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Chaudhry A, Selwyn J, Adams E, Bradley EA. Heart Failure in Complex Congenital Heart Disease of the Adult. Curr Cardiol Rep 2022; 24:1727-1735. [PMID: 36197543 PMCID: PMC9901216 DOI: 10.1007/s11886-022-01788-0] [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] [Accepted: 09/20/2022] [Indexed: 02/08/2023]
Abstract
PURPOSE OF REVIEW Adult congenital heart disease (ACHD) patients have demonstrated improved survival, especially those with severely complex disease, mainly single-ventricle/Fontan physiology and those with a systemic right ventricle. We describe the heart failure phenotypes of complex CHD, reversible causes for heart failure, and considerations for advanced therapy. RECENT FINDINGS While initially marketed for application to patients with acquired causes for heart failure, newer devices and technologies have started to be used in the ACHD population. After reversible causes for heart failure in CHD are addressed, it is reasonable to consider use of new device-based technologies and orthotopic heart transplant (OHT) for end-stage disease. New heart failure technology and organ transplant should carefully be considered and applied in complex ACHD, where there may be significant improvement in morbidity and mortality.
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Affiliation(s)
- Anisa Chaudhry
- Division of Cardiovascular Medicine, Penn State Heart and Vascular Institute, Pennsylvania State University College of Medicine, Penn State Milton S. Hershey Medical Center, Hershey, PA 17033, USA
| | - Julia Selwyn
- Department of Internal Medicine, Pennsylvania State University College of Medicine, Penn State Milton S. Hershey Medical Center, Hershey, PA, USA
| | - Elizabeth Adams
- Division of Cardiovascular Medicine, Penn State Heart and Vascular Institute, Pennsylvania State University College of Medicine, Penn State Milton S. Hershey Medical Center, Hershey, PA 17033, USA
| | - Elisa A. Bradley
- Division of Cardiovascular Medicine, Penn State Heart and Vascular Institute, Pennsylvania State University College of Medicine, Penn State Milton S. Hershey Medical Center, Hershey, PA 17033, USA,Department of Cellular and Molecular Physiology, Pennsylvania State University College of Medicine, Penn State Milton S. Hershey Medical Center, Hershey, PA, USA
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2
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Ahmad Z, Jin LH, Penny DJ, Rusin CG, Peskin CS, Puelz C. Optimal Fenestration of the Fontan Circulation. Front Physiol 2022; 13:867995. [PMID: 35846014 PMCID: PMC9280082 DOI: 10.3389/fphys.2022.867995] [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: 02/01/2022] [Accepted: 05/13/2022] [Indexed: 11/20/2022] Open
Abstract
In this paper, we develop a pulsatile compartmental model of the Fontan circulation and use it to explore the effects of a fenestration added to this physiology. A fenestration is a shunt between the systemic and pulmonary veins that is added either at the time of Fontan conversion or at a later time for the treatment of complications. This shunt increases cardiac output and decreases systemic venous pressure. However, these hemodynamic benefits are achieved at the expense of a decrease in the arterial oxygen saturation. The model developed in this paper incorporates fenestration size as a parameter and describes both blood flow and oxygen transport. It is calibrated to clinical data from Fontan patients, and we use it to study the impact of a fenestration on several hemodynamic variables, including systemic oxygen availability, effective oxygen availability, and systemic venous pressure. In certain scenarios corresponding to high-risk Fontan physiology, we demonstrate the existence of a range of fenestration sizes in which the systemic oxygen availability remains relatively constant while the systemic venous pressure decreases.
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Affiliation(s)
- Zan Ahmad
- Courant Institute of Mathematical Sciences, New York University, New York, NY, United States
| | - Lynn H. Jin
- Courant Institute of Mathematical Sciences, New York University, New York, NY, United States
- School of Physics, Georgia Institute of Technology, Atlanta, GA, United States
| | - Daniel J. Penny
- Department of Pediatrics, Section of Cardiology, Baylor College of Medicine and Texas Children’s Hospital, Houston, TX, United States
| | - Craig G. Rusin
- Department of Pediatrics, Section of Cardiology, Baylor College of Medicine and Texas Children’s Hospital, Houston, TX, United States
| | - Charles S. Peskin
- Courant Institute of Mathematical Sciences, New York University, New York, NY, United States
| | - Charles Puelz
- Courant Institute of Mathematical Sciences, New York University, New York, NY, United States
- Department of Pediatrics, Section of Cardiology, Baylor College of Medicine and Texas Children’s Hospital, Houston, TX, United States
- *Correspondence: Charles Puelz,
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3
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Zhao S, Guo J, Sun Z, Cui T. Long-term survival of patients with unoperated single ventricle heart defect: Four case reports and literature review. JOURNAL OF CLINICAL ULTRASOUND : JCU 2022; 50:467-473. [PMID: 35235214 DOI: 10.1002/jcu.23177] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/01/2021] [Revised: 01/04/2022] [Accepted: 02/11/2022] [Indexed: 06/14/2023]
Abstract
A single ventricle (SV) heart defect is a rare complex congenital cardiac malformation, accounting for approximately 1%-2% of congenital heart diseases. Surgical intervention is the mainstay treatment for SV patients, although patients who do not receive surgical intervention may also survive. We followed up four adult patients who had SV since birth without surgical intervention and they had a good prognosis. The common characteristics of four long-term SV survivors were investigated by reviewing their medical records and the literature, and the current treatment methods for SV patients were also reviewed. The clinical presentation and long-term prognosis of SV patients without surgical intervention depend on the presence or absence of pulmonary blood flow obstruction, pulmonary vascular resistance, ventricular shape and function, aortic blood flow obstruction, and the atrioventricular valve shape and function. While the Fontan operation has become a common and effective method for SV treatment, long-term outcomes are fraught with morbidity and mortality. In our opinion, such patients with balanced hemodynamic condition could be followed and treated conservatively. Major cardiac surgery which leads to gross hemodynamic adjustments should be avoided. However, additional prospective study will be necessary to verify this assertion. This report aims to improve the prognosis as well as quality of life of SV patients.
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Affiliation(s)
- Shengnan Zhao
- Department of Ultrasound, China-Japan Union Hospital of Jilin University, Changchun, China
| | - Jiantao Guo
- Department of Cardiac Surgery, The First Hospital of Jilin University, Changchun, China
| | - Zhixia Sun
- Department of Ultrasound, China-Japan Union Hospital of Jilin University, Changchun, China
| | - Tingting Cui
- Department of Ultrasound, China-Japan Union Hospital of Jilin University, Changchun, China
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Ciliberti P, Ciancarella P, Bruno P, Curione D, Bordonaro V, Lisignoli V, Panebianco M, Chinali M, Secinaro A, Galletti L, Guccione P. Cardiac Imaging in Patients After Fontan Palliation: Which Test and When? Front Pediatr 2022; 10:876742. [PMID: 35652057 PMCID: PMC9149285 DOI: 10.3389/fped.2022.876742] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/15/2022] [Accepted: 04/13/2022] [Indexed: 11/13/2022] Open
Abstract
The Fontan operation represents the final stage of a series of palliative surgical procedures for children born with complex congenital heart disease, where a "usual" biventricular physiology cannot be restored. The palliation results in the direct connection of the systemic venous returns to the pulmonary arterial circulation without an interposed ventricle. In this unique physiology, systemic venous hypertension and intrathoracic pressures changes due to respiratory mechanics play the main role for propelling blood through the pulmonary vasculature. Although the Fontan operation has dramatically improved survival in patients with a single ventricle congenital heart disease, significant morbidity is still a concern. Patients with Fontan physiology are in fact suffering from a multitude of complications mainly due to the increased systemic venous pressure. Consequently, these patients need close clinical and imaging monitoring, where cardiac exams play a key role. In this article, we review the main cardiac imaging modalities available, summarizing their main strengths and limitations in this peculiar setting. The main purpose is to provide a practical approach for all clinicians involved in the care of these patients, even for those less experienced in cardiac imaging.
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Affiliation(s)
- Paolo Ciliberti
- Department of Cardiac Surgery, Cardiology, Heart and Lung Transplantation Bambino Gesu' Children's Hospital, IRCCS, Rome, Italy
| | - Paolo Ciancarella
- Advanced Cardiothoracic Imaging Unit, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
| | - Pasqualina Bruno
- Department of Cardiac Surgery, Cardiology, Heart and Lung Transplantation Bambino Gesu' Children's Hospital, IRCCS, Rome, Italy
| | - Davide Curione
- Advanced Cardiothoracic Imaging Unit, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
| | - Veronica Bordonaro
- Advanced Cardiothoracic Imaging Unit, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
| | - Veronica Lisignoli
- Department of Cardiac Surgery, Cardiology, Heart and Lung Transplantation Bambino Gesu' Children's Hospital, IRCCS, Rome, Italy
| | - Mario Panebianco
- Department of Cardiac Surgery, Cardiology, Heart and Lung Transplantation Bambino Gesu' Children's Hospital, IRCCS, Rome, Italy
| | - Marcello Chinali
- Department of Cardiac Surgery, Cardiology, Heart and Lung Transplantation Bambino Gesu' Children's Hospital, IRCCS, Rome, Italy
| | - Aurelio Secinaro
- Advanced Cardiothoracic Imaging Unit, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
| | - Lorenzo Galletti
- Department of Cardiac Surgery, Cardiology, Heart and Lung Transplantation Bambino Gesu' Children's Hospital, IRCCS, Rome, Italy
| | - Paolo Guccione
- Department of Cardiac Surgery, Cardiology, Heart and Lung Transplantation Bambino Gesu' Children's Hospital, IRCCS, Rome, Italy
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Sallmon H, Ovroutski S, Schleiger A, Photiadis J, Weber SC, Nordmeyer J, Berger F, Kramer P. Late Fontan failure in adult patients is predominantly associated with deteriorating ventricular function. Int J Cardiol 2021; 344:87-94. [PMID: 34563595 DOI: 10.1016/j.ijcard.2021.09.042] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/21/2021] [Revised: 08/19/2021] [Accepted: 09/20/2021] [Indexed: 12/24/2022]
Abstract
BACKGROUND The Fontan operation is a palliative procedure and a substantial number of patients eventually experiences late Fontan circulation failure. Previous concepts of Fontan failure implicate increasing pulmonary vascular resistance (PVR) as a key contributor to late circulatory failure. However, data to support this assumption are sparse. We sought to characterize longitudinal hemodynamic and echocardiographic findings in adult failing Fontan patients. METHODS We performed a retrospective cohort study in adult Fontan patients, identifying patients with Fontan failure. Hemodynamic, echocardiographic and clinical data were recorded. RESULTS Of 173 adult patients (median follow-up after Fontan 20.2 years [IQR 15.7-24.3]), 48 (28%) showed signs of clinical Fontan failure. Thirty-seven patients (77.1%) exhibited ventricular dysfunction (systolic dysfunction defined by ejection fraction ≤45%, n = 22, or diastolic dysfunction defined by systemic ventricular end-diastolic pressure (SVEDP) ≥12 mmHg, n = 15). Elevated indexed PVR (≥2.5 WU*m2) was only observed in 9 (18.8%) patients. Ejection fraction declined from 60% [IQR 55-65] to 47% [IQR 35-55] during follow-up (p < 0.001). Mean pulmonary artery pressure and SVEDP increased from 11 mmHg [IQR 9-15] to 15 mmHg [IQR 12-18] and from 7 mmHg [IQR 4-10] to 11 mmHg [IQR 8-15] (both p < 0.001), respectively, while indexed PVR did not change significantly (2.1 [IQR 1.1-2.4] vs. 1.7 [IQR 1.1-2.5] WU*m2, p = 0.949). Fontan failure-associated mortality during follow-up was substantial (23/48; 48%). CONCLUSIONS Systolic and diastolic ventricular dysfunction are frequent features in late Fontan failure in adults, while increases in PVR were rarely observed. The intricate interplay between hemodynamic compromises in Fontan failure deserves further research to optimize treatment strategies and outcome.
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Affiliation(s)
- Hannes Sallmon
- Department of Pediatric Cardiology, Charité - Universitätsmedizin Berlin, Germany; Department of Congenital Heart Disease/Pediatric Cardiology, German Heart Center Berlin, Germany
| | - Stanislav Ovroutski
- Department of Congenital Heart Disease/Pediatric Cardiology, German Heart Center Berlin, Germany
| | - Anastasia Schleiger
- Department of Congenital Heart Disease/Pediatric Cardiology, German Heart Center Berlin, Germany
| | - Joachim Photiadis
- Department of Congenital Heart Surgery, German Heart Center Berlin, Germany
| | - Sven C Weber
- Department of Pediatric Cardiology, Charité - Universitätsmedizin Berlin, Germany
| | - Johannes Nordmeyer
- Department of Congenital Heart Disease/Pediatric Cardiology, German Heart Center Berlin, Germany
| | - Felix Berger
- Department of Pediatric Cardiology, Charité - Universitätsmedizin Berlin, Germany; Department of Congenital Heart Disease/Pediatric Cardiology, German Heart Center Berlin, Germany; DZHK (German Center for Cardiovascular Research), Partner Site Berlin, Germany
| | - Peter Kramer
- Department of Congenital Heart Disease/Pediatric Cardiology, German Heart Center Berlin, Germany.
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Amedro P, Gavotto A, Abassi H, Picot MC, Matecki S, Malekzadeh-Milani S, Levy M, Ladouceur M, Ovaert C, Aldebert P, Thambo JB, Fraisse A, Humbert M, Cohen S, Baruteau AE, Karsenty C, Bonnet D, Hascoet S. Efficacy of phosphodiesterase type 5 inhibitors in univentricular congenital heart disease: the SV-INHIBITION study design. ESC Heart Fail 2020; 7:747-756. [PMID: 32147955 PMCID: PMC7160497 DOI: 10.1002/ehf2.12630] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2019] [Revised: 01/04/2020] [Accepted: 01/12/2020] [Indexed: 12/14/2022] Open
Abstract
Aims In univentricular hearts, selective lung vasodilators such as phosphodiesterase type 5 (PDE5) inhibitors would decrease pulmonary resistance and improve exercise tolerance. However, the level of evidence for the use of PDE5 inhibitors in patients with a single ventricle (SV) remains limited. We present the SV‐INHIBITION study rationale, design, and methods. Methods and results The SV‐INHIBITION trial is a nationwide multicentre, randomized, double blind, placebo‐controlled, Phase III study, aiming to evaluate the efficacy of sildenafil on the ventilatory efficiency during exercise, in teenagers and adult patients (>15 years old) with an SV. Patients with a mean pulmonary arterial pressure >15 mmHg and a trans‐pulmonary gradient >5 mmHg, measured by cardiac catheterization, will be eligible. The primary outcome is the variation of the VE/VCO2 slope, measured by a cardiopulmonary exercise test, between baseline and 6 months of treatment. A total of 50 patients are required to observe a decrease of 5 ± 5 points in the VE/VCO2 slope, with a power of 90% and an alpha risk of 5%. The secondary outcomes are clinical outcomes, oxygen saturation, 6 min walk test, SV function, NT‐proBNP, peak VO2, stroke volume, mean pulmonary arterial pressure, trans‐pulmonary gradient, SF36 quality of life score, safety, and acceptability. Conclusions The SV‐INHIBITION study aims to answer the question whether PDE5 inhibitors should be prescribed in patients with an SV. This trial has been built focusing on the three levels of research defined by the World Health Organization: disability (exercise tolerance), deficit (SV function), and handicap (quality of life).
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Affiliation(s)
- Pascal Amedro
- Paediatric and Congenital Cardiology Department, M3C Regional Reference CHD Centre, CHU Montpellier, Montpellier, France.,PhyMedExp, CNRS, INSERM, University of Montpellier, CHU Montpellier, Montpellier, France
| | - Arthur Gavotto
- Paediatric and Congenital Cardiology Department, M3C Regional Reference CHD Centre, CHU Montpellier, Montpellier, France
| | - Hamouda Abassi
- Paediatric and Congenital Cardiology Department, M3C Regional Reference CHD Centre, CHU Montpellier, Montpellier, France
| | | | - Stefan Matecki
- Paediatric and Congenital Cardiology Department, M3C Regional Reference CHD Centre, CHU Montpellier, Montpellier, France.,PhyMedExp, CNRS, INSERM, University of Montpellier, CHU Montpellier, Montpellier, France
| | - Sophie Malekzadeh-Milani
- Paediatric Cardiology Department, AP-HP, Necker-Enfants malades, M3C National Reference Centre, Paris Descartes University, Sorbonne Paris Cite, Paris, France
| | - Marilyne Levy
- Paediatric Cardiology Department, AP-HP, Necker-Enfants malades, M3C National Reference Centre, Paris Descartes University, Sorbonne Paris Cite, Paris, France
| | - Magalie Ladouceur
- Adult Congenital Heart Disease Unit, Department of Cardiology, M3C National Reference Centre, European Hospital Georges Pompidou, Paris, France
| | - Caroline Ovaert
- Paediatric and Congenital Medico-Surgical Cardiology Department, M3C Regional Reference Centre, AP-HM, La Timone University Hospital, Marseille, France.,Laboratory of Medical Genetics, INSERM UMR 1251, Aix-Marseille University, Marseille, France
| | - Philippe Aldebert
- Paediatric and Congenital Medico-Surgical Cardiology Department, M3C Regional Reference Centre, AP-HM, La Timone University Hospital, Marseille, France
| | - Jean-Benoit Thambo
- Paediatric and Adult Congenital Heart Disease Department, Hôpital Cardiologique du Haut-Lévêque, M3C National Reference Centre, CHU de Bordeaux, Bordeaux, France
| | - Alain Fraisse
- Pediatric Cardiology Service, Royal Brompton and Harefield Hospital Trust, London, UK
| | - Marc Humbert
- Department of Pulmonology, PH National Reference Centre, APHP, Kremlin-Bicetre, Paris, France.,Paris-Sud Faculty of Medicine, INSERM U999, Marie-Lannelongue Hospital, M3C National Reference Centre, Paris-Sud University, Paris-Saclay, Le Plessis-Robinson, Paris, France
| | - Sarah Cohen
- Paris-Sud Faculty of Medicine, INSERM U999, Marie-Lannelongue Hospital, M3C National Reference Centre, Paris-Sud University, Paris-Saclay, Le Plessis-Robinson, Paris, France
| | - Alban-Elouen Baruteau
- Paediatric and Congenital Cardiology Department, M3C Regional Reference CHD Centre, CHU Nantes, Nantes, France
| | - Clement Karsenty
- Paediatric and Congenital Cardiology Department, M3C Regional Reference CHD Centre, CHU Toulouse, Toulouse, France
| | - Damien Bonnet
- Paediatric Cardiology Department, AP-HP, Necker-Enfants malades, M3C National Reference Centre, Paris Descartes University, Sorbonne Paris Cite, Paris, France
| | - Sebastien Hascoet
- Paris-Sud Faculty of Medicine, INSERM U999, Marie-Lannelongue Hospital, M3C National Reference Centre, Paris-Sud University, Paris-Saclay, Le Plessis-Robinson, Paris, France
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7
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Rutkowski D, Medero R, Ruesink T, Roldan-Alzate A. Modeling Physiological Flow Variation in Fontan Models with 4d Flow Mri, Particle Image Velocimetry, and Arterial Spin Labeling. J Biomech Eng 2019; 141:1065454. [PMID: 31596919 DOI: 10.1115/1.4045110] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2019] [Indexed: 11/08/2022]
Abstract
The Fontan procedure is a successful palliation for single ventricle defect. Yet, a number of complications still occur in Fontan patients due to abnormal blood flow dynamics, necessitating improved flow analysis and treatment methods. Phase-contrast magnetic resonance imaging (MRI) has emerged as a suitable method for such flow analysis. However, limitations on altering physiological blood flow conditions in the patient while in the MRI bore inhibit experimental investigation of a variety of factors that contribute to impaired cardiovascular health in these patients. Furthermore, resolution and flow regime limitations in phase contrast MRI pose a challenge for accurate and consistent flow characterization. In this study, patient-specific physical models were created based on nine Fontan geometries and MRI experiments mimicking low and high flow conditions, as well as steady and pulsatile flow, were conducted. Additionally, an optically transparent Fontan model was created for flow analyses using a particle image velocimetry (PIV) system, arterial spin labeling (ASL), and four-dimensional (4D) flow MRI. Differences, though non-statistically significant, were observed between flow conditions and between patient-specific models. Large between-model variation supported the need for further improvement for patient-specific modeling on each unique Fontan anatomical configuration. Furthermore, high resolution PIV and flow tracking ASL data provided flow information that was not obtainable with 4D flow MRI alone.
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Affiliation(s)
- David Rutkowski
- Mechanical Engineering, University of Wisconsin - Madison, Madison, WI, United States; Radiology, University of Wisconsin - Madison, Madison, WI, United States
| | - Rafael Medero
- Mechanical Engineering, University of Wisconsin - Madison, Madison, WI, United States; Radiology, University of Wisconsin - Madison, Madison, WI, United States
| | - Timothy Ruesink
- Mechanical Engineering, University of Wisconsin - Madison, Madison, WI, United States; Radiology, University of Wisconsin - Madison, Madison, WI, United States
| | - Alejandro Roldan-Alzate
- Mechanical Engineering, University of Wisconsin - Madison, Madison, WI, United States; Radiology, University of Wisconsin - Madison, Madison, WI, United States; Biomedical Engineering, University of Wisconsin - Madison, Madison, WI, United States
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8
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Latus H, Lederle A, Khalil M, Kerst G, Schranz D, Apitz C. Evaluation of pulmonary endothelial function in Fontan patients. J Thorac Cardiovasc Surg 2019; 158:523-531.e1. [DOI: 10.1016/j.jtcvs.2018.11.144] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/10/2018] [Revised: 11/08/2018] [Accepted: 11/22/2018] [Indexed: 11/28/2022]
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Collins JLG, Law MA, Borasino S, Erwin WC, Cleveland DC, Alten JA. Routine Sildenafil Does Not Improve Clinical Outcomes After Fontan Operation. Pediatr Cardiol 2017; 38:1703-1708. [PMID: 28884212 DOI: 10.1007/s00246-017-1716-4] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/29/2017] [Accepted: 08/31/2017] [Indexed: 11/30/2022]
Abstract
Fontan operation can be complicated by persistent chest tube output (CTO) leading to prolonged hospital length of stay (LOS). Postoperative sildenafil administration has been shown to improve clinical outcomes in selected patients after Fontan. We initiated a practice change utilizing intravenous (IV) sildenafil in early postoperative period in all patients undergoing Fontan operation with aim to decrease LOS and CTO. Nineteen patients (February 2014-May 2016) received 0.35 mg/kg sildenafil IV (three doses) followed by enteral, 1 mg/kg every eight hours until hospital discharge. Clinical outcomes were compared to 84 pre-protocol controls. Vital signs were recorded after second sildenafil dose. Demographics were similar between groups. Sildenafil group had longer median LOS [9 (7, 11) vs. 13 (8, 25) days, p = 0.016]. CTO days were longer [6 (5, 8) vs. 8 (6, 13) days, p = 0.011]. Sildenafil group had longer mechanical ventilation [6.9 (3.5, 11.1) vs. 4 (2, 7) h, p = 0.045] and longer oxygen therapy [99 (52, 225) vs. 14.5 (14, 56) h, p = 0.001]. There was a trend towards more albumin 5% resuscitation in first 24 h [17 (1, 30) vs. 21 (10, 40) ml/kg, p = 0.069]. There was no difference in inotrope score at 24 h, maximum lactate, or fluid balance. Readmission rates were similar. There was no mortality. IV sildenafil was well tolerated, and no doses were held. Routine early administration of sildenafil after Fontan operation is not associated with an improvement in any measured clinical outcome, including postoperative CTO, LOS, colloid administration, or duration of mechanical ventilation.
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Affiliation(s)
- J Leslie Gaddis Collins
- Division of Pediatric Cardiology, University of Alabama at Birmingham, Birmingham, AL, 35233, USA
| | - Mark A Law
- Division of Pediatric Cardiology, University of Alabama at Birmingham, Birmingham, AL, 35233, USA
| | - Santiago Borasino
- Division of Pediatric Cardiology, Section of Cardiac Critical Care, University of Alabama at Birmingham, Birmingham, AL, 35233, USA
| | - W Clinton Erwin
- School of Medicine, University of Alabama at Birmingham, Birmingham, AL, 35233, USA
| | - David C Cleveland
- Division of Cardiothoracic Surgery, University of Alabama at Birmingham, Birmingham, AL, 35233, USA
| | - Jeffrey A Alten
- Division of Pediatric Cardiology, Section of Cardiac Critical Care, University of Alabama at Birmingham, Birmingham, AL, 35233, USA. .,Section of Pediatric Cardiac Critical Care Medicine, University of Alabama at Birmingham, 1600 5th Avenue South, Children's Park Place Suite 210, Birmingham, AL, 35233, USA.
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10
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Sildenafil in Infants and Children. CHILDREN-BASEL 2017; 4:children4070060. [PMID: 28737730 PMCID: PMC5532552 DOI: 10.3390/children4070060] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 05/17/2017] [Revised: 07/08/2017] [Accepted: 07/21/2017] [Indexed: 11/19/2022]
Abstract
Pulmonary arterial hypertension (PAH) management has been transformed in recent times with the advent of cheap and effective diagnostic tools and therapy. Sildenafil, a phosphodiesterase-V inhibitor, has been at the centre of this treatment, and its success in treating PAH has led to its widespread uptake in adult and paediatric pulmonary hypertension (PH), as a first line treatment choice. This might apply to persistent pulmonary hypertension of the newborn (PPHN) or bronchopulmonary dysplasia, as well as to more complex diseases, such as idiopathic pulmonary hypertension. Although recent data regarding long-term mortality and the repeal of Food and Drug Administration (FDA) approval has complicated the issue, Sildenafil continues to be the major treatment option for paediatric PH for patients in a variety of contexts, and this does not seem likely to change in the foreseeable future. In this review, we provide a summary of pulmonary hypertension in infants and children and the use of Sildenafil for such diseases.
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11
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Gurvitz M, Burns KM, Brindis R, Broberg CS, Daniels CJ, Fuller SMPN, Honein MA, Khairy P, Kuehl KS, Landzberg MJ, Mahle WT, Mann DL, Marelli A, Newburger JW, Pearson GD, Starling RC, Tringali GR, Valente AM, Wu JC, Califf RM. Emerging Research Directions in Adult Congenital Heart Disease: A Report From an NHLBI/ACHA Working Group. J Am Coll Cardiol 2016; 67:1956-64. [PMID: 27102511 DOI: 10.1016/j.jacc.2016.01.062] [Citation(s) in RCA: 74] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/25/2015] [Revised: 12/21/2015] [Accepted: 01/25/2016] [Indexed: 12/20/2022]
Abstract
Congenital heart disease (CHD) is the most common birth defect, affecting about 0.8% of live births. Advances in recent decades have allowed >85% of children with CHD to survive to adulthood, creating a growing population of adults with CHD. Little information exists regarding survival, demographics, late outcomes, and comorbidities in this emerging group, and multiple barriers impede research in adult CHD. The National Heart, Lung, and Blood Institute and the Adult Congenital Heart Association convened a multidisciplinary working group to identify high-impact research questions in adult CHD. This report summarizes the meeting discussions in the broad areas of CHD-related heart failure, vascular disease, and multisystem complications. High-priority subtopics identified included heart failure in tetralogy of Fallot, mechanical circulatory support/transplantation, sudden cardiac death, vascular outcomes in coarctation of the aorta, late outcomes in single-ventricle disease, cognitive and psychiatric issues, and pregnancy.
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Affiliation(s)
- Michelle Gurvitz
- Harvard Medical School, Boston Adult Congenital Heart and Pulmonary Hypertension Program, Boston Children's Hospital and Brigham and Women's Hospital, Boston, Massachusetts.
| | - Kristin M Burns
- National Heart, Lung, and Blood Institute, Bethesda, Maryland
| | | | | | | | | | | | - Paul Khairy
- Universite de Montreal, Montreal, Quebec, Canada
| | | | - Michael J Landzberg
- Harvard Medical School, Boston Adult Congenital Heart and Pulmonary Hypertension Program, Boston Children's Hospital and Brigham and Women's Hospital, Boston, Massachusetts
| | | | | | - Ariane Marelli
- McGill University Health Center, Montreal, Quebec, Canada
| | - Jane W Newburger
- Harvard Medical School, Boston Children's Hospital, Boston, Massachusetts
| | - Gail D Pearson
- National Heart, Lung, and Blood Institute, Bethesda, Maryland
| | | | | | - Anne Marie Valente
- Harvard Medical School, Boston Adult Congenital Heart and Pulmonary Hypertension Program, Boston Children's Hospital and Brigham and Women's Hospital, Boston, Massachusetts
| | - Joseph C Wu
- Stanford University School of Medicine, Palo Alto, California
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12
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Javed W, Chaggar PS, Venkateswaran R, Shaw SM. Prolonged asystole in a patient with an isolated left ventricular assist device. Future Cardiol 2016; 12:533-8. [DOI: 10.2217/fca-2016-0022] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
Left ventricular assist devices (LVADs) are well established in the management of end-stage heart failure as either destination therapy, a bridge prior to cardiac transplantation or during myocardial recovery. Despite LVADs requiring adequate left ventricular preload to effectively augment systemic circulation, there have been rare cases of patients with LVADs surviving sustained, normally fatal arrhythmias, such as ventricular fibrillation and asystole. Whilst current reports describe an LVAD patient surviving 15 days with such an arrhythmia, we describe the case of a patient with an LVAD surviving 104 days of asystole via a Fontan mechanism of circulation, which we believe is the longest known survival of a sustained fatal arrhythmia. This case highlights the physiology of circulations supported by LVADs and the unique challenges that may arise in managing ambulant LVAD patients, such as predicting prognosis. Given the increasing use of LVADs to treat end-stage heart failure, these issues are likely to become more frequently encountered in the future.
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Affiliation(s)
- Wasim Javed
- Lancashire Teaching Hospitals NHS Foundation Trust, Preston, UK
| | | | | | - Steven M Shaw
- The Transplant Centre, Wythenshawe Hospital, Manchester, UK
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13
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Latus H, Gerstner B, Kerst G, Moysich A, Gummel K, Apitz C, Bauer J, Schranz D. Effect of Inhaled Nitric Oxide on Blood Flow Dynamics in Patients After the Fontan Procedure Using Cardiovascular Magnetic Resonance Flow Measurements. Pediatr Cardiol 2016; 37:504-11. [PMID: 26547436 DOI: 10.1007/s00246-015-1307-1] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/29/2015] [Accepted: 11/02/2015] [Indexed: 10/22/2022]
Abstract
Invasive hemodynamic studies have shown that nitric oxide (NO), a selective pulmonary vasodilator, can lower pulmonary vascular resistance in Fontan patients. Because oximetry-derived flow quantification may be unreliable, we sought to detect changes in blood flow within the Fontan circulation after inhalation of NO using cardiovascular magnetic resonance (CMR). Thirty-three patients (mean age 12.8 ± 7.0 years) after the Fontan procedure underwent CMR as part of their routine clinical assessment. Standard two-dimensional blood flow measurements were performed in the Fontan tunnel, superior vena cava (SVC) and ascending aorta (AAO) before and after inhalation of 40 ppm NO for 8-10 min. Systemic-to-pulmonary collateral (SPC) flow was calculated as AAO - (SVC + tunnel). Heart rate (82 ± 18 to 81 ± 18 bpm; p = 0.31) and transcutaneous oxygen saturations (93 ± 4 to 94 ± 3 %; p = 0.13) did not change under NO inhalation. AAO flow (3.23 ± 0.72 to 3.12 ± 0.79 l/min/m(2); p = 0.08) decreased, tunnel flow (1.58 ± 0.40 to 1.65 ± 0.46 l/min/m(2); p = 0.032) increased, and SVC flow (1.01 ± 0.39 to 1.02 ± 0.40 l/min/m(2); p = 0.50) remained unchanged resulting in higher total caval flow (Qs) (2.59 ± 0.58 to 2.67 ± 0.68 l/min/m(2); p = 0.038). SPC flow decreased significantly from 0.64 ± 0.52 to 0.45 ± 0.51 l/min/m(2) (p = 0.002) and resulted in a significant decrement of the Qp/Qs ratio (1.23 ± 0.23 to 1.15 ± 0.23; p = 0.001). Inhalation of NO in Fontan patients results in significant changes in pulmonary and systemic blood flow. The reduction in SPC flow is accompanied by a net increase in effective systemic blood flow suggesting beneficial effects of pulmonary vasodilators on cardiac output, tissue perfusion and exercise capacity.
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Affiliation(s)
- Heiner Latus
- Pediatric Heart Center, Justus-Liebig-University of Giessen, Feulgenstr. 12, 35392, Giessen, Germany.
| | - Bettina Gerstner
- Pediatric Heart Center, Justus-Liebig-University of Giessen, Feulgenstr. 12, 35392, Giessen, Germany
| | - Gunter Kerst
- Pediatric Heart Center, Justus-Liebig-University of Giessen, Feulgenstr. 12, 35392, Giessen, Germany
| | - Axel Moysich
- Pediatric Heart Center, Justus-Liebig-University of Giessen, Feulgenstr. 12, 35392, Giessen, Germany
| | - Kerstin Gummel
- Pediatric Heart Center, Justus-Liebig-University of Giessen, Feulgenstr. 12, 35392, Giessen, Germany
| | - Christian Apitz
- Pediatric Heart Center, Justus-Liebig-University of Giessen, Feulgenstr. 12, 35392, Giessen, Germany
| | - Juergen Bauer
- Pediatric Heart Center, Justus-Liebig-University of Giessen, Feulgenstr. 12, 35392, Giessen, Germany
| | - Dietmar Schranz
- Pediatric Heart Center, Justus-Liebig-University of Giessen, Feulgenstr. 12, 35392, Giessen, Germany
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14
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Schicchi N, Secinaro A, Muscogiuri G, Ciliberti P, Leonardi B, Santangelo T, Napolitano C, Agliata G, Basile MC, Guidi F, Tomà P, Giovagnoni A. Multicenter review: role of cardiovascular magnetic resonance in diagnostic evaluation, pre-procedural planning and follow-up for patients with congenital heart disease. Radiol Med 2015; 121:342-51. [DOI: 10.1007/s11547-015-0608-z] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2015] [Accepted: 11/16/2015] [Indexed: 01/21/2023]
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15
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Control of respiration-driven retrograde flow in the subdiaphragmatic venous return of the Fontan circulation. ASAIO J 2015; 60:391-9. [PMID: 24814833 DOI: 10.1097/mat.0000000000000093] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
Respiration influences the subdiaphragmatic venous return in the total cavopulmonary connection (TCPC) of the Fontan circulation whereby both the inferior vena cava (IVC) and hepatic vein flows can experience retrograde motion. Controlling retrograde flows could improve patient outcomes. Using a patient-specific model within a Fontan mock circulatory system with respiration, we inserted a valve into the IVC to examine its effects on local hemodynamics while varying retrograde volumes by changing vascular impedances. A bovine valved conduit reduced IVC retrograde flow to within 3% of antegrade flow in all cases. The valve closed only under conditions supporting retrograde flow and its effects on local hemodynamics increased with larger retrograde volume. Liver and TCPC pressures improved only when the valve leaflets were closed whereas cycle-averaged pressures improved only slightly (<1 mm Hg). Increased pulmonary vascular resistance raised mean circulation pressures, but the valve functioned and cardiac output improved and stabilized. Power loss across the TCPC improved by 12%-15% (p < 0.05) with a valve. The effectiveness of valve therapy is dependent on patient vascular impedance.
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16
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Derk G, Houser L, Miner P, Williams R, Moriarty J, Finn P, Alejos J, Aboulhosn J. Efficacy of endothelin blockade in adults with Fontan physiology. CONGENIT HEART DIS 2015; 10:E11-6. [PMID: 24890846 DOI: 10.1111/chd.12189] [Citation(s) in RCA: 36] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/11/2014] [Indexed: 11/28/2022]
Abstract
OBJECTIVE Phosphodiesterase-5 inhibitors have shown to improve cardiac output and functional capacity in Fontan patients. We sought to test the efficacy and safety of endothelin blockade with bosentan in adult patients with Fontan physiology. DESIGN Ten patients were enrolled and seven patients completed this single-center open-label clinical trial. Patients were treated with bosentan for 4 months. Cardiac magnetic resonance imaging (MRI), 6-minute walking distance (6MWD), brain natriuretic peptide, and New York Heart Association functional class were compared before and after treatment using paired t-test. RESULTS The 6MWD improved by 73 m, from a mean of 435 m (standard deviation [SD] = 92, standard error [SE] = 35) to 508 m (SD = 93, SE = 35) (P = .03). MRI resting aortic flow increased from 3.3 L/minute (SD = 1.27, SE = 0.73) to 4.4 L/minute (SD = 0.9, SE = 0.54) (P = .03). New York Heart Association class was unchanged in three patients, improved in three patients and worsened in one patient. Brain natriuretic peptide, aspartate aminotransferase, and alanine aminotransferase did not change significantly. Of the three patients with elevated baseline bilirubin, two normalized at the completion of the study, while the other was unchanged. Mean duration of therapy was 4.1 ± 0.51 months. Three adverse advents occurred. One patient complained of fatigue and chest pain after 87 days and withdrew from the study. After extensive workup, it was determined that her symptoms were not related to treatment. The second patient suffered palpitations and fatigue after 75 days; no concerning arrhythmias were identified and symptoms improved with increased antiarrhythmic dose. The third patient developed fatigue on therapy and decided to stop therapy; fatigue improved following drug discontinuation. There were no deaths or hospitalizations. CONCLUSIONS In this cohort of adult patients with Fontan physiology, endothelin blockade with bosentan resulted in improved 6MWD and MRI-derived resting cardiac output, suggesting a positive effect on pulmonary vascular resistance and pulmonary blood flow. Bosentan was well tolerated and hepatic function was not adversely affected.
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Affiliation(s)
- Gwendolyn Derk
- Ahmanson/UCLA Adult Congenital Heart Disease, University of California Los Angeles, Los Angeles, Calif, USA
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Kim YH, Chae MH, Choi DY. Inhaled iloprost for the treatment of patient with Fontan circulation. KOREAN JOURNAL OF PEDIATRICS 2014; 57:461-3. [PMID: 25379048 PMCID: PMC4219950 DOI: 10.3345/kjp.2014.57.10.461] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/09/2013] [Revised: 10/13/2013] [Accepted: 10/20/2013] [Indexed: 11/27/2022]
Abstract
Decreased exercise capacity after Fontan surgery is relatively common and the failure of the Fontan state gradually increases with age. However, there is no further treatment for patients with Fontan circulation. Pulmonary vasodilation therapy is an effective method to solve this problem because pulmonary vascular resistance is a major factor of the Fontan problem. Inhaled iloprost is a chemically stable prostacyclin analogue and a potent pulmonary vasodilator. We experienced two cases of Fontan patients treated with inhaled iloprost for 12 weeks. The first patient was an 18-year-old female with pulmonary atresia with an intact ventricular septum, and the second patient was a 22-year-old male with a double outlet right ventricle. Fifteen years have passed since both patients received Fontan surgery. While the pulmonary pressure was not decreased significantly, improved exercise capacity and cardiac output were observed without any major side effects in both patients. The iloprost inhalation therapy was well tolerated and effective for the symptomatic treatment of Fontan patients.
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Affiliation(s)
- Yong Hyun Kim
- Department of Pediatrics, Gachon University Gil Medical Center, Incheon, Korea
| | - Moon Hee Chae
- Department of Pediatrics, Gachon University Gil Medical Center, Incheon, Korea
| | - Deok Young Choi
- Department of Pediatrics, Gachon University Gil Medical Center, Incheon, Korea
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18
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Beghetti M, Wacker Bou Puigdefabregas J, Merali S. Sildenafil for the treatment of pulmonary hypertension in children. Expert Rev Cardiovasc Ther 2014; 12:1157-84. [DOI: 10.1586/14779072.2014.958077] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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19
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Influence of Pulmonary Artery Size on Early Outcome After the Fontan Operation. Ann Thorac Surg 2014; 97:1387-93. [DOI: 10.1016/j.athoracsur.2013.11.068] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/28/2013] [Revised: 11/19/2013] [Accepted: 11/25/2013] [Indexed: 11/18/2022]
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20
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Predictors of sildenafil effects on exercise capacity in adolescents and adults with Fontan circulation. Clin Res Cardiol 2014; 103:641-6. [PMID: 24639042 DOI: 10.1007/s00392-014-0694-2] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/02/2013] [Accepted: 02/26/2014] [Indexed: 10/25/2022]
Abstract
OBJECTIVE A single dose of sildenafil improves exercise capacity in Fontan patients. However, a recent study failed to show a long-term effect of sildenafil. This study evaluated whether there are factors that might predict sildenafil effects. METHODS We studied 36 patients (16-42 years, 14 female) with univentricular heart after various modifications of the Fontan surgery (13 APC, 16 AVC, 7 TCPC). They performed two cardiopulmonary exercise tests, with at least 120 min rest and a single dose of 50 mg sildenafil in between. RESULTS After sildenafil administration, patients improved their peak oxygen uptake from 64.5 to 67.3 % predicted (p = 0.0003) without change in ventilatory efficiency ([Formula: see text] slope), oxygen saturation (SpO2) at rest or at peak exercise, respiratory exchange ratio. In addition, resting systolic blood pressure was slightly reduced after sildenafil administration. There was a moderate negative correlation of this improvement to baseline peak oxygen uptake (r = -0.395; p = 0.017). The change in peak oxygen uptake could not be correlated to time of surgery, type of surgery, NT-pro-BNP, or to other clinical data. Nevertheless, all four patients with NT-pro-BNP levels higher than 1,000 pg/ml had the most prominent improvements in exercise capacity. CONCLUSIONS Fontan patients have an improved exercise capacity after a single dose of sildenafil. Patients with worse baseline peak oxygen uptake profit more.
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Takatsuki S, Ivy DD. Current challenges in pediatric pulmonary hypertension. Semin Respir Crit Care Med 2013; 34:627-44. [PMID: 24037630 DOI: 10.1055/s-0033-1356461] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/23/2023]
Abstract
Pulmonary arterial hypertension (PAH) in the pediatric population is associated with a variety of underlying diseases and causes, significantly morbidity and mortality. In the majority of patients, PAH in children is idiopathic or associated with congenital heart disease (CHD), with pulmonary hypertension (PH) associated with connective tissue disease, a rare cause in children. Classification of pediatric PH has generally followed the WHO classification, but recognition of the importance of fetal origins of PH and developmental abnormalities have led to the formation of a new pediatric-specific classification. Incidence data from the Netherlands has revealed an annual incidence and point prevalence of 0.7 and 4.4 for idiopathic PAH and 2.2 and 15.6 for associated pulmonary arterial hypertension-CHD cases per million children. Although the treatment with new selective pulmonary vasodilators offers hemodynamic and functional improvement in pediatric populations, the treatments in children largely depend on results from evidence-based adult studies and experience of clinicians treating children. A recent randomized clinical trial of sildenafil and its long-term extension has led to disparate recommendations in the United States and Europe.
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Affiliation(s)
- Shinichi Takatsuki
- Department of Pediatrics, University of Colorado School of Medicine, Children's Hospital Colorado, Aurora, Colorado
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23
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Gewillig M. Clinical research to optimize the Fontan concept: a long, difficult, but rewarding, journey. Eur J Cardiothorac Surg 2012; 43:154-5. [PMID: 22872441 DOI: 10.1093/ejcts/ezs378] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
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Affiliation(s)
- Shakeel A Qureshi
- Evelina Children’s Hospital, 6th Floor, Westminster Bridge Road, London, SE1 7EH, UK
| | - Lee Benson
- Cardiac Diagnostic & Interventional Unit Cardiology, The Hospital for Sick Children, University of Toronto, 555 University Avenue, Toronto, Ontario M5G 1X8, Canada
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