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Bolia R, Alremawi S, Noble C, Justo R, Ward C, Lewindon PJ. Shear-wave elastography for monitoring Fontan-associated liver disease: A prospective cohort study. J Pediatr Gastroenterol Nutr 2024; 79:126-130. [PMID: 38477364 DOI: 10.1002/jpn3.12182] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/03/2023] [Revised: 01/13/2024] [Accepted: 02/20/2024] [Indexed: 03/14/2024]
Abstract
The spectrum of Fontan-associated liver disease (FALD) varies from abnormal liver function tests to fibrosis and even cirrhosis. In this prospective study, we evaluated the role of shear-wave elastography (SWE) in predicting the presence of advanced FALD. Forty-eight patients (30 males, 13.9 [6-21] years) with a Fontan circulation were evaluated at 8.3 (2.1-18.7) years since the Fontan surgery. The median liver stiffness measurement (LSM) value was higher than values in normal children at 15.4 (9.5-38.7) kPa. The LSMs had a weak but significant correlation with age at the time of LSM (r = 0.25, p = 0.01) and duration post-Fontan surgery (r = 0.31, p = 0.02). It had a poor correlation with the concomitant aspartate transaminase-to-platelet ratio index (r = 0.1, p = 0.39). No difference in the elastography values between children with and without ultrasound evidence of advanced liver disease (17.7 [interquartile range, IQR: 4] vs. 16.1 [IQR: 6], p = 0.62] was observed. Further studies are required to determine the precise role of SWE as a noninvasive marker of liver fibrosis in FALD.
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Affiliation(s)
- Rishi Bolia
- Department of Gastroenterology, Hepatology and Liver Transplant, Queensland Children's Hospital, Brisbane, Australia
| | - Sara Alremawi
- Department of Gastroenterology, Hepatology and Liver Transplant, Queensland Children's Hospital, Brisbane, Australia
| | - Charlton Noble
- Department of Gastroenterology, Hepatology and Liver Transplant, Queensland Children's Hospital, Brisbane, Australia
| | - Robert Justo
- Department of Cardiology, Queensland Children's Hospital, Brisbane, Australia
| | - Cameron Ward
- Department of Cardiology, Queensland Children's Hospital, Brisbane, Australia
| | - Peter J Lewindon
- Department of Gastroenterology, Hepatology and Liver Transplant, Queensland Children's Hospital, Brisbane, Australia
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Lu CW, Wu CH, Huang MT, Lee CS, Chen HL, Lin MT, Chiu SN, Tseng WC, Chen CA, Wang JK, Wu MH. Liver fibrosis detected by diffusion-weighted magnetic resonance imaging and its functional correlates in Fontan patients. Eur J Cardiothorac Surg 2024; 66:ezae249. [PMID: 38913856 DOI: 10.1093/ejcts/ezae249] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/21/2024] [Revised: 04/17/2024] [Accepted: 06/23/2024] [Indexed: 06/26/2024] Open
Abstract
OBJECTIVES The evaluation of Fontan-associated liver disease is often challenging. Diffusion-weighted magnetic resonance imaging can detect hepatic fibrosis from capillary perfusion and diffusion abnormalities from extracellular matrix accumulation. This study investigated its role in the evaluation of liver disease in Fontan patients and explored possible diagnostic methods for early detection of advanced liver fibrosis. METHODS Stable adult Fontan patients who could safely be examined with magnetic resonance imaging were enrolled, and blood biomarkers, transient elastography were also examined. RESULTS Forty-six patients received diffusion-weighted imaging; and 58.7% were diagnosed with advanced liver fibrosis (severe liver fibrosis, 37.0%, and cirrhosis 21.7%). Two parameters of hepatic dysfunction, platelet counts (Spearman's ρ: -0.456, P = 0.001) and cholesterol levels (Spearman's ρ: -0.383, P = 0.009), decreased with increasing severity of fibrosis. Using transient elastography, a cut-off value of 14.2 kPa predicted the presence of advanced liver fibrosis, but with a low positive predictive value. When we included platelet count, cholesterol, post-Fontan years and transient elastography values as a composite, the capability of predicting advanced liver fibrosis was the most satisfactory (C statistic 0.817 ± 0.071, P < 0.001). A cut-off value of 5.0 revealed a sensitivity of 78% and a specificity of 82%. CONCLUSIONS In Fontan patients, diffusion-weighted imaging was helpful in detecting liver fibrosis that was correlated with hepatic dysfunction. A simple score was proposed for long-term surveillance and early detection of advanced liver disease in adult Fontan patients. For adult Fontan patients with a calculated score > 5.0, we may consider timely diffusion-weight imaging and early management for liver complications.
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Affiliation(s)
- Chun-Wei Lu
- Adult Congenital Heart Center, National Taiwan University Hospital, Taipei, Taiwan
- Department of Pediatrics, National Taiwan University Hospital, Taipei, Taiwan
| | - Chih-Horng Wu
- Department of Medical Imaging, National Taiwan University Hospital, Taipei, Taiwan
| | - Miao-Tzu Huang
- Department of Medical Research, National Taiwan University Hospital, Taipei, Taiwan
| | - Chee-Seng Lee
- Department of Pediatrics, National Taiwan University Hospital Hsin-Chu Biomedical Park Branch, Hsin-Chu, Taiwan
| | - Huey-Ling Chen
- Department of Pediatrics, National Taiwan University Hospital, Taipei, Taiwan
| | - Ming-Tai Lin
- Department of Pediatrics, National Taiwan University Hospital, Taipei, Taiwan
| | - Shuenn-Nan Chiu
- Department of Pediatrics, National Taiwan University Hospital, Taipei, Taiwan
| | - Wei-Chieh Tseng
- Department of Pediatrics, National Taiwan University Hospital, Taipei, Taiwan
| | - Chun-An Chen
- Department of Pediatrics, National Taiwan University Hospital, Taipei, Taiwan
| | - Jou-Kou Wang
- Department of Pediatrics, National Taiwan University Hospital, Taipei, Taiwan
| | - Mei-Hwan Wu
- Adult Congenital Heart Center, National Taiwan University Hospital, Taipei, Taiwan
- Department of Pediatrics, National Taiwan University Hospital, Taipei, Taiwan
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Bulut OP, Bailey SS, Bhat DP. Accuracy of elastography versus biopsy in assessing severity of liver fibrosis in young Fontan patients. Cardiol Young 2024:1-7. [PMID: 38804649 DOI: 10.1017/s1047951124025241] [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: 05/29/2024]
Abstract
OBJECTIVES We performed a single-centre retrospective study comparing the accuracy of non-invasive elastography with liver biopsy in accurate assessment of Fontan-associated liver disease. METHODS Fontan patients who underwent combined assessment with a percutaneous liver biopsy and non-invasive elastography between January 2015 and December 2023 at our Children's hospital were included. Liver biopsies were classified using the Congestive Hepatic Fibrosis Score as early Fontan-associated liver disease (scores 1, 2) and advanced Fontan-associated liver disease (score 3/bridging fibrosis and score 4/cirrhosis). Elastography values were categorised as advanced Fontan-associated liver disease for liver elasticity >2.1 m/s by ultrasound and liver stiffness >5 KPa on magnetic resonance elastography. RESULTS We included 130 patients (116 children, 89%, mean age at biopsy: 14.6 years ± 3.6) who underwent liver biopsy at a mean duration of 11.1 years (±0.3) following Fontan surgery. Advanced Fontan-associated liver disease was noted in 41 (31.5%) patients with 13 (10%) showing frank cirrhosis. Pre-biopsy ultrasound showed advanced liver fibrosis in 18/125 (14%), with low sensitivity (23%), high specificity (90%), and low accuracy (68%, k = 0.1) in diagnosing advanced Fontan-associated liver disease. Similarly, pre-biopsy magnetic resonance elastography showed advanced fibrosis in 23/86 (27%) of patients, with low sensitivity (30%), fair specificity (75%), and low accuracy (63%, k = 0.1). Interestingly, advanced Fontan-associated liver disease was missed by ultrasound in 29% and by magnetic resonance elastography in 25% of patients. Advanced Fontan-associated liver disease was associated with lower platelet count (p = 0.02) and higher Gamma-glutamyl Transferase levels (p = 0.02). CONCLUSION Advanced hepatic fibrosis is common among paediatric Fontan patients. Non-invasive elastography may overestimate and underestimate the degree of liver fibrosis, and therefore, liver biopsy may be required for confirming disease severity.
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Affiliation(s)
- Ozlem P Bulut
- Division of Gastroenterology, Phoenix Children's Hospital, University of Arizona Phoenix, Phoenix, AZ, USA
| | - Smita S Bailey
- Division of Radiology, Phoenix Children's Hospital, University of Arizona Phoenix, Phoenix, AZ, USA
| | - Deepti P Bhat
- Division of Cardiology, Phoenix Children's Hospital, University of Arizona Phoenix, Phoenix, AZ, USA
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Hitawala AA, Gopalakrishna H, Mironova M, Livinski AA, Wright EC, Downing T, Ito S, Fisher SD, Cedars AM, John AS, Heller T. Meta-analysis: Incidence of cirrhosis and hepatocellular carcinoma in patients with Fontan palliation. Aliment Pharmacol Ther 2024; 59:1020-1032. [PMID: 38497159 DOI: 10.1111/apt.17952] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/10/2023] [Revised: 12/10/2023] [Accepted: 03/03/2024] [Indexed: 03/19/2024]
Abstract
BACKGROUND AND AIMS The Fontan palliation is the final stage of surgery for many children born with univentricular physiology. Almost all Fontan patients develop liver fibrosis which may eventually lead to cirrhosis and hepatocellular carcinoma (HCC). These are important causes of morbidity and mortality in these patients. We performed a systematic review and meta-analysis to assess the incidence of cirrhosis and HCC in Fontan patients and stratify it based on time since surgery. METHODS A literature search of seven databases identified 1158 records. Studies reporting the number of cirrhosis and HCC cases in Fontan patients and time since Fontan surgery were included. In the cirrhosis cohort, we included only those studies where all patients underwent liver biopsy. RESULTS A total of 23 studies were included: 12 and 13 studies in the cirrhosis and HCC cohorts, respectively, with two studies included in both cohorts. The incidence of cirrhosis was 0.97 per 100 patient-years (95% CI 0.57-1.63), with the incidence and cumulative incidence ≥20 years post Fontan surgery being 1.61 per 100 patient-years (95% CI 1.24-2.08) and 32.2% (95% CI 25.8%-39.4%), respectively. The incidence of HCC was 0.12 per 100 patient-years (95% CI 0.07-0.21), with the incidence and cumulative incidence ≥20 years post Fontan surgery being 0.20 per 100 patient-years (95% CI 0.12-0.35) and 3.9% (95% CI 2.2%-6.8%), respectively. Only about 70% of patients with HCC (20/28) had underlying cirrhosis. CONCLUSION The incidence of cirrhosis and HCC increases over time, especially at ≥20 years post Fontan surgery. Studies are needed to further identify at-risk patients in order to streamline surveillance for these highly morbid conditions.
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Affiliation(s)
- Asif A Hitawala
- Liver Disease Branch, National Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health, Bethesda, Maryland, USA
| | - Harish Gopalakrishna
- Liver Disease Branch, National Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health, Bethesda, Maryland, USA
| | - Maria Mironova
- Liver Disease Branch, National Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health, Bethesda, Maryland, USA
| | - Alicia A Livinski
- National Institutes of Health Library, Office of Research Services, Office of the Director, National Institutes of Health, Bethesda, Maryland, USA
| | - Elizabeth C Wright
- Office of the Director, National Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health, Bethesda, Maryland, USA
| | - Tacy Downing
- Division of Pediatric Cardiology, Children's National Hospital, Washington, DC, USA
| | - Seiji Ito
- Division of Pediatric Cardiology, Children's National Hospital, Washington, DC, USA
| | - Stacy D Fisher
- Adult Congenital Heart Disease Center, Johns Hopkins Heart and Vascular Institute, Baltimore, Maryland, USA
| | - Ari M Cedars
- Adult Congenital Heart Disease Center, Johns Hopkins Heart and Vascular Institute, Baltimore, Maryland, USA
| | - Anitha S John
- Division of Pediatric Cardiology, Children's National Hospital, Washington, DC, USA
| | - Theo Heller
- Translational Hepatology Section, Liver Disease Branch, National Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health, Bethesda, Maryland, USA
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Ohfuji S, Tanaka A, Kogiso T, Kanto T. Epidemiology of Fontan-associated liver disease in Japan: Results from a nationwide survey in 2021. Hepatol Res 2024. [PMID: 38526972 DOI: 10.1111/hepr.14040] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/04/2023] [Revised: 02/15/2024] [Accepted: 03/05/2024] [Indexed: 03/27/2024]
Abstract
AIM Although the Fontan procedure has improved the survival of patients with single-ventricle heart disease, the long-term consequences of the procedure have been a concern. This study aimed to explore the patients' postoperative clinical characteristics, including a diagnosis of Fontan-associated liver disease (FALD). METHODS A nationwide Japanese epidemiological survey of post-Fontan patients was undertaken in 2021. The survey targets were selected from all departments of pediatrics, pediatric surgery, cardiology, cardiovascular surgery, and gastroenterology using stratified random sampling by the number of beds. Each department was asked to complete a mail-back questionnaire on the numbers of patients and their clinical characteristics. The diagnosis of FALD was made by each attending physician. RESULTS The estimated number of post-Fontan patients was 7810 (95% confidence interval, 5430-10 200) in 2020, with a period prevalence of 61.9 per million. During the follow-up of 13.8 years after the Fontan procedure, 40% of patients were diagnosed with FALD. An elevated γ-glutamyl transpeptidase level was the most common finding leading to the FALD diagnosis (41%), and 45% of the patients also showed liver fibrosis. Compared with non-FALD patients, FALD patients were older, had longer duration since the Fontan procedure, and had more severe cardiac or liver conditions. However, more than half of the non-FALD patients had elevated liver enzyme levels, suggesting underestimation of the number of FALD patients. CONCLUSIONS In 2020, approximately 40% of post-Fontan patients underwent follow-up with a diagnosis of FALD, although the lack of established diagnostic criteria for FALD could affect the reported prevalence of FALD.
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Affiliation(s)
- Satoko Ohfuji
- Department of Public Health, Osaka Metropolitan University Graduate School of Medicine, Osaka, Japan
| | - Atsushi Tanaka
- Department of Medicine, Teikyo University School of Medicine, Tokyo, Japan
| | - Tomomi Kogiso
- Department of Internal Medicine and Gastroenterology, Tokyo Women's Medical University, Tokyo, Japan
| | - Tatsuya Kanto
- The Research Center for Hepatitis and Immunology, National Center for Global Health and Medicine, Ichikawa, Japan
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Heering G, Lebovics N, Agarwal R, Frishman WH, Lebovics E. Fontan-Associated Liver Disease: A Review. Cardiol Rev 2024:00045415-990000000-00231. [PMID: 38477576 DOI: 10.1097/crd.0000000000000684] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/14/2024]
Abstract
Fontan-associated liver disease (FALD) is a chronic complication of the Fontan procedure, a palliative surgery for patients with congenital heart disease that results in a single-ventricle circulation. The success of the Fontan procedure has led to a growing population of post-Fontan patients living well into adulthood. For this population, FALD is a major cause of morbidity and mortality. It encompasses a spectrum of hepatic abnormalities, ranging from mild fibrosis to cirrhosis and hepatocellular carcinoma. The pathophysiology of FALD is multifactorial, involving hemodynamic and inflammatory factors. The diagnosis and monitoring of FALD present many challenges. Conventional noninvasive tests that use liver stiffness as a surrogate marker of fibrosis are unreliable in FALD, where liver stiffness is also a result of congestion due to the Fontan circulation. Even invasive tissue sampling is inconsistent due to the patchy distribution of fibrosis. FALD is also associated with both benign and malignant liver lesions, which may exhibit similar imaging features. There is therefore a need for validated diagnostic and surveillance protocols to address these challenges. The definitive treatment of end-stage FALD is also a subject of controversy. Both isolated heart transplantation and combined heart-liver transplantation have been employed, with the latter becoming increasingly preferred in the US. This article reviews the current literature on the epidemiology, pathophysiology, diagnosis, and management of FALD, and highlights knowledge gaps that require further research.
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Affiliation(s)
- Gabriel Heering
- From the Department of Medicine, Westchester Medical Center/New York Medical College, Valhalla, NY
| | - Nachum Lebovics
- From the Department of Medicine, Westchester Medical Center/New York Medical College, Valhalla, NY
- Albert Einstein College of Medicine, Bronx, NY
| | - Raksheeth Agarwal
- From the Department of Medicine, Westchester Medical Center/New York Medical College, Valhalla, NY
- Internal Medicine at Jacobi Medical Center/Albert Einstein College of Medicine, Bronx, NY
| | - William H Frishman
- From the Department of Medicine, Westchester Medical Center/New York Medical College, Valhalla, NY
| | - Edward Lebovics
- From the Department of Medicine, Westchester Medical Center/New York Medical College, Valhalla, NY
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Brown MJ, Kolbe AB, Hull NC, Hilscher M, Kamath PS, Yalon M, Gu CN, Amawi ADT, Venkatesh SK, Wells ML. Imaging of Fontan-Associated Liver Disease. J Comput Assist Tomogr 2024; 48:1-11. [PMID: 37574655 DOI: 10.1097/rct.0000000000001533] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/15/2023]
Abstract
ABSTRACT The Fontan procedure is the definitive treatment for patients with single-ventricle physiology. Surgical advances have led to a growing number of patients surviving into adulthood. Fontan-associated liver disease (FALD) encompasses a spectrum of pathologic liver changes that occur secondary to altered physiology including congestion, fibrosis, and the development of liver masses. Assessment of FALD is difficult and relies on using imaging alongside of clinical, laboratory, and pathology information. Ultrasound, computed tomography, and magnetic resonance imaging are capable of demonstrating physiologic and hepatic parenchymal abnormalities commonly seen in FALD. Several novel imaging techniques including magnetic resonance elastography are under study for use as biomarkers for FALD progression. Imaging has a central role in detection and characterization of liver masses as benign or malignant. Benign FNH-like masses are commonly encountered; however, these can display atypical features and be mistaken for hepatocellular carcinoma (HCC). Fontan patients are at elevated risk for HCC, which is a feared complication and has a poor prognosis in this population. While imaging screening for HCC is widely advocated, no consensus has been reached regarding an optimal surveillance regimen.
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Affiliation(s)
- Mark J Brown
- From the Mayo Graduate School of Medicine: Mayo School of Graduate Medical Education
| | - Amy B Kolbe
- Department of Radiology, Mayo Clinic College of Medicine and Science, Mayo Clinic, Rochester, MN
| | - Nathan C Hull
- Department of Radiology, Mayo Clinic College of Medicine and Science, Mayo Clinic, Rochester, MN
| | - Moira Hilscher
- Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Patrick S Kamath
- Department of Gastroenterology and Hepatology, Mayo Clinic College of Medicine and Science, Mayo Clinic
| | | | - Chris N Gu
- Department of Radiology, Mayo Clinic College of Medicine and Science, Mayo Clinic, Rochester, MN
| | - Ali Dean T Amawi
- Department of Internal Medicine, NYC Health and Hospital/Lincoln Medical Center, New York City, NY
| | - Sudhakar K Venkatesh
- Department of Radiology, Mayo Clinic College of Medicine and Science, Mayo Clinic, Rochester, MN
| | - Michael L Wells
- Department of Radiology, Mayo Clinic College of Medicine and Science, Mayo Clinic, Rochester, MN
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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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de Lange C, Möller T, Hebelka H. Fontan-associated liver disease: Diagnosis, surveillance, and management. Front Pediatr 2023; 11:1100514. [PMID: 36937979 PMCID: PMC10020358 DOI: 10.3389/fped.2023.1100514] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/16/2022] [Accepted: 02/09/2023] [Indexed: 03/06/2023] Open
Abstract
The Fontan operation is a lifesaving procedure for patients with functional single-ventricle congenital heart disease, where hypoplastic left heart syndrome is the most frequent anomaly. Hemodynamic changes following Fontan circulation creation are now increasingly recognized to cause multiorgan affection, where the development of a chronic liver disease, Fontan-associated liver disease (FALD), is one of the most important morbidities. Virtually, all patients with a Fontan circulation develop liver congestion, resulting in fibrosis and cirrhosis, and most patients experience childhood onset. FALD is a distinctive type of congestive hepatopathy, and its pathogenesis is thought to be a multifactorial process driven by increased nonpulsatile central venous pressure and decreased cardiac output, both of which are inherent in the Fontan circulation. In the advanced stage of liver injury, complications of portal hypertension often occur, and there is a risk of developing secondary liver cancer, reported at young age. However, FALD develops with few clinical symptoms, a surprisingly variable degree of severity in liver disease, and with little relation to poor cardiac function. The disease mechanisms and modifying factors of its development are still not fully understood. As one of the more important noncardiac complications of the Fontan circulation, FALD needs to be diagnosed in a timely manner with a structured monitoring scheme of disease development, early detection of malignancy, and determination of the optimal time point for transplantation. There is also a clear need for consensus on the best surveillance strategy for FALD. In this regard, imaging plays an important role together with clinical scoring systems, biochemical workups, and histology. Patients operated on with a Fontan circulation are generally followed up in cardiology units. Ultimately, the resulting multiorgan affection requires a multidisciplinary team of healthcare personnel to address the different organ complications. This article discusses the current concepts, diagnosis, and management of FALD, with special emphasis on the role of different imaging techniques in the diagnosis and monitoring of disease progression, as well as current recommendations for liver disease surveillance.
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Affiliation(s)
- Charlotte de Lange
- Department of Pediatric Radiology, Queen Silvia Children’s Hospital, Sahlgrenska University Hospital, Gothenburg, Sweden
- Institution of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Thomas Möller
- Department of Pediatric Cardiology, Oslo University Hospital, Oslo, Norway
| | - Hanna Hebelka
- Department of Pediatric Radiology, Queen Silvia Children’s Hospital, Sahlgrenska University Hospital, Gothenburg, Sweden
- Institution of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
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10
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Chaloupecký V, Jičínská D, Tomek V, Materna O, Gebauer R, Poruban R, Antonová P, Adla T, Štefánek M, Illinger V, Kotaška K, Janoušek J. Impact of liver fibrosis and nodules formation on hemodynamics in young adults after total cavopulmonary connection. A magnetic resonance study. Front Cardiovasc Med 2022; 9:986653. [PMID: 36247450 PMCID: PMC9558211 DOI: 10.3389/fcvm.2022.986653] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2022] [Accepted: 09/08/2022] [Indexed: 11/15/2022] Open
Abstract
Background The aim of this study was to analyze the relation between the hepatic fibrosis markers, liver morphology and hemodynamics assessed by magnetic resonance imaging (MRI) after total cavopulmonary connection (TCPC). Materials and methods Adult patients after TCPC performed in childhood between 1993 and 2003 are the subjects of this observational study. The follow-up protocol consisted of clinical and echocardiographic examination, liver elastography, cardiopulmonary exercise test, MRI hemodynamics and liver morphology assessment and direct enhanced liver fibrosis (ELF) test. Results The cohort consisted of 39 patients (46% female) with a median age at study 26 (IQR 23–28) years and interval from TCPC 21 (IQR 20–23) years. There was no correlation between ELF test and any MRI variables, but procollagen III amino-terminal peptide (PIIINP), a single component of ELF test, correlated significantly with ventricular end-diastolic volume (r = 0.33; p = 0.042) and inferior vena cava flow (r = 0.47; p = 0.003). Fifteen (38%) patients with liver nodules had compared to other 24 patients higher end-diastolic volume (ml/m2) 102.8 ± 20.0 vs. 88.2 ± 17.7; p = 0.023, respectively. PIIINP correlated significantly with inferior vena cava flow (r = 0.56; p = 0.030) and with end-diastolic volume (r = 0.53; p = 0.043), but only in patients with liver nodules. Conclusion Gradual progression of liver fibrosis, particularly hepatic arterialization caused by liver nodules formation, increases inferior vena cava flow and subsequent ventricular volume overload may further compromise single ventricle functional reserve in adult patients after TCPC.
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Affiliation(s)
- Václav Chaloupecký
- Children’s Heart Centre, Second Faculty of Medicine, Charles University in Prague and Motol University Hospital, Prague, Czechia
- *Correspondence: Václav Chaloupecký,
| | - Denisa Jičínská
- Children’s Heart Centre, Second Faculty of Medicine, Charles University in Prague and Motol University Hospital, Prague, Czechia
| | - Viktor Tomek
- Children’s Heart Centre, Second Faculty of Medicine, Charles University in Prague and Motol University Hospital, Prague, Czechia
| | - Ondřej Materna
- Children’s Heart Centre, Second Faculty of Medicine, Charles University in Prague and Motol University Hospital, Prague, Czechia
| | - Roman Gebauer
- Children’s Heart Centre, Second Faculty of Medicine, Charles University in Prague and Motol University Hospital, Prague, Czechia
| | - Rudolf Poruban
- Children’s Heart Centre, Second Faculty of Medicine, Charles University in Prague and Motol University Hospital, Prague, Czechia
| | - Petra Antonová
- Department of Cardiovascular Surgery, Second Faculty of Medicine, Charles University in Prague and Motol University Hospital, Prague, Czechia
| | - Theodor Adla
- Department of Radiology, Second Faculty of Medicine, Charles University in Prague and Motol University Hospital, Prague, Czechia
| | - Matěj Štefánek
- Department of Radiology, Second Faculty of Medicine, Charles University in Prague and Motol University Hospital, Prague, Czechia
| | - Vojtěch Illinger
- Department of Rehabilitation and Sports Medicine, Second Faculty of Medicine, Charles University in Prague and Motol University Hospital, Prague, Czechia
| | - Karel Kotaška
- Department of Medical Chemistry and Clinical Biochemistry, Second Faculty of Medicine, Charles University in Prague and Motol University Hospital, Prague, Czechia
| | - Jan Janoušek
- Children’s Heart Centre, Second Faculty of Medicine, Charles University in Prague and Motol University Hospital, Prague, Czechia
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Application of alkaline phosphatase‑to‑platelet ratio as a novel noninvasive index predicts liver fibrosis in patients with chronic hepatitis B. Exp Ther Med 2022; 24:619. [PMID: 36160889 PMCID: PMC9468833 DOI: 10.3892/etm.2022.11556] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2022] [Accepted: 07/13/2022] [Indexed: 11/23/2022] Open
Abstract
Assessment of the extent of liver fibrosis is a crucial requirement for the design of antiviral treatments for patients with chronic hepatitis B (CHB). Several non-invasive predictive indices have been developed as potential alternatives to liver biopsy for fibrosis assessment. The present study aimed to establish a novel non-invasive method for predicting liver fibrosis in patients with CHB. A total of 382 patients with CHB who underwent liver biopsy and pathological examination at The Second Hospital of Anhui Medical University (Hefei, China) were enrolled into the present study. Liver fibrosis was assessed according to the meta-analysis of histological data in viral hepatitis scoring system. Logistic regression analyses were performed to explore possibly significant characteristics associated with liver fibrosis. In addition, potential correlations between the alkaline phosphatase (AKP)-to-platelet count (PLT) ratio (APPR) and the aspartate transaminase-to-platelet ratio index (APRI), fibrosis index based on four factors (FIB-4) and γ-glutamyl transpeptidase-to-platelet ratio (GPR) were assessed using Spearman's correlation analysis. Subsequently, the performance of APPR was compared with APRI, FIB-4 and GPR using receiver operating characteristic (ROC) analysis. Logistic regression analysis identified AKP and PLT to be significant independent predictors of fibrosis. Therefore, an index was then constructed for predicting the degree of fibrosis, which was expressed using the formula APPR=AKP (IU/ml)/PLT (1x109/l). APPR was found to be positively associated with the fibrotic stage of the liver in addition to being positively correlated with APRI, FIB-4 and GPR. The area under the ROC curve (AUROC) values of APPR were also significantly higher compared with those of APRI and FIB-4 in predicting significant fibrosis but were equal to those of GPR. However, for advanced fibrosis and cirrhosis, the AUROC value of APPR was shown to be higher compared with that of APRI, FIB-4 and GPR. In conclusion, these observations suggest that APPR is a viable marker that can be used to assess liver fibrosis in patients with CHB.
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Restaino K, Maeda K. Commentary: The future for the adult Fontan … what to see in the liver? J Thorac Cardiovasc Surg 2022; 164:1186-1187. [DOI: 10.1016/j.jtcvs.2022.01.023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/14/2022] [Revised: 01/14/2022] [Accepted: 01/18/2022] [Indexed: 11/30/2022]
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