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Kim YY, Lluri G, Haeffele C, Daugherty T, Krasuski RA, Serfas JD, de Freitas RA, Porlier A, Lubert AM, Wu FM, Valente AM, Krieger EV, Buber J, Rodriguez FH, Gaignard S, Saraf A, Hindes M, Earing MG, Lewis MJ, Rosenbaum MS, Zaidi AN, Hopkins K, Bradley EA, Cedars AM, Ko JL, Franklin WJ, Frederickson A, Ginde S, Grewal J, Nyman A, Min J, Schluger C, Rand E, Rosenthal BE, Hilscher M, Rychik J, Hoteit MA. Hepatocellular carcinoma in survivors after Fontan operation: a case-control study. Eur Heart J 2024; 45:1477-1480. [PMID: 38085593 DOI: 10.1093/eurheartj/ehad788] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/30/2023] [Accepted: 11/16/2023] [Indexed: 01/25/2024] Open
Affiliation(s)
- Yuli Y Kim
- Division of Cardiology, Hospital of the University of Pennsylvania, Perelman Center for Advanced Medicine, 2nd Floor E. Pavilion, 3400 Civic Center Boulevard, Philadelphia, PA 19104, USA
- Division of Cardiology, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Gentian Lluri
- Ahmanson/UCLA Adult Congenital Heart Disease Center, Division of Cardiology, Department of Medicine, University of California Los Angeles, Los Angeles, CA, USA
| | | | - Tami Daugherty
- Division of Cardiovascular Medicine, Stanford Medicine, Stanford, CA, USA
| | | | | | - R Andrew de Freitas
- Division of Pediatric Cardiology, Anne & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL, USA
| | - Avaliese Porlier
- Division of Pediatric Cardiology, Anne & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL, USA
| | - Adam M Lubert
- Cincinnati Children's Hospital Heart Institute, Department of Pediatrics, University of Cincinnati, Cincinnati, OH, USA
| | - Fred M Wu
- Division of Cardiology, Department of Medicine, Brigham and Women's Hospital, Boston, MA, USA
- Department of Cardiology, Boston Children's Hospital, Boston, MA, USA
| | - Anne Marie Valente
- Division of Cardiology, Department of Medicine, Brigham and Women's Hospital, Boston, MA, USA
- Department of Cardiology, Boston Children's Hospital, Boston, MA, USA
| | - Eric V Krieger
- University of Washington Medical Center, University of Washington School of Medicine, Seattle, WA, USA
- Seattle Children's Hospital, Seattle, WA, USA
| | - Jonathan Buber
- University of Washington Medical Center, University of Washington School of Medicine, Seattle, WA, USA
| | | | - Scott Gaignard
- Department of Pediatrics, Emory University, Atlanta, GA, USA
| | - Anita Saraf
- Department of Pediatrics, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Morgan Hindes
- Department of Pediatrics, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | | | - Matthew J Lewis
- Division of Cardiology, Columbia University Irving Medical Center, NewYork, NY, USA
| | - Marlon S Rosenbaum
- Division of Cardiology, Columbia University Irving Medical Center, NewYork, NY, USA
| | - Ali N Zaidi
- Mount Sinai Adult Congenital Heart Disease Center, Mount Sinai Heart, NewYork, NY, USA
| | - Kali Hopkins
- Mount Sinai Adult Congenital Heart Disease Center, Mount Sinai Heart, NewYork, NY, USA
| | - Elisa A Bradley
- Division of Cardiovascular Medicine, The Ohio State University, Columbus, OH, USA
| | - Ari M Cedars
- Department of Pediatrics, Johns Hopkins Department of Medicine, Baltimore, MD, USA
| | - Jong L Ko
- Department of Pediatrics, Johns Hopkins Department of Medicine, Baltimore, MD, USA
| | - Wayne J Franklin
- Division of Pediatric Cardiology, Phoenix Children's Hospital, Phoenix, AZ, USA
- Department of Child Health, University of Arizona College of Medicine-Phoenix, Phoenix, AZ, USA
| | - Abby Frederickson
- Division of Pediatric Cardiology, Phoenix Children's Hospital, Phoenix, AZ, USA
| | - Salil Ginde
- Department of Pediatrics, Children's Hospital of Wisconsin, Milwaukee, WI, USA
| | - Jasmine Grewal
- Division of Cardiology, St.Paul's Hospital, University of British Columbia, Vancouver, BC, Canada
| | - Annique Nyman
- Division of Cardiology, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Jungwon Min
- Department of Biomedical and Health Informatics, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Charlotte Schluger
- Department of Biomedical and Health Informatics, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Elizabeth Rand
- Division of Hepatology, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Benjamin E Rosenthal
- Department of Medicine, Hospital of the University of Pennsylvania, Philadelphia, PA, USA
| | - Moira Hilscher
- Division of Hepatology, Hospital of the University of Pennsylvania, Philadelphia, PA, USA
| | - Jack Rychik
- Division of Cardiology, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Maarouf A Hoteit
- Division of Hepatology, Hospital of the University of Pennsylvania, Philadelphia, PA, USA
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Alemany VS, Crawford A, Gauvreau K, Bucholz EM, del Nido PJ, Schidlow DN, Nathan M. Early and long-term outcomes following cardiac surgery for patients with heterotaxy syndrome. JTCVS Open 2024; 18:167-179. [PMID: 38690436 PMCID: PMC11056491 DOI: 10.1016/j.xjon.2024.02.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/06/2023] [Revised: 12/17/2023] [Accepted: 02/06/2024] [Indexed: 05/02/2024]
Abstract
Objective Heterotaxy syndrome is a complex multisystem abnormality historically associated with high morbidity and mortality. We sought to evaluate the early and long-term outcomes after cardiac surgery in heterotaxy syndrome. Methods This is a single-center retrospective review of patients with heterotaxy syndrome undergoing single-ventricle palliation or primary or staged biventricular repair from 1998 to 2018. Patients were stratified by single ventricle versus biventricular physiology, and the severity of atrioventricular valve regurgitation. Demographics, anatomic characteristics, and early and late outcomes, including the length of stay, mortality, and surgical or catheter reinterventions, were analyzed. Results Among 250 patients, 150 (60%) underwent biventricular repair. In-hospital mortality was 7.6% (n = 19). Median follow-up was 5.2 (range, 0-16) years. Among survivors to discharge, mortality was 19% (n = 44) and reintervention was 52% (n = 120). Patients with moderate/severe atrioventricular valve regurgitation were older (32 vs 16 months, P = .02), were more likely to experience adverse events during their index surgical admission (72% vs 46%, P < .001), and had longer in-hospital length of stay (20 vs 12 days, P = .009). Among patients with moderate to severe atrioventricular valve regurgitation, single-ventricle palliation is associated with a greater risk of unplanned reintervention compared with patients undergoing biventricular repair (hazard ratio, 2.13; CI, 1.10-4.12; P = .025). Conclusions There was no significant difference in early or late outcomes in single-ventricle versus biventricular repair strategies in heterotaxy. In the subgroup of patients with moderate/severe atrioventricular valve regurgitation, patients who underwent single-ventricle palliation were 2.5 times more likely to need a late reintervention compared with those undergoing biventricular repair.
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Affiliation(s)
- Victor S. Alemany
- Department of Cardiac Surgery, Boston Children's Hospital, Boston, Mass
| | - Alexis Crawford
- Department of Cardiac Surgery, Boston Children's Hospital, Boston, Mass
| | - Kimberlee Gauvreau
- Department of Cardiology, Boston Children's Hospital, Boston, Mass
- Department of Biostatistics, Harvard School of Public Health, Boston, Mass
| | - Emily M. Bucholz
- Department of Cardiology, Boston Children's Hospital, Boston, Mass
| | - Pedro J. del Nido
- Department of Cardiac Surgery, Boston Children's Hospital, Boston, Mass
- Department of Surgery, Harvard Medical School, Boston, Mass
| | - David N. Schidlow
- Department of Cardiology, Boston Children's Hospital, Boston, Mass
- Department of Pediatrics, Harvard Medical School, Boston, Mass
| | - Meena Nathan
- Department of Cardiac Surgery, Boston Children's Hospital, Boston, Mass
- Department of Surgery, Harvard Medical School, Boston, Mass
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Alsoufi B, Kozik D, Perrotta M, Wilkens S, Lambert AN, Deshpande S, Slaughter M, Trivedi J. Trends and outcomes of heart transplantation in adults with congenital heart disease. Eur J Cardiothorac Surg 2024; 65:ezae086. [PMID: 38447194 DOI: 10.1093/ejcts/ezae086] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/18/2023] [Revised: 02/09/2024] [Accepted: 03/05/2024] [Indexed: 03/08/2024] Open
Abstract
OBJECTIVES Heart transplantation for adult congenital heart disease is complicated and associated with challenging pretransplant support, long waiting and high early post-transplant mortality. We explored if surgical and medical advances and allocation system changes have affected outcomes. METHODS From United Network for Organ Sharing database, adults with congenital heart disease listed for heart transplantation were queried. To explore practice and outcome trends, patients were divided into 4 eras (eras 1-3: nearly 3 equal periods from 1992 to 2018, era 4: after 2018, corresponding with new allocation system). Univariate and multivariable analysis was performed to evaluate outcomes. RESULTS A total of 2737 patients were listed. There was gradual increase in listed and transplanted patients, along with significant increase in use of mechanical support, simultaneous kidney and liver transplantation. While proportion of transplanted remained constant, there was decrease in proportion delisted/died after listing (P = 0.01) and waiting list duration (P = 0.01), especially in era 4. Thirty-day post-transplant mortality remains high; however, it has significantly improved starting era 3 (P = 0.01). Current survival at 1-year and 5-years is 85% and 65%, with improvement mainly related to decreased early death. On multivariable analysis, factors associated with survival were lower glomerular filtration rate (hazard ratio = 0.99, P = 0.042), bilirubin (hazard ratio = 1.17, P<0.001) and mechanical ventilation (hazard ratio = 2.3, P=0.004). CONCLUSIONS Heart transplantation in adults with congenital heart disease is increasing, along with added complexity, higher usage of pretransplant mechanical support and simultaneous organ transplantation. Despite that, more complex patients do not experience worse outcomes. Early mortality improved but remains high. New donor allocation system allowed shorter waiting time and higher proportion transplanted without altering early mortality.
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Affiliation(s)
- Bahaaldin Alsoufi
- Department of Cardiothoracic Surgery, University of Louisville and Norton Children's Hospital, Louisville, KY, USA
| | - Deborah Kozik
- Department of Cardiothoracic Surgery, University of Louisville and Norton Children's Hospital, Louisville, KY, USA
| | - Melissa Perrotta
- Department of Pediatrics, University of Louisville and Norton Children's Hospital, Louisville, KY, USA
| | - Sarah Wilkens
- Department of Pediatrics, University of Louisville and Norton Children's Hospital, Louisville, KY, USA
| | - Andrea Nicole Lambert
- Department of Pediatrics, University of Louisville and Norton Children's Hospital, Louisville, KY, USA
| | - Shriprasad Deshpande
- Department of Cardiology and Cardiac Critical Care, Children's National Hospital, Washington, DC, USA
| | - Mark Slaughter
- Department of Cardiothoracic Surgery, University of Louisville and Norton Children's Hospital, Louisville, KY, USA
| | - Jaimin Trivedi
- Department of Cardiothoracic Surgery, University of Louisville and Norton Children's Hospital, Louisville, KY, USA
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Miwa K, Tsumura S, Kanaya T, Kido T, Tominaga Y, Kawai S, Teguri Y. Impact of the Rudimentary Chamber on Outcomes in Fontan Patients. World J Pediatr Congenit Heart Surg 2024:21501351241227882. [PMID: 38404011 DOI: 10.1177/21501351241227882] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/27/2024]
Abstract
Background: We sought to evaluate the influence of the rudimentary ventricle on long-term outcomes after the Fontan operation, focusing on exercise capacity and cardiac performance. Methods: Between 1995 and 2021, 290 patients underwent a total cavopulmonary connection. "Two-ventricle" Fontan circulation was defined as a rudimentary ventricle >30% of the dominant ventricle or >50% of its predicted normal value. This cohort was compared with patients with single-ventricle Fontan circulation. The primary endpoint was Fontan failure, and the secondary endpoints were VO2 and cardiac catheterization data at ten years postoperatively. Results: The median follow-up after the Fontan operation was 7.9 years (interquartile range: 1.9-13.9). No significant difference was found in Fontan failure-free survival between the "two-ventricle" Fontan circulation group and the single-ventricle Fontan circulation group (83/91, 93% vs 156/199, 78%), respectively at 20 years; P = .11). No significant difference was found in VO2 or cardiac performance except cardiac index, with 2.9 (2.3-4.8) versus 2.5 (2.3-4.3) L/min/m2 (P = .047). Fifty-one patients in the "two-ventricle" Fontan circulation group were followed up for over ten years after the Fontan operation. In the subgroup analysis of this cohort, the rudimentary ventricular end-diastolic volume/dominant ventricular end-diastolic volume ratio showed a significant positive correlation with dominant ventricular end-diastolic pressure (r = 0.58 [95% CI 0.35-0.74], P = .002) and a significant negative correlation with VO2 (r = -0.61 [95% CI -0.80 to -0.28], P = .001). Conclusions: The rudimentary ventricle was not significantly associated with any clinical disadvantages regarding Fontan failure. However, a large rudimentary ventricle was significantly associated with higher end-diastolic pressure and lower exercise capacity.
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Affiliation(s)
- Koji Miwa
- Department of Cardiovascular Surgery, Osaka Women's and Children's Hospital, Izumi, Osaka, Japan
| | - Sanae Tsumura
- Department of Cardiovascular Surgery, Osaka Women's and Children's Hospital, Izumi, Osaka, Japan
| | - Tomomitsu Kanaya
- Department of Cardiovascular Surgery, Osaka Women's and Children's Hospital, Izumi, Osaka, Japan
| | - Takashi Kido
- Department of Cardiovascular Surgery, Osaka Women's and Children's Hospital, Izumi, Osaka, Japan
| | - Yuji Tominaga
- Department of Cardiovascular Surgery, Osaka Women's and Children's Hospital, Izumi, Osaka, Japan
| | - Shota Kawai
- Department of Cardiovascular Surgery, Osaka Women's and Children's Hospital, Izumi, Osaka, Japan
| | - Yuta Teguri
- Department of Cardiovascular Surgery, Osaka Women's and Children's Hospital, Izumi, Osaka, Japan
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Sakamoto I, Yamamura K, Ishikita A, Nagata H, Umemoto S, Nishizaki A, Kakino T, Ide T, Tsutsui H. Oxygen inhalation decreases the central venous pressure in adult patients late after Fontan operations. J Cardiol 2024:S0914-5087(24)00036-4. [PMID: 38401702 DOI: 10.1016/j.jjcc.2024.02.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/08/2023] [Revised: 02/15/2024] [Accepted: 02/16/2024] [Indexed: 02/26/2024]
Abstract
BACKGROUND Elevated central venous pressure (CVP) and decreased arterial oxygen saturation (SaO2) are the characteristics of patients after Fontan operations and determine morbidity and mortality in the long-term. Oxygen inhalation therapy theoretically increases SaO2 and may decrease the elevated CVP in these patients. However, there is no previous study to support this hypothesis. This study aimed to determine the acute effects of oxygen inhalation on the hemodynamics of adult patients late after Fontan operations using cardiac catheterization. METHODS This study enrolled 58 consecutive adult patients (median age, 30 years; female, n = 24) who had undergone Fontan operations. We assessed the hemodynamic changes during oxygen inhalation (2 L/min) with a nasal cannula in cardiac catheterization. We divided the studied patients into two groups according to the reduction in CVP during oxygen inhalation using the median value: responders (>2 mmHg) and non-responders (≤2 mmHg). Clinical characteristics of the responders to oxygen inhalation were investigated with uni- and multivariate analyses. RESULTS SaO2 increased from 93.3 % (91.3-94.5 %) to 97.5 % (95.2-98.4 %) (p < 0.001) and CVP decreased from 12 mmHg (11-14 mmHg) to 10 mmHg (9-12 mmHg) (p < 0.001) after oxygen inhalation. There was a weak but significant correlation between the increase in SaO2 and the decrease in CVP (R = 0.29, p = 0.025). Pulmonary blood flow increased from 4.1 L/min (3.5-5.0 L/min) to 4.4 L/min (3.7-5.3 L/min) (p = 0.007), while systemic blood flow showed no significant changes. A multivariate analysis revealed that high baseline CVP was associated with a larger decrease in CVP (>2 mmHg) after oxygen inhalation. CONCLUSIONS Oxygen inhalation increased SaO2 and decreased CVP, especially in patients with high baseline CVP. Further studies with home oxygen therapy are needed to investigate the long-term effects of oxygen inhalation in adult patients who underwent Fontan operations.
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Affiliation(s)
- Ichiro Sakamoto
- Department of Cardiovascular Medicine, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Kenichiro Yamamura
- Department of Pediatrics, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan; Department of Cardiovascular Intensive Care, Fukuoka Children's Hospital, Fukuoka, Japan.
| | - Ayako Ishikita
- Department of Cardiovascular Medicine, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Hazumu Nagata
- Department of Pediatrics, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Shintaro Umemoto
- Department of Cardiovascular Medicine, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Akiko Nishizaki
- Department of Cardiovascular Medicine, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Takamori Kakino
- Department of Cardiovascular Medicine, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Tomomi Ide
- Department of Cardiovascular Medicine, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Hiroyuki Tsutsui
- Department of Cardiovascular Medicine, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
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Pace Napoleone C, Aidala E, Cascarano MT, Deorsola L, Iannandrea S, Longobardo A, Bonaveglio E, Zanin M, Peruzzi L. Hemoadsorption Contribution in Failing Fontan Pediatric Heart Transplantation. Cardiorenal Med 2024; 14:67-73. [PMID: 38219721 DOI: 10.1159/000535575] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/02/2023] [Accepted: 11/07/2023] [Indexed: 01/16/2024] Open
Abstract
INTRODUCTION A systemic inflammatory response is triggered in patients undergoing cardiothoracic surgery with cardiopulmonary bypass (CPB). This response is particularly evident in pediatric patients, especially those of low weight and after undergoing long CPB, and can severely impair the surgical result. Adsorptive blood purification techniques have been proposed to limit this systemic inflammatory response. To test its efficacy, we added the hemoadsorption filter Jafron HA 380 to CPB in a much compromised pediatric patient who underwent heart transplantation. METHODS A 10-year-old single ventricle patient previously treated with Fontan operation was listed for heart transplantation due to the evidence of failing Fontan condition. He experienced many episodes of cardiac arrest and underwent heart transplantation in much compromised general and hemodynamic conditions. The hemoadsorption filter Jafron HA 380 was used for all the duration of CPB, and the inflammatory biomarker interleukin 6 (IL-6) was assayed. RESULTS Postoperative outcome was uneventful and comparable to that of elective pediatric heart transplantation. IL-6 levels showed an impressive postoperative reduction, and after 2 days, the IL-6 level was comparable with a typical uneventful post-transplant course. CONCLUSIONS The use of hemoadsorption filter can contribute to improve the pediatric transplant results, especially in very high-risk patients.
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Affiliation(s)
- Carlo Pace Napoleone
- Pediatric and Congenital Cardiac Surgery, Regina Margherita Children's Hospital, Torino, Italy
| | - Enrico Aidala
- Pediatric and Congenital Cardiac Surgery, Regina Margherita Children's Hospital, Torino, Italy
| | - Maria Teresa Cascarano
- Pediatric and Congenital Cardiac Surgery, Regina Margherita Children's Hospital, Torino, Italy
| | - Luca Deorsola
- Pediatric and Congenital Cardiac Surgery, Regina Margherita Children's Hospital, Torino, Italy
| | - Stefania Iannandrea
- Pediatric Cardiac Anesthesiology and Intensive Care Unit, Regina Margherita Children's Hospital, Torino, Italy
| | - Annalisa Longobardo
- Pediatric Cardiac Anesthesiology and Intensive Care Unit, Regina Margherita Children's Hospital, Torino, Italy
| | - Enrico Bonaveglio
- Pediatric Cardiac Anesthesiology and Intensive Care Unit, Regina Margherita Children's Hospital, Torino, Italy
| | - Mattia Zanin
- Pediatric Cardiac Anesthesiology and Intensive Care Unit, Regina Margherita Children's Hospital, Torino, Italy
| | - Licia Peruzzi
- Pediatric Nephrology, Regina Margherita Children's Hospital, Torino, Italy
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Sethasathien S, Leemasawat K, Silvilairat S, Sittiwangkul R, Makonkawkeyoon K, Leerapun A, Kongkarnka S, Inmutto N, Suksai S, Apaijai N, Chattipakorn SC, Chattipakorn N. Mitochondrial dysfunction is associated with the severity of liver fibrosis in patients after the Fontan operation. J Cell Mol Med 2024; 28:e18035. [PMID: 37966270 PMCID: PMC10826431 DOI: 10.1111/jcmm.18035] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2023] [Revised: 10/26/2023] [Accepted: 10/30/2023] [Indexed: 11/16/2023] Open
Abstract
The gold standard for determining the severity of liver disease in Fontan patients is now liver biopsy. Since it is an invasive procedure, this study determined the possibility of applying mitochondrial function from isolated peripheral blood mononuclear cells (PBMCs) as a non-invasive indicator of liver fibrosis. Fontan patients (n = 37) without known liver disease were analysed cross-sectionally. Patients were classified according to their histology using the METAVIR score as follows; F0/F1-no/mild fibrosis; F2-moderate fibrosis; and F3/F4-cirrhosis. Peripheral blood mononuclear cells were assessed for mitochondrial activity and apoptosis. This study did not find any significant differences in cardiac function among the groups according to liver histology. Interestingly, our findings indicated a significant decrease in maximal respiration and spare respiratory capacity, in both the moderate (F2) and cirrhosis (F3/F4) groups compared with the group without significant fibrosis (F0/F1). Moreover, the cirrhosis group exhibited higher levels of apoptosis and lower levels of live cells, compared with both the moderate and no significant fibrosis groups. In conclusion, the degree of liver fibrosis in Fontan patients is strongly correlated with mitochondrial dysfunction in PBMCs. Mitochondrial function and apoptosis could potentially serve as novel markers for tracking the progression of liver fibrosis in these patients.
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Affiliation(s)
- Saviga Sethasathien
- Division of Pediatric Cardiology, Department of Pediatrics, Faculty of MedicineChiang Mai UniversityChiang MaiThailand
| | - Krit Leemasawat
- Division of Cardiovascular Diseases, Department of Medicine, Faculty of MedicineChiang Mai UniversityChiang MaiThailand
| | - Suchaya Silvilairat
- Division of Pediatric Cardiology, Department of Pediatrics, Faculty of MedicineChiang Mai UniversityChiang MaiThailand
| | - Rekwan Sittiwangkul
- Division of Pediatric Cardiology, Department of Pediatrics, Faculty of MedicineChiang Mai UniversityChiang MaiThailand
| | - Krit Makonkawkeyoon
- Division of Pediatric Cardiology, Department of Pediatrics, Faculty of MedicineChiang Mai UniversityChiang MaiThailand
| | - Apinya Leerapun
- Division of Gastroenterology Diseases, Department of Medicine, Faculty of MedicineChiang Mai UniversityChiang MaiThailand
| | - Sarawut Kongkarnka
- Department of Pathology, Faculty of MedicineChiang Mai UniversityChiang MaiThailand
| | - Nakarin Inmutto
- Department of Radiology, Faculty of MedicineChiang Mai UniversityChiang MaiThailand
| | - Supanai Suksai
- Cardiac Electrophysiology Research and Training Center, Faculty of MedicineChiang Mai UniversityChiang MaiThailand
- Center of Excellence in Cardiac Electrophysiology ResearchChiang Mai UniversityChiang MaiThailand
| | - Nattayaporn Apaijai
- Cardiac Electrophysiology Research and Training Center, Faculty of MedicineChiang Mai UniversityChiang MaiThailand
- Center of Excellence in Cardiac Electrophysiology ResearchChiang Mai UniversityChiang MaiThailand
- Cardiac Electrophysiology Unit, Department of Physiology, Faculty of MedicineChiang Mai UniversityChiang MaiThailand
| | - Siriporn C. Chattipakorn
- Cardiac Electrophysiology Research and Training Center, Faculty of MedicineChiang Mai UniversityChiang MaiThailand
- Center of Excellence in Cardiac Electrophysiology ResearchChiang Mai UniversityChiang MaiThailand
- Department of Oral Biology and Diagnostic Sciences, Faculty of DentistryChiang Mai UniversityChiang MaiThailand
| | - Nipon Chattipakorn
- Cardiac Electrophysiology Research and Training Center, Faculty of MedicineChiang Mai UniversityChiang MaiThailand
- Center of Excellence in Cardiac Electrophysiology ResearchChiang Mai UniversityChiang MaiThailand
- Cardiac Electrophysiology Unit, Department of Physiology, Faculty of MedicineChiang Mai UniversityChiang MaiThailand
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Balaji S, Evers PD, Batra AS, Moore J. Management of Junctional Rhythm in Patients After the Fontan Operation: A Multicenter Congenital Cardiology Survey. Pediatr Cardiol 2024; 45:63-67. [PMID: 37740738 DOI: 10.1007/s00246-023-03296-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/25/2023] [Accepted: 09/05/2023] [Indexed: 09/25/2023]
Abstract
Sinus node dysfunction with concomitant junctional rhythm (JR) is frequently observed among Fontan patients and has been recognized as a contributor to heart failure. The impact and management of JR is unclear. A survey was mailed to all members of the Pediatric and Congenital Electrophysiology society (PACES) and members were asked to forward the questionnaire to their non-electrophysiology colleagues. Responses were received from 154 physicians (88 electrophysiologists (EP's) and 66 non-EP's (46 pediatric cardiologists and 20 adult congenital cardiologists). There were few differences in the response between EP's and non-EP's. Overall, 57% recommended an annual ambulatory ECG (AECG). A significant majority (80%) opted to continue to follow patients with significant periods of JR on AECG as long as the patients were asymptomatic, and showed no echocardiographic signs of cardiac decompensation. However, 84% would place a pacemaker in a patient with JR who was having open chest surgery for other reasons. Finally, pacemaker placement would be performed by 91% if a patient with JR showed signs of heart failure. Most congenital cardiologists would not recommend pacemaker placement in asymptomatic Fontan patients with JR. Further studies are needed on the Fontan population to determine the impact of SND and JR on longer term outcomes and to determine the role and optimal timing of pacemaker placement in these patients.
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Affiliation(s)
- Seshadri Balaji
- Division of Cardiology, Department of Pediatrics, Oregon Health & Science University, 707, SW Gaines Street, Mailcode: CDRC-P, Portland, OR, 97239, USA.
| | - Patrick D Evers
- Division of Cardiology, Department of Pediatrics, Oregon Health & Science University, 707, SW Gaines Street, Mailcode: CDRC-P, Portland, OR, 97239, USA
| | - Anjan S Batra
- Division of Cardiology, Department of Pediatrics, University of California, Irvine, CA, USA
| | - Jeremy Moore
- Division of Cardiology, Department of Pediatrics, University of California, Los Angeles, CA, USA
- Ahmanson/UCLA Adult Congenital Heart Disease Program, University of California, Los Angeles, CA, USA
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Hakim K, Mekki N, Benothmen R, Malek M, Abdelkader J, Hela M, Mizouni H, Fatma O. Assessment of ventricular function after total cavo-pulmonary derivation in adult patients: Interest of global longitudinal strain. J Cardiovasc Thorac Res 2023; 15:262-268. [PMID: 38357562 PMCID: PMC10862030 DOI: 10.34172/jcvtr.2023.32880] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2023] [Accepted: 11/27/2023] [Indexed: 02/16/2024] Open
Abstract
Ventricular dysfunction is the most frequent complication in adult patients post-Fontan completion. Through this work, we aim to evaluate ventricular systolic function by conventional echographic parameters and by global longitudinal strain (GLS) to determine the prediction of early ventricular systolic dysfunction. This is a prospective monocentric study enrolling 15 clinically stable adult Fontan patients with preserved ejection fraction (EF). Myocardial deformation study by GLS with speckle tracking technique in addition to a standard Doppler transthoracic echocardiography (TTE) was performed. Cardiac magnetic resonance imaging (CMR) was also performed. A comparison of echocardiographic and CMR parameters was made. In comparison to CMR-derived EF, we found a significant correlation with GLS and TTE-derived EF (P=0.003 and 0.014). We divided our population into two groups based on the cut-off value of 50% of CMR derived EF. Comparison of GLS in both groups showed a significant correlation (P=0.003). A cut-off value of -13.3% showed sensitivity of 67% and specificity of 100%. GLS has a moderate diagnostic value for systolic myocardial dysfunction in the population of adult patients with Fontan circulation.
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Affiliation(s)
- Kaouther Hakim
- Pediatric Cardiology Department, La Rabta University Hospital of Tunis, Tunisia
| | - Nouha Mekki
- Pediatric Cardiology Department, La Rabta University Hospital of Tunis, Tunisia
| | - Rihab Benothmen
- Pediatric Cardiology Department, La Rabta University Hospital of Tunis, Tunisia
| | - Mokbli Malek
- Radiology Department, La Rabta University Hospital of Tunis, Tunisia
| | - Jarray Abdelkader
- Radiology Department, La Rabta University Hospital of Tunis, Tunisia
| | - Msaad Hela
- Pediatric Cardiology Department, La Rabta University Hospital of Tunis, Tunisia
| | - Habiba Mizouni
- Radiology Department, La Rabta University Hospital of Tunis, Tunisia
| | - Ouarda Fatma
- Pediatric Cardiology Department, La Rabta University Hospital of Tunis, Tunisia
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10
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Kwon SJ, Im YM, Park JY, Kim DH, Yun TJ. Duplex ultrasound abnormalities of the lower limb veins might precede clinical venous reflux signs in post-Fontan adolescents and young adults. J Vasc Surg Venous Lymphat Disord 2023; 11:1107-1113. [PMID: 37451317 DOI: 10.1016/j.jvsv.2023.06.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2023] [Revised: 06/25/2023] [Accepted: 06/28/2023] [Indexed: 07/18/2023]
Abstract
OBJECTIVE After the Fontan operation (ie, direct anastomosis of the caval veins to the pulmonary arteries, constituting right ventricular bypass circulation), high central venous pressure can lead to peripheral venous stasis and venous valvar insufficiency. We hypothesized that post-Fontan patients are at a higher risk of developing lower extremity venous lesions detectable using duplex ultrasound, even if clinical signs of chronic venous disease might not be evident. METHODS A total of 87 transplantation-free survivors after the Fontan procedure who reached adolescence or young adulthood (current age, 15-30 years) participated in a leg vein duplex ultrasound study. The median age at the Fontan procedure, median age at the vein study, and median interval between the two were 3.65 years (interquartile range [IQR], 3.1-5.3 years), 21.7 years (IQR, 18.9-24.7 years), and 16.6 years (IQR, 14.9-19.4 years), respectively. Duplex ultrasound scanning was performed using a venous ultrasound imaging system (Logiq P7; GE Healthcare). The patients were categorized according to the presence of venous reflux (VR) in the superficial, deep, or perforating venous systems: no VR, superficial VR (SVR), deep VR (DVR), perforating VR (PVR), and a combination of multiple venous systems. Correlation of the duplex ultrasound-detected venous lesions with clinical severity using the modified CEAP (clinical, etiological, anatomical, pathophysiological) classification was analyzed using Spearman's correlation analysis. RESULTS Leg pain was reported by 48 of 87 patients (55.2%). The duplex ultrasound findings for the cohort were no VR in 21 patients (24.1%), SVR in 22 (25.3%), isolated PVR in 21 (24.1%), and reflux of multiple venous systems in 23 patients, including SVR and PVR in 19, DVR and PVR in 1, and SVR, PVR, and DVR in 3 patients. Although the patients with advanced venous lesions detected by duplex ultrasound tended to have a higher CEAP clinical class (P < .001), VR of any venous system on duplex ultrasound was present even in patients with a lower CEAP clinical class. The CEAP clinical class was C0 for 66 patients (76%), and VR of any venous system was present on duplex ultrasound in 66 patients (76%). CONCLUSIONS The prevalence of lower extremity venous lesions detected by duplex ultrasound is strikingly high in post-Fontan adolescents and young adults, and duplex ultrasound-detected venous abnormalities can precede clinical manifestations. Early detection and timely intervention for leg vein problems are mandatory for post-Fontan patients, especially for those considered to have risk factors for developing chronic lower extremity venous disease.
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Affiliation(s)
- Su Jin Kwon
- Division of Pediatric Cardiac Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Yu-Mi Im
- Department of Nursing, Dankook University, Cheonan, Republic of Korea
| | | | - Dong-Hee Kim
- Division of Pediatric Cardiac Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Tae-Jin Yun
- Division of Pediatric Cardiac Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea.
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11
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Najashi KA, Najashi NA, Ahmed T, Abdelnaeem R, Alolit S, Zuaybir AA, Atiyah M, Trout AT, Alsaied T, Veldtman GR. The prognostic role of liver volumetry in Fontan patients. Cardiol Young 2023; 33:1834-1839. [PMID: 36258282 DOI: 10.1017/s1047951122002992] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
BACKGROUND AND HYPOTHESES High venous pressures and associated hepatic congestion are important drivers for Fontan-associated liver disease. The prognostic significance of hepatomegaly as a marker of congestion however is not well defined and is further explored in this research study. METHODS Fontan patients who have had liver ultrasound scans were identified from the Prince Sultan Cardiac Centre Fontan Database and had their anatomic, surgical, clinical histories abstracted from the electronic medical records following institutional ethics approval. Liver volumes were determined retrospectively from reviewing individual US images, and these, divided into tertiles, were analysed in the context of the predefined endpoints of (i) Primary - death or heart or liver transplantation, or (ii) Secondary - combined endpoint of death, transplantation, arrhythmia, or protein-losing enteropathy. RESULTS Mean indexed liver volumes for the entire cohort (n = 199) were 1065.1 ± 312.1 ml/m2, range 387 to 2071 ml/m2. Patients with the largest liver volumes (highest tertile) were less likely to have a functioning fenestration compared to those in the lowest tertile 44% versus 56% p = 0.016 and experienced the highest burden of mortality and heart or heart-liver transplantation, p = 0.016, and were more likely to reach the composite endpoint of death, protein-losing enteropathy, arrhythmia, or transplantation, p = 0.010. Liver volumes had an overall predictive accuracy for the combined outcome of 61% (CI 53%, 67%, p = 0.009). CONCLUSIONS Liver volumetry may serve as a potentially important congestion biomarker for adverse outcomes after the Fontan operation.
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Affiliation(s)
- Khalid Al Najashi
- Pediatric Cardiology Department, Prince Sultan Cardiac Center, Riyadh, Saudi Arabia
| | - Nejoud Al Najashi
- Radiology Department, Prince Sultan Medical Military City, Riyadh, Saudi Arabia
| | - Taghreed Ahmed
- Pediatric Cardiology Department, Prince Sultan Cardiac Center, Riyadh, Saudi Arabia
| | - Rayan Abdelnaeem
- Pediatric Cardiology Department, Prince Sultan Cardiac Center, Riyadh, Saudi Arabia
| | - Sultan Alolit
- Radiology Department, Prince Sultan Medical Military City, Riyadh, Saudi Arabia
| | - Amani Al Zuaybir
- Radiology Department, Prince Sultan Medical Military City, Riyadh, Saudi Arabia
| | - Merna Atiyah
- Pediatric Cardiology Department, Prince Sultan Cardiac Center, Riyadh, Saudi Arabia
| | - Andrew T Trout
- Department of Radiology, Cincinnati Children's Hospital Medical Center and University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Tarek Alsaied
- Paediatric Cardiology, UPMC Children's Hospital of Pittsburgh, PA, USA
| | - Gruschen R Veldtman
- Scottish Adult Congenital Cardiac Service, Golden Jubilee National Hospital, Glasgow, Scotland, UK
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12
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Çınar B, Atik SU, Gökalp S, Çilsal E, Şahin M, Kamalı H, Onan İS, Genç SB, Yıldız O, Haydin S, Baydili KN, Ergül Y, Güzeltaş A. Predictors of prolonged pleural effusion after Fontan operation. Cardiol Young 2023; 33:2094-2100. [PMID: 36911913 DOI: 10.1017/s1047951123000264] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/14/2023]
Abstract
Prolonged pleural effusion is a fairly common condition which has considerable impact on complicated and longer hospital stays after Fontan surgery. Identifying the patient population prone to have pleural effusions is still seeking for an answer. This study is to determine the variables that may predict prolonged pleural effusion according to the data of 69 patients who underwent Fontan operation between June 2018 and December 2020 and survived to date. Prolonged pleural effusion was defined as the need for a chest tube for more than 7 days. Two patient groups, with and without prolonged effusion, were compared in terms of pre-, peri-, and post-operative variables. The patients were subdivided into "high-risk" and "low-risk" groups based on the pre-operative catheterisation data. The most frequent main diagnosis was tricuspid atresia (n: 13, 19%). Among 69 patients, 28 (40%) had prolonged pleural effusion whereas 11 (16%) had effusions that lasted longer than 14 days. Ten patients among prolonged effusion group (35%) had pulmonary atresia coexistent with the main diagnosis. Fontan operation was performed in 6 patients (8.7%) over the age of 10, and 4 of these patients (67%) had prolonged pleural effusion. Among numerous variables, statistical significance between the two groups was achieved in pre-operative mean pulmonary artery pressure, post-operative albumin, C-reactive protein levels, length of hospital stay, duration of chest tube drainage, and amount of effusion per day. Early recognition and treatment strategies with routine medical protocol use remain to be the cornerstone for the management of post-operative prolonged pleural effusions after Fontan surgery.
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Affiliation(s)
- Betül Çınar
- Department of Pediatric Cardiology, Mehmet Akif Ersoy Thoracic and Cardiovascular Surgery Training and Research Hospital, Istanbul, 34303, Turkey
| | - Sezen Ugan Atik
- Department of Pediatric Cardiology, Mehmet Akif Ersoy Thoracic and Cardiovascular Surgery Training and Research Hospital, Istanbul, 34303, Turkey
| | - Selman Gökalp
- Department of Pediatric Cardiology, Mehmet Akif Ersoy Thoracic and Cardiovascular Surgery Training and Research Hospital, Istanbul, 34303, Turkey
| | - Erman Çilsal
- Department of Pediatric Cardiology, Mehmet Akif Ersoy Thoracic and Cardiovascular Surgery Training and Research Hospital, Istanbul, 34303, Turkey
| | - Murat Şahin
- Department of Pediatric Cardiology, Mehmet Akif Ersoy Thoracic and Cardiovascular Surgery Training and Research Hospital, Istanbul, 34303, Turkey
| | - Hacer Kamalı
- Department of Pediatric Cardiology, Mehmet Akif Ersoy Thoracic and Cardiovascular Surgery Training and Research Hospital, Istanbul, 34303, Turkey
| | - İsmihan Selen Onan
- Department of Pediatric Cardiovascular Surgery, Mehmet Akif Ersoy Thoracic and Cardiovascular Surgery Training and Research Hospital, Istanbul, 34303, Turkey
| | - Serhat Bahadır Genç
- Department of Pediatric Cardiovascular Surgery, Mehmet Akif Ersoy Thoracic and Cardiovascular Surgery Training and Research Hospital, Istanbul, 34303, Turkey
| | - Okan Yıldız
- Department of Pediatric Cardiovascular Surgery, Mehmet Akif Ersoy Thoracic and Cardiovascular Surgery Training and Research Hospital, Istanbul, 34303, Turkey
| | - Sertaç Haydin
- Department of Pediatric Cardiovascular Surgery, Mehmet Akif Ersoy Thoracic and Cardiovascular Surgery Training and Research Hospital, Istanbul, 34303, Turkey
| | - Kürşad Nuri Baydili
- Department of Biostatistics, University of Health Sciences, Istanbul, Turkey
| | - Yakup Ergül
- Department of Pediatric Cardiology, Mehmet Akif Ersoy Thoracic and Cardiovascular Surgery Training and Research Hospital, Istanbul, 34303, Turkey
| | - Alper Güzeltaş
- Department of Pediatric Cardiology, Mehmet Akif Ersoy Thoracic and Cardiovascular Surgery Training and Research Hospital, Istanbul, 34303, Turkey
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13
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Benjamin C, Franklin WJ, Garn B, Awerbach JD. Transcatheter thrombectomy of acute pulmonary embolism in an adult Fontan patient: a case report. Eur Heart J Case Rep 2023; 7:ytad401. [PMID: 37719000 PMCID: PMC10500413 DOI: 10.1093/ehjcr/ytad401] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2022] [Revised: 08/02/2023] [Accepted: 08/15/2023] [Indexed: 09/19/2023]
Abstract
Background The Fontan operation is a well-described palliative procedure for functional single-ventricle patients. This population has an increased risk of thrombo-embolic events. Adequate imaging, and therefore diagnosis, requires an understanding of the unique anatomy and physiology of a Fontan. Optimal strategies for the prevention and treatment of thrombo-embolic complications in the Fontan population are poorly defined. Case summary A 28-year-old female with a history of Ebstein anomaly of the tricuspid valve status post-Fontan presented with chest pain and acute hypoxia. Computed tomographic angiography (CTA) reported a submassive pulmonary embolism (PE). She was initiated on a heparin drip. Catheterization demonstrated elevated Fontan pressures and a large thrombus in the right lower pulmonary artery that was removed with an aspiration device. The patient was transitioned to a direct oral anticoagulant (DOAC) following the procedure. Discussion Thrombotic complications are common in the adult Fontan population. Given the morbidity and mortality associated with this complication, the use of proper imaging techniques is imperative. Traditional CTA imaging for PE in Fontan patients often has contrast filling defects related to their anatomy and physiology. Utilization of adequate imaging techniques helps decrease cost and additional radiation exposure. In addition, it avoids inappropriate hospitalization, need for anticoagulation, and potential need for catheterization toconfirm or exclude the presence of PE. For Fontan patients with a thrombus, prior event, and no contraindications, current guidelines recommend oral anticoagulation with a vitamin K antagonist; however, there are increasing data on the use of DOACs in this population.
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Affiliation(s)
- Christina Benjamin
- Center for Heart Care, Phoenix Children’s, 1919 E Thomas Rd, Phoenix, AZ 85016, USA
- Department of Child Health, University of Arizona College of Medicine-Phoenix, Phoenix, AZ, USA
| | - Wayne J Franklin
- Center for Heart Care, Phoenix Children’s, 1919 E Thomas Rd, Phoenix, AZ 85016, USA
- Department of Child Health, University of Arizona College of Medicine-Phoenix, Phoenix, AZ, USA
- Department of Internal Medicine, University of Arizona College of Medicine-Phoenix, Phoenix, AZ, USA
| | - Byron Garn
- Center for Heart Care, Phoenix Children’s, 1919 E Thomas Rd, Phoenix, AZ 85016, USA
- Department of Child Health, University of Arizona College of Medicine-Phoenix, Phoenix, AZ, USA
| | - Jordan D Awerbach
- Center for Heart Care, Phoenix Children’s, 1919 E Thomas Rd, Phoenix, AZ 85016, USA
- Department of Child Health, University of Arizona College of Medicine-Phoenix, Phoenix, AZ, USA
- Department of Internal Medicine, University of Arizona College of Medicine-Phoenix, Phoenix, AZ, USA
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14
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Abdulkarim A, Shaji S, Elfituri M, Gunsaulus M, Zafar MA, Zaidi AN, Pass RH, Feingold B, Kurland G, Kreutzer J, Ghassemzadeh R, Goldstein B, West S, Alsaied T. Pulmonary Complications in Patients With Fontan Circulation: JACC Review Topic of the Week. J Am Coll Cardiol 2023; 81:2434-2444. [PMID: 37344046 DOI: 10.1016/j.jacc.2023.04.036] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/07/2023] [Revised: 04/03/2023] [Accepted: 04/10/2023] [Indexed: 06/23/2023]
Abstract
The Fontan operation has resulted in significant improvement in survival of patients with single ventricle physiology. As a result, there is a growing population of individuals with Fontan physiology reaching adolescence and adulthood. Despite the improved survival, there are long-term morbidities associated with the Fontan operation. Pulmonary complications are common and may contribute to both circulatory and pulmonary insufficiency, leading ultimately to Fontan failure. These complications include restrictive lung disease, sleep abnormalities, plastic bronchitis, and cyanosis. Cyanosis post-Fontan procedure can be attributed to multiple causes including systemic to pulmonary venous collateral channels and pulmonary arteriovenous malformations. This review presents the unique cardiopulmonary interactions in the Fontan circulation. Understanding the cardiopulmonary interactions along with improved recognition and treatment of pulmonary abnormalities may improve the long-term outcomes in this growing patient population. Interventions focused on improving pulmonary function including inspiratory muscle training and endurance training have shown a promising effect post-Fontan procedure.
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Affiliation(s)
- Ali Abdulkarim
- Department of Pediatrics, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Shawn Shaji
- Heart Institute, University of Pittsburgh Medical Center, Children's Hospital of Pittsburgh, Pittsburgh, Pennsylvania, USA; Division of Pediatric Cardiology, Department of Pediatrics, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Mahmud Elfituri
- Department of Pediatrics, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Megan Gunsaulus
- Heart Institute, University of Pittsburgh Medical Center, Children's Hospital of Pittsburgh, Pittsburgh, Pennsylvania, USA; Division of Pediatric Cardiology, Department of Pediatrics, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Muhammad A Zafar
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
| | - Ali N Zaidi
- Mount Sinai Heart, Mount Sinai Kravis Children's Heart Center, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Robert H Pass
- Department of Pediatrics, Icahn School of Medicine at Mount Sinai, Division of Pediatric Cardiology and Mount Sinai Kravis Children's Heart Center, New York, New York, USA
| | - Brian Feingold
- Heart Institute, University of Pittsburgh Medical Center, Children's Hospital of Pittsburgh, Pittsburgh, Pennsylvania, USA; Division of Pediatric Cardiology, Department of Pediatrics, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Geoffrey Kurland
- University of Pittsburgh Medical Center, Children's Hospital of Pittsburgh, Pittsburgh, Pennsylvania, USA; Division of Pediatric Pulmonology, Department of Pediatrics, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Jacqueline Kreutzer
- Heart Institute, University of Pittsburgh Medical Center, Children's Hospital of Pittsburgh, Pittsburgh, Pennsylvania, USA; Division of Pediatric Cardiology, Department of Pediatrics, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Rod Ghassemzadeh
- University of Pittsburgh Medical Center, Children's Hospital of Pittsburgh, Department of Critical Care, Pittsburgh, Pennsylvania, USA
| | - Bryan Goldstein
- Heart Institute, University of Pittsburgh Medical Center, Children's Hospital of Pittsburgh, Pittsburgh, Pennsylvania, USA; Division of Pediatric Cardiology, Department of Pediatrics, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Shawn West
- Heart Institute, University of Pittsburgh Medical Center, Children's Hospital of Pittsburgh, Pittsburgh, Pennsylvania, USA; Division of Pediatric Cardiology, Department of Pediatrics, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Tarek Alsaied
- Heart Institute, University of Pittsburgh Medical Center, Children's Hospital of Pittsburgh, Pittsburgh, Pennsylvania, USA; Division of Pediatric Cardiology, Department of Pediatrics, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA.
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15
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Katz DA, Gao Z, Freytag J, Mahendran A, Szugye C, Woodly S, Alvarez TCE, Lubert AM, Alsaied T, Goldstein SL, Opotowsky AR. Associations Between Characteristics of Individuals With Fontan Circulation With Blood and Urine Biomarkers of Kidney Injury and Dysfunction. J Am Heart Assoc 2023:e029130. [PMID: 37345835 DOI: 10.1161/jaha.122.029130] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 06/23/2023]
Abstract
Background Fontan circulation is associated with kidney injury and dysfunction, often unappreciated until Fontan circulatory failure. We hypothesized that cystatin C-estimated glomerular filtration rate (eGFR) would identify chronic kidney disease more frequently and that urine kidney injury biomarkers would be higher with declining Fontan physiological features. Methods and Results We enrolled 100 ambulatory individuals. Blood and urinary laboratory measurements were compared with demographics and clinically obtained data. Different eGFR equations were used for individuals aged ≥19 years and <19 years. Chronic kidney disease was defined as eGFR <90 mL/min per 1.73 m2. Median (25th-75th percentile) age was 19 (14-26) years, and 43% were female patients. Cystatin C eGFR detected chronic kidney disease (37%) in more patients than creatinine eGFR (11%). Cystatin C eGFR was positively associated, and skeletal muscle mass was negatively associated, with creatinine eGFR in both univariate (cystatin C eGFR β=0.44±0.12, P=0.0006; skeletal muscle mass β=-0.72±0.32, P=0.03) and multivariable analysis (cystatin C eGFR β=0.43±0.12, P=0.0005; skeletal muscle mass β=-0.69±0.29, P=0.02). Urine neutrophil gelatinase-associated lipocalin concentration correlated with Fontan pressure (r=0.28; P=0.04), ventricular end-diastolic pressure (r=0.28; P=0.04), and body fat mass (r=0.26; P=0.03). Conclusions Cystatin C eGFR identified more kidney dysfunction, likely attributable to creatinine eGFR being confounded by skeletal muscle mass. Elevated urine neutrophil gelatinase-associated lipocalin was associated with worse Fontan hemodynamics and higher percentage body fat, suggesting that higher venous pressure and higher adiposity are associated with ongoing kidney injury.
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Affiliation(s)
- David A Katz
- Department of Pediatrics University of Cincinnati College of Medicine Cincinnati OH USA
- Heart Institute Cincinnati Children's Hospital Medical Center Cincinnati OH USA
- Cincinnati Adult Congenital Heart Disease Program Cincinnati OH USA
| | - Zhiqian Gao
- Heart Institute Cincinnati Children's Hospital Medical Center Cincinnati OH USA
| | - Joshua Freytag
- Heart Institute Cincinnati Children's Hospital Medical Center Cincinnati OH USA
| | - Arjun Mahendran
- Department of Pediatrics University of Cincinnati College of Medicine Cincinnati OH USA
- Heart Institute Cincinnati Children's Hospital Medical Center Cincinnati OH USA
- Cincinnati Adult Congenital Heart Disease Program Cincinnati OH USA
| | - Cassandra Szugye
- Heart Institute Cincinnati Children's Hospital Medical Center Cincinnati OH USA
| | - Shalayna Woodly
- Heart Institute Cincinnati Children's Hospital Medical Center Cincinnati OH USA
| | | | - Adam M Lubert
- Department of Pediatrics University of Cincinnati College of Medicine Cincinnati OH USA
- Heart Institute Cincinnati Children's Hospital Medical Center Cincinnati OH USA
- Cincinnati Adult Congenital Heart Disease Program Cincinnati OH USA
| | - Tarek Alsaied
- The Heart and Vascular Institute, Pittsburgh Children's Hospital Medical Center and Department of Pediatrics, University of Pittsburgh Pittsburgh PA USA
| | - Stuart L Goldstein
- Department of Pediatrics University of Cincinnati College of Medicine Cincinnati OH USA
- Heart Institute Cincinnati Children's Hospital Medical Center Cincinnati OH USA
- Heart Institute Research Core Cincinnati OH USA
- Center for Acute Care Nephrology Cincinnati OH USA
| | - Alexander R Opotowsky
- Department of Pediatrics University of Cincinnati College of Medicine Cincinnati OH USA
- Heart Institute Cincinnati Children's Hospital Medical Center Cincinnati OH USA
- Cincinnati Adult Congenital Heart Disease Program Cincinnati OH USA
- Heart Institute Research Core Cincinnati OH USA
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16
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Castellanos DA, Ahmad S, St Clair N, Sleeper LA, Lu M, Schidlow DN, Rathod RH, Yin SM, Esch JJ, Annese D, Powell AJ, Quiñonez L, Shaikh R, Ghelani SJ. Magnetic resonance three-dimensional steady-state free precession imaging of the thoracic duct in patients with Fontan circulation and its relationship to outcomes. J Cardiovasc Magn Reson 2023; 25:28. [PMID: 37303061 PMCID: PMC10258944 DOI: 10.1186/s12968-023-00937-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2022] [Accepted: 05/11/2023] [Indexed: 06/13/2023] Open
Abstract
BACKGROUND Lymphatic complications are common in patients with Fontan circulation. Three-dimensional balanced steady-state free precession (3D bSSFP) angiography by cardiovascular magnetic resonance (CMR) is widely used for cardiovascular anatomical assessment. We sought to determine the frequency of thoracic duct (TD) visualization using 3D bSSFP images and assess whether TD characteristics are associated with clinical outcomes. METHODS This was a retrospective, single-center study of patients with Fontan circulation who underwent CMR. Frequency matching of age at CMR was used to construct a comparison group of patients with repaired tetralogy of Fallot (rTOF). TD characteristics included maximum diameter and a qualitative assessment of tortuosity. Clinical outcomes included protein-losing enteropathy (PLE), plastic bronchitis, listing for heart transplantation, and death. A composite outcome was defined as presence of any of these events. RESULTS The study included 189 Fontan patients (median age 16.1 years, IQR 11.0-23.2 years) and 36 rTOF patients (median age 15.7 years, IQR 11.1-23.7 years). The TD diameter was larger (median 2.50 vs. 1.95 mm, p = 0.002) and more often well visualized (65% vs. 22%, p < 0.001) in Fontan patients vs. rTOF patients. TD dimension increased mildly with age in Fontan patients, R = 0.19, p = 0.01. In Fontan patients, the TD diameter was larger in those with PLE vs. without PLE (age-adjusted mean 4.11 vs. 2.72, p = 0.005), and was more tortuous in those with NYHA class ≥ II vs. class I (moderate or greater tortuosity 75% vs. 28.5%, p = 0.02). Larger TD diameter was associated with a lower ventricular ejection fraction that was independent of age (partial correlation = - 0.22, p = 0.02). More tortuous TDs had a higher end-systolic volume (mean 70.0 mL/m2 vs. 57.3 mL/m2, p = 0.03), lower creatinine (mean 0.61 mg/dL vs. 0.70 mg/dL, p = 0.04), and a higher absolute lymphocyte count (mean 1.80 K cells/µL vs. 0.76 K cells/µL, p = 0.003). The composite outcome was present in 6% of Fontan patients and was not associated with TD diameter (p = 0.50) or tortuosity (p = 0.09). CONCLUSIONS The TD is well visualized in two-thirds of patients with Fontan circulation on 3D-bSSFP images. Larger TD diameter is associated with PLE and increased TD tortuosity is associated with an NYHA class ≥ II.
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Affiliation(s)
- Daniel A Castellanos
- Department of Cardiology, Boston Children's Hospital, 300 Longwood Ave, BCH 3215, Boston, MA, 02115, USA.
- Department of Pediatrics, Harvard Medical School, Boston, MA, USA.
| | - Sidra Ahmad
- Department of Cardiology, Boston Children's Hospital, 300 Longwood Ave, BCH 3215, Boston, MA, 02115, USA
| | - Nicole St Clair
- Department of Cardiology, Boston Children's Hospital, 300 Longwood Ave, BCH 3215, Boston, MA, 02115, USA
| | - Lynn A Sleeper
- Department of Cardiology, Boston Children's Hospital, 300 Longwood Ave, BCH 3215, Boston, MA, 02115, USA
- Department of Pediatrics, Harvard Medical School, Boston, MA, USA
| | - Minmin Lu
- Department of Cardiology, Boston Children's Hospital, 300 Longwood Ave, BCH 3215, Boston, MA, 02115, USA
| | - David N Schidlow
- Department of Cardiology, Boston Children's Hospital, 300 Longwood Ave, BCH 3215, Boston, MA, 02115, USA
- Department of Pediatrics, Harvard Medical School, Boston, MA, USA
| | - Rahul H Rathod
- Department of Cardiology, Boston Children's Hospital, 300 Longwood Ave, BCH 3215, Boston, MA, 02115, USA
- Department of Pediatrics, Harvard Medical School, Boston, MA, USA
| | - Suellen M Yin
- Department of Cardiology, Boston Children's Hospital, 300 Longwood Ave, BCH 3215, Boston, MA, 02115, USA
- Department of Pediatrics, Harvard Medical School, Boston, MA, USA
| | - Jesse J Esch
- Department of Cardiology, Boston Children's Hospital, 300 Longwood Ave, BCH 3215, Boston, MA, 02115, USA
- Department of Pediatrics, Harvard Medical School, Boston, MA, USA
| | - David Annese
- Department of Cardiology, Boston Children's Hospital, 300 Longwood Ave, BCH 3215, Boston, MA, 02115, USA
| | - Andrew J Powell
- Department of Cardiology, Boston Children's Hospital, 300 Longwood Ave, BCH 3215, Boston, MA, 02115, USA
- Department of Pediatrics, Harvard Medical School, Boston, MA, USA
| | - Luis Quiñonez
- Department of Cardiac Surgery, Boston Children's Hospital and Harvard Medical School, Boston, MA, USA
| | - Raja Shaikh
- Department of Radiology, Boston Children's Hospital and Harvard Medical School, Boston, MA, USA
| | - Sunil J Ghelani
- Department of Cardiology, Boston Children's Hospital, 300 Longwood Ave, BCH 3215, Boston, MA, 02115, USA
- Department of Pediatrics, Harvard Medical School, Boston, MA, USA
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17
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Rao PS. Therapy of Patients with Cardiac Malposition. Children (Basel) 2023; 10:children10040739. [PMID: 37189988 DOI: 10.3390/children10040739] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/10/2023] [Revised: 03/31/2023] [Accepted: 04/14/2023] [Indexed: 05/17/2023]
Abstract
Positional abnormalities per se do not require treatment, but in their place, the accompanying pulmonary pathology in dextroposition patients and pathophysiologic hemodynamic abnormalities resulting from multiple defects in patients with cardiac malposition should be the focus of treatment. At the time of the first presentation, treating the pathophysiologic aberrations caused by the defect complex, whether it is by improving the pulmonary blood flow or restricting it, is the first step. Some patients with simpler or single defects are amenable to surgical or transcatheter therapy and should be treated accordingly. Other associated defects should also be treated appropriately. Biventricular or univentricular repair dependent on the patient's cardiac structure should be planned. Complications in-between Fontan stages and after conclusion of Fontan surgery may occur and should be promptly diagnosed and addressed accordingly. Several other cardiac abnormalities unrelated to the initially identified heart defects may manifest in adulthood, and they should also be treated.
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Affiliation(s)
- P Syamasundar Rao
- Children's Heart Institute, Children's Memorial Hermann Hospital, McGovern Medical School, University of Texas-Houston, 6410 Fannin Street, UTPB Suite # 425, Houston, TX 77030, USA
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18
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Kamp A, Moore JP, Khairy P. How to Perform Catheter Ablation of Atrial Tachyarrhythmia after the Fontan Operation. Heart Rhythm 2023:S1547-5271(23)00294-1. [PMID: 36963742 DOI: 10.1016/j.hrthm.2023.03.023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/16/2023] [Revised: 03/13/2023] [Accepted: 03/16/2023] [Indexed: 03/26/2023]
Affiliation(s)
- Anna Kamp
- Nationwide Children's Hospital, The Ohio State University, Columbus, OH
| | - Jeremy P Moore
- Ahmanson/UCLA Adult Congenital Heart Disease Center, Los Angeles, CA
| | - Paul Khairy
- Montreal Heart Institute, Université de Montréal, Montreal, Canada.
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19
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Neidenbach R, Freilinger S, Stöcker F, Ewert P, Nagdyman N, Oberhoffer-Fritz R, Pieper L, Kaemmerer H, Hager A. Clinical aspects and targeted inspiratory muscle training in children and adolescents with Fontan circulation: a randomized controlled trial. Cardiovasc Diagn Ther 2023; 13:11-24. [PMID: 36864956 PMCID: PMC9971296 DOI: 10.21037/cdt-22-308] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2022] [Accepted: 12/23/2022] [Indexed: 02/21/2023]
Abstract
Background Since 1968, thousands of patients with a morphologically or functionally univentricular heart have been treated with a total cavopulmonary connection/Fontan operation. Because of the resulting passive pulmonary perfusion, blood flow is assisted by the pressure shift during respiration. Respiratory training is known to improve exercise capacity and cardiopulmonary function. However, there are limited data on whether respiratory training can also improve physical performance after Fontan surgery. The aim of the present study was to clarify the effects of six months of daily home-based inspiratory muscle training (IMT) aimed at increasing physical performance by strengthening respiratory muscles, improving lung function and peripheral oxygenation. Methods In this non-blinded randomized controlled trial, the effects of IMT on lung capacity and exercise capacity were measured in a large cohort of 40 Fontan patients (25% female; 12.3±2.2 years) who were under regular follow-up by the outpatient clinic of the Department of Congenital Heart Defects and Pediatric Cardiology of the German Heart Center Munich. After a lung function test and a cardiopulmonary exercise test, patients were randomly assigned in a parallel arm design to either an intervention group (IG) or a control group (CG) via stratified and computer-generated letter randomization from May 2014 to May 2015. The IG completed a daily, telephone-monitored IMT of three sets of 30 repetitions for six months with an inspiratory resistive training device (POWERbreathe medic®), the CG continued their usual daily activities without an IMT until the second examination within the timeframe of November 2014 until November 2015. Results After six months of IMT, lung capacity values in the IG (n=18) did not increase significantly compared to the CG [n=19; ΔFVC: IG: 0.21±0.16 l vs. CG 0.22±0.31 l; P=0.946 (CI: -0.16, 0.17); ΔFEV1: CG: 0.14±0.30 vs. IG: 0.17±0.20 P=0.707 (CI: -0.20, 0.14)]. Exercise capacity did not improve significantly, yet the maximum workload achieved trended to improve with an increase of 14% in the IG vs. 6.5% in the CG [P=0.113 (CI: -15.8, 1.76)]. There was a significant increase of oxygen saturation at rest in the IG compared to the CG [IG: 3.31%±4.09% vs. CG: 0.17%±2.92%, P=0.014 (CI: -5.60, -0.68)]. Compared to the CG, the mean oxygen saturation at peak exercise no longer dropped below 90% in the IG. This observation is thus not statistically significant, yet of clinical relevance. Conclusions The results of this study show benefits of an IMT in young Fontan patients. Even if some data are not statistically significant, they may still be clinically relevant and may contribute to a multidisciplinary approach in patient care. IMT should therefore be an additional target and integrated into the training program to improve the prognosis of Fontan patients. Trial Registration German Clinical Trials Register; DRKS.de; registration ID: DRKS00030340.
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Affiliation(s)
- Rhoia Neidenbach
- Department of Congenital Heart Disease and Pediatric Cardiology, German Heart Centre Munich, Technical University Munich, Munich, Germany;,Chair of Preventive Pediatrics, Department of Sport and Health Sciences, Technical University of Munich, Munich, Germany;,Department of Sports Medicine, Exercise Physiology and Prevention, Institute of Sport Science, University of Vienna, Vienna, Austria
| | - Sebastian Freilinger
- Department of Congenital Heart Disease and Pediatric Cardiology, German Heart Centre Munich, Technical University Munich, Munich, Germany;,Chair of Preventive Pediatrics, Department of Sport and Health Sciences, Technical University of Munich, Munich, Germany
| | - Fabian Stöcker
- Chair of Preventive Pediatrics, Department of Sport and Health Sciences, Technical University of Munich, Munich, Germany
| | - Peter Ewert
- Department of Congenital Heart Disease and Pediatric Cardiology, German Heart Centre Munich, Technical University Munich, Munich, Germany
| | - Nicole Nagdyman
- Department of Congenital Heart Disease and Pediatric Cardiology, German Heart Centre Munich, Technical University Munich, Munich, Germany
| | - Renate Oberhoffer-Fritz
- Department of Congenital Heart Disease and Pediatric Cardiology, German Heart Centre Munich, Technical University Munich, Munich, Germany;,Chair of Preventive Pediatrics, Department of Sport and Health Sciences, Technical University of Munich, Munich, Germany
| | - Lars Pieper
- Department of Congenital Heart Disease and Pediatric Cardiology, German Heart Centre Munich, Technical University Munich, Munich, Germany
| | - Harald Kaemmerer
- Department of Congenital Heart Disease and Pediatric Cardiology, German Heart Centre Munich, Technical University Munich, Munich, Germany
| | - Alfred Hager
- Department of Congenital Heart Disease and Pediatric Cardiology, German Heart Centre Munich, Technical University Munich, Munich, Germany
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20
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Fujii T, Moriichi A, Kakee N, Kato H, Tomita H. Epidemiologic study of patients after Fontan operation based on Medical Aid Program for Chronic Pediatric Diseases of Specified Categories cohort. Cardiol Young 2023; 33:248-54. [PMID: 35678166 DOI: 10.1017/S1047951122000555] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Nationwide registry data of patients with single-ventricle physiology have been rarely reported. The Medical Aid Program for Chronic Pediatric Diseases of Specified Categories (Japan) has contributed to the financial support of medical expense for patients younger than 20 years with chronic paediatric disease, and almost all children in Japan who require disease-specific treatment voluntarily apply to this programme. The epidemiology and medium- to long-term outcome of patients following a Fontan procedure were investigated using the database. The usefulness of this epidemiologic investigation in identifying real-world objectives and clinical applications was also examined. A total of 2862 patients who underwent a Fontan operation were identified from 18,589 patients with chronic heart disease registered to the medical aid programme. The details of symptoms, treatment, and somatic growth were evaluated, from which we were able to clarify the nationwide data regarding the current status of post-Fontan patients younger than 20 years. This study elucidated the current status of post-Fontan patients under 20 years of age in Japan. Data analysis of the Medical Aid Program for Chronic Pediatric Diseases of Specified Categories cohort provided useful information towards understanding the comprehensive status of patients with chronic heart disease and contributed to improved disease management.
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21
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Polat AB, Ertürk M, Uzunhan O, Karademir N, Öztarhan K. 27 years of experience with the Fontan procedure: characteristics and clinical outcomes of children in a tertiary referral hospital. J Cardiothorac Surg 2023; 18:38. [PMID: 36653817 PMCID: PMC9850550 DOI: 10.1186/s13019-023-02148-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2022] [Accepted: 01/10/2023] [Indexed: 01/19/2023] Open
Abstract
BACKGROUND The Fontan operation has improved the survival of children born with congenital heart disease with single ventricle physiology. The most widely adopted variations of the Fontan procedure are the extracardiac conduit, the lateral tunnel ve the intra/extracardiac conduit with fenestration. Despite advances in the treatment and prevention of early and late complications that may develop after Fontan surgery, morbidity still remains an important problem. METHODS 304 patients who underwent Fontan surgery in our center between 1995 and 2022 were included in our study. The complications that developed in patients who underwent primary Fontan or lateral tunnel surgery and extracardiac conduit Fontan application were compared. RESULTS Classic Fontan surgery and lateral tunnel surgery were performed in 26 of the patients, and extracardiac Fontan surgery was performed in 278 patients. 218 of 304 cases were patients with single ventricular pathology. 86 cases were patients with two ventricular morphologies but complex cardiac pathology. Fenestration was performed in only 6 patients, other patients did not require fenestration. The mean follow-up period of our patients was 12 years (3 months-27 years). When the complications between Fontan procedures were compared in our study, it was found that the length of hospital stay and mortality were statistically significantly reduced in patients who underwent extracardiac Fontan surgery. There was no significant difference in terms of complications that can be seen after Fontan surgery and the length of stay in the intensive care unit. CONCLUSION Fontan complex is a palliative surgery for children with complex heart disease. Palliative surgical operations aimed at the preparation of the Fontan circulation lead to the preparation of the pulmonary vascular bed and the preservation of ventricular function. The techniques applied in Fontan surgery affect the early and long-term complications and the survival of the patients. In our study, when we examined the patients who extracardiac conduit Fontan procedure for the non-cardiac route, we found that mortality and morbidity were minimal.
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Affiliation(s)
- Ahmet Bülent Polat
- grid.414934.f0000 0004 0644 9503Department of Cardiovascular Surgery, Florence Nightingale Hospital, T.C. Demiroglu Bilim University, İzzetpaşa Mah, Abide-I Hürriyet Cad, No:166, Sisli, 34394 Istanbul, Turkey
| | - Murat Ertürk
- grid.414934.f0000 0004 0644 9503Department of Cardiovascular Surgery, Florence Nightingale Hospital, T.C. Demiroglu Bilim University, İzzetpaşa Mah, Abide-I Hürriyet Cad, No:166, Sisli, 34394 Istanbul, Turkey
| | - Ozan Uzunhan
- grid.414934.f0000 0004 0644 9503Department of Newborn, Florence Nightingale Hospital, T.C. Demiroglu Bilim University, İzzetpaşa Mah, Abide-I Hürriyet Cad, No:166, Sisli, 34394 Istanbul, Turkey
| | - Nur Karademir
- grid.414934.f0000 0004 0644 9503Florence Nightingale Hospital, T.C. Demiroglu Bilim University, İzzetpaşa Mah, Abide-I Hürriyet Cad, No:166, Sisli, 34394 Istanbul, Turkey
| | - Kazım Öztarhan
- grid.414934.f0000 0004 0644 9503Department of Pediatric Cardiology, Florence Nightingale Hospital, T.C. Demiroglu Bilim University, İzzetpaşa Mah, Abide-I Hürriyet Cad, No:166, Sisli, 34394 Istanbul, Turkey
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22
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Ghelani SJ, Lu M, Sleeper LA, Prakash A, Castellanos DA, Clair NS, Powell AJ, Rathod RH. Longitudinal changes in ventricular size and function are associated with death and transplantation late after the Fontan operation. J Cardiovasc Magn Reson 2022; 24:56. [PMID: 36372887 PMCID: PMC9661807 DOI: 10.1186/s12968-022-00884-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2021] [Accepted: 08/16/2022] [Indexed: 11/15/2022] Open
Abstract
BACKGROUND Cross-sectional studies have reported that ventricular dilation and dysfunction are associated with adverse clinical outcome in Fontan patients; however, longitudinal changes and their relationship with outcome are not known. METHODS This was a single-center retrospective analysis of Fontan patients with at least 2 cardiovascular magnetic resonance (CMR) scans without intervening interventions. Serial measures of end-diastolic volume index (EDVI), end-systolic volume index (ESVI), ejection fraction (EF), indexed mass (massi), mass-to-volume ratio, and end-systolic wall stress (ESWS) were used to estimate within-patient change over time. Changes were compared for those with and without a composite outcome (death, heart transplant, or transplant listing) as well as between patients with left (LV) and right ventricular (RV) dominance. RESULTS Data from 156 patients were analyzed with a mean age at 1st CMR of 17.8 ± 9.6 years. 490 CMRs were included with median of 3 CMRs/patient (range 2-9). On regression analysis with mixed effects models, volumes and ESWS increased, while mass, mass-to-volume ratio, and EF decreased over time. With a median follow-up of 10.2 years, 14% met the composite outcome. Those with the composite outcome had a greater increase in EDVI compared to those without (4.7 vs. 0.8 ml/BSA1.3/year). Compared with LV dominance, RV dominance was associated with a greater increase in ESVI (1.4 vs. 0.5 ml/BSA1.3/year), a greater decrease in EF (- 0.61%/year vs. - 0.24%/year), and a higher rate of the composite outcome (21% vs. 8%). CONCLUSIONS Ventricles in the Fontan circulation exhibit a steady decline in performance with an increase in EDVI, ESVI, and ESWS, and decrease in EF, mass index, and mass-to-volume ratio. Those with death or need for heart transplantation have a faster increase in EDVI. Patients with rapid increase in EDVI (> 5 ml/BSA1.3/year) may be at a higher risk of adverse outcomes and may benefit from closer surveillance. RV dominance is associated with worse clinical outcomes and remodeling compared to LV dominance.
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Affiliation(s)
- Sunil J Ghelani
- Department of Cardiology, Boston Children's Hospital, 300 Longwood Ave, Boston, MA, 02115, USA.
- Department of Pediatrics, Harvard Medical School, Boston, MA, USA.
| | - Minmin Lu
- Department of Cardiology, Boston Children's Hospital, 300 Longwood Ave, Boston, MA, 02115, USA
| | - Lynn A Sleeper
- Department of Cardiology, Boston Children's Hospital, 300 Longwood Ave, Boston, MA, 02115, USA
- Department of Pediatrics, Harvard Medical School, Boston, MA, USA
| | - Ashwin Prakash
- Department of Cardiology, Boston Children's Hospital, 300 Longwood Ave, Boston, MA, 02115, USA
- Department of Pediatrics, Harvard Medical School, Boston, MA, USA
| | - Daniel A Castellanos
- Department of Cardiology, Boston Children's Hospital, 300 Longwood Ave, Boston, MA, 02115, USA
- Department of Pediatrics, Harvard Medical School, Boston, MA, USA
| | - Nicole St Clair
- Department of Cardiology, Boston Children's Hospital, 300 Longwood Ave, Boston, MA, 02115, USA
| | - Andrew J Powell
- Department of Cardiology, Boston Children's Hospital, 300 Longwood Ave, Boston, MA, 02115, USA
- Department of Pediatrics, Harvard Medical School, Boston, MA, USA
| | - Rahul H Rathod
- Department of Cardiology, Boston Children's Hospital, 300 Longwood Ave, Boston, MA, 02115, USA
- Department of Pediatrics, Harvard Medical School, Boston, MA, USA
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23
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Kojima T, Toda K, Nabeshima T, Yoshiba S, Kobayashi T, Sumitomo N. Efficacy of a phosphodiesterase type 5 inhibitor on the pulmonary artery index and postoperative hemodynamics after a Fontan operation. Heart Vessels 2022; 37:1921-1927. [PMID: 35585360 DOI: 10.1007/s00380-022-02089-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/10/2021] [Accepted: 04/27/2022] [Indexed: 11/24/2022]
Abstract
There have been no reports regarding the influence of a change in the pulmonary artery index before or after a Fontan operation. Moreover, the factors that might affect the change in the pulmonary artery index are unclear. This was a retrospective study, which included 94 patients who underwent a Fontan operation. We divided the patients into two groups according to the change in the pulmonary artery index before and after the Fontan operation: the increased pulmonary artery index group (n = 51) and decreased pulmonary artery index group (n = 43). The pulmonary artery index after the Fontan operation was significantly higher in the increased pulmonary artery index group than decreased pulmonary artery index group (p < 0.0001). The central venous pressure (p < 0.0001) and pulmonary vascular resistance (p = 0.007) were significantly lower in the increased pulmonary artery index group. The mixed venous oxygen saturation was significantly higher in the increased pulmonary artery index group (p < 0.0001). The pulmonary artery index was more increased in the patients who were administered a phosphodiesterase type 5 inhibitor than in those who were not (p = 0.03). The change in the pulmonary artery index reflected the hemodynamics after a Fontan operation during the short term. In that respect, phosphodiesterase type 5 inhibitors might be involved in the process.
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Affiliation(s)
- Takuro Kojima
- Department of Pediatric Cardiology, Saitama International Medical Center, 1397-1 Yamane, Hidaka, Saitama, 350-1298, Japan
| | - Koichi Toda
- Department of Pediatric Cardiology, Saitama International Medical Center, 1397-1 Yamane, Hidaka, Saitama, 350-1298, Japan
| | - Taisuke Nabeshima
- Department of Pediatric Cardiology, Saitama International Medical Center, 1397-1 Yamane, Hidaka, Saitama, 350-1298, Japan
| | - Shigeki Yoshiba
- Department of Pediatric Cardiology, Saitama International Medical Center, 1397-1 Yamane, Hidaka, Saitama, 350-1298, Japan
| | - Toshiki Kobayashi
- Department of Pediatric Cardiology, Saitama International Medical Center, 1397-1 Yamane, Hidaka, Saitama, 350-1298, Japan
| | - Naokata Sumitomo
- Department of Pediatric Cardiology, Saitama International Medical Center, 1397-1 Yamane, Hidaka, Saitama, 350-1298, Japan.
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24
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Hur MH, Kim H, Lee JH. Hepatocellular carcinoma diagnosed in a patient who had Fontan operation 30 years ago: a case report. J Liver Cancer 2022; 22:188-193. [PMID: 37383407 PMCID: PMC10035737 DOI: 10.17998/jlc.2022.08.17] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/26/2022] [Revised: 08/11/2022] [Accepted: 08/17/2022] [Indexed: 06/30/2023]
Abstract
The Fontan operation is performed in patients with a single ventricle. As the systemic venous return is directly connected to the pulmonary circulation during this procedure, chronic hepatic congestion is induced, leading to Fontan-associated liver disease (FALD) including liver cirrhosis and hepatocellular carcinoma (HCC). In this report, we present a case of HCC diagnosed in a patient who underwent the Fontan operation 30 years ago. The patient underwent regular surveillance for FALD, which revealed a 4 cm-sized hepatic mass with elevated serum alpha-fetoprotein. After surgical treatment, there was no evidence of HCC recurrence during 3 years of follow-up. As the risk of HCC and Fontan-associated liver cirrhosis increases with the duration elapsed since the operation, regular surveillance should be emphasized. Serial follow-up of serum alpha-fetoprotein levels and abdominal imaging are necessary to achieve early and accurate diagnosis of HCC in post-Fontan patients.
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Affiliation(s)
- Moon Haeng Hur
- Department of Internal Medicine and Liver Research Institute, Seoul National University College of Medicine, Seoul, Korea
| | - Haeryoung Kim
- Department of Pathology, Seoul National University College of Medicine, Seoul, Korea
| | - Jeong-Hoon Lee
- Department of Internal Medicine and Liver Research Institute, Seoul National University College of Medicine, Seoul, Korea
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25
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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] [What about the content of this article? (0)] [Affiliation(s)] [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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26
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Haranal M, Kiniu NM, Srimurugan B, Latiff HA, Sivalingam S. Role of intrapulmonary artery septation in univentricular hearts. Asian Cardiovasc Thorac Ann 2022; 30:935-938. [PMID: 35876306 DOI: 10.1177/02184923221115969] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
The optimal management of functionally univentricular hearts with a significant unbalanced pulmonary blood flow is unclear. The role of cavopulmonary shunt in the rehabilitation of hypoplastic pulmonary arteries is limited. Intrapulmonary artery septation is a technique, wherein a systemic-to-pulmonary artery shunt provides an additional source of blood flow to rehabilitate the hypoplastic pulmonary artery. We report a case of functionally univentricular heart with hypoplastic left pulmonary artery following a cavopulmonary shunt in whom intrapulmonary artery septation resulted in adequate growth of the left pulmonary artery.
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Affiliation(s)
- Maruti Haranal
- Department of Cardiac Surgery, National Heart Institute, Kuala Lumpur, Malaysia
| | - Naomi Mukuhi Kiniu
- Department of Pediatric Cardiology, National Heart Institute, Kuala Lumpur, Malaysia
| | - Balaji Srimurugan
- Department of Pediatric Cardiac Surgery, Amrita Institute of Medical Sciences and Research, Kochi, India
| | - Haifa Abdul Latiff
- Department of Pediatric Cardiology, National Heart Institute, Kuala Lumpur, Malaysia
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27
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Sainathan S, Said SM, Agala CB, Mullinari L, Sharma M. National outcomes of the Fontan operation with endocardial cushion defect. J Card Surg 2022; 37:3151-3158. [PMID: 35788993 DOI: 10.1111/jocs.16742] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2022] [Revised: 04/22/2022] [Accepted: 06/13/2022] [Indexed: 11/30/2022]
Abstract
BACKGROUND The traditional outcomes of the Fontan operation (FO) in endocardial cushion defect (ECD) patients have been suboptimal. Previous studies have been limited by the smaller number of ECD patients, longer study period with an era effect, and do not directly compare short-term outcomes of FO in ECD patients with non-ECD patients. Our study aims to address these shortcomings. METHODS A retrospective analysis of the Kids Inpatient Database (2009, 2012, and 2016) for the FO was done. The groups were divided into those who underwent FO with ECD as compared to non-ECD diagnosis. The data were abstracted for demographics, clinical characteristics, and operative outcomes. Standard statistical tests were used. RESULTS Three thousand three hundred eighty patients underwent the FO of which 360 patients (11%) were FO-ECD. ECD patients were more likely to have Down syndrome, Heterotaxy syndrome, transposition/DORV, and TAPVR as compared to non-ECD patients. FO-ECD had a higher discharge-mortality (2.84% vs. 0.45%, p = .04). The length of stay (16 vs. 13 days, p = .05) and total charges incurred ($283, 280 vs. $234, 106, p = .03) for the admission were higher in the FO-ECD as compared to non-ECD patients. In multivariable analysis, ECD diagnosis, cardiac arrest, acute kidney injury, and postoperative hemorrhage were predictors of mortality. CONCLUSION Contemporary outcomes for FO are excellent with very low overall operative mortality. However, the outcomes in ECD patients are inferior with higher operative mortality than in non-ECD patients. The occurrence of postoperation complications and a diagnosis of ECD were predictive of a negative outcome.
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Affiliation(s)
- Sandeep Sainathan
- Department of Surgery, Section of Pediatric Cardiothoracic Surgery, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA.,Department of Surgery, Section of Pediatric Cardiothoracic Surgery, University of Miami, Miami, Florida, USA
| | - Sameh M Said
- Department of Surgery, Section of Pediatric Cardiothoracic Surgery, University of Minnesota, Minneapolis, Minnesota, USA
| | - Chris B Agala
- Department of Surgery/Biostatistics, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Leonardo Mullinari
- Department of Surgery, Section of Pediatric Cardiothoracic Surgery, University of Miami, Miami, Florida, USA
| | - Mahesh Sharma
- Department of Surgery, Section of Pediatric Cardiothoracic Surgery, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
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Miyamura F, Matsuo O, Nakamura K. Torsion of wandering spleen after Fontan operation in a patient with situs inversus: a rare complication. Cardiol Young 2022; 33:1-2. [PMID: 35656572 DOI: 10.1017/s1047951122001755] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Torsion of wandering spleen after the Fontan operation with situs inversus is rare.Here, we report the case of a 6-year-old girl with a single ventricle and complete situs inversus who developed torsion of wandering spleen due to splenomegaly caused by post-operative haemodynamics of the Fontan operation. The platelet count was suggested to be useful in predicting splenic torsion.
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Affiliation(s)
- Fumiya Miyamura
- Department of Pediatrics, Faculty of Life Science, Kumamoto University, Kumamoto, Japan
| | - Osamu Matsuo
- Department of Pediatrics, Faculty of Life Science, Kumamoto University, Kumamoto, Japan
| | - Kimitoshi Nakamura
- Department of Pediatrics, Faculty of Life Science, Kumamoto University, Kumamoto, Japan
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29
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Sethasathien S, Silvilairat S, Sittiwangkul R, Makonkawkeyoon K, Pongprot Y, Woragidpoonpol S. Liver nodules after the Fontan operation: role of the computerised tomography scan. Cardiol Young 2022; 32:930-5. [PMID: 34365989 DOI: 10.1017/S1047951121003309] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Currently, there is an increasing prevalence of liver nodules in patients following the Fontan operation. The appropriate non-invasive modalities have been applied to assess a diagnosis of Fontan-associated liver disease. The aims of this study were to determine the prevalence and associated factors for the presence of liver nodules using CT scan. A cross-sectional study of 34 patients older than 15 years of age was recruited. Ultrasound upper abdomen, ultrasound liver elastography, and CT scan of the upper abdomen were performed after the Fontan operation. The median age of patients was 20 years (range 14-36 years). The median age at the Fontan operation was 7 years (range 5-17 years) and the duration after the Fontan operation was 12 years (range 4-22 years). The prevalence of liver nodules was 62% as detected by CT scans. Hepatic vein pressure in patients with liver nodules was significantly higher than in those without liver nodules. Hepatic vein pressure above 13 mmHg was a factor associated with liver nodules. There was little agreement between the ultrasound of the upper abdomen and CT scan of the upper abdomen in the evaluation of liver nodules. Hepatic pressure was the only associated factor for the occurrence of liver nodules in patients following the Fontan operation. The prevalence of liver nodules was very high after the Fontan operation. The upper abdomen CT scan should be performed for the surveillance of liver nodules in every Fontan patient over the age of 15 years.
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Javadi E, Laudenschlager S, Kheyfets V, Di Maria M, Stone M, Jamali S, Powell AJ, Moghari MH. Predicting Hemodynamic Performance of Fontan Operation for Glenn Physiology using Computational Fluid Dynamics: Ten Patient-specific Cases. J Clin Images Med Case Rep 2022; 3:1916. [PMID: 36339935 PMCID: PMC9631545 DOI: 10.52768/2766-7820/1916] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/16/2023]
Abstract
Single ventricle hearts have only one ventricle that can pump blood effectively and the treatment requires three stages of operations to reconfigure the heart and circulatory system. At the second stage, Glenn procedure is performed to connect superior vena cava (SVC) to the pulmonary arteries (PA). For the third and most complex operation, called Fontan, an extracardiac conduit is used to connect inferior vena cava (IVC) to the PL and thereafter no deoxygenated blood goes to the heart. Predicting Hemodynamic Performance of Fontan Operation using computational fluid dynamics (CFD) is hypothesized to improve outcomes and optimize this treatment planning in children with single-ventricle heart disease. An important reason for this surgical planning is to reduce the development of pulmonary arteriovenous malformations (PAVM) and the need to perform Fontan revisions. The purpose of this study was to develop amodel for Fontan surgical planning and use this model to compare blood circulation in two designed graft types of Fontan operation known as T-shape and Y-graft. The functionality of grafts was compared in terms of power loss (PL) and hepatic flow distribution (HFD), a known factor in PAVM development. To perform this study, ten single-ventricle children with Glenn physiology were included and a CFD model was developed to estimate the blood flow circulation to the left and right pulmonary arteries. The estimated blood flow by CFD was compared with that measured by cardiovascular magnetic resonance. Results showed that there was an excellent agreement between the net blood flow in the right and left pulmonary arteries computed by CFD and CMR (ICC= 0.98, P-value ≥0.21). After validating the accuracy of each CFD model, Fontan operations using T-shape and Y-graft conduits were performed in silico for each patient and the developed CFD model was used to predict the post-surgical PL and HFD. We found that the PL in the Y-graft was significantly lower than in the T-shape (P-value ≤0.001) and HFD was significantly better balanced in Y-graft compared to the T-shape (P-value=0.004).
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Affiliation(s)
- Elahe Javadi
- Mechanical and Industrial Engineering Department, Northeastern University, Boston, MA, USA
| | - Sebastian Laudenschlager
- School of Medicine, University of Colorado Aurora, and Department of Radiology, Children’s Hospital Colorado, Aurora, CO, USA
| | - Vitaly Kheyfets
- Paediatric Critical Care Medicine; Developmental Lung Biology and CVP Research Laboratories, School of Medicine, University of Colorado, Aurora, CO, USA
| | - Michael Di Maria
- Department of Pediatrics, University of Colorado, and Department of Cardiology, Children’s Hospital Colorado, Aurora, CO, USA
| | - Matthew Stone
- Department of Surgery, University of Colorado, and Children’s Hospital Colorado, Aurora, CO, USA
| | - Safa Jamali
- Mechanical and Industrial Engineering Department, Northeastern University, Boston, MA, USA
| | - Andrew J. Powell
- Department of Cardiology, Boston Children’s Hospital, Boston, MA, USA
| | - Mehdi H. Moghari
- School of Medicine, University of Colorado Aurora, and Department of Radiology, Children’s Hospital Colorado, Aurora, CO, USA
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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] [What about the content of this article? (0)] [Affiliation(s)] [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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Hasegawa M, Iwai S, Kugo Y. Fontan operation for tricuspid atresia with absent pulmonary valve: a case series. Cardiol Young 2022; 32:813-4. [PMID: 34497001 DOI: 10.1017/S1047951121003772] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Combined tricuspid atresia and absent pulmonary valve with dysplasia of the right ventricular myocardium is a very rare congenital heart anomaly with a poor prognosis. We present three cases of this rare disease that reached the Fontan operation without prior surgical intervention of the right ventricle or pulmonary artery; no right ventriclar dilation was detected. All patients had uneventful post-operative courses.
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Furuta T, Muneuchi J, Sugitani Y, Yoshino M. Focal segmental glomerulosclerosis in patients after Fontan operation: is this a Fontan-associated renal disease? Cardiol Young 2022; 32:837-9. [PMID: 34521494 DOI: 10.1017/S1047951121003929] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
Despite acceptable survival for Fontan operation, there are concerns about late complications affecting the major organs. We herein present two cases of adults after Fontan operation who developed focal segmental glomerulosclerosis. These cases suggest that focal segmental glomerulosclerosis is owing to haemodynamic incompetence associated with Fontan operation, including congestion, hypoxia, and hyperviscosity, which may be called Fontan-associated renal disease.
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Sethasathien S, Leemasawat K, Silvilairat S, Sittiwangkul R, Chattipakorn SC, Chattipakorn N. Screening modalities for the diagnosis of Fontan-associated liver disease: evidence from the past for future development. Am J Transl Res 2022; 14:1433-1453. [PMID: 35422957 PMCID: PMC8991157] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2021] [Accepted: 02/06/2022] [Indexed: 06/14/2023]
Abstract
Approximately 70,000 patients who have undergone the Fontan operation worldwide survive into adulthood, however the majority of these patients are faced with long-term post-operative complications due to specific hemodynamic changes. Fontan-associated liver disease (FALD) is a challenging complication characterized by various spectra. Of these, liver congestion and liver fibrosis potentially lead to cirrhosis and liver nodules. The most serious condition associated with the development of liver nodules is hepatocellular carcinoma. Various non-invasive modalities including blood tests, ultrasound scans of the upper abdomen, ultrasound elastography of the liver, computed tomography scans, magnetic resonance imaging and magnetic resonance elastography of the liver have been used as alternatives to liver biopsies for FALD assessment in post-Fontan patients. To date, a detailed understanding of the pathophysiology and natural history of these patients, and the most appropriate modality for the effective investigation of this condition is incomplete. In this comprehensive review, reports regarding the currently available screening modalities used in the detection of FALD are summarized and discussed. The findings of this review, including identification of any current knowledge gaps, can pave the way for the development of effective future strategies in the surveillance and ultimately the treatment of post-Fontan patients.
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Affiliation(s)
- Saviga Sethasathien
- Division of Pediatric Cardiology, Department of Pediatrics, Faculty of Medicine, Chiang Mai UniversityChiang Mai 50200, Thailand
| | - Krit Leemasawat
- Division of Cardiovascular Diseases, Department of Medicine, Faculty of Medicine, Chiang Mai UniversityChiang Mai 50200, Thailand
| | - Suchaya Silvilairat
- Division of Pediatric Cardiology, Department of Pediatrics, Faculty of Medicine, Chiang Mai UniversityChiang Mai 50200, Thailand
| | - Rekwan Sittiwangkul
- Division of Pediatric Cardiology, Department of Pediatrics, Faculty of Medicine, Chiang Mai UniversityChiang Mai 50200, Thailand
| | - Siriporn C Chattipakorn
- Cardiac Electrophysiology Research and Training Center, Faculty of Medicine, Chiang Mai UniversityChiang Mai 50200, Thailand
- Center of Excellence in Cardiac Electrophysiology Research, Chiang Mai UniversityChiang Mai 50200, Thailand
| | - Nipon Chattipakorn
- Cardiac Electrophysiology Research and Training Center, Faculty of Medicine, Chiang Mai UniversityChiang Mai 50200, Thailand
- Center of Excellence in Cardiac Electrophysiology Research, Chiang Mai UniversityChiang Mai 50200, Thailand
- Cardiac Electrophysiology Unit, Department of Physiology, Faculty of Medicine, Chiang Mai UniversityChiang Mai 50200, Thailand
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Alnoor M, Burch G, Armsby L, Batra A, Balaji S. Hemodynamic Impact of Atrial Pacing in Patients with Fontan Physiology and Junctional Rhythm: A Cardiac Catheterization Study. Pediatr Cardiol 2022; 43:508-514. [PMID: 34661729 DOI: 10.1007/s00246-021-02747-2] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/30/2021] [Accepted: 09/29/2021] [Indexed: 11/24/2022]
Abstract
Sinus node dysfunction is a common problem and adversely impacts patients who have undergone the Fontan operation. In Fontan patients with an adequate junctional escape rhythm, the benefit of atrial pacing to restore atrioventricular synchrony remains unclear. Data were collected retrospectively on all Fontan patients with junctional rhythm who underwent atrial pacing during cardiac catheterization. Hemodynamics were obtained at baseline and after atrial pacing for 5-10 min. Seven patients, mean age 10 years (3-21) were studied. The type of Fontan was extracardiac in 6 and lateral tunnel in one. Patients were paced at 10 bpm faster than their junctional rate. With pacing, there was a significant decrease in left atrial pressure from (mean ± SEM) 8.8 ± 2.6 to 5.5 ± 2.9 mmHg (p = 0.02), a significant increase in cardiac index from 2.7 ± 0.8 to 3.5 ± 1 L/min/m2 (p = 0.01) and pulmonary blood flow from 2.1 ± 0.6 to 2.7 ± 0.7 L/min/m2 (p = 0.001), and no significant change in pulmonary artery pressure, from 13.4 ± 2.8 to 12.4 mmHg ± 3.6 (p = 0.06) or pulmonary vascular resistance from 2.1 ± 0.86 to 3.25 ± 1.9 WU × M2 (p = 0.1). In Fontan patients with junctional rhythm, atrial pacing decreased the left atrial pressure, increased cardiac output and did not significantly change the pulmonary artery pressure. Our study supports further investigation into the utility of prophylactic atrial pacemaker implantation in Fontan patients with significant durations of JR on ambulatory monitoring.
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Affiliation(s)
- Mohammad Alnoor
- Division of Cardiology, Department of Pediatrics, Oregon Health & Science University, 700 SW Campus Dr, Portland, OR, 97239, USA.
| | - Grant Burch
- Division of Cardiology, Department of Pediatrics, Oregon Health & Science University, 700 SW Campus Dr, Portland, OR, 97239, USA
| | - Laurie Armsby
- Division of Cardiology, Department of Pediatrics, Oregon Health & Science University, 700 SW Campus Dr, Portland, OR, 97239, USA
| | - Anjan Batra
- Division of Cardiology, Department of Pediatrics, University of California-Irvine, Irvine, CA, USA
| | - Seshadri Balaji
- Division of Cardiology, Department of Pediatrics, Oregon Health & Science University, 700 SW Campus Dr, Portland, OR, 97239, USA
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Muneuchi J, Watanabe M, Sugitani Y, Doi H, Furuta T, Kobayashi M, Ezaki H, Ochiai Y. Long-Term Outcomes After an Individualized Strategy in Patients with Pulmonary Atresia and Intact Ventricular Septum. Pediatr Cardiol 2022; 43:435-442. [PMID: 34559262 DOI: 10.1007/s00246-021-02740-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/10/2021] [Accepted: 09/16/2021] [Indexed: 12/19/2022]
Abstract
This retrospective cohort study aimed to explore the long-term outcomes of an individualized strategy in patients with pulmonary atresia and intact ventricular septum (PAIVS). We analyzed survival and reintervention rates and identified risk factors for outcomes in patients with PAIVS treated based on individual right heart structures between 1979 and 2019. Ninety-five patients were included in this study. The z-scores of the pulmonary annulus, tricuspid annulus, and right ventricular end-diastolic volume were - 3.30 (- 15.15 to 1.83), - 0.70 (- 4.65 to 2.33), and - 1.51 (- 6.35 to 1.18), respectively. Right ventricular-dependent coronary circulation occurred in 15% of the patients. Among the 63 patients attempting biventricular strategy at first, 55 patients achieved biventricular circulation, 3 patients had one-and-a-half circulation, and 4 patients died perioperatively. Among the 33 patients attempting univentricular strategy at first, 10 patients died before the completion of Fontan operation, 17 patients (48%) accomplished Fontan operation, and 5 patients waited for Fontan operation. In one patient, conversion to biventricular circulation occurred. During the follow-up period of 720 person-years, the 20-year survival rate was significantly higher in patients with biventricular circulation than in those patients with univentricular circulation (93% vs. 67%, P < 0.001). Freedom from reintervention rates at 20 years was significantly lower in patients with biventricular circulation than in those patients with univentricular circulation (29% vs. 72%, P < 0.001). The pulmonary annulus z-score was an independent risk factor for reintervention in patients with biventricular circulation. Patients with biventricular circulation had an acceptable survival rate, but a high reintervention rate. Meanwhile, patients with univentricular circulation had high mortality before the completion of Fontan operation, although the reintervention rate was relatively low.
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Affiliation(s)
- Jun Muneuchi
- Department of Pediatrics, Kyushu Hospital, Japan Community Healthcare Organization, 1-8-1, Kishinoura, Yahatanishi-ku, Kitakyushu, Fukuoka, 806-8501, Japan.
| | - Mamie Watanabe
- Department of Pediatrics, Kyushu Hospital, Japan Community Healthcare Organization, 1-8-1, Kishinoura, Yahatanishi-ku, Kitakyushu, Fukuoka, 806-8501, Japan
| | - Yuichiro Sugitani
- Department of Pediatrics, Kyushu Hospital, Japan Community Healthcare Organization, 1-8-1, Kishinoura, Yahatanishi-ku, Kitakyushu, Fukuoka, 806-8501, Japan
| | - Hirohito Doi
- Department of Pediatrics, Kyushu Hospital, Japan Community Healthcare Organization, 1-8-1, Kishinoura, Yahatanishi-ku, Kitakyushu, Fukuoka, 806-8501, Japan
| | - Takashi Furuta
- Department of Pediatrics, Kyushu Hospital, Japan Community Healthcare Organization, 1-8-1, Kishinoura, Yahatanishi-ku, Kitakyushu, Fukuoka, 806-8501, Japan
| | - Masaru Kobayashi
- Department of Pediatrics, Kyushu Hospital, Japan Community Healthcare Organization, 1-8-1, Kishinoura, Yahatanishi-ku, Kitakyushu, Fukuoka, 806-8501, Japan
| | - Hiroki Ezaki
- Department of Pediatrics, Kyushu Hospital, Japan Community Healthcare Organization, 1-8-1, Kishinoura, Yahatanishi-ku, Kitakyushu, Fukuoka, 806-8501, Japan
| | - Yoshie Ochiai
- Department of Cardiovascular Surgery, Kyushu Hospital, Japan Community Healthcare Organization, Kitakyushu, Japan
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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] [What about the content of this article? (0)] [Affiliation(s)] [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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Ohuchi H, Mori A, Nakai M, Fujimoto K, Iwasa T, Sakaguchi H, Kurosaki K, Shiraishi I. Pulmonary Arteriovenous Fistulae After Fontan Operation: Incidence, Clinical Characteristics, and Impact on All-Cause Mortality. Front Pediatr 2022; 10:713219. [PMID: 35757115 PMCID: PMC9218217 DOI: 10.3389/fped.2022.713219] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/22/2021] [Accepted: 02/28/2022] [Indexed: 11/30/2022] Open
Abstract
BACKGROUND The Fontan operation is a surgical procedure used in children with univentricular hearts. Pulmonary arteriovenous fistulae (PAVF) is a major complication after a Fontan operation. However, the incidence and related clinical pathophysiology of PAVF remain unclear. PURPOSE This study aimed to clarify the incidence of PAVF, its clinical characteristics, and its influence on all-cause mortality. METHODS AND RESULTS We serially assessed the presence of PAVF using pulmonary artery angiography and/or contrast echocardiography during catheterization in 391 consecutive patients who underwent the Fontan procedure and compared the results with the Fontan pathophysiology and all-cause mortality. PAVF developed in 36 patients (9.2%), including 30 diffuse- and six discrete-PAVF types. The PAVF-free rates at 1, 5, 10, 15, 20, and ≥25 years after Fontan operation were 97, 96, 93, 88, 87, and 83%, respectively. The mean arterial blood oxygen saturation (SaO2) in patients with diffuse PAVF at each corresponding postoperative stage were 90, 91, 91, 91, 89, and 88%, respectively, indicating lower SaO2 levels than those in patients without PAVF (all p < 0.01). However, there was no difference in the SaO2 levels between patients with discrete PAVF and those without PAVF. During a median follow-up period of 2.9 years after the last catheterization, 31 patients, including 12 patients with PAVF, died. Patients with PAVF, especially those with diffuse PAVF, had a higher mortality rate (p = 0.01) than those without PAVF (hazard ratio: 3.6, 95% confidence interval: 1.6-7.8, p = 0.0026). CONCLUSION Patients who underwent Fontan surgery had an increased incidence of PAVF as they aged. Discrete PAVF did not influence SaO2 or mortality, whereas the presence of diffuse PAVF caused hypoxia and was associated with all-cause mortality.
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Affiliation(s)
- Hideo Ohuchi
- Department of Pediatric Cardiology, National Cerebral and Cardiovascular Center, Suita, Japan.,Adult Congenital Heart Disease, National Cerebral and Cardiovascular Center, Suita, Japan
| | - Aki Mori
- Department of Pediatric Cardiology, National Cerebral and Cardiovascular Center, Suita, Japan
| | - Michikazu Nakai
- Department of Medical and Health Information Management, National Cerebral and Cardiovascular Center, Suita, Japan
| | - Kazuto Fujimoto
- Department of Pediatric Cardiology, National Cerebral and Cardiovascular Center, Suita, Japan
| | - Toru Iwasa
- Department of Pediatric Cardiology, National Cerebral and Cardiovascular Center, Suita, Japan
| | - Heima Sakaguchi
- Department of Pediatric Cardiology, National Cerebral and Cardiovascular Center, Suita, Japan
| | - Kenichi Kurosaki
- Department of Pediatric Cardiology, National Cerebral and Cardiovascular Center, Suita, Japan
| | - Isao Shiraishi
- Department of Pediatric Cardiology, National Cerebral and Cardiovascular Center, Suita, Japan
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Yalta K, Yetkin E, Taylan G. Fontan Circulation Might be Associated with Peripartum Cardiomyopathy: A Review of Mechanistic and Clinical Aspects. Curr Cardiol Rev 2021; 17:e051121192311. [PMID: 33726653 PMCID: PMC8950506 DOI: 10.2174/1573403x17666210316121842] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/25/2020] [Revised: 12/30/2020] [Accepted: 01/18/2021] [Indexed: 12/30/2022] Open
Abstract
Fontan operation has been defined as a palliative surgery connecting systemic venous return and pulmonary circulation in patients with certain forms of complex congenital heart disease (CHD). Fortunately, it has improved overall survival and chance of successful pregnancies among these patients. However, Fontan circulation (FC), as a potential trade-off, might be associated with specific late or post-gestational complications, including peripartum cardiomyopathy (PPCM) largely through its adverse effects on the placenta and inflammation-oxidation stress. Importantly, diagnosis of superimposed PPCM in women with FC might be a diagnostic challenge, requiring a high index of suspicion. Accordingly, the present paper aims to highlight the potential association of FC with PPCM evolution largely based on certain mechanistic and clinical perspectives.
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Affiliation(s)
- Kenan Yalta
- Cardiology Department, Trakya University, Edirne, Turkey;
| | - Ertan Yetkin
- Cardiology Department, Derindere Hospital, Istanbul, Turkey,Address correspondence to this author at the Cardiology Department, Derindere Hospital, Istanbul, Turkey; Tel: +905327136721; E-mail:
| | - Gokay Taylan
- Cardiology Department, Trakya University, Edirne, Turkey;
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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] [What about the content of this article? (0)] [Affiliation(s)] [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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Cohen MS. Ventricular contribution and the impact on outcome of the Fontan operation: less is more or more is less? Eur J Cardiothorac Surg 2021; 60:1082-1083. [PMID: 34008021 DOI: 10.1093/ejcts/ezab242] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Affiliation(s)
- Meryl S Cohen
- Department of Pediatrics, University of Pennsylvania, Perelman School of Medicine, Philadelphia, PA, USA.,Division of Cardiology, The Children's Hospital of Philadelphia, Philadelphia, PA, USA
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Okólska M, Łach J, Matusik PT, Pająk J, Mroczek T, Podolec P, Tomkiewicz-Pająk L. Heart Rate Variability and Its Associations with Organ Complications in Adults after Fontan Operation. J Clin Med 2021; 10:jcm10194492. [PMID: 34640508 PMCID: PMC8509291 DOI: 10.3390/jcm10194492] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2021] [Revised: 09/10/2021] [Accepted: 09/22/2021] [Indexed: 11/18/2022] Open
Abstract
Reduction of heart rate variability (HRV) parameters may be a risk factor and precede the occurrence of arrhythmias or the development of heart failure and complications in people with postinfarct left ventricular dysfunction and after coronary artery bypass grafting. Data on this issue in adults after a Fontan operation (FO) are scarce. This study assessed the association between HRV, exercise capacity, and multiorgan complications in adults after FO. Data were obtained from 30 FO patients (mean age 24 ± 5.4 years) and 30 healthy controls matched for age and sex. HRV was investigated in all patients by clinical examination, laboratory tests, echocardiography, a cardiopulmonary exercise test, and 24-h electrocardiogram. The HRV parameters were reduced in the FO group. Reduced HRV parameters were associated with patients’ age at the time of FO, time since surgery, impaired exercise capacity, chronotropic incompetence parameters, and multiorgan complications. Univariate analysis showed that saturated O2 at rest, percentage difference between adjacent NN intervals of >50 ms duration, and peak heart rate were associated with chronotropic index. Multivariable analysis revealed that all three variables were independent predictors of the chronotropic index. The results of this study suggest novel pathophysiological mechanisms that link HRV, physical performance, and organ damage in patients after FO.
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Affiliation(s)
- Magdalena Okólska
- Cardiological Outpatient Clinic, Department of Cardiovascular Diseases, John Paul II Hospital, 31-202 Krakow, Poland;
| | - Jacek Łach
- Department of Cardiac and Vascular Diseases, Institute of Cardiology, Jagiellonian University Medical College, John Paul II Hospital, 31-202 Krakow, Poland; (J.Ł.); (P.P.); (L.T.-P.)
| | - Paweł T. Matusik
- Department of Electrocardiology, Institute of Cardiology, Faculty of Medicine, Jagiellonian University Medical College, John Paul II Hospital, 31-202 Krakow, Poland
- Correspondence: ; Tel.: +48-12-614-23-81
| | - Jacek Pająk
- Department of Pediatric Heart Surgery and General Pediatric Surgery, Medical University of Warsaw, 02-091 Warsaw, Poland;
| | - Tomasz Mroczek
- Department of Pediatric Cardiac Surgery, Jagiellonian University, 30-663 Krakow, Poland;
| | - Piotr Podolec
- Department of Cardiac and Vascular Diseases, Institute of Cardiology, Jagiellonian University Medical College, John Paul II Hospital, 31-202 Krakow, Poland; (J.Ł.); (P.P.); (L.T.-P.)
| | - Lidia Tomkiewicz-Pająk
- Department of Cardiac and Vascular Diseases, Institute of Cardiology, Jagiellonian University Medical College, John Paul II Hospital, 31-202 Krakow, Poland; (J.Ł.); (P.P.); (L.T.-P.)
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Hayabuchi Y, Homma Y, Kagami S. Three-dimensional imaging of pulmonary arterial vasa vasorum using optical coherence tomography in patients after bidirectional Glenn and Fontan procedures. Eur Heart J Cardiovasc Imaging 2021; 22:941-949. [PMID: 32413104 DOI: 10.1093/ehjci/jeaa098] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/19/2019] [Revised: 01/31/2020] [Accepted: 04/16/2020] [Indexed: 11/13/2022] Open
Abstract
AIMS We evaluated pulmonary arterial (PA) vasa vasorum (VV) in Fontan candidate patients with a novel three-dimensional (3D) imaging technique using optical coherence tomography (OCT). METHODS AND RESULTS This prospective study assessed the development of adventitial VV in the distal PA of 10 patients with bidirectional Glenn circulation (BDG group, 1.6 ± 0.3 years) and Fontan circulation (Fontan group, 3.3 ± 0.3 years), and in 20 children with normal PA haemodynamics and morphology (Control group, 1.5 ± 0.3 years). We assessed the PA VV with two-dimensional (2D) cross-sectional, multi-planar reconstruction (MPR), and volume rendering (VR) imaging. VV development was evaluated by the VV area/volume ratio, defined as the VV area/volume divided by the adventitial area/volume. Compared to the control group, the observed VV number and diameter on 3D images of MPR and VR were significantly higher, and curved and torturous-shaped VV were more frequently observed in the BDG and Fontan groups (P < 0.001, all). The median VV volume ratio was significantly greater in the BDG than in the control group (3.38% vs. 0.61%; P < 0.001). Although the VV volume ratio decreased significantly after the Fontan procedure (2.64%, P = 0.005 vs. BDG), the ratio remained higher than in the control group (P < 0.001 vs. control). CONCLUSION 3D OCT imaging is a novel method that can be used to evaluate adventitial PA VV and may provide pathophysiological insight into the role of the PA VV in these patients.
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Affiliation(s)
- Yasunobu Hayabuchi
- Department of Pediatrics, Tokushima University, Kuramoto-cho-3, Tokushima 770-8503, Japan
| | - Yukako Homma
- Department of Pediatrics, Tokushima University, Kuramoto-cho-3, Tokushima 770-8503, Japan
| | - Shoji Kagami
- Department of Pediatrics, Tokushima University, Kuramoto-cho-3, Tokushima 770-8503, Japan
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Ozawa H, Hoashi T, Ohuchi H, Kurosaki K, Ichikawa H. Long-Term Outcomes After Fenestration Closure in High-Risk Fontan Candidates. Pediatr Cardiol 2021; 42:1356-1364. [PMID: 33881601 DOI: 10.1007/s00246-021-02619-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/09/2020] [Accepted: 04/15/2021] [Indexed: 10/21/2022]
Abstract
The study aimed to assess the long-term outcomes after fenestration closure in patients at risk for Fontan failure. Of 119 patients who underwent Fontan operation between 1995 and 2004, fenestration was not created in 89 patients (NF group) and created in 30 patients with hypoplastic left heart syndrome, heterotaxy syndrome, high pulmonary arterial pressure, high systemic ventricular end-diastolic pressure, low ventricular ejection fraction, or atrioventricular valve regurgitation. All fenestrations were closed spontaneously or by catheter/surgical interventions, excepting two patients, and therefore, they were excluded. In fenestration group, patients with pre-Fontan mean pulmonary arterial pressure ≥ 15 mmHg or systemic atrioventricular valve regurgitation ≥ moderate were classified as high-risk Fontan candidates (F-HR group, n = 16), and the remaining patients were as standard-risk (F-SR group, n = 12). Protein-losing enteropathy-free survival rates did not differ among the three groups (p = 0.72). Serial follow-up catheter examinations after Fontan operation were completed in 69 patients in NF group and 11 patients in both F-SR and F-HR groups. Cardiac index and pulmonary vascular resistance significantly and similarly decreased over time in all groups, though the F-HR group showed lowest arterial oxygen saturation, lowest cardiac index, and highest pulmonary vascular resistance. The F-HR group also showed much veno-venous collaterals (p = 0.049), low peak oxygen consumption (p = 0.019), and low anaerobic threshold (p = 0.023) as compared to those in the F-SR group. In F-HR group, cyanosis remained after fenestration closure due to transformation from fenestration to veno-venous collaterals, which resulted in elevation of pulmonary vascular resistance, low cardiac index, and deterioration of exercise tolerance.
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Affiliation(s)
- Hideto Ozawa
- Department of Pediatric Cardiovascular Surgery, National Cerebral and Cardiovascular Center, 6-1 Kishibe-Shimmachi, Suita, Osaka, 564-8565, Japan
| | - Takaya Hoashi
- Department of Pediatric Cardiovascular Surgery, National Cerebral and Cardiovascular Center, 6-1 Kishibe-Shimmachi, Suita, Osaka, 564-8565, Japan.
| | - Hideo Ohuchi
- Department of Pediatric Cardiology, National Cerebral and Cardiovascular Center, Suita, Japan
| | - Kenichi Kurosaki
- Department of Pediatric Cardiology, National Cerebral and Cardiovascular Center, Suita, Japan
| | - Hajime Ichikawa
- Department of Pediatric Cardiovascular Surgery, National Cerebral and Cardiovascular Center, 6-1 Kishibe-Shimmachi, Suita, Osaka, 564-8565, Japan
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45
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Krimly A, Jain CC, Egbe A, Alzahrani A, Al Najashi K, Albert-Brotons D, Veldtman GR. The pulmonary vascular bed in patients with functionally univentricular physiology and a Fontan circulation. Cardiol Young 2021; 31:1241-50. [PMID: 34378498 DOI: 10.1017/S104795112100192X] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
Fontan palliation represents one of the most remarkable surgical advances in the management of individuals born with functionally univentricular physiology. The operation secures adult survival for all but a few with unfavourable anatomy and/or physiology. Inherent to the physiology is passive transpulmonary blood flow, which produces a vulnerability to adequate filling of the systemic ventricle at rest and during exertion. Similarly, the upstream effects of passive flow in the lungs are venous congestion and venous hypertension, especially marked during physical activity. The pulmonary vascular bed has emerged as a defining character on the stage of Fontan circulatory behaviour and clinical outcomes. Its pharmacologic regulation and anatomic rehabilitation therefore seem important strategic therapeutic targets. This review seeks to delineate the important aspects of pulmonary artery development and maturation in functionally univentricular physiology patients, pulmonary artery biology, pulmonary vascular reserve with exercise, and pulmonary artery morphologic and pharmacologic rehabilitation.
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46
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Yang Y, Feng Z, Ma K, Zhang S, Zhang B, Qi L, Wang G, Li S. Long-term results of concomitant atrioventricular valve intervention and the Fontan operation. Eur J Cardiothorac Surg 2021; 59:832-838. [PMID: 33538305 DOI: 10.1093/ejcts/ezaa464] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/05/2020] [Revised: 10/09/2020] [Accepted: 10/25/2020] [Indexed: 11/14/2022] Open
Abstract
OBJECTIVES The optimal timing for atrioventricular valve (AVV) repair in patients with a Fontan circulation remains controversial. Few studies have reported the long-term outcomes of AVV repair concomitant with a Fontan operation. METHODS From January 2006 to December 2018, a total of 89 patients who developed moderate or severe AVV regurgitation before a Fontan operation were divided into 2 groups: group 1, including 37 patients who did not undergo concomitant AVV repair; and group 2, including 52 patients who received AVV repair concomitant with a Fontan operation. RESULTS The mean age at the time of the Fontan operation was 6.74 years for group 1 and 8.96 years for group 2, respectively. Early death occurred in 3 patients [2 patients (5.4%) in group 2, patient 1 (1.9%) in group 1]. Freedom from long-term death, cardiac function reduction and protein-losing enteropathy were similar among the 2 groups. Common AVV function was apparently poorer than mitral valve function after repair [hazard ratio (HR) 3.83, 95% confidence interval (CI) 1.31-11.17; P = 0.014]. The occurrence of AVV valve failure in group 1 was lower than that in group 2 (HR 0.44, 95% CI 0.22-0.91; P = 0.026). AVV function became worse during the follow-up period than that at discharge in both groups (P = 0.03 in group 1 and P = 0.001 in group 2). CONCLUSIONS The long-term results of AVV repair concomitant with a Fontan operation are favourable.
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Affiliation(s)
- Yang Yang
- Pediatric Cardiac Surgery Center, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, China
| | - Zicong Feng
- Pediatric Cardiac Surgery Center, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, China
| | - Kai Ma
- Pediatric Cardiac Surgery Center, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, China
| | - Sen Zhang
- Pediatric Cardiac Surgery Center, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, China
| | - Benqing Zhang
- Pediatric Cardiac Surgery Center, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, China
| | - Lei Qi
- Pediatric Cardiac Surgery Center, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, China
| | - Guanxi Wang
- Pediatric Cardiac Surgery Center, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, China
| | - Shoujun Li
- Pediatric Cardiac Surgery Center, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, China
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Schafstedde M, Nordmeyer S, Schleiger A, Nordmeyer J, Berger F, Kramer P, Ovroutski S. Persisting and reoccurring cyanosis after Fontan operation is associated with increased late mortality. Eur J Cardiothorac Surg 2021; 61:54-61. [PMID: 34195822 DOI: 10.1093/ejcts/ezab298] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/24/2020] [Revised: 04/22/2021] [Accepted: 05/13/2021] [Indexed: 12/23/2022] Open
Abstract
OBJECTIVES The Fontan operation aims at reducing cyanosis and cardiac volume overload in patients with complex univentricular heart malformations. However, persisting or reoccurring cyanosis is frequently observed. We sought to systematically determine the prevalence and clinical consequences of persisting and secondary cyanosis after Fontan operation. METHODS A total of 331 Fontan patients, operated between 1984 and 2016 with a median postoperative follow-up of 7.9 (interquartile range 2.6-15.8) years, were studied retrospectively. Cyanosis was defined as transcutaneous oxygen saturation ≤93% at rest measured by pulse oximetry. Prevalence of cyanosis was analysed at 3 different time points (t1 = post-Fontan operation, t2 = post-Fontan cardiac catheterization, t3 = last follow-up) and the association of cyanosis with mortality was examined. RESULTS Prevalence of cyanosis was 50% at t1 and 39% at t3. Fenestration was patent in 71% and 33% of all cyanotic patients at t1 and t3, respectively. In patients with clinical indication for catheterization (t2; n = 178/331), prevalence of cyanosis was 72%. At t2, patent fenestration (33%), veno-venous collaterals (24%) or both (32%) were present. Thirty-six (11%) patients died during follow-up. In a time-varying multivariable Cox regression analysis, cyanosis was the strongest predictor for late mortality (P < 0.001, hazard ratio 12.2, 95% confidence interval 3.7-40.5). CONCLUSIONS Prevalence of cyanosis was considerable during long-term follow-up after Fontan operation and-as a surrogate parameter for unfavourable Fontan haemodynamics-is associated with increased late mortality. Accordingly, particular attention should be directed towards the persistence or reoccurrence of cyanosis during follow-up since it may indicate haemodynamic attrition and development of Fontan failure.
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Affiliation(s)
- Marie Schafstedde
- Department of Congenital Heart Disease/Paediatric Cardiology, German Heart Center Berlin, Berlin, Germany.,Institute for Cardiovascular Computer-Assisted Medicine, Charité Universitätsmedizin Berlin, Berlin, Germany.,Berlin Institute of Health, Berlin, Germany.,DZHK (German Center for Cardiovascular Research), Partner Site Berlin, Germany
| | - Sarah Nordmeyer
- Department of Congenital Heart Disease/Paediatric Cardiology, German Heart Center Berlin, Berlin, Germany.,Institute for Cardiovascular Computer-Assisted Medicine, Charité Universitätsmedizin Berlin, Berlin, Germany
| | - Anastasia Schleiger
- Department of Congenital Heart Disease/Paediatric Cardiology, German Heart Center Berlin, Berlin, Germany
| | - Johannes Nordmeyer
- Department of Congenital Heart Disease/Paediatric Cardiology, German Heart Center Berlin, Berlin, Germany
| | - Felix Berger
- Department of Congenital Heart Disease/Paediatric Cardiology, German Heart Center Berlin, Berlin, Germany.,DZHK (German Center for Cardiovascular Research), Partner Site Berlin, Germany.,Department of Paediatric Cardiology, Charité Universitätsmedizin Berlin, Berlin, Germany
| | - Peter Kramer
- Department of Congenital Heart Disease/Paediatric Cardiology, German Heart Center Berlin, Berlin, Germany
| | - Stanislav Ovroutski
- Department of Congenital Heart Disease/Paediatric Cardiology, German Heart Center Berlin, Berlin, Germany
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Jagosz M, Kowalska W, Lenarczyk R, Knop M, Fiszer R, Średniawa B, Jędrzejczyk-Patej E. Radiofrequency catheter ablation as a treatment option in a patient with hypoplastic left heart syndrome and atrial flutter after Fontan operation-Case report. J Arrhythm 2021; 37:1101-1104. [PMID: 34386138 PMCID: PMC8339114 DOI: 10.1002/joa3.12579] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2021] [Revised: 04/27/2021] [Accepted: 05/22/2021] [Indexed: 11/23/2022] Open
Affiliation(s)
- Marta Jagosz
- Student Scientific Society Department of Cardiology Division of Medical Sciences in Zabrze Medical University of Silesia Katowice Poland
| | - Wiktoria Kowalska
- Student Scientific Society Department of Cardiology Division of Medical Sciences in Zabrze Medical University of Silesia Katowice Poland
| | - Radosław Lenarczyk
- Department of Cardiology Congenital Heart Diseases and Electrotherapy Silesian Centre for Heart Diseases Zabrze Poland
| | - Mateusz Knop
- Division of Medical Sciences in Zabrze Department of Congenital Heart Diseases and Pediatric Cardiology Medical University of Silesia Katowice Poland
| | - Roland Fiszer
- Division of Medical Sciences in Zabrze Department of Congenital Heart Diseases and Pediatric Cardiology Medical University of Silesia Katowice Poland
| | - Beata Średniawa
- Division of Medical Sciences in Zabrze, Medical University of Silesia, Katowice, Poland, Department of Cardiology, Silesian Center for Heart Diseases, Zabrze, Poland Katowice Poland
| | - Ewa Jędrzejczyk-Patej
- Department of Cardiology Congenital Heart Diseases and Electrotherapy Silesian Centre for Heart Diseases Zabrze Poland
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49
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Katz DA, Peck D, Lubert AM, Possner M, Zafar F, Trout AT, Palermo JJ, Anwar N, Dillman JR, Powell AW, Xanthakos SA, Opotowsky AR, Veldtman G, Alsaied T. Hepatic Steatosis in Patients With Single Ventricle and a Fontan Circulation. J Am Heart Assoc 2021; 10:e019942. [PMID: 33880928 PMCID: PMC8200742 DOI: 10.1161/jaha.120.019942] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
Background Hepatic steatosis, caused by nonalcoholic fatty liver disease, is a leading cause of chronic liver disease. The interplay between hepatic steatosis and the development of liver disease following the Fontan procedure is not well understood. This study examined the prevalence and associations of hepatic steatosis in patients with a Fontan circulation. Methods and Results This was a single‐center retrospective study of 95 patients with a Fontan circulation with liver magnetic resonance imaging performed between 2012 and 2019. The average age at magnetic resonance imaging was 21.5±8.5 years. The percent liver fat signal was determined using magnetic resonance chemical shift‐encoded proton density fat fraction imaging. Hepatic steatosis was defined as liver fat ≥5% and was present in 10.5% of the cohort. The presence of hepatic steatosis was associated with higher body mass index (29±4 versus 24±6 kg/m2, P=0.006), a higher frequency of obesity (50% versus 12%, P=0.015), lower high‐density lipoprotein cholesterol (35±9 versus 43±14 mg/dL, P=0.050), and greater subcutaneous fat thickness (2.6±0.7 versus 1.8±1.0 cm, P=0.043). There was no association between hepatic steatosis and cardiovascular imaging or hemodynamic variables from cardiac catheterization. Conclusions Risk factors for hepatic steatosis in patients with Fontan circulation include obesity and dyslipidemia, similar to what is seen in the general population. Fontan hemodynamics were not associated with hepatic steatosis.
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Affiliation(s)
- David A Katz
- Department of Pediatrics University of Cincinnati College of Medicine Cincinnati OH.,The Heart Institute Cincinnati Children's Hospital Medical Center Cincinnati OH
| | - Daniel Peck
- Department of Pediatrics University of Cincinnati College of Medicine Cincinnati OH.,The Heart Institute Cincinnati Children's Hospital Medical Center Cincinnati OH
| | - Adam M Lubert
- Department of Pediatrics University of Cincinnati College of Medicine Cincinnati OH.,The Heart Institute Cincinnati Children's Hospital Medical Center Cincinnati OH
| | - Mathias Possner
- Department of Pediatrics University of Cincinnati College of Medicine Cincinnati OH.,The Heart Institute Cincinnati Children's Hospital Medical Center Cincinnati OH
| | - Faizeen Zafar
- Department of Pediatrics University of Cincinnati College of Medicine Cincinnati OH
| | - Andrew T Trout
- Department of Pediatrics University of Cincinnati College of Medicine Cincinnati OH.,Department of Radiology Cincinnati Children's Hospital Medical Center Cincinnati OH.,Department of Radiology University of Cincinnati College of Medicine Cincinnati OH
| | - Joseph J Palermo
- Department of Pediatrics University of Cincinnati College of Medicine Cincinnati OH.,Department of Gastroenterology Cincinnati Children's Hospital Medical Center Cincinnati OH
| | - Nadeem Anwar
- Department of Gastroenterology University of Cincinnati Cincinnati OH
| | - Jonathan R Dillman
- Department of Radiology Cincinnati Children's Hospital Medical Center Cincinnati OH.,Department of Radiology University of Cincinnati College of Medicine Cincinnati OH
| | - Adam W Powell
- Department of Pediatrics University of Cincinnati College of Medicine Cincinnati OH.,The Heart Institute Cincinnati Children's Hospital Medical Center Cincinnati OH
| | - Stavra A Xanthakos
- Department of Pediatrics University of Cincinnati College of Medicine Cincinnati OH.,Department of Gastroenterology Cincinnati Children's Hospital Medical Center Cincinnati OH
| | - Alexander R Opotowsky
- Department of Pediatrics University of Cincinnati College of Medicine Cincinnati OH.,The Heart Institute Cincinnati Children's Hospital Medical Center Cincinnati OH
| | - Gruschen Veldtman
- King Faisal Specialist Hospital and Research Centre Riyadh Saudi Arabia
| | - Tarek Alsaied
- Department of Pediatrics University of Cincinnati College of Medicine Cincinnati OH.,The Heart Institute Cincinnati Children's Hospital Medical Center Cincinnati OH
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Konstantinov IE, Backer CL, Yerebakan C, Alsoufi B. At the forefront of congenital cardiothoracic surgery: 2020-2021. J Thorac Cardiovasc Surg 2021; 162:178-182. [PMID: 33972113 DOI: 10.1016/j.jtcvs.2021.03.108] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/18/2021] [Revised: 03/18/2021] [Accepted: 03/23/2021] [Indexed: 11/17/2022]
Affiliation(s)
- Igor E Konstantinov
- Department of Cardiac Surgery, Royal Children's Hospital, Department of Paediatrics, University of Melbourne, Heart Research Group, Murdoch Children's Research Institute, Melbourne Centre for Cardiovascular Genomics and Regenerative Medicine, Melbourne, Australia.
| | - Carl L Backer
- Section of Pediatric Cardiothoracic Surgery, UK HealthCare Kentucky Children's Hospital, Lexington, Ky; Heart Institute and Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Can Yerebakan
- Cardiac Surgery, Children's National Heart Institute, Washington, DC
| | - Bahaaldin Alsoufi
- Department of Cardiothoracic Surgery, University of Louisville and Norton Children's Hospital, Louisville, Ky
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