functionally Univentricular Versus Biventricular Circulation. World J Pediatr Congenit Heart Surg 2021; 12:352-359. [PMID: 33942695 DOI: 10.1177/2150135121990650] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND Varying single center data exist regarding the posttransplant outcomes of patients with single ventricle circulation, particularly following the Fontan operation. We sought to better elucidate these results in patients with congenital heart disease (CHD) through combining two national databases. METHODS The United Network for Organ Sharing (UNOS) transplantation database was merged with the Pediatric Health Information System (PHIS), an administrative database with 71% of UNOS patients matched. Patients undergoing transplantation at a PHIS hospital from 2006 to 2017 were categorized as single ventricle or biventricular strategy based on their diagnoses and procedures in 90% of patients. When known, single ventricle patients were further analyzed by their palliative stage post-Glenn or post-Fontan (known in 31%). RESULTS A total of 1,517 CHD transplantations were identified, 67% with single ventricle strategy (1,016). Single ventricle, biventricular, and indeterminate patients had similar survival (log-rank P > .1). Risk factors for mortality in patients with CHD were extracorporeal membrane oxygenation (ECMO) support at transplant (hazard: 2.27), ABO blood type incompatibility (hazard: 1.61), African American recipient (hazard 1.42), and liver dysfunction (hazard 1.29). A total of 130 confirmed Fontan and 185 confirmed bidirectional Glenn patients underwent transplantation, each with survival equivalent to biventricular patients (log-rank P > .500). For Fontan patients, renal dysfunction (hazard: 5.40) and transplant <1 year after Fontan (hazard 2.82) were found to be associated with mortality. CONCLUSIONS Single ventricle patients, as a group, experience similar outcomes as biventricular patients with CHD undergoing transplantation, and this extends to Fontan patients. Risk factors for mortality correlate with end-organ dysfunction as well as race and ABO blood type incompatibility in the CHD population.
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Affiliation(s)
- Kyle W Riggs
- Heart Institute, 2518Cincinnati Children's Hospital, Cincinnati, OH, USA
| | - John T Broderick
- Heart Institute, 2518Cincinnati Children's Hospital, Cincinnati, OH, USA
| | - Nina Price
- Heart Institute, 2518Cincinnati Children's Hospital, Cincinnati, OH, USA
| | - Clifford Chin
- Heart Institute, 2518Cincinnati Children's Hospital, Cincinnati, OH, USA
| | - Farhan Zafar
- Heart Institute, 2518Cincinnati Children's Hospital, Cincinnati, OH, USA
| | - David L S Morales
- Heart Institute, 2518Cincinnati Children's Hospital, Cincinnati, OH, USA
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8
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Spinner JA, Denfield SW, Puri K, Morris SA, Costello JM, Moffett BS, Wang Y, Shekerdemian LS, Tunuguntla HP, Price JF, Heinle JS, Adachi I, Dreyer WJ, Cabrera AG. Hospital outcomes for pediatric heart transplant recipients undergoing tracheostomy: A multi-institutional analysis. Pediatr Transplant 2021; 25:e13904. [PMID: 33179431 DOI: 10.1111/petr.13904] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/26/2020] [Revised: 09/28/2020] [Accepted: 10/02/2020] [Indexed: 11/28/2022]
Abstract
Tracheostomy is associated with increased mortality and resource utilization in children with CHD. However, the prevalence and hospital outcomes of tracheostomy in children with HTx are not known. We describe the prevalence and compare the post-HTx hospital outcomes of pediatric patients with Pre-TT and Post-TT to those without tracheostomy. A multi-institutional retrospective cohort study was performed using the Pediatric Health Information System database. Hospital mortality, mediastinitis, LOS, and costs were compared among patients with Pre-TT, Post-TT, and no tracheostomy. Pre-TT was identified in 29 (1.1%) and Post-TT was identified in 41 (1.6%) of 2603 index HTx hospitalizations. Patients with Pre-TT were younger and more likely to have CHD, a non-cardiac birth defect, or an airway anomaly compared to those without Pre-TT. Pre-TT was not independently associated with increased post-HTx in-hospital mortality. Age at HTx < 1 year, CHD, and Post-TT were associated with increased in-hospital mortality. Pre-TT that occurred during the HTx hospitalization and Post-TT were associated with increased resource utilization. Tracheostomy was not associated with mediastinitis.
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Affiliation(s)
- Joseph A Spinner
- Department of Pediatrics, Lillie Frank Abercrombie Section of Pediatric and Congenital Cardiology, Baylor College of Medicine/Texas Children's Hospital, Houston, TX, USA
| | - Susan W Denfield
- Department of Pediatrics, Lillie Frank Abercrombie Section of Pediatric and Congenital Cardiology, Baylor College of Medicine/Texas Children's Hospital, Houston, TX, USA
| | - Kriti Puri
- Department of Pediatrics, Lillie Frank Abercrombie Section of Pediatric and Congenital Cardiology, Baylor College of Medicine/Texas Children's Hospital, Houston, TX, USA
| | - Shaine A Morris
- Department of Pediatrics, Lillie Frank Abercrombie Section of Pediatric and Congenital Cardiology, Baylor College of Medicine/Texas Children's Hospital, Houston, TX, USA
| | - John M Costello
- Department of Pediatrics, The Medical University of South Carolina, Charleston, SC, USA
| | - Brady S Moffett
- Department of Pediatrics, Lillie Frank Abercrombie Section of Pediatric and Congenital Cardiology, Baylor College of Medicine/Texas Children's Hospital, Houston, TX, USA
| | - Yunfei Wang
- Department of Pediatrics, Cardiovascular Research Core - Section of Cardiology, Baylor College of Medicine/Texas Children's Hospital, Houston, TX, USA
| | - Lara S Shekerdemian
- Division of Critical Care Medicine, Department of Pediatrics, Baylor College of Medicine/Texas Children's Hospital, Houston, TX, USA
| | - Hari P Tunuguntla
- Department of Pediatrics, Lillie Frank Abercrombie Section of Pediatric and Congenital Cardiology, Baylor College of Medicine/Texas Children's Hospital, Houston, TX, USA
| | - Jack F Price
- Department of Pediatrics, Lillie Frank Abercrombie Section of Pediatric and Congenital Cardiology, Baylor College of Medicine/Texas Children's Hospital, Houston, TX, USA
| | - Jeffrey S Heinle
- Division of Congenital Heart Surgery, Department of Surgery, Baylor College of Medicine/Texas Children's Hospital, Houston, TX, USA
| | - Iki Adachi
- Division of Congenital Heart Surgery, Department of Surgery, Baylor College of Medicine/Texas Children's Hospital, Houston, TX, USA
| | - William J Dreyer
- Department of Pediatrics, Lillie Frank Abercrombie Section of Pediatric and Congenital Cardiology, Baylor College of Medicine/Texas Children's Hospital, Houston, TX, USA
| | - Antonio G Cabrera
- Division of Pediatric Cardiology, Department of Pediatrics/Primary Children's Hospital Heart Center, University of Utah, Salt Lake City, UT, USA
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9
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Systemic ventricular assist device support in Fontan patients: A report by ACTION. J Heart Lung Transplant 2021; 40:368-376. [DOI: 10.1016/j.healun.2021.01.011] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2020] [Revised: 01/03/2021] [Accepted: 01/13/2021] [Indexed: 12/31/2022] Open
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10
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Sganga D, Hollander SA, Vaikunth S, Haeffele C, Bensen R, Navaratnam M, McDonald N, Profita E, Maeda K, Concepcion W, Bernstein D, Chen S. Comparison of combined heart‒liver vs heart-only transplantation in pediatric and young adult Fontan recipients. J Heart Lung Transplant 2021; 40:298-306. [PMID: 33485775 PMCID: PMC8026537 DOI: 10.1016/j.healun.2020.12.008] [Citation(s) in RCA: 21] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2020] [Revised: 11/23/2020] [Accepted: 12/23/2020] [Indexed: 10/22/2022] Open
Abstract
BACKGROUND Indications for a heart‒liver transplantation (HLT) for Fontan recipients are not well defined. We compared listing characteristics, post-operative complications, and post-transplant outcomes of Fontan recipients who underwent HLT with those of patients who underwent heart-only transplantation (HT). We hypothesized that patients who underwent HLT have increased post-operative complications but superior survival outcomes compared with patients who underwent HT. METHODS We performed a retrospective review of Fontan recipients who underwent HLT or HT at a single institution. Characteristics at the time of listing, including the extent of liver disease determined by laboratory, imaging, and biopsy data, were compared. Post-operative complications were assessed, and the Kaplan‒Meier survival method was used to compare post-transplant survival. Univariate regression analyses were performed to identify the risk factors for increased mortality and morbidity among patients who underwent HT. RESULTS A total of 47 patients (9 for HLT, 38 for HT) were included. Patients who underwent HLT were older, were more likely to be on dual inotrope therapy, and had evidence of worse liver disease. Whereas ischemic time was longer for the group who underwent HLT, post-operative complications were similar. Over a median post-transplant follow-up of 17 (interquartile range: 5-52) months, overall mortality for the cohort was 17%; only 1 patient who underwent HLT died (11%) vs 7 patients who underwent HT (18%) (p = 0.64). Among patients who underwent HT, cirrhosis on pre-transplant imaging was associated with worse outcomes. CONCLUSIONS Despite greater inotrope need and more severe liver disease at the time of listing, Fontan recipients undergoing HLT have post-transplant outcomes comparable with those of patients undergoing HT. HLT may offer a survival benefit for Fontan recipients with liver disease.
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Affiliation(s)
| | | | | | | | | | | | - Nancy McDonald
- Division of Pediatric Cardiology, Lucile Packard Children's Hospital, Palo Alto, California
| | | | - Katsuhide Maeda
- Department of Cardiothoracic Surgery, Children's Hospital of Philadelphia, Philadelphia, Pennsylvannia
| | - Waldo Concepcion
- Department of Transplantation Services, Mohammed Bin Rashid University School of Medicine, Dubai, UAE
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11
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Tuite GC, Quintessenza JA, Asante-Korang A, Ghazarian SR, Wisotzkey BL, Shah S, Stapleton GE, Decker JA, Herbert CE, Kartha V, Alexander P, Carapellucci J, Krasnopero D, Hanson J, Goldenberg NA, Do NL, Mavroudis C, Karl TR, Boucek RJ, Kutty S, Vricella LA, van Gelder HM, Jacobs JP. Heart Transplantation for Pediatric and Congenital Cardiac Disease: A Comparison of Two Eras over 23 Years and 188 Transplants at a Single Institution. World J Pediatr Congenit Heart Surg 2021; 12:17-26. [PMID: 33407028 DOI: 10.1177/2150135120954149] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND To assess changes in patterns of practice and outcomes over time, we reviewed all patients who underwent heart transplantation (HTx) at our institution and compared two consecutive eras with significantly different immunosuppressive protocols (cohort 1 [80 HTx, June 1995-June 2006]; cohort 2 [108 HTx, July 2006-September 2018]). METHODS Retrospective study of 180 patients undergoing 188 HTx (June 1995-September 2018; 176 first time HTx, 10 second HTx, and 2 third HTx). In 2006, we commenced pre-HTx desensitization for highly sensitized patients and started using tacrolimus as our primary postoperative immunosuppressive agent. The primary outcome was mortality. Survival was modeled by the Kaplan-Meier method. Univariable and multivariable Cox proportional hazard models were created to identify prognostic factors for survival. RESULTS Our 188 HTx included 18 neonates, 85 infants, 83 children, and 2 adults (>18 years). Median age was 260.0 days (range: 5 days-23.8 years). Median weight was 7.5 kg (range: 2.2-113 kg). Patients in cohort 1 were less likely to have been immunosensitized preoperatively (12.5% vs 28.7%, P = .017). Nevertheless, Kaplan-Meier analysis suggested superior survival in cohort 2 (P = .0045). Patients in cohort 2 were more likely to be alive one year, five years, and ten years after HTx. Multivariable analysis identified the earlier era (hazard ratio [HR] [95% confidence interval] for recent era = 0.32 [0.14-0.73]), transplantation after prior Norwood operation (HR = 4.44 [1.46-13.46]), and number of prior cardiac operations (HR = 1.33 [1.03-1.71]) as risk factors for mortality. CONCLUSIONS Our analysis of 23 years of pediatric and congenital HTx reveals superior survival in the most recent 12-year era, despite the higher proportion of patients with elevated panel reactive antibody in the most recent era. This improvement was temporally associated with changes in our immunosuppressive strategy.
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Affiliation(s)
- Genevieve C Tuite
- Johns Hopkins All Children's Heart Institute, Saint Petersburg, FL, USA
| | | | | | | | | | - Shawn Shah
- Johns Hopkins All Children's Heart Institute, Saint Petersburg, FL, USA
| | - Gary E Stapleton
- Pediatric Interventional Cardiology, Texas Children's Hospital, Houston, TX, USA
| | - Jamie A Decker
- Johns Hopkins All Children's Heart Institute, Saint Petersburg, FL, USA
| | - Carrie E Herbert
- Department of Pediatrics, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Vyas Kartha
- Johns Hopkins All Children's Heart Institute, Saint Petersburg, FL, USA
| | - Plato Alexander
- Johns Hopkins All Children's Heart Institute, Saint Petersburg, FL, USA
| | | | - Diane Krasnopero
- Children's Heart Center, Children's Healthcare of Atlanta, Emory University, Atlanta, GA, USA
| | - Jade Hanson
- Johns Hopkins All Children's Heart Institute, Saint Petersburg, FL, USA
| | - Neil A Goldenberg
- Johns Hopkins All Children's Heart Institute, Saint Petersburg, FL, USA
| | - Nhue L Do
- Division of Pediatric Cardiac Surgery, Vanderbilt University, Nashville, TN, USA
| | | | - Tom R Karl
- Johns Hopkins All Children's Heart Institute, Saint Petersburg, FL, USA
| | | | - Shelby Kutty
- Division of Pediatric Cardiology, 1466Johns Hopkins University, Baltimore, MD, USA
| | - Luca A Vricella
- Division of Pediatric Cardiac Surgery, 2462University of Chicago, IL, USA
| | - Hugh M van Gelder
- Cardiac Surgery, US Department of Veteran Affairs, Tampa, Florida, USA
| | - Jeffrey P Jacobs
- Congenital Heart Center, Division of Thoracic and Cardiovascular Surgery, Department of Surgery, University of Florida, Gainesville, FL, USA
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12
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Hassan W, Kotak S, Khatri M, Ahmed A, Ahmed J, Ali SS, Khan TM. Efficacy of heart transplantation in patients with a failing Fontan: a systematic review and meta-analysis. THE CARDIOTHORACIC SURGEON 2021. [DOI: 10.1186/s43057-021-00043-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
Abstract
Background
As the population of patients with Fontan palliation grows, so does the number of patients with Fontan failure, necessitating heart transplantation. However, due to mainly small-sized studies, outcomes after heart transplantation in these patients remain unclear. The objective of this study was to review the available literature and conduct a meta-analysis to provide well-powered and generalizable estimates of outcomes after heart transplantation in patients with a failing Fontan.
Main text
PubMed, Embase, and MEDLINE databases were searched for original studies of patients with a failing Fontan who underwent heart transplantation. The outcomes included were 1-year and 5-year survival, acute rejection, renal dysfunction, sepsis, and multi-organ failure. Proportions were pooled using random effects models to derive pooled proportions (PPs) and corresponding 95% confidence intervals (CIs). Meta-regression analysis was done to study the effects of age and gender on key outcomes. Sixteen retrospective single-center cohort studies with 426 Fontan patients undergoing heart transplantation were included in this meta-analysis. Pooled analysis of this study further revealed that 1-year survival after heart transplantation was 79.9% ([75.8%, 83.7%]; I2 = 1.92%), and 5-year survival rate was 72.5% ([62.1%, 81.9%]; I2 = 72.12%). Secondary outcomes after heart transplantation of failed Fontan procedure were acute rejection (PP 20% [7.4%, 36.8%]; I2 = 72.48%), renal dysfunction (PP 31.3% [10.5%, 57.2%]; I2 = 75.42%), multi-organ failure (PP 18.6% [2.8 to 43.9%]; I2= 69.60%), and sepsis (PP 21.1% [9%, 36.8%]; I2 = 61.19%).
Conclusion
Cardiac transplantation in patients with a failing Fontan is associated with acceptable interventional success and improved survival rates.
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13
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Fate of patients with single ventricles who do not undergo the Fontan procedure. Ann Thorac Surg 2021; 114:25-33. [PMID: 33609544 DOI: 10.1016/j.athoracsur.2021.02.011] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/07/2020] [Revised: 01/04/2021] [Accepted: 02/08/2021] [Indexed: 11/24/2022]
Abstract
BACKGROUND The Fontan procedure, the last of a series of palliative operations for patients born with single ventricles, is associated with a significant late burden of complications. There are other strategies for patients who are suboptimal candidates for Fontan completion, however the long-term outcomes of these different surgical options have not been clearly elucidated. We performed a systematic literature review to establish the current role of other treatment approaches besides the Fontan procedure. METHODS MEDLINE and Embase databases were systematically searched for articles describing the long-term outcomes of patients with single ventricles who have not received the Fontan procedure. RESULTS A total of 36 articles met all inclusion criteria. There is a scarcity of contemporary data on the non-Fontan cohort. Historical studies provided a significant contribution. CONCLUSIONS Long-term survival in unoperated patients with single ventricles is possible under the rare conditions of having balanced hemodynamics. Up to half of patients may survive on only a systemic-to-pulmonary artery shunt or bidirectional cavopulmonary shunt for over 20 years with reasonable functional status. In patients with a failing single ventricle, the bidirectional cavopulmonary shunt is an excellent bridge to heart transplantation and may provide better post-transplant survival than those with a Fontan circulation. Currently, the Fontan procedure continues to be the best definitive palliation for patients born with single ventricle lesions. However, for those with borderline indications, other strategies should be carefully considered.
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14
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Stephens EH, Tannous P, Mongé MC, Eltayeb O, Devlin PJ, Backer CL, Forbess JM, Pahl E. Normalization of hemodynamics is delayed in patients with a single ventricle after pediatric heart transplantation. J Thorac Cardiovasc Surg 2020; 159:1986-1996. [DOI: 10.1016/j.jtcvs.2019.09.135] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/26/2019] [Revised: 09/04/2019] [Accepted: 09/09/2019] [Indexed: 10/25/2022]
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15
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Denfield SW, Azeka E, Das B, Garcia-Guereta L, Irving C, Kemna M, Reinhardt Z, Thul J, Dipchand AI, Kirk R, Davies RR, Miera O. Pediatric cardiac waitlist mortality-Still too high. Pediatr Transplant 2020; 24:e13671. [PMID: 32198830 DOI: 10.1111/petr.13671] [Citation(s) in RCA: 24] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/29/2019] [Revised: 01/18/2020] [Accepted: 01/21/2020] [Indexed: 12/28/2022]
Abstract
Cardiac transplantation for children with end-stage cardiac disease with no other medical or surgical options is now standard. The number of children in need of cardiac transplant continues to exceed the number of donors considered "acceptable." Therefore, there is an urgent need to understand which recipients are in greatest need of transplant before becoming "too ill" and which "marginal" donors are acceptable in order to reduce waitlist mortality. This article reviewed primarily pediatric studies reported over the last 15 years on waitlist mortality around the world for the various subgroups of children awaiting heart transplant and discusses strategies to try to reduce the cardiac waitlist mortality.
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Affiliation(s)
- Susan W Denfield
- Division of Pediatric Cardiology, Texas Children's Hospital, Baylor College of Medicine, Houston, TX, USA
| | - Estela Azeka
- Division of Pediatric Cardiology, University of Sao Paolo, Sao Paolo, Brazil
| | - Bibhuti Das
- Texas Children's Hospital, Baylor College of Medicine, Austin, TX, USA
| | - Luis Garcia-Guereta
- Division of Pediatric Cardiology, Hospital Universitario La Paz, Madrid, Spain
| | - Claire Irving
- Division of Pediatric Cardiology, Children's Hospital Westmead, Sydney, NSW, Australia
| | - Mariska Kemna
- Division of Pediatric Cardiology, Seattle Children's Hospital, Seattle, WA, USA
| | - Zdenka Reinhardt
- Division of Pediatric Cardiology, Freeman Hospital, New Castle upon Tyne, UK
| | - Josef Thul
- Division of Pediatric Cardiology, Children's Heart Center, University of Giessen, Giessen, Germany
| | - Anne I Dipchand
- Labatt Family Heart Centre, Hospital for Sick Children, University of Toronto, Toronto, ON, Canada
| | - Richard Kirk
- Division of Pediatric Cardiology, Children's Medical Center, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Ryan R Davies
- Department of Cardiovascular and Thoracic Surgery, Children's Medical Center, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Oliver Miera
- Department of Congenital Heart Disease/Pediatric Cardiology, Deutsches Herzzentrum, Berlin, Germany
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16
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Kumar TKS. The failing Fontan. Indian J Thorac Cardiovasc Surg 2020; 37:82-90. [PMID: 33603286 DOI: 10.1007/s12055-020-00931-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2019] [Revised: 01/13/2020] [Accepted: 01/28/2020] [Indexed: 11/30/2022] Open
Abstract
Nearly 50 years back, Francis Fontan pioneered an operation for tricuspid atresia that bears his name today. The operation has since undergone numerous modifications and continues to be widely applied to an array of single ventricles. Despite restoring normal oxygen levels in the body, the operation creates a neoportal system where adequate cardiac output can be generated only at the expense of increased systemic venous congestion. This results in slow but relentless damage to the end organ systems especially the liver. Continuous surveillance of the patient to monitor this circulation, that will ultimately fail, is of paramount importance. Timely medical and cardiac catheterization and surgical intervention can extend the life span of Fontan patients. Ultimately a change of the hemodynamic circuit in the form of heart transplantation or ventricular assist device will be required to salvage the failing Fontan circuit.
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Affiliation(s)
- T K Susheel Kumar
- Department of Cardiothoracic Surgery, New York University, 530 First Avenue, New York, NY 10016 USA
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17
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Abstract
Half a century has passed since the original Fontan palliation. In the interim, surgical and medical advancements have allowed more single ventricle patients to reach Fontan and long-term survival for Fontan patients to improve significantly. However, the risk for Fontan failure and need for heart transplantation remains. In this article we discuss mechanisms of Fontan failure, risk factors and special considerations for Fontan patients in both medical and surgical management around heart transplantation and provide an updated review of survival for Fontan patients after heart transplantation.
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Affiliation(s)
- Amanda D McCormick
- Division of Pediatric Cardiology, C.S. Mott Children's Hospital, Ann Arbor, MI, USA
| | - Kurt R Schumacher
- Division of Pediatric Cardiology, C.S. Mott Children's Hospital, Ann Arbor, MI, USA
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18
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19
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Abstract
The care of children with hypoplastic left heart syndrome is constantly evolving. Prenatal diagnosis of hypoplastic left heart syndrome will aid in counselling of parents, and selected fetuses may be candidates for in utero intervention. Following birth, palliation can be undertaken through staged operations: Norwood (or hybrid) in the 1st week of life, superior cavopulmonary connection at 4-6 months of life, and finally total cavopulmonary connection (Fontan) at 2-4 years of age. Children with hypoplastic left heart syndrome are at risk of circulatory failure their entire life, and selected patients may undergo heart transplantation. In this review article, we summarise recent advances in the critical care management of patients with hypoplastic left heart syndrome as were discussed in a focused session at the 12th International Conference of the Paediatric Cardiac Intensive Care Society held on 9 December, 2016, in Miami Beach, Florida.
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20
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Kenny LA, DeRita F, Nassar M, Dark J, Coats L, Hasan A. Transplantation in the single ventricle population. Ann Cardiothorac Surg 2018; 7:152-159. [PMID: 29492393 DOI: 10.21037/acs.2018.01.16] [Citation(s) in RCA: 30] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
The single ventricle patient population comprises the most complex cohort presenting to the cardiac transplant team, in terms of demographics, anatomic substrate, and unique physiology. It is also the most rapidly growing diagnostic group presenting for heart transplantation. In this manuscript, we aim to describe the changing landscape of transplantation in single ventricle conditions through reflection on our own institution's practice and experience, alongside contemporary literature review. Single ventricle patients are heterogeneous in terms of age, anatomic diagnosis and physiology according to surgical stage of repair. Progress in surgical palliative strategies has impacted upon the present composition of the population, with growing numbers of hypoplastic left heart syndrome patients and those with late physiology failure following Fontan completion. Multiple prior surgeries, immunological sensitivity and multi-organ involvement impart high peri-operative risk but can be mitigated in part by careful pre-operative planning by a dedicated multi-disciplinary team addressing issues such as planning of concurrent reconstructive surgery, minimizing the post-operative effect of collaterals, timely harvesting, oversizing of donor organs to minimize graft failure, and strategies to address anticipated post-operative elevation in pulmonary vascular resistance. Determining optimal timing for transplant in these patients remains unclear, but understanding the risk of alternative surgical options can help guide decision making with regards to listing.
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Affiliation(s)
- Louise A Kenny
- Adult Congenital and Paediatric Heart Unit, Freeman Hospital, Newcastle upon Tyne NHS Foundation Trust, Newcastle Upon Tyne, UK
| | - Fabrizio DeRita
- Adult Congenital and Paediatric Heart Unit, Freeman Hospital, Newcastle upon Tyne NHS Foundation Trust, Newcastle Upon Tyne, UK
| | - Mohamed Nassar
- Adult Congenital and Paediatric Heart Unit, Freeman Hospital, Newcastle upon Tyne NHS Foundation Trust, Newcastle Upon Tyne, UK.,Cardiothoracic Surgery Department, Alexandria University, Alexandria, Egypt
| | - John Dark
- Adult Congenital and Paediatric Heart Unit, Freeman Hospital, Newcastle upon Tyne NHS Foundation Trust, Newcastle Upon Tyne, UK.,Institute of Cellular Medicine, Faculty of Medical Sciences, Newcastle University, Newcastle upon Tyne, UK
| | - Louise Coats
- Adult Congenital and Paediatric Heart Unit, Freeman Hospital, Newcastle upon Tyne NHS Foundation Trust, Newcastle Upon Tyne, UK.,Cardiovascular Research Centre, Institute of Genetic Medicine, Newcastle University, Newcastle upon Tyne, UK
| | - Asif Hasan
- Adult Congenital and Paediatric Heart Unit, Freeman Hospital, Newcastle upon Tyne NHS Foundation Trust, Newcastle Upon Tyne, UK
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21
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Marrone C, Ferrero P, Uricchio N, Sebastiani R, Vittori C, Ciuffreda M, Terzi A, Galletti L. The unnatural history of failing univentricular hearts: outcomes up to 25 years after heart transplantation. Interact Cardiovasc Thorac Surg 2017; 25:892-897. [DOI: 10.1093/icvts/ivx352] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2016] [Accepted: 09/19/2017] [Indexed: 11/12/2022] Open
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22
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Rahmenbedingungen für ein Kinderherztransplantationsprogramm. ZEITSCHRIFT FUR HERZ THORAX UND GEFASSCHIRURGIE 2017. [DOI: 10.1007/s00398-017-0164-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
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23
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Kirklin JK, Pearce FB, Dabal RJ, Carlo WF, Mauchley DC. Challenges of Cardiac Transplantation Following the Fontan Procedure. World J Pediatr Congenit Heart Surg 2017; 8:480-486. [DOI: 10.1177/2150135117714460] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- James K. Kirklin
- Division of Cardiothoracic Surgery, Department of Surgery, University of Alabama at Birmingham, Birmingham, AL, USA
| | - F. Bennett Pearce
- Division of Pediatric Cardiology, Department of Pediatrics, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Robert J. Dabal
- Division of Cardiothoracic Surgery, Department of Surgery, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Waldemar F. Carlo
- Division of Pediatric Cardiology, Department of Pediatrics, University of Alabama at Birmingham, Birmingham, AL, USA
| | - David C. Mauchley
- Division of Cardiothoracic Surgery, Department of Surgery, University of Alabama at Birmingham, Birmingham, AL, USA
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24
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Meta-Analysis of the Effectiveness of Heart Transplantation in Patients With a Failing Fontan. Am J Cardiol 2017; 119:1269-1274. [PMID: 28233535 DOI: 10.1016/j.amjcard.2017.01.001] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/07/2016] [Revised: 01/03/2017] [Accepted: 01/03/2017] [Indexed: 12/20/2022]
Abstract
The Fontan procedure is increasingly being used to palliate univentricular physiology. It is a complex anatomic and physiologic repair that can fail at any age, often leaving heart transplantation as the only remaining solution. A meta-analysis was performed to achieve the aim of systematically evaluating the existing evidence for survival after heart transplantation in patients who have undergone a Fontan palliation. MEDLINE, Embase, PubMed, and Web of Science were searched for original research studies. The primary outcome was mortality at 1 and 5 years after transplantation. Five hundred eighty-two records were screened, after the removal of duplicates, 12 retrospective observational studies were selected for inclusion in our meta-analysis. This encompassed a total of 351 Fontan patients undergoing heart transplantation. Mean age was 14 years (range 7 to 24 years) and 65% were men. One- and 5-year survival rates after heart transplantation were found to be 80.3% (95% CI 75.9% to 84.2%) and 71.2% (95% CI 66.3% to 75.7%), respectively. No significant association was found between age, gender, and pulmonary pressures and 1-year mortality. In conclusion, in the largest analysis to date, we found that heart transplantation in younger patients after Fontan procedure has an acceptable early and mid-term mortality. It is comparable to published mortality data of heart transplantation for other forms of congenital heart disease. Heart transplantation in the younger failing Fontan population appears to be a reasonable option when all other avenues have been exhausted and appropriate screening has taken place.
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25
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Fontan Patient Survival After Pediatric Heart Transplantation Has Improved in the Current Era. Ann Thorac Surg 2017; 103:1315-1320. [DOI: 10.1016/j.athoracsur.2016.08.110] [Citation(s) in RCA: 49] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/17/2016] [Revised: 08/10/2016] [Accepted: 08/31/2016] [Indexed: 11/20/2022]
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26
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Vaughn G, Moore J, Lamberti J, Canter C. Management of the failing Fontan: Medical, interventional and surgical treatment. PROGRESS IN PEDIATRIC CARDIOLOGY 2016. [DOI: 10.1016/j.ppedcard.2016.07.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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27
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Kirklin JK, Carlo WF, Pearce FB. Current Expectations for Cardiac Transplantation in Patients With Congenital Heart Disease. World J Pediatr Congenit Heart Surg 2016; 7:685-695. [DOI: 10.1177/2150135116660701] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2016] [Accepted: 06/14/2016] [Indexed: 11/15/2022]
Abstract
Congenital heart disease accounts for 40% of pediatric heart transplants and presents unique challenges to the transplant team. Suitability for transplantation is defined in part by degree of sensitization, pulmonary vascular resistance, and hepatic reserves. The incremental transplant risk for patients with congenital heart disease occurs within the first 3 months, after which survival is equivalent to transplantation for cardiomyopathy. Single ventricle with prior palliation, and especially the failing Fontan, carry the highest risk for transplantation and are least amenable to bridging with mechanical circulatory support. More effective bridging to transplant with mechanical circulatory support will require improvements in the adverse event profile of available pumps and the introduction of miniaturized continuous flow technology. The major barriers to routine long-term survival are chronic allograft failure and allograft vasculopathy. Despite these many challenges, continuing improvements in the care of pediatric heart transplant patients have pushed the median posttransplant survival past 15 years for children and to 20 years for infants.
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Affiliation(s)
- James K. Kirklin
- Division of Cardiothoracic Surgery, Department of Surgery, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Waldemar F. Carlo
- Division of Pediatric Cardiology, Department of Pediatrics, University of Alabama School of Medicine, Birmingham, AL, USA
| | - F. Bennett Pearce
- Division of Pediatric Cardiology, Department of Pediatrics, University of Alabama School of Medicine, Birmingham, AL, USA
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28
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Schilling C, Dalziel K, Nunn R, Du Plessis K, Shi WY, Celermajer D, Winlaw D, Weintraub RG, Grigg LE, Radford DJ, Bullock A, Gentles TL, Wheaton GR, Hornung T, Justo RN, d'Udekem Y. The Fontan epidemic: Population projections from the Australia and New Zealand Fontan Registry. Int J Cardiol 2016; 219:14-9. [DOI: 10.1016/j.ijcard.2016.05.035] [Citation(s) in RCA: 87] [Impact Index Per Article: 10.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/15/2016] [Revised: 05/10/2016] [Accepted: 05/12/2016] [Indexed: 01/23/2023]
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29
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Lin SN, Huang SC, Chen YS, Chih NH, Wang CH, Chou NK, Yu HY, Wu IH, Shun CT, Wang SS. Case Series: Heart Transplantation After Fontan Operation-Single-Center Experience. Transplant Proc 2016; 48:959-64. [PMID: 27234779 DOI: 10.1016/j.transproceed.2016.01.037] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2015] [Accepted: 01/14/2016] [Indexed: 11/30/2022]
Abstract
BACKGROUND Fontan failure (FF) occurs rarely. In patients with Fontan failure, heart transplantation is believed to be the most effective therapy. We review our experience in heart transplantations after the Fontan operation. METHODS From July 1987 to December 2014, 4 of 513 patients underwent orthotopic heart transplantation (OHT). Among them, 4 were due to FF. We reviewed these 4 cases via retrospective chart review. Clinical history, laboratory data, surgical technique, perioperative variables, and outcomes of long-term follow-up are presented herein. The primary outcomes were hospital mortality, 1-year-survival rate, and 4-year-survival rate. The secondary outcome is the improvement in patients with protein-losing enteropathy. RESULTS The hospital mortality rate was 0% in the 4 FF patients receiving OHT. No surgically related hemorrhage or infection was observed. The 1-year-survival rate was 100% (n = 4) and the 4-year-survival rate 50% (n = 2). One patient died of posttransplantation lymphoproliferative disorder. Hypoalbuminemia improved in 1 of 3 patients 4 months after OHT. CONCLUSIONS Despite technical challenges, heart transplantation can be performed successfully in patients with Fontan operation. However, protein-losing enteropathy might not be resolved quickly after heart transplantation.
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Affiliation(s)
- S-N Lin
- Department of Surgery, National Taiwan University Hospital, Taipei, Taiwan
| | - S-C Huang
- Department of Surgery, National Taiwan University Hospital, Taipei, Taiwan
| | - Y-S Chen
- Department of Surgery, National Taiwan University Hospital, Taipei, Taiwan
| | - N-H Chih
- Department of Surgery, National Taiwan University Hospital, Taipei, Taiwan
| | - C-H Wang
- Department of Surgery, National Taiwan University Hospital, Taipei, Taiwan
| | - N-K Chou
- Department of Surgery, National Taiwan University Hospital, Taipei, Taiwan
| | - H-Y Yu
- Department of Surgery, National Taiwan University Hospital, Taipei, Taiwan
| | - I-H Wu
- Department of Surgery, National Taiwan University Hospital, Taipei, Taiwan
| | - C-T Shun
- Department of Pathology, National Taiwan University Hospital, Taipei, Taiwan
| | - S-S Wang
- Department of Surgery, National Taiwan University Hospital, Taipei, Taiwan; Department of Surgery, Fu Jen Catholic University Hospital, and Fu Jen Catholic University College of Medicine, New Taipei City, Taiwan.
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30
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Alsoufi B, Deshpande S, McCracken C, Kogon B, Vincent R, Mahle WT, Kanter K. Era effect on survival following paediatric heart transplantation. Eur J Cardiothorac Surg 2016; 50:742-751. [DOI: 10.1093/ejcts/ezw108] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/07/2015] [Revised: 02/04/2016] [Accepted: 03/04/2016] [Indexed: 11/14/2022] Open
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31
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Shi WY, Yong MS, McGiffin DC, Jain P, Ruygrok PN, Marasco SF, Finucane K, Keogh A, d'Udekem Y, Weintraub RG, Konstantinov IE. Heart transplantation in Fontan patients across Australia and New Zealand. Heart 2016; 102:1120-6. [DOI: 10.1136/heartjnl-2015-308848] [Citation(s) in RCA: 35] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/16/2015] [Accepted: 02/16/2016] [Indexed: 12/20/2022] Open
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32
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Miller JR, Simpson KE, Epstein DJ, Lancaster TS, Henn MC, Schuessler RB, Balzer DT, Shahanavaz S, Murphy JJ, Canter CE, Eghtesady P, Boston US. Improved survival after heart transplant for failed Fontan patients with preserved ventricular function. J Heart Lung Transplant 2016; 35:877-83. [PMID: 27068035 DOI: 10.1016/j.healun.2016.02.005] [Citation(s) in RCA: 42] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2015] [Revised: 01/06/2016] [Accepted: 02/23/2016] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND Patients with a failing Fontan continue to have decreased survival after heart transplant (HT), particularly those with preserved ventricular function (PVF) compared with impaired ventricular function (IVF). In this study we evaluated the effect of institutional changes on post-HT outcomes. METHODS Data were retrospectively collected for all Fontan patients who underwent HT. Mode of failure was defined by the last echocardiogram before HT, with mild or no dysfunction considered PVF and moderate or severe considered IVF. Outcomes were compared between early era (EE, 1995 to 2008) and current era (CE, 2009 to 2014). Management changes in the CE included volume load reduction with aortopulmonary collateral (APC) embolization, advanced cardiothoracic imaging, higher goal donor/recipient weight ratio and aggressive monitoring for post-HT vasoplegia. RESULTS A total of 47 patients were included: 27 in the EE (13 PVF, 14 IVF) and 20 in the CE (12 PVF, 8 IVF). Groups were similar pre-HT, except for more PLE in PVF patients. More patients underwent APC embolization in the CE (80% vs 28%, p < 0.01). There was no difference in donor/recipient weight ratio between eras. There was a trend toward higher primary graft failure for PVF in the EE (77% vs 36%, p = 0.05) but not the CE (42% vs 75%, p = 0.20). Overall, 1-year survival improved in the CE (90%) from the EE (63%) (p = 0.05), mainly due to increased survival for PVF (82 vs 38%, p = 0.04). CONCLUSIONS Post-HT survival for failing Fontan patients has improved, particularly for PVF. In the CE, our Fontan patients had a 1-year post-HT survival similar to other indications.
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Affiliation(s)
- Jacob R Miller
- Division of Cardiothoracic Surgery, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Kathleen E Simpson
- Section of Pediatric Cardiology, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Deirdre J Epstein
- Section of Pediatric Cardiothoracic Surgery, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Timothy S Lancaster
- Division of Cardiothoracic Surgery, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Matthew C Henn
- Division of Cardiothoracic Surgery, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Richard B Schuessler
- Division of Cardiothoracic Surgery, Washington University School of Medicine, St. Louis, Missouri, USA
| | - David T Balzer
- Section of Pediatric Cardiology, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Shabana Shahanavaz
- Section of Pediatric Cardiology, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Joshua J Murphy
- Section of Pediatric Cardiology, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Charles E Canter
- Section of Pediatric Cardiology, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Pirooz Eghtesady
- Section of Pediatric Cardiothoracic Surgery, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Umar S Boston
- Department of Surgery, Division of Pediatric Cardiac Surgery, University of Tennessee Health Science Center, Memphis, Tennessee, USA.
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Ross HJ, Law Y, Book WM, Broberg CS, Burchill L, Cecchin F, Chen JM, Delgado D, Dimopoulos K, Everitt MD, Gatzoulis M, Harris L, Hsu DT, Kuvin JT, Martin CM, Murphy AM, Singh G, Spray TL, Stout KK. Transplantation and Mechanical Circulatory Support in Congenital Heart Disease. Circulation 2016; 133:802-20. [DOI: 10.1161/cir.0000000000000353] [Citation(s) in RCA: 102] [Impact Index Per Article: 12.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
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34
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Alsoufi B, Mahle WT, Manlhiot C, Deshpande S, Kogon B, McCrindle BW, Kanter K. Outcomes of heart transplantation in children with hypoplastic left heart syndrome previously palliated with the Norwood procedure. J Thorac Cardiovasc Surg 2016; 151:167-74, 175.e1-2. [DOI: 10.1016/j.jtcvs.2015.09.081] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/29/2015] [Revised: 09/01/2015] [Accepted: 09/12/2015] [Indexed: 11/16/2022]
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35
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Outcomes and risk factors for heart transplantation in children with congenital heart disease. J Thorac Cardiovasc Surg 2015; 150:1455-62.e3. [DOI: 10.1016/j.jtcvs.2015.06.029] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/21/2014] [Revised: 06/04/2015] [Accepted: 06/07/2015] [Indexed: 11/19/2022]
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36
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37
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Affiliation(s)
- Daphne T Hsu
- From the Division of Pediatric Cardiology, Department of Pediatrics, Albert Einstein College of Medicine and the Children's Hospital at Montefiore, Bronx, NY.
| | - Jacqueline M Lamour
- From the Division of Pediatric Cardiology, Department of Pediatrics, Albert Einstein College of Medicine and the Children's Hospital at Montefiore, Bronx, NY
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Alsoufi B, Deshpande S, McCracken C, Kogon B, Vincent R, Mahle W, Kanter K. Results of heart transplantation following failed staged palliation of hypoplastic left heart syndrome and related single ventricle anomalies. Eur J Cardiothorac Surg 2015; 48:792-8; discussion 798-9. [DOI: 10.1093/ejcts/ezu547] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/12/2014] [Accepted: 12/10/2014] [Indexed: 12/21/2022] Open
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Schumacher KR, Almond C, Singh TP, Kirk R, Spicer R, Hoffman TM, Hsu D, Naftel DC, Pruitt E, Zamberlan M, Canter CE, Gajarski RJ. Predicting graft loss by 1 year in pediatric heart transplantation candidates: an analysis of the Pediatric Heart Transplant Study database. Circulation 2015; 131:890-8. [PMID: 25587099 DOI: 10.1161/circulationaha.114.009120] [Citation(s) in RCA: 49] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Pediatric data on the impact of pre-heart transplantation (HTx) risk factors on early post-HTx outcomes remain inconclusive. Thus, among patients with previous congenital heart disease or cardiomyopathy, disease-specific risk models for graft loss were developed with the use pre-HTx recipient and donor characteristics. METHODS AND RESULTS Patients enrolled in the Pediatric Heart Transplant Study (PHTS) from 1996 to 2006 were stratified by pre-HTx diagnosis into cardiomyopathy and congenital heart disease cohorts. Logistic regression identified independent, pre-HTx risk factors. Risk models were constructed for 1-year post-HTx graft loss. Donor factors were added for model refinement. The models were validated with the use of patients transplanted from 2007 to 2009. Risk factors for graft loss were identified in patients with cardiomyopathy (n=896) and congenital heart disease (n=965). For cardiomyopathy, independent risk factors were earlier year of transplantation, nonwhite race, female sex, diagnosis other than dilated cardiomyopathy, higher blood urea nitrogen, and panel reactive antibody >10%. The recipient characteristic risk model had good accuracy in the validation cohort, with predicted versus actual survival of 97.5% versus 95.3% (C statistic, 0.73). For patients with congenital heart disease, independent risk factors were nonwhite race, history of Fontan, ventilator dependence, higher blood urea nitrogen, panel reactive antibody >10%, and lower body surface area. The risk model was less accurate, with 86.6% predicted versus 92.4% actual survival, in the validation cohort (C statistic, 0.63). Donor characteristics did not enhance model precision. CONCLUSIONS Risk factors for 1-year post-HTx graft loss differ on the basis of pre-HTx cardiac diagnosis. Modeling effectively stratifies the risk of graft loss in patients with cardiomyopathy and may be an adjunctive tool in allocation policies and center performance metrics.
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Affiliation(s)
- Kurt R Schumacher
- From University of Michigan, Mott Children's Hospital, Ann Arbor (K.R.S., M.Z., R.J.G.); Lucille Packard Children's Hospital, Palo Alto, CA (C.A.); Children's Hospital, Boston, MA (T.P.S.); Freeman Hospital, Newcastle Upon Tyne, UK (R.K.); Children's Hospital of Omaha, NE (R.S.); Nationwide Children's Hospital, Columbus, OH (T.M.H.); Children's Hospital at Montefiore, Bronx, NY (D.H.); University of Alabama at Birmingham (D.C.N., E.P.); and St. Louis Children's Hospital, MO (C.E.C.).
| | - Christopher Almond
- From University of Michigan, Mott Children's Hospital, Ann Arbor (K.R.S., M.Z., R.J.G.); Lucille Packard Children's Hospital, Palo Alto, CA (C.A.); Children's Hospital, Boston, MA (T.P.S.); Freeman Hospital, Newcastle Upon Tyne, UK (R.K.); Children's Hospital of Omaha, NE (R.S.); Nationwide Children's Hospital, Columbus, OH (T.M.H.); Children's Hospital at Montefiore, Bronx, NY (D.H.); University of Alabama at Birmingham (D.C.N., E.P.); and St. Louis Children's Hospital, MO (C.E.C.)
| | - Tajinder P Singh
- From University of Michigan, Mott Children's Hospital, Ann Arbor (K.R.S., M.Z., R.J.G.); Lucille Packard Children's Hospital, Palo Alto, CA (C.A.); Children's Hospital, Boston, MA (T.P.S.); Freeman Hospital, Newcastle Upon Tyne, UK (R.K.); Children's Hospital of Omaha, NE (R.S.); Nationwide Children's Hospital, Columbus, OH (T.M.H.); Children's Hospital at Montefiore, Bronx, NY (D.H.); University of Alabama at Birmingham (D.C.N., E.P.); and St. Louis Children's Hospital, MO (C.E.C.)
| | - Richard Kirk
- From University of Michigan, Mott Children's Hospital, Ann Arbor (K.R.S., M.Z., R.J.G.); Lucille Packard Children's Hospital, Palo Alto, CA (C.A.); Children's Hospital, Boston, MA (T.P.S.); Freeman Hospital, Newcastle Upon Tyne, UK (R.K.); Children's Hospital of Omaha, NE (R.S.); Nationwide Children's Hospital, Columbus, OH (T.M.H.); Children's Hospital at Montefiore, Bronx, NY (D.H.); University of Alabama at Birmingham (D.C.N., E.P.); and St. Louis Children's Hospital, MO (C.E.C.)
| | - Robert Spicer
- From University of Michigan, Mott Children's Hospital, Ann Arbor (K.R.S., M.Z., R.J.G.); Lucille Packard Children's Hospital, Palo Alto, CA (C.A.); Children's Hospital, Boston, MA (T.P.S.); Freeman Hospital, Newcastle Upon Tyne, UK (R.K.); Children's Hospital of Omaha, NE (R.S.); Nationwide Children's Hospital, Columbus, OH (T.M.H.); Children's Hospital at Montefiore, Bronx, NY (D.H.); University of Alabama at Birmingham (D.C.N., E.P.); and St. Louis Children's Hospital, MO (C.E.C.)
| | - Timothy M Hoffman
- From University of Michigan, Mott Children's Hospital, Ann Arbor (K.R.S., M.Z., R.J.G.); Lucille Packard Children's Hospital, Palo Alto, CA (C.A.); Children's Hospital, Boston, MA (T.P.S.); Freeman Hospital, Newcastle Upon Tyne, UK (R.K.); Children's Hospital of Omaha, NE (R.S.); Nationwide Children's Hospital, Columbus, OH (T.M.H.); Children's Hospital at Montefiore, Bronx, NY (D.H.); University of Alabama at Birmingham (D.C.N., E.P.); and St. Louis Children's Hospital, MO (C.E.C.)
| | - Daphne Hsu
- From University of Michigan, Mott Children's Hospital, Ann Arbor (K.R.S., M.Z., R.J.G.); Lucille Packard Children's Hospital, Palo Alto, CA (C.A.); Children's Hospital, Boston, MA (T.P.S.); Freeman Hospital, Newcastle Upon Tyne, UK (R.K.); Children's Hospital of Omaha, NE (R.S.); Nationwide Children's Hospital, Columbus, OH (T.M.H.); Children's Hospital at Montefiore, Bronx, NY (D.H.); University of Alabama at Birmingham (D.C.N., E.P.); and St. Louis Children's Hospital, MO (C.E.C.)
| | - David C Naftel
- From University of Michigan, Mott Children's Hospital, Ann Arbor (K.R.S., M.Z., R.J.G.); Lucille Packard Children's Hospital, Palo Alto, CA (C.A.); Children's Hospital, Boston, MA (T.P.S.); Freeman Hospital, Newcastle Upon Tyne, UK (R.K.); Children's Hospital of Omaha, NE (R.S.); Nationwide Children's Hospital, Columbus, OH (T.M.H.); Children's Hospital at Montefiore, Bronx, NY (D.H.); University of Alabama at Birmingham (D.C.N., E.P.); and St. Louis Children's Hospital, MO (C.E.C.)
| | - Elizabeth Pruitt
- From University of Michigan, Mott Children's Hospital, Ann Arbor (K.R.S., M.Z., R.J.G.); Lucille Packard Children's Hospital, Palo Alto, CA (C.A.); Children's Hospital, Boston, MA (T.P.S.); Freeman Hospital, Newcastle Upon Tyne, UK (R.K.); Children's Hospital of Omaha, NE (R.S.); Nationwide Children's Hospital, Columbus, OH (T.M.H.); Children's Hospital at Montefiore, Bronx, NY (D.H.); University of Alabama at Birmingham (D.C.N., E.P.); and St. Louis Children's Hospital, MO (C.E.C.)
| | - Mary Zamberlan
- From University of Michigan, Mott Children's Hospital, Ann Arbor (K.R.S., M.Z., R.J.G.); Lucille Packard Children's Hospital, Palo Alto, CA (C.A.); Children's Hospital, Boston, MA (T.P.S.); Freeman Hospital, Newcastle Upon Tyne, UK (R.K.); Children's Hospital of Omaha, NE (R.S.); Nationwide Children's Hospital, Columbus, OH (T.M.H.); Children's Hospital at Montefiore, Bronx, NY (D.H.); University of Alabama at Birmingham (D.C.N., E.P.); and St. Louis Children's Hospital, MO (C.E.C.)
| | - Charles E Canter
- From University of Michigan, Mott Children's Hospital, Ann Arbor (K.R.S., M.Z., R.J.G.); Lucille Packard Children's Hospital, Palo Alto, CA (C.A.); Children's Hospital, Boston, MA (T.P.S.); Freeman Hospital, Newcastle Upon Tyne, UK (R.K.); Children's Hospital of Omaha, NE (R.S.); Nationwide Children's Hospital, Columbus, OH (T.M.H.); Children's Hospital at Montefiore, Bronx, NY (D.H.); University of Alabama at Birmingham (D.C.N., E.P.); and St. Louis Children's Hospital, MO (C.E.C.)
| | - Robert J Gajarski
- From University of Michigan, Mott Children's Hospital, Ann Arbor (K.R.S., M.Z., R.J.G.); Lucille Packard Children's Hospital, Palo Alto, CA (C.A.); Children's Hospital, Boston, MA (T.P.S.); Freeman Hospital, Newcastle Upon Tyne, UK (R.K.); Children's Hospital of Omaha, NE (R.S.); Nationwide Children's Hospital, Columbus, OH (T.M.H.); Children's Hospital at Montefiore, Bronx, NY (D.H.); University of Alabama at Birmingham (D.C.N., E.P.); and St. Louis Children's Hospital, MO (C.E.C.)
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Mauchley DC, Mitchell MB. Transplantation in the Fontan patient. Semin Thorac Cardiovasc Surg Pediatr Card Surg Annu 2015; 18:7-16. [PMID: 25939837 DOI: 10.1053/j.pcsu.2015.01.001] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2014] [Revised: 12/30/2014] [Accepted: 01/08/2015] [Indexed: 06/04/2023]
Abstract
The failing Fontan circulation presents difficult treatment challenges. When Fontan revision and or intervention for treatable arrhythmias is not feasible, heart transplantation is the only therapeutic option. Particular challenges presented by these patients include limited ability to assess hemodynamics, complex anatomy, multiple prior procedures, and unique underlying pathologic states. These issues complicate the decision-making process for further surgical intervention verses transplantation. The pre-transplant evaluation, transplant operation, and post-operative management are more problematic for these patients compared with most patients undergoing transplantation. Consequently, failing Fontan patients constitute one of the highest risk heart transplant subsets.
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Affiliation(s)
- David C Mauchley
- Instructor of Surgery, Department of Surgery, Division of Cardiothoracic Surgery, University of Colorado at Denver Health Sciences Center, Aurora, CO
| | - Max B Mitchell
- Professor of Surgery, Department of Surgery, Division of Cardiothoracic Surgery, University of Colorado at Denver Health Sciences Center and Children's Hospital Colorado Heart Institute, Aurora, CO.
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Razzouk AJ, Bailey LL. Heart transplantation in children for end-stage congenital heart disease. Semin Thorac Cardiovasc Surg Pediatr Card Surg Annu 2014; 17:69-76. [PMID: 24725720 DOI: 10.1053/j.pcsu.2014.01.009] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Heart transplantation (HT) as primary therapy for children with congenital heart disease (CHD) has become unusual. With improved early results of reconstructive surgery, the population of children and adults surviving with CHD is expanding. End-stage CHD related to myocardial dysfunction or circulation failure after prior surgery is becoming more common as an indication for HT. This heterogeneous group of CHD recipients referred for HT presents unique decision-making, technical, and physiologic challenges. Historically, a diagnosis of CHD has been a major risk factor for early mortality after HT. Rescue HT, especially in the setting of failing Fontan physiology, has the worst outcome. Early referral (before end-organ damage), proper selection, and optimization of recipients, as well as meticulous intra- and postoperative management are crucial to improving early outcomes of HT in this population. Beyond the early post-HT period, children with end-stage CHD experience long-term survival comparable to most other non-CHD recipients.
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Affiliation(s)
- Anees J Razzouk
- Department of Cardiovascular and Thoracic Surgery, Loma Linda University Children's Hospital, Loma Linda, CA.
| | - Leonard L Bailey
- Department of Cardiovascular and Thoracic Surgery, Loma Linda University Children's Hospital, Loma Linda, CA
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Padalino MA, Maschietto N, Motta R, Badano L, Stellin G. One‐and‐a‐Half Ventricle Repair as a Surgical Alternative to Fontan Revision in an Adult. J Card Surg 2014; 29:832-5. [DOI: 10.1111/jocs.12410] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Affiliation(s)
- M. A. Padalino
- Department of Cardiac, Thoracic and Vascular SciencesPediatric and Congenital Cardiac Surgery UnitUniversity of Padova Medical SchoolPadovaItaly
| | - N. Maschietto
- Department of Woman and Child's HealthPediatric CardiologyUniversity of Padova Medical SchoolPadovaItaly
| | - R. Motta
- Department of MedicineRadiology UnitUniversity of Padova Medical SchoolPadovaItaly
| | - L. Badano
- Department of Cardiac, Thoracic and Vascular SciencesCardiac UnitUniversity of Padova Medical SchoolPadovaItaly
| | - G. Stellin
- Department of Cardiac, Thoracic and Vascular SciencesPediatric and Congenital Cardiac Surgery UnitUniversity of Padova Medical SchoolPadovaItaly
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Michielon G, van Melle JP, Wolff D, Di Carlo D, Jacobs JP, Mattila IP, Berggren H, Lindberg H, Padalino MA, Meyns B, Prêtre R, Helvind M, Carrel T, Ebels T. Favourable mid-term outcome after heart transplantation for late Fontan failure. Eur J Cardiothorac Surg 2014; 47:665-71. [PMID: 25035415 DOI: 10.1093/ejcts/ezu280] [Citation(s) in RCA: 40] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
OBJECTIVES Fontan failure (FF) represents a growing and challenging indication for paediatric orthotopic heart transplantation (OHT). The aim of this study was to identify predictors of the best mid-term outcome in OHT after FF. METHODS Twenty-year multi-institutional retrospective analysis on OHT for FF. RESULTS Between 1991 and 2011, 61 patients, mean age 15.0 ± 9.7 years, underwent OHT for failing atriopulmonary connection (17 patients = 27.8%) or total cavopulmonary connection (44 patients = 72.2%). Modality of FF included arrhythmia (14.8%), complex obstructions in the Fontan circuit (16.4%), protein-losing enteropathy (PLE) (22.9%), impaired ventricular function (31.1%) or a combination of the above (14.8%). The mean time interval between Fontan completion and OHT was 10.7 ± 6.6 years. Early FF occurred in 18%, requiring OHT 0.8 ± 0.5 years after Fontan. The hospital mortality rate was 18.3%, mainly secondary to infection (36.4%) and graft failure (27.3%). The mean follow-up was 66.8 ± 54.2 months. The overall Kaplan-Meier survival estimate was 81.9 ± 1.8% at 1 year, 73 ± 2.7% at 5 years and 56.8 ± 4.3% at 10 years. The Kaplan-Meier 5-year survival estimate was 82.3 ± 5.9% in late FF and 32.7 ± 15.0% in early FF (P = 0.0007). Late FF with poor ventricular function exhibited a 91.5 ± 5.8% 5-year OHT survival. PLE was cured in 77.7% of hospital survivors, but the 5-year Kaplan-Meier survival estimate in PLE was 46.3 ± 14.4 vs 84.3 ± 5.5% in non-PLE (P = 0.0147). Cox proportional hazards identified early FF (P = 0.0005), complex Fontan pathway obstruction (P = 0.0043) and PLE (P = 0.0033) as independent predictors of 5-year mortality. CONCLUSIONS OHT is an excellent surgical option for late FF with impaired ventricular function. Protein dispersion improves with OHT, but PLE negatively affects the mid-term OHT outcome, mainly for early infective complications.
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Affiliation(s)
- Guido Michielon
- Department of Cardiothoracic Surgery, University of Groningen, University Medical Center Groningen, Groningen, Netherlands
| | - Joost P van Melle
- Department of Cardiology, University of Groningen, University Medical Center Groningen, Groningen, Netherlands
| | - Djoeke Wolff
- Department of Cardiothoracic Surgery, University of Groningen, University Medical Center Groningen, Groningen, Netherlands
| | | | | | - Ilkka P Mattila
- Hospital for Children and Adolescents, University of Helsinki, Helsinki, Finland
| | - Hakan Berggren
- Children's Heart Center, The Queen Silvia Children's Hospital, Goteborg, Sweden
| | | | - Massimo A Padalino
- Pediatric and Congenital Cardiac Surgery Unit, Department of Cardiac, Thoracic and Vascular Sciences, University of Padova Medical School, Padova, Italy
| | - Bart Meyns
- Department of Cardiac Surgery, University Hospital UZ Leuven, Leuven, Belgium
| | - René Prêtre
- Pediatric and Congenital Cardiac Surgery, University Children's Hospital, Zurich, Switzerland
| | - Morten Helvind
- Department of Cardiothoracic Surgery, Rigs Hospitalet, Copenhagen, Denmark
| | - Thierry Carrel
- Clinic for Cardiovascular Surgery, Swiss Cardiovascular Center University Hospital, Bern, Switzerland
| | - Tjark Ebels
- Department of Cardiothoracic Surgery, University of Groningen, University Medical Center Groningen, Groningen, Netherlands
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Shah KB, Kwakkel-van Erp JM, Migliore C, Orr Y, Corris PA, Glanville AR, Slaughter MS, West LJ, Mehra MR. Scientific progress in heart and lung failure, mechanical circulatory support, and transplantation: Highlights from the Journal of Heart and Lung Transplantation. J Heart Lung Transplant 2014; 33:223-8. [DOI: 10.1016/j.healun.2013.11.011] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2013] [Accepted: 11/27/2013] [Indexed: 11/24/2022] Open
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Abstract
Although the Fontan operation may provide a durable circulation for some patients with functionally univentricular hearts for several decades, circulatory failure becomes more common over time. Medical and/or surgical interventions can improve the circulation for some period of time; however, many patients will experience end-stage circulatory failure. Heart transplantation may be considered in these patients. This review will cover the indications and evaluation for heart transplantation, management of patients while waiting for heart transplantation and the current outcomes of transplantation in this population.
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Lastinger L, Zaidi AN. The adult with a fontan: a panacea without a cure? Review of long-term complications. Circ J 2013; 77:2672-81. [PMID: 24152723 DOI: 10.1253/circj.cj-13-1105] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
The univentricular heart includes a spectrum of complex cardiac defects that are managed by staged palliative surgical procedures, ultimately resulting in a Fontan procedure. Since 1971, when it was first developed, the procedure has undergone several variations. These patients require lifelong management, including a thorough knowledge of their anatomic substrate, hemodynamic status, management of rhythm and ventricular function, together with multi-organ evaluation. As these patients enter middle age, there is increasing awareness of long-term complications and mortality. This review highlights the concept behind the staged surgical palliations, the unique single ventricle physiology and the long-term complications in this complex cohort of patients.
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Affiliation(s)
- Lauren Lastinger
- Division of Pediatrics and Internal Medicine, Nationwide Children's Hospital and the Ohio State University
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Backer CL, Russell HM, Pahl E, Mongé MC, Gambetta K, Kindel SJ, Gossett JG, Hardy C, Costello JM, Deal BJ. Heart transplantation for the failing Fontan. Ann Thorac Surg 2013; 96:1413-1419. [PMID: 23987899 DOI: 10.1016/j.athoracsur.2013.05.087] [Citation(s) in RCA: 81] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/30/2013] [Revised: 05/22/2013] [Accepted: 05/24/2013] [Indexed: 12/21/2022]
Abstract
BACKGROUND Patients with failing Fontan circulation are at high risk for complications after heart transplantation (HTx) because of multiple prior operations, elevated panel reactive antibody, hepatic dysfunction, coagulopathy, protein-losing enteropathy (PLE), and poor nutrition. The purpose of this review was to evaluate the outcome of HTx for these patients, including those who are status post-Fontan conversion. METHODS Of 206 heart transplants at Ann & Robert H. Lurie Children's Hospital of Chicago from 1990 to 2012, 22 patients had a failing Fontan. Median age at HTx was 12.2 years, median interval from initial Fontan to HTx was 7.1 years. Potential preoperative risk factors included PLE (n = 15), mechanical ventilation (n = 8), prior Fontan conversion (n = 7), renal failure (n = 3), and plastic bronchitis (n = 2) Median number of prior operations was 3. Donor branch pulmonary arteries were used in 17 patients. RESULTS There were 5 early deaths (23%), due to graft failure (1), pulmonary hypertension (1), and infection (3). There were 3 late deaths (13%) at 1, 5, and 8 years. Two of 3 patients with preoperative renal failure died. Survivors who had preoperative PLE (n = 11) and preoperative plastic bronchitis (n = 2) experienced complete resolution of these pathological conditions after heart transplantation. Median length of stay was 30 days. Five of 7 Fontan conversion patients survived, and 6 of 8 preoperative ventilator-dependent patients survived. One-, 5-, and 10-year survival was 77%, 66%, and 45%, respectively. CONCLUSIONS The operative mortality of HTx for patients with a failing Fontan is high. Using the donor branch pulmonary arteries greatly facilitated the transplant. Because infection caused the majority of early deaths, lower intensity initial immunosuppression may be warranted. Transplantation was successful in treating PLE in all survivors. Prior Fontan conversion was not a risk factor. Preoperative mechanical ventilation was not a risk factor. Preoperative renal failure may be a relative contraindication. Earlier referral of failing Fontan patients may improve results.
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Affiliation(s)
- Carl L Backer
- Division of Cardiovascular Thoracic Surgery, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois; Department of Surgery, Northwestern University Feinberg School of Medicine, Chicago, Illinois.
| | - Hyde M Russell
- Division of Cardiovascular Thoracic Surgery, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois; Department of Surgery, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Elfriede Pahl
- Division of Cardiology, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois; Department of Pediatrics, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Michael C Mongé
- Division of Cardiovascular Thoracic Surgery, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois; Department of Surgery, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Katheryn Gambetta
- Division of Cardiology, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois
| | - Steven J Kindel
- Division of Cardiology, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois
| | - Jeffrey G Gossett
- Division of Cardiology, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois
| | - Courtney Hardy
- Division of Anesthesiology, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois
| | - John M Costello
- Division of Cardiology, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois
| | - Barbara J Deal
- Division of Cardiology, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois; Department of Pediatrics, Northwestern University Feinberg School of Medicine, Chicago, Illinois
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Dipchand AI, Kirk R, Mahle WT, Tresler MA, Naftel DC, Pahl E, Miyamoto SD, Blume E, Guleserian KJ, White-Williams C, Kirklin JK. Ten yr of pediatric heart transplantation: a report from the Pediatric Heart Transplant Study. Pediatr Transplant 2013; 17:99-111. [PMID: 23442098 DOI: 10.1111/petr.12038] [Citation(s) in RCA: 72] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 11/19/2012] [Indexed: 11/27/2022]
Abstract
The PHTS was founded in 1991 as a not-for-profit organization dedicated to the advancement of the science and treatment of children during listing for and following heart transplantation. Now, 21 yr later, the PHTS has contributed significantly to the field, most notably in the form of outcomes analyses and risk factor assessment, in addition to amassing the most detailed dataset on pediatric heart transplant recipients worldwide. The purpose of this report is to review the last decade of pediatric patients listed for heart transplantation (January 1, 2000-December 31, 2009) and summarize the changes, trends, outcomes, and lessons learned.
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