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Brosig S, Wagner R, Twal R, Meier S, Vollroth M, Markel F, Dähnert I, Kostelka M, Paech C. "Quality of life" analysis in the long-term follow-up after "Fontan" palliation for CHDs-a single-centre experience. Cardiol Young 2024:1-13. [PMID: 38287708 DOI: 10.1017/s1047951123004547] [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: 01/31/2024]
Abstract
BACKGROUND Complex CHDs are life threatening, and surgical treatment is needed for survival. Fontan palliation led to a significant increase in survival rates during the last decades. Consequently, quality of life became more essential. While a reduced quality of life compared to healthy children has been reported, detailed knowledge about individual quality of life and particular areas is lacking. Furthermore, the effect of different risk factors on quality of life is only rarely evaluated. METHOD AND RESULTS Database of the department for pediatric cardiology, Heart Center Leipzig, was screened for children after total cavopulmonary connection palliation. n = 39 patients were included in the study, the outcome after total cavopulmonary connection was analysed in detail and quality of life data were collected and analysed using the standardised questionnaire "Pediatric quality of life inventory", version 4.0. We compared the total health score of our patients to the mean score of healthy children in the literature. The mean follow-up time was 6.4 ± 3.2 years, the overall survival was 100% after maximal follow-up time of 11.1 years. We could not find any age or gender dependence, nor an influence of age at total cavopulmonary connection on the later quality of life. Yet, patients with three-staged surgery exhibited a worse quality of life than patients with two-staged palliation. Late complications might influence quality of life, but patient number is too small, to find universal results. CONCLUSION The total cavopulmonary connection palliation affects physical and psychological quality of life as well as cardiac health independently from age and gender. More patients and longer observation should be examined to confirm the results.
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Affiliation(s)
- Susann Brosig
- Department of Pediatric Cardiology, Heart Center Leipzig, University Leipzig, Leipzig, Germany
| | - Robert Wagner
- Medical Practice Pediatric Cardiology, Leipzig, Germany
| | - Rabie Twal
- Department of Pediatric Cardiology, Heart Center Leipzig, University Leipzig, Leipzig, Germany
| | - Sabine Meier
- Department of Pediatric Cardiology, Heart Center Leipzig, University Leipzig, Leipzig, Germany
| | - Marcel Vollroth
- Department of Pediatric Cardiology, Heart Center Leipzig, University Leipzig, Leipzig, Germany
| | - Franziska Markel
- Department of Pediatric Cardiology, Heart Center Leipzig, University Leipzig, Leipzig, Germany
| | - Ingo Dähnert
- Department of Pediatric Cardiology, Heart Center Leipzig, University Leipzig, Leipzig, Germany
| | - Martin Kostelka
- Department of Pediatric Cardiology, Heart Center Leipzig, University Leipzig, Leipzig, Germany
| | - Christian Paech
- Department of Pediatric Cardiology, Heart Center Leipzig, University Leipzig, Leipzig, Germany
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Aly S, Mertens L, Friedberg MK, Dragulescu A. Longitudinal Changes in Ventricular Mechanics in Adolescents After the Fontan Operation. J Am Soc Echocardiogr 2023; 36:998-1007. [PMID: 37236378 DOI: 10.1016/j.echo.2023.04.021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/12/2022] [Revised: 04/19/2023] [Accepted: 04/24/2023] [Indexed: 05/28/2023]
Abstract
BACKGROUND Ventricular dysfunction is a significant clinical challenge in the long-term follow-up of patients with single-ventricle (SV) physiology. Ventricular function and myocardial mechanics can be studied using speckle-tracking echocardiography, which provides information on myocardial deformation. Limited information is available on serial changes in SV myocardial mechanics after the Fontan operation. The aim of this study was to describe serial changes in myocardial mechanics in children after the Fontan operation and the relationship of these changes with myocardial fibrosis markers as obtained by cardiac magnetic resonance and exercise performance parameters. METHODS The authors hypothesized that ventricular mechanics decline in patients with SVs over time and are associated with increased myocardial fibrosis and reduced exercise performance. A single-center retrospective cohort study including adolescents after the Fontan operation was conducted. Ventricular strain and torsion were assessed using speckle-tracking echocardiography. Cardiac magnetic resonance and cardiopulmonary exercise testing data closest to the latest echocardiographic examinations were performed. The most recent follow-up echocardiographic and cardiac magnetic resonance data were compared with those from sex- and age-matched control subjects and with individual patients' early post-Fontan data. RESULTS Fifty patients with SVs (31 left ventricle, 13 right ventricle [RV], and six codominant) were included. Median time at follow-up echocardiography from the time of Fontan was 12.8 years (interquartile range [IQR], 10.6 to 16.6 years). Compared with early post-Fontan echocardiography, follow-up assessment showed reduced global longitudinal strain (-17.5% [IQR, -14.5% to -19.5%] vs -19.8% [IQR, -16.0% to -21.7%], P = .01], circumferential strain (-15.7% [IQR, -11.4% to -18.7%] vs -18.9% [IQR, -15.2% to -25.0%], P = .009), and torsion (1.28°/cm [IQR, 0.51°/cm to 1.74°/cm] vs 1.72°/cm [IQR, 0.92°/cm to 2.34°/cm], P = .02), with decreased apical rotation but no significant change in basal rotation. Single RVs had lower torsion compared with single left ventricles (1.04°/cm [IQR, 0.12°/cm to 2.20°/cm] vs 1.25°/cm [IQR, 0.25°/cm to 2.51°/cm], P = .01). T1 values were higher in patients with SV compared with control subjects (1,009 ± 36 vs 958 ± 40 msec, P = .004) and in those with single RVs compared with single left ventricles (1,023 ± 19 vs 1,006 ± 17 msec, P = .02). T1 was correlated with circumferential strain (r = 0.59, P = .04) and inversely correlated with O2 saturation (r = -0.67, P < .001) and torsion (r = -0.71, P = .02). Peak oxygen consumption was correlated with torsion (r = 0.52, P = .001) and untwist rates (r = 0.23, P = .03). CONCLUSIONS After the Fontan procedures, there is a progressive decrease in myocardial deformation parameters. The progressive decrease in SV torsion is related to a decrease in apical rotation, which is more pronounced in single RVs. Decreased torsion is associated with increased markers of myocardial fibrosis and lower maximal exercise capacity. Torsional mechanics may be an important parameter to monitor after Fontan palliation, but further prognostic information is required.
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Affiliation(s)
- Safwat Aly
- Division of Cardiology, Department of Pediatrics, The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada; Division of Cardiac Imaging, Department of Cardiology, Boston Children's Hospital, Boston, Massachusetts.
| | - Luc Mertens
- Division of Cardiology, Department of Pediatrics, The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
| | - Mark K Friedberg
- Division of Cardiology, Department of Pediatrics, The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
| | - Andreea Dragulescu
- Division of Cardiology, Department of Pediatrics, The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
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Lin HC, Huang SC, Wu MH, Wang JK, Lin MT, Chen CA, Lu CW, Chen YS, Chiu SN. Preoperative N-terminal pro-brain natriuretic peptide is associated with Fontan outcomes. J Thorac Cardiovasc Surg 2022; 164:770-780.e3. [PMID: 35031137 DOI: 10.1016/j.jtcvs.2021.11.082] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/11/2021] [Revised: 11/20/2021] [Accepted: 11/30/2021] [Indexed: 11/25/2022]
Abstract
OBJECTIVE The role of preoperative N-terminal pro-brain natriuretic peptide level in patient outcomes after the Fontan operation remains unclear. METHODS The medical records of all patients who underwent their first Fontan operation from June 2011 to October 2019 in our tertiary referral pediatric cardiac center were retrospectively reviewed. Preoperative hemodynamic factors and N-terminal pro-brain natriuretic peptide were analyzed to test the association of mortality and morbidity. RESULTS We enrolled 110 patients (men/women 62/48; median age, 4.1 [3.4, 5.8] years; median follow-up period, 4.28 [2.31, 6.71] years). Almost all operations were extracardiac conduits (98.2%). Primary outcomes of death, Fontan takedown, and heart transplantation were observed in 9 patients (8.2%). Abnormal ventricular contractility, elevated preoperative pulmonary artery pressure, high pulmonary vascular resistance index, and high log10 N-terminal pro-brain natriuretic peptide level were associated with poor outcomes. SECONDARY OUTCOMES atrioventricular valve regurgitation moderate or greater, elevated pulmonary artery pressure, high pulmonary vascular resistance index, and high log10 N-terminal pro-brain natriuretic peptide level were associated with rehospitalization due to heart failure. Multivariable Cox regression analysis revealed that log10 N-terminal pro-brain natriuretic peptide was the only significant predictor of all primary and secondary outcomes. A scoring system including factors of pulmonary artery pressure, pulmonary vascular resistance index, and N-terminal pro-brain natriuretic peptide was established, and the risk stratification is associated with outcomes after the Fontan operation. CONCLUSIONS High preoperative N-terminal pro-brain natriuretic peptide was associated with poor outcomes after the Fontan operation.
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Affiliation(s)
- Hsin-Chia Lin
- Graduate Institute of Clinical Medicine, National Taiwan University College of Medicine, Taipei, Taiwan; Department of Pediatrics, National Taiwan University Hospital Yunlin Branch, Yunlin, Taiwan; Department of Pediatrics, National Taiwan University Children's Hospital, Taipei, Taiwan
| | - Shu-Chien Huang
- Department of Cardiovascular Surgery, National Taiwan University Hospital, Taipei, Taiwan
| | - Mei-Hwan Wu
- Department of Pediatrics, National Taiwan University Children's Hospital, Taipei, Taiwan
| | - Jou-Kou Wang
- Department of Pediatrics, National Taiwan University Children's Hospital, Taipei, Taiwan
| | - Ming-Tai Lin
- Department of Pediatrics, National Taiwan University Children's Hospital, Taipei, Taiwan
| | - Chun-An Chen
- Department of Pediatrics, National Taiwan University Children's Hospital, Taipei, Taiwan
| | - Chun-Wei Lu
- Department of Pediatrics, National Taiwan University Children's Hospital, Taipei, Taiwan
| | - Yih-Sharng Chen
- Department of Cardiovascular Surgery, National Taiwan University Hospital, Taipei, Taiwan
| | - Shuenn-Nan Chiu
- Department of Pediatrics, National Taiwan University Children's Hospital, Taipei, Taiwan.
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Malankar DP, Mali S, Dhake S, Mhatre A, Bind D, Soni B, Kandavel D, Raj J, Patel P, Garekar S. Fontan procedure on deep hypothermic circulatory arrest: Short-term results and technique. Ann Pediatr Cardiol 2022; 15:238-243. [PMID: 36589646 PMCID: PMC9802610 DOI: 10.4103/apc.apc_158_21] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/06/2021] [Revised: 09/12/2021] [Accepted: 04/05/2022] [Indexed: 11/17/2022] Open
Abstract
Background Various operative strategies are described for the Fontan procedure. In this study, we describe our short-term results and technique of Fontan procedure on cardiopulmonary bypass (CPB) and deep hypothermic circulatory arrest (DHCA). Methods This was a retrospective study of 32 patients, median age of 6 years (4-19 years) and median weight of 20 kg (13-51 kg), who underwent Fontan procedure on CPB and DHCA from July 2016 to July 2021. Results The median CPB time was 125 min (77-186 min), the median DHCA time was 42 min (27-50 min), and the median Fontan pressure was 14 mmHg (10-18 mmHg). The median time to extubation was 4 h (1-20 h), the duration of chest tube drainage was 8 days (5-24 days), and the median intensive care unit stay was 4 days (3-8 days). The presence of heterotaxy was associated with longer duration of pleural drainage (P = 0.01). There was no operative mortality and no major adverse events such as seizures, gross neurological deficits, or arrhythmias in the postoperative period. Conclusions Fontan procedure can be safely performed on CPB and DHCA with good operative results. This operative strategy may be used in special circumstances like in patients with situs and systemic venous anomalies and those requiring repair of a complex intracardiac defect. Long-term follow-up will be required to evaluate if this strategy has any impact on the neurodevelopmental outcome and the long-term sequelae of Fontan.
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Affiliation(s)
- Dhananjay P Malankar
- Department of Paediatric Cardiac Surgery, Fortis Paediatric and Congenital Heart Centre, Mumbai, Maharashtra, India
| | - Shivaji Mali
- Department of Paediatric Cardiac Anaesthesia and Critical Care, Fortis Paediatric and Congenital Heart Centre, Mumbai, Maharashtra, India
| | - Shyam Dhake
- Department of Paediatric Cardiac Anaesthesia and Critical Care, Fortis Paediatric and Congenital Heart Centre, Mumbai, Maharashtra, India
| | - Amit Mhatre
- Department of Paediatric Cardiac Anaesthesia and Critical Care, Fortis Paediatric and Congenital Heart Centre, Mumbai, Maharashtra, India
| | - Dilip Bind
- Department of Paediatric Cardiac Anaesthesia and Critical Care, Fortis Paediatric and Congenital Heart Centre, Mumbai, Maharashtra, India
| | - Bharat Soni
- Department of Paediatric Cardiac Surgery, Fortis Paediatric and Congenital Heart Centre, Mumbai, Maharashtra, India
| | - Dinesh Kandavel
- Department of Paediatric Cardiac Surgery, Fortis Paediatric and Congenital Heart Centre, Mumbai, Maharashtra, India
| | - Jinil Raj
- Department of Perfusion Technology, Fortis Paediatric and Congenital Heart Centre, Mumbai, Maharashtra, India
| | - Parvez Patel
- Department of Paediatric Cardiology, Fortis Paediatric and Congenital Heart Centre, Mumbai, Maharashtra, India
| | - Swati Garekar
- Department of Paediatric Cardiology, Fortis Paediatric and Congenital Heart Centre, Mumbai, Maharashtra, India
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Rao PS. Single Ventricle-A Comprehensive Review. CHILDREN (BASEL, SWITZERLAND) 2021; 8:441. [PMID: 34073809 PMCID: PMC8225092 DOI: 10.3390/children8060441] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/28/2021] [Revised: 05/20/2021] [Accepted: 05/21/2021] [Indexed: 02/06/2023]
Abstract
In this paper, the author enumerates cardiac defects with a functionally single ventricle, summarizes single ventricle physiology, presents a summary of management strategies to address the single ventricle defects, goes over the steps of staged total cavo-pulmonary connection, cites the prevalence of inter-stage mortality, names the causes of inter-stage mortality, discusses strategies to address the inter-stage mortality, reviews post-Fontan issues, and introduces alternative approaches to Fontan circulation.
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Affiliation(s)
- P Syamasundar Rao
- McGovern Medical School, University of Texas-Houston, Children's Memorial Hermann Hospital, 6410 Fannin Street, UTPB Suite # 425, Houston, TX 77030, USA
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Aoki M, Hirono K, Higuma T, Suzuki Y, Nakayama K, Ichida F, Origasa H, Nishida N, Imura J, Emoto N, Yoshimura N. Endothelin-1 may play an important role in the Fontan circulation. Interact Cardiovasc Thorac Surg 2018; 26:480-486. [PMID: 29177420 DOI: 10.1093/icvts/ivx378] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2017] [Accepted: 10/19/2017] [Indexed: 11/14/2022] Open
Abstract
OBJECTIVES Our goal was to evaluate whether endothlin-1 (ET-1) plays an important role in the Fontan circulation. METHODS Thirteen patients with single-ventricle physiology (Glenn circulation, n = 7; Fontan circulation, n = 6) were evaluated using lung histopathological and immunohistochemical studies and then compared with the normal autopsied controls without congenital heart disease (n = 13). We evaluated the medial thickness of the small pulmonary arteries. For 10 of these patients, quantitative real-time polymerase chain reaction analyses of ET-1, endothelin receptors Type A and Type B, endothelin-converting enzyme-1 and endothelial nitric oxide synthase were performed. RESULTS The medial thickness of the small pulmonary arteries in patients with single-ventricle physiology was greater than that of those in the control group (P = 0.0341). Severe medial hypertrophy of the pulmonary arteries was observed in patients who had poor outcomes. Immunohistochemical studies revealed that the marked expression of ET-1 was observed in the endothelium and media of their pulmonary arteries. In these patients, the messenger RNA expression of ET-1 was also increased. Two patients showed high levels of expression of ETAR and ETBR, although these 2 cases maintain good Fontan circulation. CONCLUSIONS Medial hypertrophy and the overexpression of ET-1 in the pulmonary arteries were observed in some patients in whom the Fontan circulation failed. Our data suggest that ET-1 may play an important role in maintaining the Fontan circulation.
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Affiliation(s)
- Masaya Aoki
- Department of Cardiovascular Surgery, University of Toyama, Toyama, Japan
| | - Keiichi Hirono
- Department of Pediatrics, University of Toyama, Toyama, Japan
| | - Tomonori Higuma
- Department of Cardiovascular Surgery, University of Toyama, Toyama, Japan
| | - Yoko Suzuki
- Department of Clinical Pharmacy, Kobe Pharmaceutical University, Kobe, Japan
| | - Kazuhiko Nakayama
- Department of Clinical Pharmacy, Kobe Pharmaceutical University, Kobe, Japan
| | - Fukiko Ichida
- Department of Pediatrics, University of Toyama, Toyama, Japan
| | - Hideki Origasa
- Division of Biostatistics and Clinical Epidemiology, University of Toyama, Toyama, Japan
| | - Naoki Nishida
- Department of Legal Medicine, University of Toyama, Toyama, Japan
| | - Johji Imura
- Department of Diagnostic Pathology, University of Toyama, Toyama, Japan
| | - Noriaki Emoto
- Department of Clinical Pharmacy, Kobe Pharmaceutical University, Kobe, Japan
| | - Naoki Yoshimura
- Department of Cardiovascular Surgery, University of Toyama, Toyama, Japan
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Nordmeyer S, Rohder M, Nordmeyer J, Miera O, Peters B, Cho MY, Photiadis J, Berger F, Ovroutski S. Systemic right ventricular morphology in the early postoperative course after extracardiac Fontan operation: is there still a need for special care? Eur J Cardiothorac Surg 2017; 51:483-489. [PMID: 28007868 DOI: 10.1093/ejcts/ezw374] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/13/2016] [Accepted: 10/10/2016] [Indexed: 11/14/2022] Open
Abstract
Objectives We aimed to compare early postoperative outcome after extracardiac (EC) Fontan operation between patients with right (RV) or left (LV) systemic ventricles. Methods In total, 173 consecutive patients (median age 4 years, median weight 14 kg) underwent EC Fontan between 1995 and 2013. Pre- and intraoperative data as well as detailed postoperative haemodynamic variables were compared between patients with LV [ n = 109 (63%)] and RV [ n = 64 (37%)]. Results : RV patients showed significantly lower mean arterial (median 55 vs 59 mmHg, P = 0.04), higher atrial (median 8 vs 6 mmHg, P = 0.03) and comparable pulmonary pressure (median 14 vs 14 mmHg, P = 0.7) as well as lower mean systemic perfusion pressure (median 39 vs 43 mmHg, P = 0.03) on Day 0 after EC Fontan. They suffered from longer intubation time (median 18 vs 12 h, P = 0.008), higher incidence of ascites (46% vs 28%, P = 0.04) and need for dialysis (21% vs 4%, P = 0.003). Prolonged inotropic support (25% vs 8%, P = 0.02) and pharmacological treatment to reduce pulmonary vascular resistance (71% vs 53%, P = 0.002) were more often used in RV patients and they showed more often supraventricular tachyarrhythmia (27% vs 5%, P < 0.001) and a longer intensive care unit-stay (median 4 vs 3 days, P = 0.03). However, early mortality, need for Fontan takedown, use of mechanical circulatory support, pleural effusions and hospital stay were not significantly different between both groups. Conclusions Patients with systemic RV demonstrate higher morbidity in the early postoperative course compared with patients with systemic LV anatomy and require intensified postoperative management to avoid postoperative Fontan failure.
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Affiliation(s)
- Sarah Nordmeyer
- Department of Congenital Heart Disease and Paediatric Cardiology, Deutsches Herzzentrum Berlin, Berlin, Germany
| | - Melanie Rohder
- Department of Congenital Heart Disease and Paediatric Cardiology, Deutsches Herzzentrum Berlin, Berlin, Germany
| | - Johannes Nordmeyer
- Department of Congenital Heart Disease and Paediatric Cardiology, Deutsches Herzzentrum Berlin, Berlin, Germany
| | - Oliver Miera
- Department of Congenital Heart Disease and Paediatric Cardiology, Deutsches Herzzentrum Berlin, Berlin, Germany
| | - Björn Peters
- Department of Congenital Heart Disease and Paediatric Cardiology, Deutsches Herzzentrum Berlin, Berlin, Germany
| | - Mi-Young Cho
- Department of Surgery for Congenital Heart Disease/Paediatric Cardiac Surgery, Deutsches Herzzentrum Berlin, Berlin, Germany
| | - Joachim Photiadis
- Department of Surgery for Congenital Heart Disease/Paediatric Cardiac Surgery, Deutsches Herzzentrum Berlin, Berlin, Germany
| | - Felix Berger
- Department of Congenital Heart Disease and Paediatric Cardiology, Deutsches Herzzentrum Berlin, Berlin, Germany
| | - Stanislav Ovroutski
- Department of Congenital Heart Disease and Paediatric Cardiology, Deutsches Herzzentrum Berlin, Berlin, Germany
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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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Fontan Operation: Indications, Short and Long Term Outcomes. Indian J Pediatr 2015; 82:1147-56. [PMID: 26088549 DOI: 10.1007/s12098-015-1803-6] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/19/2015] [Accepted: 05/25/2015] [Indexed: 10/23/2022]
Abstract
Fontan operation, since its original description, has undergone a number of modifications so that it is now a staged, total cavo-pulmonary connection with fenestration. Stage I is palliation, depending upon the pathophysiology of the defect complex in early life, Stage II is bidirectional Glenn at about the age of 6 mo and Stage III is transfer of inferior vena caval blood to the pulmonary circuit along with fenestration between 2 to 4 y. Any patient that has only one functioning ventricle is a candidate for Fontan surgery. The morbidity and mortality have remarkably improved since the institution of staged, total cavo-pulmonary connection with fenestration. Complications during follow up continue to occur, though diminished with the newer modifications, and should be promptly addressed.
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Zhong SW, Zhang YQ, Chen LJ, Wang SS, Li WH, Sun YJ. Ventricular Twisting and Dyssynchrony in Children with Single Left Ventricle Using Three-Dimensional Speckle Tracking Imaging after the Fontan Operation. Echocardiography 2015; 33:606-17. [DOI: 10.1111/echo.13103] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Affiliation(s)
- Shu-Wen Zhong
- Department of Pediatrics; Shanghai Children's Medical Center; Shanghai Jiaotong University School of Medicine; Shanghai China
| | - Yu-Qi Zhang
- Department of Pediatric Cardiology; Shanghai Children's Medical Center; Shanghai Jiaotong University School of Medicine; Shanghai China
| | - Li-Jun Chen
- Department of Pediatric Cardiology; Shanghai Children's Medical Center; Shanghai Jiaotong University School of Medicine; Shanghai China
| | - Shan-Shan Wang
- Department of Pediatrics; Shanghai Children's Medical Center; Shanghai Jiaotong University School of Medicine; Shanghai China
| | - Wei-Hua Li
- Department of Pediatrics; Shanghai Children's Medical Center; Shanghai Jiaotong University School of Medicine; Shanghai China
| | - Yan-Jun Sun
- Department of Pediatric Thoracic and Cardiovascular Surgery; Shanghai Children's Medical Center; Shanghai Jiaotong University School of Medicine; Shanghai China
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11
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Liu VJ, Yong MS, d’Udekem Y, Weintraub RG, Praporski S, Brizard CP, Konstantinov IE. Outcomes of Atrioventricular Valve Operation in Patients With Fontan Circulation. Ann Thorac Surg 2015; 99:1632-8. [DOI: 10.1016/j.athoracsur.2015.01.035] [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: 12/01/2014] [Revised: 12/27/2014] [Accepted: 01/06/2015] [Indexed: 10/23/2022]
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12
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Podzolkov VP, Chiaureli MR, Yurlov IA, Zelenikin MM, Kovalev DV, Dontsova VI, Astrakhantseva TO, Putiato NA, Zaets SB. Results of Fontan operation in patients with atrioventricular valve regurgitation. Eur J Cardiothorac Surg 2014; 48:308-14; discussion 314-5. [DOI: 10.1093/ejcts/ezu489] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/15/2014] [Accepted: 10/24/2014] [Indexed: 11/14/2022] Open
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13
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Schlangen J, Petko C, Hansen JH, Michel M, Hart C, Uebing A, Fischer G, Becker K, Kramer HH. Two-dimensional global longitudinal strain rate is a preload independent index of systemic right ventricular contractility in hypoplastic left heart syndrome patients after Fontan operation. Circ Cardiovasc Imaging 2014; 7:880-6. [PMID: 25270741 DOI: 10.1161/circimaging.114.002110] [Citation(s) in RCA: 49] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Assessment of systemic right ventricular (RV) function in patients with hypoplastic left heart syndrome is important during long-term follow-up after Fontan repair. Traditional echocardiographic parameters to evaluate systolic ventricular function are affected by loading conditions. The only generally accepted load-independent parameter of systolic function, end systolic elastance (Ees), requires invasive catheterization. Therefore, we sought to determine if parameters obtained by 2-dimensional speckle tracking (2DST) were affected by acute changes in preload and correlated with catheterization-derived indices of RV contractility in hypoplastic left heart syndrome patients after Fontan palliation. METHODS AND RESULTS Fifty-two patients with hypoplastic left heart syndrome (median age, 6.6; range 2.9-22.2 years) were prospectively enrolled to have echocardiography and conductance catheter studies performed simultaneously. We compared traditional echo, 2-dimensional speckle tracking and catheterization-derived parameters during different states of preload at baseline and during dobutamine infusion. Global longitudinal strain (S) showed a tendency to decrease with preload reduction, whereas global longitudinal strain rate (SR) did not change (S: -17.7 ± 3.4% versus -16.9 ± 3.8%, P=0.08; SR: -1.30 ± 0.29 versus -1.34 ± 0.34 s(-1), P=0.3). S did not change with dobutamine infusion (-17.7 ± 3.4% versus -18.4 ± 3.9%, P=0.24), whereas SR increased significantly (-1.30 ± 0.29 versus -2.26 ± 0.49 s(-1), P<0.001). RV Ees correlated with SR (rs= -0.47, P<0.001), but not with S (rs=0.07, P=0.5) or other echocardiographic parameters. CONCLUSIONS In contrast to S, SR was not affected by preload and correlated with Ees of the systemic RV. SR may be a useful noninvasive surrogate of RV contractility and suitable for follow-up of patients with hypoplastic left heart syndrome after Fontan palliation.
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Affiliation(s)
- Jana Schlangen
- From the Department for Congenital Heart Disease and Paediatric Cardiology, University Hospital of Schleswig-Holstein, Campus Kiel, Kiel, Germany (J.S., C.P., J.H.H., M.M., C.H., G.F., K.B., H.-H.K.); Department of Pediatric, Fetal and Congenital Cardiology, Hawaii Permanente Medical Group, Kaiser Permanente Moanalua Medical Center, Honolulu, HI (C.P.); and Adult Congenital Heart Disease Centre and National Centre for Pulmonary Hypertension, Royal Brompton and Harefield NHS Foundation Trust, London, United Kingdom (A.U.).
| | - Colin Petko
- From the Department for Congenital Heart Disease and Paediatric Cardiology, University Hospital of Schleswig-Holstein, Campus Kiel, Kiel, Germany (J.S., C.P., J.H.H., M.M., C.H., G.F., K.B., H.-H.K.); Department of Pediatric, Fetal and Congenital Cardiology, Hawaii Permanente Medical Group, Kaiser Permanente Moanalua Medical Center, Honolulu, HI (C.P.); and Adult Congenital Heart Disease Centre and National Centre for Pulmonary Hypertension, Royal Brompton and Harefield NHS Foundation Trust, London, United Kingdom (A.U.)
| | - Jan H Hansen
- From the Department for Congenital Heart Disease and Paediatric Cardiology, University Hospital of Schleswig-Holstein, Campus Kiel, Kiel, Germany (J.S., C.P., J.H.H., M.M., C.H., G.F., K.B., H.-H.K.); Department of Pediatric, Fetal and Congenital Cardiology, Hawaii Permanente Medical Group, Kaiser Permanente Moanalua Medical Center, Honolulu, HI (C.P.); and Adult Congenital Heart Disease Centre and National Centre for Pulmonary Hypertension, Royal Brompton and Harefield NHS Foundation Trust, London, United Kingdom (A.U.)
| | - Miriam Michel
- From the Department for Congenital Heart Disease and Paediatric Cardiology, University Hospital of Schleswig-Holstein, Campus Kiel, Kiel, Germany (J.S., C.P., J.H.H., M.M., C.H., G.F., K.B., H.-H.K.); Department of Pediatric, Fetal and Congenital Cardiology, Hawaii Permanente Medical Group, Kaiser Permanente Moanalua Medical Center, Honolulu, HI (C.P.); and Adult Congenital Heart Disease Centre and National Centre for Pulmonary Hypertension, Royal Brompton and Harefield NHS Foundation Trust, London, United Kingdom (A.U.)
| | - Christopher Hart
- From the Department for Congenital Heart Disease and Paediatric Cardiology, University Hospital of Schleswig-Holstein, Campus Kiel, Kiel, Germany (J.S., C.P., J.H.H., M.M., C.H., G.F., K.B., H.-H.K.); Department of Pediatric, Fetal and Congenital Cardiology, Hawaii Permanente Medical Group, Kaiser Permanente Moanalua Medical Center, Honolulu, HI (C.P.); and Adult Congenital Heart Disease Centre and National Centre for Pulmonary Hypertension, Royal Brompton and Harefield NHS Foundation Trust, London, United Kingdom (A.U.)
| | - Anselm Uebing
- From the Department for Congenital Heart Disease and Paediatric Cardiology, University Hospital of Schleswig-Holstein, Campus Kiel, Kiel, Germany (J.S., C.P., J.H.H., M.M., C.H., G.F., K.B., H.-H.K.); Department of Pediatric, Fetal and Congenital Cardiology, Hawaii Permanente Medical Group, Kaiser Permanente Moanalua Medical Center, Honolulu, HI (C.P.); and Adult Congenital Heart Disease Centre and National Centre for Pulmonary Hypertension, Royal Brompton and Harefield NHS Foundation Trust, London, United Kingdom (A.U.)
| | - Gunther Fischer
- From the Department for Congenital Heart Disease and Paediatric Cardiology, University Hospital of Schleswig-Holstein, Campus Kiel, Kiel, Germany (J.S., C.P., J.H.H., M.M., C.H., G.F., K.B., H.-H.K.); Department of Pediatric, Fetal and Congenital Cardiology, Hawaii Permanente Medical Group, Kaiser Permanente Moanalua Medical Center, Honolulu, HI (C.P.); and Adult Congenital Heart Disease Centre and National Centre for Pulmonary Hypertension, Royal Brompton and Harefield NHS Foundation Trust, London, United Kingdom (A.U.)
| | - Kolja Becker
- From the Department for Congenital Heart Disease and Paediatric Cardiology, University Hospital of Schleswig-Holstein, Campus Kiel, Kiel, Germany (J.S., C.P., J.H.H., M.M., C.H., G.F., K.B., H.-H.K.); Department of Pediatric, Fetal and Congenital Cardiology, Hawaii Permanente Medical Group, Kaiser Permanente Moanalua Medical Center, Honolulu, HI (C.P.); and Adult Congenital Heart Disease Centre and National Centre for Pulmonary Hypertension, Royal Brompton and Harefield NHS Foundation Trust, London, United Kingdom (A.U.)
| | - Hans-Heiner Kramer
- From the Department for Congenital Heart Disease and Paediatric Cardiology, University Hospital of Schleswig-Holstein, Campus Kiel, Kiel, Germany (J.S., C.P., J.H.H., M.M., C.H., G.F., K.B., H.-H.K.); Department of Pediatric, Fetal and Congenital Cardiology, Hawaii Permanente Medical Group, Kaiser Permanente Moanalua Medical Center, Honolulu, HI (C.P.); and Adult Congenital Heart Disease Centre and National Centre for Pulmonary Hypertension, Royal Brompton and Harefield NHS Foundation Trust, London, United Kingdom (A.U.)
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Heck PB, Müller J, Weber R, Hager A. Value of N-terminal pro brain natriuretic peptide levels in different types of Fontan circulation. Eur J Heart Fail 2014; 15:644-9. [DOI: 10.1093/eurjhf/hft063] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Affiliation(s)
- Pinar Bambul Heck
- Department of Pediatric Cardiology and Congenital Heart Disease; Deutsches Herzzentrum München, Technische Universität München; Lazarettstr. 36 D-0636 München Germany
| | - Jan Müller
- Department of Pediatric Cardiology and Congenital Heart Disease; Deutsches Herzzentrum München, Technische Universität München; Lazarettstr. 36 D-0636 München Germany
| | - Ruth Weber
- Department of Pediatric Cardiology and Congenital Heart Disease; Deutsches Herzzentrum München, Technische Universität München; Lazarettstr. 36 D-0636 München Germany
| | - Alfred Hager
- Department of Pediatric Cardiology and Congenital Heart Disease; Deutsches Herzzentrum München, Technische Universität München; Lazarettstr. 36 D-0636 München Germany
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15
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Koch AM, Zink S, Singer H, Dittrich S. B-type natriuretic peptide levels in patients with functionally univentricular hearts after total cavopulmonary connection. Eur J Heart Fail 2014; 10:60-2. [DOI: 10.1016/j.ejheart.2007.11.001] [Citation(s) in RCA: 37] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/12/2007] [Revised: 10/30/2007] [Accepted: 11/05/2007] [Indexed: 10/22/2022] Open
Affiliation(s)
- Andreas M.E. Koch
- Department of Paediatric Cardiology; University of Erlangen-Nürnberg; Germany
| | - Stefan Zink
- Department of Paediatric Cardiology; University of Erlangen-Nürnberg; Germany
| | - Helmut Singer
- Department of Paediatric Cardiology; University of Erlangen-Nürnberg; Germany
| | - Sven Dittrich
- Department of Paediatric Cardiology; University of Erlangen-Nürnberg; Germany
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Transient hemodynamic changes upon changing a BCPA into a TCPC in staged Fontan operation: a computational model study. ScientificWorldJournal 2013; 2013:486815. [PMID: 24319371 PMCID: PMC3844169 DOI: 10.1155/2013/486815] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2013] [Accepted: 09/19/2013] [Indexed: 11/17/2022] Open
Abstract
The clinical benefits of the Fontan operation in treating single-ventricle defects have been well documented. However, perioperative mortality or morbidity remains a critical problem. The purpose of the present study was to identify the cardiovascular factors that dominate the transient hemodynamic changes upon the change of a bidirectional cavopulmonary (Glenn) anastomosis (BCPA) into a total cavopulmonary connection (TCPC). For this purpose, two computational models were constructed to represent, respectively, a single-ventricle circulation with a BCPA and that with a TCPC. A series of model-based simulations were carried out to quantify the perioperative hemodynamic changes under various cardiovascular conditions. Obtained results indicated that the presence of a low pulmonary vascular resistance and/or a low lower-body vascular resistance is beneficial to the increase in transpulmonary flow upon the BCPA to TCPC change. Moreover, it was found that ventricular diastolic dysfunction and mitral valve regurgitation, despite being well-known risk factors for poor postoperative outcomes, do not cause a considerable perioperative reduction in transpulmonary flow. The findings may help physicians to assess the perioperative risk of the TCPC surgery based on preoperative measurement of cardiovascular function.
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Wallihan DB, Podberesky DJ, Marino BS, Sticka JS, Serai S. Relationship of MR elastography determined liver stiffness with cardiac function after Fontan palliation. J Magn Reson Imaging 2013; 40:1328-35. [PMID: 24408379 DOI: 10.1002/jmri.24496] [Citation(s) in RCA: 40] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2013] [Accepted: 09/28/2013] [Indexed: 01/15/2023] Open
Abstract
PURPOSE To use MR elastography to assess liver stiffness in patients with congenital heart disease palliated with the Fontan procedure and correlate findings with cardiac index and other functional parameters obtained during cardiac MRI. MATERIALS AND METHODS We performed a retrospective study of 14 patients (15 examinations) with Fontan circulation who underwent both cardiac MRI and liver MR elastography (MRE) on the same day. Liver stiffness was determined by calculating the mean liver stiffness from four slice locations. The cardiac index and other flow measurements were calculated from phase contrast MR imaging. RESULTS The MRE was abnormal on all examinations with a median liver stiffness of 4.0 kPa (range, 3.4-6.2 kPa; normal adult liver stiffness is < 2.51 kPa). The cardiac index decreased as the duration of Fontan circulation (Fontan duration) increased (P = 0.005). We found a statistically significant inverse correlation between liver stiffness and cardiac index (P = 0.02), as well as the ejection fraction (P = 0.002). Patients with long Fontan durations (≥ 20 years) had greater liver stiffness compared with those having a shorter duration (P = 0.02). CONCLUSION MRE shows promise as a monitoring tool in the Fontan population, demonstrating an elevated liver stiffness in all patients, which inversely correlated with the MR determined cardiac index.
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Affiliation(s)
- Daniel B Wallihan
- Cincinnati Children's Hospital Medical Center, Department of Radiology, Cincinnati, Ohio, USA
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Fujii Y, Sano S, Asou T, Imoto Y, Oshima Y, Kawasaki S, Kishimoto H, Sakamoto K, Maeda M, Yamagishi M, Matsuo K. Outcomes of One-Lung Fontan Operation: A Retrospective Multicenter Study in Japan. Ann Thorac Surg 2012; 94:1275-80; discussion 1280. [DOI: 10.1016/j.athoracsur.2012.04.080] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/31/2012] [Revised: 04/19/2012] [Accepted: 04/23/2012] [Indexed: 11/29/2022]
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19
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Katewa A, Marwah A, Singh V, Ramaswamy A, Sharma R. Anatomic biventricular repair in right isomerism with noncommitted ventricular septal defect. World J Pediatr Congenit Heart Surg 2012; 3:385-8. [PMID: 23804876 DOI: 10.1177/2150135112438231] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Biventricular repair in right atrial isomerism is rarely feasible due to associated anomalies of venous connection, ventricular imbalance, nonroutabilty of the interventricular communication, a common atrioventricular junction, and inadequate pulmonary arterial branches. These patients are also often not ideal for univentricular repair due to some of the above associations. We describe a novel surgical technique that was utilized in such a patient for biventricular repair of a child with right atrial isomerism with total anomalous pulmonary venous connection, regurgitant common atrioventricular valve, hypoplastic left ventricle, nonroutable ventricular septal defect, and pulmonary stenosis.
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Affiliation(s)
- Ashish Katewa
- Department of Pediatric Cardiac Surgery, Intensive Care Fortis-Escorts Heart Institute, Okhla, New Delhi, India
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20
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Pulsatile venous waveform quality affects the conduit performance in functional and "failing" Fontan circulations. Cardiol Young 2012; 22:251-62. [PMID: 22008697 DOI: 10.1017/s1047951111001491] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
OBJECTIVE To investigate the effect of pulsatility of venous flow waveform in the inferior and superior caval vessels on the performance of functional and "failing" Fontan patients based on two primary performance measures - the conduit power loss and the distribution of inferior caval flow (hepatic factors) to the lungs. METHODS Doppler angiography flows were acquired from two typical extra-cardiac conduit "failing" Fontan patients, aged 13 and 25 years, with ventricle dysfunction. Using computational fluid dynamics, haemodynamic efficiencies of "failing", functional, and in vitro-generated mechanically assisted venous flow waveforms were evaluated inside an idealised total cavopulmonary connection with a caval offset. To investigate the effect of venous pulsatility alone, cardiac output was normalised to 3 litres per minute in all cases. To quantify the pulsatile behaviour of venous flows, two new performance indices were suggested. RESULTS Variations in the pulsatile content of venous waveforms altered the conduit efficiency notably. High-frequency and low-amplitude oscillations lowered the pulsatile component of the power losses in "failing" Fontan flow waveforms. Owing to the offset geometry, hepatic flow distribution depended strongly on the ratio of time-dependent caval flows and the pulsatility content rather than mixing at the junction. "Failing" Fontan flow waveforms exhibited less balanced hepatic flow distribution to lungs. CONCLUSIONS The haemodynamic efficiency of single-ventricle circulation depends strongly on the pulsatility of venous flow waveforms. The proposed performance indices can be calculated easily in the clinical setting in efforts to better quantify the energy efficiency of Fontan venous waveforms in pulsatile settings.
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Shiraishi S, Uemura H, Kagisaki K, Hagino I, Kobayashi J, Takahashi M, Yagihara T. Long-term results of total cavopulmonary connection with low ejection fraction. Gen Thorac Cardiovasc Surg 2011; 59:686-92. [PMID: 21984136 DOI: 10.1007/s11748-011-0812-2] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2010] [Accepted: 04/04/2011] [Indexed: 11/25/2022]
Abstract
PURPOSE The aim of this study was to investigate the surgical outcomes and change in cardiac performance after total cavopulmonary connection (TCPC) in patients with reduced ventricular ejection preoperatively. METHODS Among the 195 patients undergoing TCPC between 1990 and 2001 were 52 who had a preoperative ejection fraction of ≤50% (30%-50%, mean 44%). A dominant ventricle was of the morphologically right type in 81% of patients. RESULTS A total of 9 of the 52 patients died early. Two patients died in the intermediate term. Postoperative exercise testing showed maximum oxygen uptake of 26.4 ± 5.8 ml/kg/min (anaerobic threshold 18.3 ± 3.2 ml/kg/ min). The cardiac index was 3.1 ± 0.9 l/min/m(2) at 1 year after TCPC, with no fundamental change at 5 years (3.1 ± 0.8 l/min/m(2)). The end-diastolic volume of the dominant ventricle was 130% ± 74% of the anticipated normal value at 1 year and 93% ± 27% at 5 years after TCPC, with ejection fractions of 48% ± 13% and 49% ± 9%, respectively. When these parameters were plotted for the individual patients, the ejection fraction increased during the first postoperative year, with the percent end-diastolic volume decreasing in 31 survivors; the trend appeared atypical in the remaining 12 survivors. Even in these patients, however, the parameters eventually changed toward favorable circumstances 5 years after TCPC. CONCLUSION Change in ventricular function was not necessarily pessimistic after TCPC in patients with reduced ventricular contraction preoperatively.
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Affiliation(s)
- Shuichi Shiraishi
- Department of Cardiovascular Surgery, National Cerebral and Cardiovascular Center, Fujishiro-dai, Suita, Osaka, Japan.
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22
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Single stage versus two stage repair for univentricular heart—our experience. Indian J Thorac Cardiovasc Surg 2011. [DOI: 10.1007/s12055-011-0096-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
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23
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Avoiding cardiopulmonary bypass in extracardiac cavopulmonary connection: Does it really matter? J Thorac Cardiovasc Surg 2010; 139:1183-8. [DOI: 10.1016/j.jtcvs.2009.10.031] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/29/2009] [Revised: 09/16/2009] [Accepted: 10/16/2009] [Indexed: 11/18/2022]
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Preoperative pulmonary hemodynamics and assessment of operability: is there a pulmonary vascular resistance that precludes cardiac operation? Pediatr Crit Care Med 2010; 11:S57-69. [PMID: 20216166 DOI: 10.1097/pcc.0b013e3181d10cce] [Citation(s) in RCA: 43] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Preoperative pulmonary vascular disease remains an important risk factor for death or right-heart failure in selected children undergoing two-ventricle repair, single-ventricle palliation, or heart transplantation. Preoperative criteria for poor outcome after operation remain unclear. The purpose of this review is to critically assess both the historic and current data and make recommendations where appropriate. An extensive literature search was undertaken in October 2009. Data were analyzed by an expert multidisciplinary team and recommendations were made by consensus. PubMed was searched in October 2009. Data were analyzed and recommendations were made by consensus of a multidisciplinary team. In patients with suspected pulmonary vascular disease anticipating a two-ventricle repair, although preoperative testing via cardiac catheterization with vasodilators is reasonable, the preoperative parameters and the precise values of these parameters that best correlate with early and late outcome remain unclear. Further investigation is warranted in selected populations, such as the growing group of children with congenital heart disease complicated by chronic lung disease of prematurity, and in the developing world where patients may be more likely to present late with advanced pulmonary vascular disease. In patients with a functional single ventricle, there is growing evidence that mean pulmonary artery pressure of >15 mm Hg may be associated with both early and late mortality after the Fontan operation. The relationship of preoperative pulmonary hemodynamics to early and late morbidity remains to be defined. There most likely is a level of preoperative pulmonary vascular disease that puts an individual patient at increased risk for death or severe cyanosis after a bidirectional cavopulmonary anastomosis. It remains unclear, however, how to best assess this risk preoperatively. The limitations in obtaining an accurate assessment of pulmonary vascular disease in the complex single ventricle are discussed. In children awaiting cardiac transplantation with elevated pulmonary vascular disease of >6 U.m and/or transpulmonary gradient of >15 mm Hg, heart transplantation is deemed feasible in most transplant centers if the administration of inotropes or vasodilators can decrease the pulmonary vascular disease to <6 U.m or transpulmonary gradient to <15 mm Hg. In patients with preoperative pulmonary vascular disease, there may be contributing factors to the pulmonary vascular disease, such as the specifics of the cardiac lesion (atrioventricular valve regurgitation, low cardiac output), parenchymal and/or airway issues, and/or individual genetic predisposition. Amelioration of any reversible factors before operation and optimization of their management in the preoperative and postoperative period are recommended.
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Leyvi G, Wasnick JD. Single-Ventricle Patient: Pathophysiology and Anesthetic Management. J Cardiothorac Vasc Anesth 2010; 24:121-30. [DOI: 10.1053/j.jvca.2009.07.018] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/18/2008] [Indexed: 11/11/2022]
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Kerendi F, Kramer ZB, Mahle WT, Kogon BE, Kanter KR, Kirshbom PM. Perioperative Risks and Outcomes of Atrioventricular Valve Surgery in Conjunction With Fontan Procedure. Ann Thorac Surg 2009; 87:1484-8; discussion 1488-9. [DOI: 10.1016/j.athoracsur.2009.02.059] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/08/2008] [Revised: 02/18/2009] [Accepted: 02/20/2009] [Indexed: 11/15/2022]
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Ba HO, Marini D, Kammache I, Ou P, Elie C, Boudjemline Y, Bonnet D, Agnoletti G. Preoperative evaluation of candidates for total cavopulmonary connection: The role of echocardiography and cardiac catheterization. Arch Cardiovasc Dis 2009; 102:303-9. [DOI: 10.1016/j.acvd.2009.02.006] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/14/2008] [Revised: 01/29/2009] [Accepted: 02/03/2009] [Indexed: 10/20/2022]
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Quantification of collateral aortopulmonary flow in patients subsequent to construction of bidirectional cavopulmonary shunts. Cardiol Young 2008; 18:485-93. [PMID: 18634715 DOI: 10.1017/s104795110800259x] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECTIVES We sought to provide a new method for quantifying collateral aortopulmonary flow in patients subsequent to construction of a bidirectional cavopulmonary shunt, and to clarify the clinical advantages of the new method. METHODS We performed lung perfusion scintigraphy and cardiac catheterization in 10 patients subsequent to construction of a bidirectional cavopulmonary shunt. First, the ratio of collateral to systemic flow was determined by whole-body images of lung perfusion scintigraphy, dividing the total lung count by the total body count minus the total lung count. Second, we integrated lung perfusion scintigraphy and cardiac catheterization data using a formula derived from the Fick principle, taking the ratio of pulmonary to systemic flow to be 1 plus the ratio calculated above and multiplied by the systemic saturation minus the inferior caval venous saturation divided by the pulmonary venous saturation minus the inferior caval venous saturation. Finally, the amount of collateral flow was obtained from the ratio of pulmonary to systemic flow. We evaluated the impact of collateral flow on the calculation of pulmonary vascular resistance. RESULTS The median age at bidirectional cavopulmonary shunt was 1.41 years, and the median age at catheterization was 2.33 years. The mean amount of collateral flow was 1.75 +/- 0.46 litres/min/m(2). The pulmonary vascular resistance calculated without considering the collateral flow was overestimated by an average of 57 +/- 23%, compared to the resistance calculated with our new method. CONCLUSIONS The use of scintigraphy combined with catheterization allows accurate determination of aortopulmonary collateral flow, and avoids overestimation of pulmonary vascular resistance in these candidates for the Fontan circulation.
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Hussain A, Arfi AM, Hussamuddin M, Haneef AA, Jamjoom A, Al-Ata J, Mo G. Comparative outcome of bidirectional Glenn shunt in patients with pulmonary vascular resistance > or = 3.5 woods units versus < 3.5 woods units. Am J Cardiol 2008; 102:907-12. [PMID: 18805120 DOI: 10.1016/j.amjcard.2008.04.063] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/12/2007] [Revised: 04/21/2008] [Accepted: 04/21/2008] [Indexed: 11/16/2022]
Abstract
Moderate to severe pulmonary hypertension is considered to be an absolute contraindication to the performance of bidirectional Glenn (BDG) shunting. However, BDG shunting has been performed in young children with pulmonary hypertension associated with unrestricted pulmonary blood flow. In this study, the medical records of patients who underwent BDG starting from October 2000 to March 2004 were reviewed. Patients were divided into 2 groups on the basis of indexed pulmonary vascular resistance (PVRI) measured in room air: a high-risk group (n = 12) with PVRI > or = 3.5 Woods units (WU)/m(2) and a low-risk group (n = 28) with PVRI <3.5 WU/m(2) in room air. The 2 groups were comparable with respect to age, weight, ventricular morphology, pulmonary arterial anatomy, and atrioventricular valve function. Mean pulmonary arterial pressure and PVRI were significantly higher in the high-risk group compared with the low-risk group (39.2 +/- 20.7 vs 15.1 +/- 6.25 mm Hg, p <0.002, and 6.0 +/- 2.5 vs 1.6 +/- 0.82 WU/m(2), p <0.0005, respectively). The ratio of pulmonary flow to systemic flow was 1.45 +/- 0.76 in the high-risk group and 1.24 +/- 1.2 in the low-risk group. In the high-risk group, mean PVRI decreased to 2.0 +/- 1.0 WU/m(2) on 100% oxygen (p <0.0005). A contraindication to Glenn shunting was PVRI >3.5 WU/m(2) on 100% oxygen. Hospital mortality was 17% (2 of 12) in the high-risk group and 4% (1 of 28) in the low-risk group. Of 10 survivors in the high-risk group, 1 had undergone a Kawashima procedure, 7 had undergone Fontan procedures (with 1 death), and 2 were awaiting the completion of Fontan procedures as of this writing. In conclusion, these preliminary data suggest that in young children with increased pulmonary flow, BDG shunting can be safely performed, despite the apparent elevation of pulmonary arterial pressure to inoperable levels, provided PVRI decreases to < or = 3.5 WU/m(2) on 100% oxygen.
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Affiliation(s)
- Arif Hussain
- King Faisal Specialist Hospital and Research Center, Jeddah, Saudi Arabia.
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Praus A, Eicken A, Balling G, Schreiber C, Hess J. Progressive intrapulmonary shunting in a child after bidirectional Glenn operation only resolved after total cavopulmonary completion. Int J Cardiol 2008; 128:e12-5. [PMID: 17706305 DOI: 10.1016/j.ijcard.2007.04.156] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/08/2007] [Accepted: 04/25/2007] [Indexed: 11/28/2022]
Abstract
We report on a girl with progressive intrapulmonary shunting after bidirectional Glenn (BDG) operation and resolution of these microscopic fistulas after completion to total cavopulmonary connection (TCPC).
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Yoshida M, Yamaguchi M, Yoshimura N, Murakami H, Matsuhisa H, Okita Y. Appropriate additional pulmonary blood flow at the bidirectional Glenn procedure is useful for completion of total cavopulmonary connection. Ann Thorac Surg 2006; 80:976-81. [PMID: 16122468 DOI: 10.1016/j.athoracsur.2005.03.090] [Citation(s) in RCA: 40] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/12/2005] [Revised: 03/14/2005] [Accepted: 03/21/2005] [Indexed: 10/25/2022]
Abstract
BACKGROUND The role and effect of additional pulmonary blood flow at the time of bidirectional Glenn procedure (BDG) is controversial. We assessed our experiences to clarify the effects of controlled additional pulmonary blood flow on outcomes after BDG. METHODS Thirty-eight patients who underwent BDG (2.1 +/- 2.1 years of age) were enrolled in this study. In group A (n = 29) additional pulmonary blood flow was controlled by the banding of the pulmonary trunk, or the previously created Blalock-Taussig shunt, to keep the central venous pressure equal to or less than 16 mm Hg at BDG. In group B (n = 9), BDG was the only source of pulmonary blood flow. RESULTS One operative death occurred in group B. In group A, 24 patients underwent total cavopulmonary connection (TCPC) 14 +/- 6 months after BDG, and the remaining 5 patients are waiting for TCPC in good condition. In group B, 6 patients underwent TCPC 8 +/- 7 months after BDG. One patient is awaiting TCPC and the remaining patient is considered unsuitable for TCPC. Cardiac catheterization performed in 32 patients showed significant decrease of pulmonary artery (Nakata) index from 307 +/- 73 to 215 +/- 45 mm2/m2 after BDG in group B (p < 0.05). On the other hand, the Nakata index stayed in higher range from 316 +/- 115 to 287 +/- 74 mm2/m2 in group A, and there was a significant correlation between the Nakata index and the percentage of its difference (Y = 40.823 - 0.144 X; n = 26, R = 0.740, p < 0.0001). CONCLUSIONS Appropriate additional pulmonary blood flow is useful for the completion of TCPC by means of suppressing the decrease in the size of the pulmonary artery, especially in patients with underdeveloped pulmonary arteries.
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Affiliation(s)
- Masahiro Yoshida
- Department of Cardiothoracic Surgery, Kobe Childre's Hospital, Kobe, Hyogo, Japan.
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Hsu JY, Wang JK, Lin MT, Wu ET, Chiu SN, Chen CA, Lue HC, Wu MH. Clinical Implications of Major Aortopulmonary Collateral Arteries in Patients With Right Isomerism. Ann Thorac Surg 2006; 82:153-7. [PMID: 16798206 DOI: 10.1016/j.athoracsur.2006.02.020] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/11/2005] [Revised: 02/02/2006] [Accepted: 02/06/2006] [Indexed: 11/23/2022]
Abstract
BACKGROUND The presence of major aortopulmonary collateral arteries (MAPCA) in patients with right isomerism may alter the prognosis, which is still unclear. METHODS From 1994 to 2003, 138 out of 155 patients (89%) with right isomerism had pulmonary stenosis or pulmonary atresia and constituted the study population. RESULTS Two groups of patients were identified, one with MAPCA and the other without. The MAPCA originating from descending thoracic aorta or aortic arch was noted in 9 patients (6.5%), with a median number of MAPCA being 3 (range, 2 to 4). Patients with MAPCA commonly had congestive heart failure (8/9, 89%) and frequent lower airway infection (6/9, 67%). In comparison with patients with MAPCA and without, the intrapericardial pulmonary artery was more frequently absent (2 of 9 vs 1 of 129, p < 0.001), and the pulmonary arterial size was smaller (McGoon ratio <1.5, 8 of 9 vs 57 of 129, p = 0.009) in the MAPCA group. The mean pulmonary arterial pressure measured was often higher than the suggested limit for Fontan circulation. Major aortopulmonary collateral arteries were addressed at a median of 6 months old (2 to 19 months old) in 5 patients. Although surgical mortality was not different for first-stage palliation and Glenn shunt in both groups, total cavopulmonary connection could only be performed in one patient with MAPCA with poor results. However, the 5-year survival of patients with and without MAPCA was not statistically different (74.1% vs 55.2%, p = 0.19). CONCLUSIONS The presence of MAPCA was uncommon but still noted in patients with right isomerism. It may cause heart failure and a less favorable pulmonary vasculature for a complete Fontan-type operation.
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MESH Headings
- Abnormalities, Multiple/mortality
- Abnormalities, Multiple/pathology
- Abnormalities, Multiple/physiopathology
- Abnormalities, Multiple/surgery
- Adolescent
- Adult
- Aorta/abnormalities
- Arteriovenous Shunt, Surgical
- Blood Pressure
- Body Patterning
- Child
- Child, Preschool
- Cohort Studies
- Collateral Circulation
- Embolization, Therapeutic
- Female
- Fontan Procedure
- Heart Defects, Congenital/physiopathology
- Heart Defects, Congenital/surgery
- Heart Failure/etiology
- Humans
- Hypertension, Pulmonary/etiology
- Infant
- Infant, Newborn
- Life Tables
- Male
- Palliative Care
- Postoperative Complications/etiology
- Postoperative Complications/mortality
- Prevalence
- Pulmonary Artery/abnormalities
- Pulmonary Artery/surgery
- Pulmonary Atresia/pathology
- Pulmonary Atresia/physiopathology
- Pulmonary Atresia/surgery
- Pulmonary Circulation
- Pulmonary Valve Stenosis/pathology
- Pulmonary Valve Stenosis/physiopathology
- Pulmonary Valve Stenosis/surgery
- Pulmonary Veins/abnormalities
- Retrospective Studies
- Treatment Outcome
- Venae Cavae/abnormalities
- Venae Cavae/surgery
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Affiliation(s)
- Jui-Yu Hsu
- Department of Pediatrics, National Taiwan University Hospital and National Taiwan University, College of Medicine, Taipei, Taiwan
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Hsu JY, Chen SJ, Wang JK, Ni YH, Chang MH, Wu MH. Clinical implication of hiatal hernia in patients with right isomerism. Acta Paediatr 2005; 94:1248-52. [PMID: 16203675 DOI: 10.1111/j.1651-2227.2005.tb02084.x] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE Despite a reported association between hiatal hernia in patients with heterotaxy syndrome, the clinical significance has remained unclear. Based on large patient cohorts, this study specifically aimed at defining the implication of hiatal hernia in patients with right isomerism. METHODS From 1994 to 2002, 143 patients were identified as having right isomerism. Among them, 119 received ultrafast computed tomography (CT) to determine the presence of hiatal hernia as well as any cardiovascular anomalies. RESULTS Hiatal hernia was found in 17 patients (seven females and 10 males, 14.3%). The upper gastrointestinal (GI) series in six patients confirmed the diagnosis of hiatal hernia in all and revealed severe gastro-oesophageal reflux in four. The most common symptom of hiatal hernia was vomiting (47%), followed by recurrent bronchiolitis or pneumonia (41.2%) and upper gastrointestinal bleeding (11.8%). Three patients with hiatal hernia underwent fundoplication for medically refractory vomiting. Seven patients were found to have midgut malrotation (5.9%), and four of these had both hiatal hernia and malrotation. Pulmonary atresia was closely associated with the presence of hiatal hernia (p=0.02). One patient with hiatal hernia died suddenly at 6 mo. However, overall mortality was similar between those patients with hiatal hernia and those without. CONCLUSIONS The incidence of hiatal hernia was considerably high in patients with right isomerism, especially in those with pulmonary atresia, and it is this that may have led to vomiting and recurrent airway infections. While an association between sudden death and hiatal hernia may well exist, this does require further clarification.
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Affiliation(s)
- Jui-Yu Hsu
- Department of Paediatrics, National Taiwan University Hospital, Taipei, Taiwan
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Mavroudis C, Stewart RD, Backer CL, Deal BJ, Young L, Franklin WH. Atrioventricular Valve Procedures with Repeat Fontan Operations: Influence of Valve Pathology, Ventricular Function, and Arrhythmias on Outcome. Ann Thorac Surg 2005; 80:29-36; discussion 36. [PMID: 15975335 DOI: 10.1016/j.athoracsur.2005.01.071] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/03/2004] [Revised: 01/20/2005] [Accepted: 01/28/2005] [Indexed: 10/25/2022]
Abstract
BACKGROUND The purpose of this study is to analyze atrioventricular valve procedures when performed in association with repeat Fontan operations and to determine the influence of atrioventricular valvar pathology, ventricular function, and arrhythmias on outcome. METHODS Between December 1994 and August 2004, 80 patients had repeat Fontan operations that included arrhythmia surgery (78 of 80), venous pathway revision (78 of 80), atrioventricular valve repair-replacement (15 of 80), and other associated procedures. Mean ages were the following: at operation, 20.3 +/- 8.4 years; at prior Fontan, 7.1 +/- 5.8 years. Atrioventricular valve procedures were performed on 8 functionally mitral and 7 functionally tricuspid valves. The average cross-clamp and cardiopulmonary bypass times were 61.9 +/- 42.8 minutes and 218 +/- 82 minutes, respectively. RESULTS Ventricular dysfunction (8% vs 54%, p < 0.0001), valvar dysfunction (13% vs 25%, p < 0.05), and atrial arrhythmias (18% vs 86%, p < 0.0001) increased during the preceding 12.0 +/- 4.7 years before the most recent Fontan operation. Multivariate analysis for death, orthotopic cardiac transplantation (OCT), or renal dialysis showed severe ventricular dysfunction, age greater than 25 years, right or ambiguous functional ventricle, and ischemic time greater than 100 minutes to be highly significant. Notably, cardiac index, elevated end diastolic pressure, and atrial fibrillation were not predictors of outcome. Mitral valve repairs were inconsistent due to probable technical misjudgments; most tricuspid valves could not be repaired. Operative and late mortality were 1.2% and 5.0%, respectively. Emergent and late OCT were 1.2% and 3.7%, respectively. CONCLUSIONS Risk factors for poor outcome are severe ventricular dysfunction, right or ambiguous single ventricle, age greater than 25 years, and ischemic time greater than 100 minutes. Mitral valves are potentially more amenable to repair than are tricuspid valves. Prosthetic valve replacement should be considered when valve repair is questionable.
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Affiliation(s)
- Constantine Mavroudis
- Department of Surgery, Northwestern University Feinberg School of Medicine, Children's Memorial Hospital, Chicago, Illinois, USA.
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Yoshimura N, Yamaguchi M, Oka S, Yoshida M, Murakami H. Pulmonary Artery Banding Still Has an Important Role in the Treatment of Congenital Heart Disease. Ann Thorac Surg 2005; 79:1463; author reply 1463-4. [PMID: 15797113 DOI: 10.1016/j.athoracsur.2003.12.113] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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Kumar SP, Rubinstein CS, Simsic JM, Taylor AB, Saul JP, Bradley SM. Lateral tunnel versus extracardiac conduit fontan procedure: a concurrent comparison. Ann Thorac Surg 2003; 76:1389-96; discussion 1396-7. [PMID: 14602257 DOI: 10.1016/s0003-4975(03)01010-5] [Citation(s) in RCA: 74] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
BACKGROUND The aim of this study was to compare the outcomes of the lateral tunnel (LT) and extracardiac conduit (ECC) Fontan procedures at a single institution over the same time period. METHODS From November 1995 through October 2002, 70 Fontan procedures were performed: 37 LT and 33 ECC. All were fenestrated; 96% were staged with a prior superior cavopulmonary connection. Compared with the ECC patients, the LT patients were younger (2.7 +/- 1.1 vs 3.9 +/- 2.5 years; p = 0.01), had a higher incidence of hypoplastic left heart syndrome (57% vs 21%; p < 0.01), and a longer aortic cross-clamp time (55 +/- 13 vs 26 +/- 15 min; p < 0.01). Weight, gender, preoperative cardiac catheterization values, and cardiopulmonary bypass time did not differ between the two groups. RESULTS Operative mortality was 2.8%, 1 patient in each group (p = 1.0). Over the first 24 hours following operation the mean Fontan pressure, transpulmonary gradient, and common atrial pressure did not differ between LT and ECC patients. The median duration of mechanical ventilation (LT 12 vs ECC 18 hours), intensive care unit stay (LT 2 vs ECC 3 days), chest tube drainage (LT 10 vs ECC 8 days), and hospital stay (LT 11 vs ECC 12 days) did not differ. The ECC patients had a higher incidence of sinus node dysfunction both in the postoperative period (27% vs LT 8%; p = 0.09), and persisting at hospital discharge (10% vs LT 0%; p = 0.02). Mean follow-up was 3.6 +/- 1.6 years in LT, and 3.0 +/- 2.2 years in ECC patients (p = 0.2). There was one late death. Actuarial survival at 5 years is 97% for LT, and 91% for ECC patients (p = 0.4); 96% of patients are in NYHA class I, and 4% in class II, with no difference between groups. Sinus node dysfunction was seen during follow-up in 15% LT vs 28% ECC patients (p = 0.2). CONCLUSIONS The LT and ECC approaches had comparable early and mid-term outcomes, including operative morbidity and mortality, postoperative hemodynamics, resource use, and mid-term survival and functional status. ECC patients had a higher incidence of sinus node dysfunction early after operation.
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Affiliation(s)
- S Prathap Kumar
- Division of Cardiothoracic Surgery, Pediatric Cardiology, Medical University of South Carolina, Charelston, USA
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