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OUP accepted manuscript. Eur J Cardiothorac Surg 2022; 62:6537500. [DOI: 10.1093/ejcts/ezac103] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/05/2021] [Revised: 01/15/2022] [Accepted: 01/27/2022] [Indexed: 11/13/2022] Open
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Liu X, Kim B, Loke YH, Mass P, Olivieri L, Hibino N, Fuge M, Krieger A. Semi-Automatic Planning and Three-Dimensional Electrospinning of Patient-Specific Grafts for Fontan Surgery. IEEE Trans Biomed Eng 2022; 69:186-198. [PMID: 34156934 PMCID: PMC8753752 DOI: 10.1109/tbme.2021.3091113] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
This paper proposes a semi-automatic Fontan surgery planning method for designing and manufacturing hemodynamically optimized patient-specific grafts. Fontan surgery is a palliative procedure for patients with a single ventricle heart defect by creating a new path using a vascular graft for the deoxygenated blood to be directed to the lungs, bypassing the heart. However, designing patient-specific grafts with optimized hemodynamic performance is a complex task due to the variety of patient-specific anatomies, confined surgical planning space, and the requirement of simultaneously considering multiple design criteria for vascular graft optimization. To address these challenges, we used parameterized Fontan pathways to explore patient-specific vascular graft design spaces and search for optimal solutions by formulating a nonlinear constrained optimization problem, which minimizes indexed power loss (iPL) of the Fontan model by constraining hepatic flow distribution (HFD), percentage of abnormal wall shear stress (%WSS) and geometric interference between Fontan pathways and the heart models (InDep) within clinically acceptable thresholds. Gaussian process regression was employed to build surrogate models of the hemodynamic parameters as well as InDep and [Formula: see text] (conduit model smoothness indicator) for optimization by pattern search. We tested the proposed method on two patient-specific models (n=2). The results showed the automatically optimized (AutoOpt) Fontan models hemodynamically outperformed or at least are comparable to manually optimized Fontan models with significantly reduced surgical planning time (15 hours versus over 2 weeks). We also demonstrated feasibility of manufacturing the AutoOpt Fontan conduits by using electrospun nanofibers.
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Affiliation(s)
- Xiaolong Liu
- Department of Mechanical Engineering, Johns Hopkins University, Baltimore, MD, USA,Department of Mechanical Engineering, University of Maryland, College Park, MD, USA
| | - Byeol Kim
- Department of Mechanical Engineering, Johns Hopkins University, Baltimore, MD, USA,Department of Mechanical Engineering, University of Maryland, College Park, MD, USA
| | - Yue-Hin Loke
- Division of Cardiology, Children’s National Hospital, Washington DC, USA
| | - Paige Mass
- Sheikh Zayed Institute for Pediatric Surgical Innovation, Children’s National Hospital, Washington DC, USA
| | - Laura Olivieri
- Division of Cardiology, Children’s National Hospital, Washington DC, USA,Sheikh Zayed Institute for Pediatric Surgical Innovation, Children’s National Hospital, Washington DC, USA
| | - Narutoshi Hibino
- Section of Cardiac Surgery, Department of Surgery, The University of Chicago Medicine, Chicago, IL, USA,Division of Cardiac Surgery, Johns Hopkins Hospital, Baltimore, MD, USA
| | - Mark Fuge
- Department of Mechanical Engineering, University of Maryland, College Park, MD, USA
| | - Axel Krieger
- Department of Mechanical Engineering, Johns Hopkins University, Baltimore, MD, USA,Department of Mechanical Engineering, University of Maryland, College Park, MD, USA
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53
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Exercise Prescription Enhances Maximal Oxygen Uptake and Anaerobic Threshold in Young Single Ventricle Patients with Fontan Circulation. Pediatr Cardiol 2022; 43:969-976. [PMID: 35106621 PMCID: PMC9098606 DOI: 10.1007/s00246-021-02806-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/03/2021] [Accepted: 12/17/2021] [Indexed: 11/08/2022]
Abstract
A modified Fontan procedure is performed to palliate single ventricle malformations. This hemodynamic arrangement sets systemic venous pressure unphysiologically high which predisposes the patient to severe long-term complications. As a means of self-care, exercise may ease transpulmonary flow. We investigated the effects of 6-month exercise prescription on pediatric Fontan patients. Eighteen stable Fontan patients (14 ± 2.6 years, 160.4 ± 11.3 cm, and 51.4 ± 14.4 kg) were recruited. Baseline fitness was assessed by physical activity questionnaire, body composition, cardiorespiratory performance, and muscle fitness tests. Exercise prescription was individually tailored for a 6-month training period at home. At entrance to the study, Fontan patients had lower than normal maximal oxygen uptake (VO2max) of 28. ± 5.9 ml/kg/min (61 ± 11% of normal). VO2max significantly correlated with weekly amount of habitual exercise and muscle mass of the lower limbs (p < 0.001 for both). After 6 months of training, the patients had improved their anaerobic threshold of 18 ± 3.5 vs 20 ± 4.8 ml/kg/min, p = 0.007, and workload tolerance of 119 ± 39 vs 132.4 ± 44 W, p = 0.001. At EUROFIT tests, the patient muscle fitness was below age-matched reference, but correlations existed between VO2max and lower limb muscle tests. Our patients with Fontan hemodynamics were able to positively respond to an exercise program by enhancing submaximal performance which should be beneficial for getting through daily activities. Future studies should correlate whether hemodynamic findings at Fontan completion influence physical activity and exercise reserves, and whether these predict predisposition to chronic complications.
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54
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Rychik J, Goldberg DJ, Rand E, Mancilla EE, Heimall J, Seivert N, Campbell D, O'Malley S, Dodds KM. A Path FORWARD: Development of a Comprehensive Multidisciplinary Clinic to Create Health and Wellness for the Child and Adolescent with a Fontan Circulation. Pediatr Cardiol 2022; 43:1175-1192. [PMID: 35604474 PMCID: PMC9125546 DOI: 10.1007/s00246-022-02930-z] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/22/2022] [Accepted: 04/28/2022] [Indexed: 12/19/2022]
Abstract
Today, it is anticipated most individuals diagnosed with single-ventricle malformation will survive surgical reconstruction through a successful Fontan operation. As greater numbers of patients survive, so has the recognition that individuals with Fontan circulation face a variety of challenges. The goal of a normal quality and duration of life will not be reached by all. The hurdles fall into a variety of domains. From a cardiovascular perspective, the Fontan circulation is fundamentally flawed by its inherent nature of creating a state of chronically elevated venous pressure and congestion, accompanied by a relatively low cardiac output. Ventricular dysfunction, atrioventricular valve regurgitation, and arrhythmia may directly impact cardiac performance and can progress with time. Problems are not limited to the cardiovascular system. Fontan circulatory physiology impacts a multitude of biological processes and health parameters outside the heart. The lymphatic circulation is under strain manifesting as variable degrees of protein-rich lymph loss and immune system dysregulation. Organ system dysfunction develops through altered perfusion profiles. Liver fibrosis is ubiquitous, and a process of systemic fibrogenesis in response to circulatory stressors may affect other organs as well. Somatic growth and development can be delayed. Behavioral and mental health problems are common, presenting as clinically important levels of anxiety and depression. Most striking is the high variability in prevalence and magnitude of these complications within the population, indicating the likelihood of additional factors enhancing or mitigating their emergence. We propose that optimal care for the individual with single ventricle and a Fontan circulation is ideally offered in a comprehensive multidisciplinary manner, with attention to elements that are beyond cardiac management alone. In this report, we share the concepts, our experiences, and perspectives on development of a clinic model-the "Fontan rehabilitation, wellness and resilience development" or FORWARD program. We provide insights into the mechanics of our multidisciplinary model of care and the benefits offered serving our growing population of individuals with a Fontan circulation and their families.
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Affiliation(s)
- Jack Rychik
- Division of Cardiology, Children's Hospital of Philadelphia, Philadelphia, USA.
- Department of Pediatrics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, USA.
- Fontan FORWARD Program, Cardiac Center at the Children's Hospital of Philadelphia, 3401 Civic Center Boulevard, Philadelphia, PA, 19104, USA.
| | - David J Goldberg
- Division of Cardiology, Children's Hospital of Philadelphia, Philadelphia, USA
- Department of Pediatrics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, USA
| | - Elizabeth Rand
- Division of Gastroenterology, Hepatology and Nutrition, Children's Hospital of Philadelphia, Philadelphia, USA
- Department of Pediatrics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, USA
| | - Edna E Mancilla
- Division of Endocrinology and Diabetes, Children's Hospital of Philadelphia, Philadelphia, USA
- Department of Pediatrics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, USA
| | - Jennifer Heimall
- Division of Allergy and Immunology, Children's Hospital of Philadelphia, Philadelphia, USA
- Department of Pediatrics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, USA
| | - Nicholas Seivert
- Department of Child and Adolescent Psychiatry, and Behavioral Sciences, Children's Hospital of Philadelphia, Philadelphia, USA
- Department of Psychiatry, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, USA
| | - Danielle Campbell
- Clinical Nutrition, Children's Hospital of Philadelphia, Philadelphia, USA
| | - Shannon O'Malley
- Division of Cardiology, Children's Hospital of Philadelphia, Philadelphia, USA
| | - Kathryn M Dodds
- Division of Cardiology, Children's Hospital of Philadelphia, Philadelphia, USA
- Department of Nursing at the University of Pennsylvania, Philadelphia, USA
- Fontan FORWARD Program, Cardiac Center at the Children's Hospital of Philadelphia, 3401 Civic Center Boulevard, Philadelphia, PA, 19104, USA
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55
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Kamsheh AM, O'Connor MJ, Rossano JW. Management of circulatory failure after Fontan surgery. Front Pediatr 2022; 10:1020984. [PMID: 36425396 PMCID: PMC9679629 DOI: 10.3389/fped.2022.1020984] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/16/2022] [Accepted: 10/18/2022] [Indexed: 11/11/2022] Open
Abstract
With improvement in survival after Fontan surgery resulting in an increasing number of older survivors, there are more patients with a Fontan circulation experiencing circulatory failure each year. Fontan circulatory failure may have a number of underlying etiologies. Once Fontan failure manifests, prognosis is poor, with patient freedom from death or transplant at 10 years of only about 40%. Medical treatments used include traditional heart failure medications such as renin-angiotensin-aldosterone system blockers and beta-blockers, diuretics for symptomatic management, antiarrhythmics for rhythm control, and phosphodiesterase-5 inhibitors to decrease PVR and improve preload. These oral medical therapies are typically not very effective and have little data demonstrating benefit; if there are no surgical or catheter-based interventions to improve the Fontan circulation, patients with severe symptoms often require inotropic medications or mechanical circulatory support. Mechanical circulatory support benefits patients with ventricular dysfunction but may not be as useful in patients with other forms of Fontan failure. Transplant remains the definitive treatment for circulatory failure after Fontan, but patients with a Fontan circulation face many challenges both before and after transplant. There remains significant room and urgent need for improvement in the management and outcomes of patients with circulatory failure after Fontan surgery.
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Affiliation(s)
- Alicia M Kamsheh
- Division of Cardiology, Children's Hospital of Philadelphia, United States
| | - Matthew J O'Connor
- Division of Cardiology, Children's Hospital of Philadelphia, United States
| | - Joseph W Rossano
- Division of Cardiology, Children's Hospital of Philadelphia, United States
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56
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Oommen S, Cantero Peral S, Qureshi MY, Holst KA, Burkhart HM, Hathcock MA, Kremers WK, Brandt EB, Larsen BT, Dearani JA, Edwards BS, Maleszewski JJ, Nelson TJ. Autologous Umbilical Cord Blood-Derived Mononuclear Cell Therapy Promotes Cardiac Proliferation and Adaptation in a Porcine Model of Right Ventricle Pressure Overload. Cell Transplant 2022; 31:9636897221120434. [PMID: 36086821 PMCID: PMC9465577 DOI: 10.1177/09636897221120434] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2021] [Revised: 07/19/2022] [Accepted: 07/31/2022] [Indexed: 11/29/2022] Open
Abstract
Congenital heart diseases, including single ventricle circulations, are clinically challenging due to chronic pressure overload and the inability of the myocardium to compensate for lifelong physiological demands. To determine the clinical relevance of autologous umbilical cord blood-derived mononuclear cells (UCB-MNCs) as a therapy to augment cardiac adaptation following surgical management of congenital heart disease, a validated model system of right ventricular pressure overload due to pulmonary artery banding (PAB) in juvenile pigs has been employed. PAB in a juvenile porcine model and intramyocardial delivery of UCB-MNCs was evaluated in three distinct 12-week studies utilizing serial cardiac imaging and end-of-study pathology evaluations. PAB reproducibly induced pressure overload leading to chronic right ventricular remodeling including significant myocardial fibrosis and elevation of heart failure biomarkers. High-dose UCB-MNCs (3 million/kg) delivered into the right ventricular myocardium did not cause any detectable safety issues in the context of arrhythmias or abnormal cardiac physiology. In addition, this high-dose treatment compared with placebo controls demonstrated that UCB-MNCs promoted a significant increase in Ki-67-positive cardiomyocytes coupled with an increase in the number of CD31+ endothelium. Furthermore, the incorporation of BrdU-labeled cells within the myocardium confirmed the biological potency of the high-dose UCB-MNC treatment. Finally, the cell-based treatment augmented the physiological adaptation compared with controls with a trend toward increased right ventricular mass within the 12 weeks of the follow-up period. Despite these adaptations, functional changes as measured by echocardiography and magnetic resonance imaging did not demonstrate differences between cohorts in this surgical model system. Therefore, this randomized, double-blinded, placebo-controlled pre-clinical trial establishes the safety of UCB-MNCs delivered via intramyocardial injections in a dysfunctional right ventricle and validates the induction of cardiac proliferation and angiogenesis as transient paracrine mechanisms that may be important to optimize long-term outcomes for surgically repaired congenital heart diseases.
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Affiliation(s)
- Saji Oommen
- Division of Cardiovascular Diseases,
Center for Regenerative Medicine, Mayo Clinic, Rochester, MN, USA
| | - Susana Cantero Peral
- Division of Cardiovascular Diseases,
Center for Regenerative Medicine, Mayo Clinic, Rochester, MN, USA
| | | | - Kimberly A. Holst
- Department of Cardiovascular Surgery,
Mayo Clinic, Rochester, MN, USA
| | - Harold M. Burkhart
- Pediatric Cardiothoracic Surgery, The
University of Oklahoma, Oklahoma City, OK, USA
| | | | - Walter K. Kremers
- Biomedical Statistics and Informatics,
Mayo Clinic, Rochester, MN, USA
| | - Emma B. Brandt
- Division of Cardiovascular Diseases,
Center for Regenerative Medicine, Mayo Clinic, Rochester, MN, USA
| | | | - Joseph A. Dearani
- Department of Cardiovascular Surgery,
Mayo Clinic, Rochester, MN, USA
| | | | | | - Timothy J. Nelson
- Division of Cardiovascular Diseases,
Center for Regenerative Medicine, Mayo Clinic, Rochester, MN, USA
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57
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Inai K. Biomarkers for heart failure and prognostic prediction in patients with Fontan circulation. Pediatr Int 2022; 64:e14983. [PMID: 34480813 DOI: 10.1111/ped.14983] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/12/2021] [Revised: 08/10/2021] [Accepted: 09/02/2021] [Indexed: 01/06/2023]
Abstract
A wide variety of pathologies are involved in heart failure in patients with congenital heart disease (CHD). Specific causes of heart failure after the Fontan procedure include not only single-ventricle circulation, but also the function of the right ventricle as the systemic ventricle, atrioventricular or semilunar valve stenosis or regurgitation, pulmonary hypertension, and left ventricular dysfunction secondary to right ventricular enlargement or dysfunction. As heart failure can occur post-Fontan, for a variety of reasons, clarification of the pathophysiology is the first step in management and treatment. At the same time, it is important to understand each patient's current condition and treatment plan to make an accurate prognosis. Because of the wide variety of pathophysiologies in post-Fontan CHD patients, however, no single biomarker is useful in all situations. Relevant biomarkers must be selected according to each patient's disease state, and combinations of multiple biomarkers should also be considered. In this review, the author describes the clinical importance of various biomarkers for patients who have undergone a Fontan procedure.
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Affiliation(s)
- Kei Inai
- Department of Pediatric Cardiology and Adult Congenital Cardiology, Tokyo Women's Medical University, Shinjuku-ku, Japan
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58
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Management of patients with single ventricle physiology across the lifespan: contributions from magnetic resonance and computed tomography imaging. Can J Cardiol 2022; 38:946-962. [DOI: 10.1016/j.cjca.2022.01.011] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2021] [Revised: 12/27/2021] [Accepted: 01/02/2022] [Indexed: 12/12/2022] Open
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Predictors of Poor Functional Status in Adult Fontan Patients Living at Moderate Altitude. Pediatr Cardiol 2021; 42:1757-1765. [PMID: 34143227 DOI: 10.1007/s00246-021-02660-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/28/2021] [Accepted: 06/08/2021] [Indexed: 10/21/2022]
Abstract
Patients who have undergone Fontan palliation have reduced exercise tolerance measured by maximal oxygen consumption (VO2 max). Declining exercise capacity is associated with increased morbidity and mortality. The impact of hemodynamics and other variables on this population's functional status is not well understood. This study sought to identify variables that predict low VO2 max in Fontan patients living at moderate altitude (5,000-8,000 feet). We performed a retrospective cohort study of 44 adult Fontan patients living at moderate altitude who had undergone cardiopulmonary exercise testing (CPET) and cardiac catheterization. We evaluated hemodynamic parameters measured during catheterization, imaging results, and laboratory studies for correlation with VO2 max measured during CPET. Our study cohort (median age 30 years, 52% female) had exercise impairment with mean VO2 max of 21.6 mL/kg/min. Higher trans-pulmonary gradient (TPG) (p < 0.001) and mean pulmonary artery (PA) pressure (p = 0.013) were predictors of lower maximal and submaximal VO2. Higher BNP values correlated with lower VO2 max (p = 0.01). Platelet count, GGT, albumin, and pulmonary vasodilator therapy did not correlate with VO2 max. None of the studied variables were associated with higher minute ventilation to peak carbon dioxide production (VE/VCO2 slope) or change in VO2 max over time. In conclusion, higher TPG and mean PA pressure predicted lower exercise tolerance amongst our cohort of adult Fontan patients living at moderate altitude. Future studies are needed to determine if these clinical variables represent viable therapeutic targets that could result in improved exercise tolerance and outcomes in patients with Fontan circulation.
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60
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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] [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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61
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Téllez L, Rodríguez de Santiago E, Albillos A. Fontan-Associated Liver Disease: Pathophysiology, Staging, and Management. Semin Liver Dis 2021; 41:538-550. [PMID: 34399435 DOI: 10.1055/s-0041-1732355] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
Fontan-associated liver disease is the term used to encompass the disorders arising from abnormal hemodynamic alterations and systemic venous congestion after the Fontan procedure. The histological changes produced in the liver are similar but not equivalent to those seen in other forms of cardiac liver disease. While the natural history of this form of liver disease is poorly established, many Fontan patients ultimately develop portal hypertension-related complications such as ascites, esophageal varices, malnutrition, and encephalopathy. Fontan survivors also show an elevated risk of hepatocellular carcinoma. Adequate staging of the liver damage is essential to anticipate screening strategies and improve global management.
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Affiliation(s)
- Luis Téllez
- Department of Gastroenterology and Hepatology, Hospital Universitario Ramón y Cajal, Instituto Ramón y Cajal de Investigación Sanitaria (IRYCIS), Centro de Investigación Biomédica en Red (CIBEREHD), Universidad de Alcalá, Madrid, Spain
| | - Enrique Rodríguez de Santiago
- Department of Gastroenterology and Hepatology, Hospital Universitario Ramón y Cajal, Instituto Ramón y Cajal de Investigación Sanitaria (IRYCIS), Centro de Investigación Biomédica en Red (CIBEREHD), Universidad de Alcalá, Madrid, Spain
| | - Agustín Albillos
- Department of Gastroenterology and Hepatology, Hospital Universitario Ramón y Cajal, Instituto Ramón y Cajal de Investigación Sanitaria (IRYCIS), Centro de Investigación Biomédica en Red (CIBEREHD), Universidad de Alcalá, Madrid, Spain
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62
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Laparoscopic hysterectomy for endometrial cancer after the Fontan procedure: The first case report. Int Cancer Conf J 2021; 11:41-45. [DOI: 10.1007/s13691-021-00513-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2021] [Accepted: 10/04/2021] [Indexed: 12/24/2022] Open
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Sughimoto K, Ueda T, Fujiwara T, Kabasawa M, Liu H. Impact of Atrial Fibrillation on Fontan Circulation: Fontan Computational Model. Ann Thorac Surg 2021; 114:1460-1467. [PMID: 34600904 DOI: 10.1016/j.athoracsur.2021.08.061] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/23/2021] [Revised: 08/23/2021] [Accepted: 08/30/2021] [Indexed: 11/01/2022]
Abstract
BACKGROUND Patients with Fontan circulation may develop heart failure resulting in atrial fibrillation during the late phase. Inotropic effects to ameliorate hemodynamics on the Fontan circulation are not well understood, especially when in atrial fibrillation. This study was performed to determine whether dobutamine therapy in patients with Fontan circulation has limited effects on improving hemodynamics. METHODS Lumped computational models (sinus and atrial fibrillation) were employed including biventricular, atriopulmonary connection (APC), and extracardiac total cavopulmonary connection (TCPC) Fontan models. The condition of atrial fibrillation including lack of atrial beat, irregular ventricular contraction, and time-varying elastance for the ventricle was introduced. A different dose of dobutamine was given by varying the elastance of the ventricle, heart rate, and peripheral resistance. RESULTS In all models, the cardiac output decreased by 22.5% to 25.8% in atrial fibrillation. At 10 μg/kg/min of dobutamine in sinus rhythm, the cardiac output increased by 32.3% in the biventricular model but by only 9.2% (p<0.001) and 9.1% (p<0.001) in the APC and TCPC Fontan models, respectively. At 10 μg/kg/min of dobutamine in atrial fibrillation, the percent increase in the cardiac output in the Fontan circulation [11.8% increase in APC (p<0.001) and 11.9% increase in TCPC (p<0.001)] was significantly less than that in the biventricular circulation (32.3% increase). CONCLUSIONS In the Fontan circulation, atrial fibrillation itself reduced the cardiac output by approximately 25%, and dobutamine had a limited effect on increasing the cardiac output, especially when in atrial fibrillation. Maintaining sinus rhythm in patients with Fontan circulation is very important.
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Affiliation(s)
- Koichi Sughimoto
- Department of Cardiovascular Surgery, Chiba Kaihin Municipal Hospital, Chiba, Japan; Graduate School of Engineering, Chiba University, Chiba, Japan
| | - Tetsuya Ueda
- Graduate School of Engineering, Chiba University, Chiba, Japan
| | - Takashi Fujiwara
- Section of Pediatric Radiology, Department of Radiology, University of Colorado, Colorado, USA
| | - Masashi Kabasawa
- Department of Cardiovascular Surgery, Chiba Kaihin Municipal Hospital, Chiba, Japan
| | - Hao Liu
- Graduate School of Engineering, Chiba University, Chiba, Japan.
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Kido T, Burri M, Mayr B, Strbad M, Cleuziou J, Hager A, Hörer J, Ono M. Impacts of stage 1 palliation and pre-Glenn pulmonary artery pressure on long-term outcomes after Fontan operation. Eur J Cardiothorac Surg 2021; 60:369-376. [PMID: 33764447 DOI: 10.1093/ejcts/ezab079] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/14/2020] [Revised: 12/29/2020] [Accepted: 01/21/2021] [Indexed: 11/13/2022] Open
Abstract
OBJECTIVES The present study was aiming to determine whether high mean pulmonary artery pressure before bidirectional cavopulmonary shunt is a risk factor for late adverse events in patients with low pulmonary artery pressure before total cavopulmonary connection (TCPC). METHODS We retrospectively reviewed the medical records of all patients undergoing both bidirectional cavopulmonary shunt and TCPC with available cardiac catheterization data. RESULTS A total of 316 patients were included in this study. The patients were divided into 4 groups according to mean pulmonary pressure: those with pre-Glenn <16 mmHg and pre-Fontan <10 mmHg (Group LL, n = 124), those with pre-Glenn ≥16 mmHg and pre-Fontan <10 mmHg (Group HL, n = 61), those with pre-Glenn <16 mmHg and pre-Fontan ≥10 mmHg (Group LH, n = 66) and those with pre-Glenn ≥16 mmHg and pre-Fontan ≥10 mmHg (Group HH, n = 65). Group HL showed significantly higher rate of adverse events after TCPC than Group LL (P = 0.02). In univariate linear analysis, a history of atrial septectomy at stage 1 palliation was associated with low pre-Glenn mean pulmonary artery pressure (Coefficient B -1.38, 95% confidence interval -2.53 to -0.24; P = 0.02), while pulmonary artery banding was a significant risk factor for elevated pre-Fontan mean pulmonary artery pressure (Coefficient B 1.68, 95% confidence interval 0.81 to 2.56, P < 0.001). CONCLUSIONS High mean pulmonary artery pressure before bidirectional cavopulmoary shunt (≥16mmHg) remains a significant risk factor for adverse events after TCPC even though mean pulmonary artery pressure decreased below 10 mmHg before TCPC.
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Affiliation(s)
- Takashi Kido
- Department of Congenital and Pediatric Heart Surgery, German Heart Center Munich, Technische Universität München, Division of Congenital and Pediatric Heart Surgery, Ludwig-Maximilians-Universität, Munich, Germany
| | - Melchior Burri
- Department of Cardiovascular Surgery, German Heart Center Munich, Technische Universität München, Munich, Germany
| | - Benedikt Mayr
- Department of Cardiovascular Surgery, German Heart Center Munich, Technische Universität München, Munich, Germany
| | - Martina Strbad
- Department of Congenital and Pediatric Heart Surgery, German Heart Center Munich, Technische Universität München, Division of Congenital and Pediatric Heart Surgery, Ludwig-Maximilians-Universität, Munich, Germany
| | - Julie Cleuziou
- Department of Congenital and Pediatric Heart Surgery, German Heart Center Munich, Technische Universität München, Division of Congenital and Pediatric Heart Surgery, Ludwig-Maximilians-Universität, Munich, Germany
| | - Alfred Hager
- Department of Pediatric Cardiology and Congenital Heart Disease, German Heart Center Munich, Technische Universität München, Munich, Germany
| | - Jürgen Hörer
- Department of Congenital and Pediatric Heart Surgery, German Heart Center Munich, Technische Universität München, Division of Congenital and Pediatric Heart Surgery, Ludwig-Maximilians-Universität, Munich, Germany
| | - Masamichi Ono
- Department of Congenital and Pediatric Heart Surgery, German Heart Center Munich, Technische Universität München, Division of Congenital and Pediatric Heart Surgery, Ludwig-Maximilians-Universität, Munich, Germany
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Cao JY, Marathe SP, Zannino D, Celermajer DS, Justo RN, Alphonso N, d'Udekem Y, Winlaw DS. Fontan operation at less than 3 years of age is not a risk factor for long-term failure. Eur J Cardiothorac Surg 2021; 61:497-504. [PMID: 34355744 DOI: 10.1093/ejcts/ezab355] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/27/2021] [Revised: 06/14/2021] [Accepted: 06/17/2021] [Indexed: 11/13/2022] Open
Abstract
OBJECTIVES The age at which the Fontan operation is performed varies globally. Over the last decade, the median age of patients having the Fontan in Australia and New Zealand has been 4.6 years, including 6% of patients younger than 3 years. Long-term outcomes of an early Fontan operation are unclear and are described in this study. METHODS Patients from the Australian and New Zealand Fontan Registry were grouped by age at Fontan. A Fontan before 3 years (early Fontan) was compared to the combined second and third quartiles by age at surgery in the Registry (3.6-6.1 years; control). Outcomes included Fontan failure (death, transplant, New York Heart Association functional group III/IV heart failure, Fontan takedown or conversion, protein losing enteropathy and plastic bronchitis), arrhythmias, thromboembolism and reinterventions. RESULTS A total of 191 patients who had early Fontan operations were compared to 781 controls. Profound or progressive cyanosis was noted more frequently in the early than in the control group (63% vs 23%; P < 0.001). The early group was followed up for a median 22.1 years. The incidence of long-term failure was similar between the 2 groups (early, 1.08 failures per 100 patient-years of follow-up vs control, 0.99; log-rank P = 0.79). Adjusted for risk factors, early age at Fontan was not a risk factor for long-term failure [hazard ratio (HR) 1.16, 95% confidence interval (CI) 0.77-1.76; P = 0.48], new-onset arrhythmia (HR 0.93, 95% CI 0.63-1.39; P = 0.73), thromboembolism (HR 0.50, 95% CI 0.28-0.91; P = 0.024) or reintervention (HR 1.08, 95% CI 0.80-1.45; P = 0.62). CONCLUSIONS Having the Fontan operation at an early age was not a risk factor for short- or long-term adverse outcomes in our cohort.
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Affiliation(s)
- Jacob Y Cao
- Sydney Medical School, University of Sydney, Sydney, Australia.,Department of Cardiology, Royal Prince Alfred Hospital, Sydney, Australia
| | - Supreet P Marathe
- Queensland Children's Hospital, Brisbane, Australia.,University of Queensland, Brisbane, Australia
| | - Diana Zannino
- Murdoch Children's Research Institute, Melbourne, Australia
| | - David S Celermajer
- Sydney Medical School, University of Sydney, Sydney, Australia.,Department of Cardiology, Royal Prince Alfred Hospital, Sydney, Australia
| | - Robert N Justo
- Queensland Children's Hospital, Brisbane, Australia.,University of Queensland, Brisbane, Australia
| | - Nelson Alphonso
- Queensland Children's Hospital, Brisbane, Australia.,University of Queensland, Brisbane, Australia
| | - Yves d'Udekem
- Murdoch Children's Research Institute, Melbourne, Australia.,Royal Children's Hospital, Melbourne, Australia
| | - David S Winlaw
- Heart Centre for Children, The Children's Hospital at Westmead, Sydney, Australia.,Heart Institute, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
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Stephens EH, Talwar AA, Devlin PJ, Eltayeb O, Mongé MC, Tsao S, Backer CL. 24-Year Results of Nonfenestrated Extracardiac Fontan Including Fontan Conversions. Ann Thorac Surg 2021; 112:619-625. [DOI: 10.1016/j.athoracsur.2020.06.019] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/12/2020] [Revised: 05/12/2020] [Accepted: 06/01/2020] [Indexed: 10/23/2022]
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Mancilla EE, Zielonka B, Roizen JD, Dodds KM, Rand EB, Heimall JR, Chen F, Wu C, Goldberg DJ, Rychik J. Growth in Children with a Fontan Circulation. J Pediatr 2021; 235:149-155.e2. [PMID: 33887332 DOI: 10.1016/j.jpeds.2021.04.019] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/09/2021] [Revised: 04/11/2021] [Accepted: 04/13/2021] [Indexed: 10/21/2022]
Abstract
OBJECTIVE To evaluate growth in a population of patients with Fontan circulation. STUDY DESIGN We performed a cross-sectional evaluation of patients followed in our multidisciplinary Fontan clinic from January 2011 through August 2015. We reviewed the historical data, anthropometry, clinical, and laboratory studies and performed bivariate and multivariate analysis of factors associated with height z score. RESULTS Patients (n = 210) were included in the study at median age 11.07 years (8.3, 14.73 years) (43% female); 138 (65%) had a dominant right systemic ventricle and 92 (44%) hypoplastic left heart syndrome. Median age at completion of Fontan circulation was 31 months (7.6, 135.8 months). Median height z score was -0.58 (-1.75, 0.26). Twenty-five (12%) had current or past history of protein-losing enteropathy (PLE). Median height z score for those with current or past history of PLE was -2.1 (-2.46, 1.24). Multivariate analysis revealed positive associations between height z score and body mass index z score, time since Fontan, mid-parental height, dominant systemic ventricle type, and serum alkaline phosphatase. Height correlated negatively with known genetic syndrome, PLE, use of stimulant or oral steroid medication. CONCLUSIONS Children with Fontan circulation have mild deficits in height, with greater deficits in those with PLE. Height z score improves with time postsurgery. Improving weight, leading to improved body mass index, may be a modifiable factor that improves growth in those who are underweight. Biochemical markers may be helpful screening tests for high-risk groups in whom to intensify interventions.
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Affiliation(s)
- Edna E Mancilla
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA; Division of Endocrinology and Diabetes, Children's Hospital of Philadelphia, Philadelphia, PA.
| | - Benjamin Zielonka
- Department of Pediatrics, Boston Children's Hospital, Harvard Medical School, Harvard University, Boston, MA
| | - Jeffrey D Roizen
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA; Division of Endocrinology and Diabetes, Children's Hospital of Philadelphia, Philadelphia, PA
| | - Kathryn M Dodds
- Division of Cardiology, Children's Hospital of Philadelphia, Philadelphia, PA; School of Nursing, University of Pennsylvania, Philadelphia, PA
| | - Elizabeth B Rand
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA; Division of Gastroenterology, Hepatology, & Nutrition, Children's Hospital of Philadelphia, Philadelphia, PA
| | - Jennifer R Heimall
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA; Division of Allergy and Immunology, Children's Hospital of Philadelphia, Philadelphia, PA
| | - Feiyan Chen
- Department of Biomedical and Health Informatics, Children's Hospital of Philadelphia, Philadelphia, PA
| | - Chao Wu
- Department of Biomedical and Health Informatics, Children's Hospital of Philadelphia, Philadelphia, PA
| | - David J Goldberg
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA; Division of Cardiology, Children's Hospital of Philadelphia, Philadelphia, PA
| | - Jack Rychik
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA; Division of Cardiology, Children's Hospital of Philadelphia, Philadelphia, PA
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Cohen LL, Przybylski R, Marshall AC, Emans JB, Hedequist DJ. Surgical Correction of Scoliosis in Children with Severe Congenital Heart Disease and Palliated Single Ventricle Physiology. Spine (Phila Pa 1976) 2021; 46:E791-E796. [PMID: 33394986 DOI: 10.1097/brs.0000000000003905] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
STUDY DESIGN Case series. OBJECTIVE In this study we focus on this group, and describe the largest cohort to date of single ventricle patients undergoing surgical correction of scoliosis at a single institution. SUMMARY OF BACKGROUND DATA Outcomes of spinal surgery for patients with congenital heart disease (CHD) have evolved and most affected patients have uncomplicated procedures. The risk of perioperative complications remains highest in patients with single ventricle ("Fontan") physiology. METHODS We reviewed patients with single ventricle CHD and operative scoliosis repair over a 25-year span. Patients who had undergone a Fontan, bidirectional Glenn, and/or Kawashima procedure before operative scoliosis repair were included. Patients were excluded if they lacked preoperative cardiac care and/or sufficient medical history at our institution. RESULTS Twenty-three patients were included. The average age at surgery was 13.6 years (range, 5-23). Seventy percent of the cohort was female (16/23). The majority of patients underwent a Fontan before scoliosis surgery (20/23, 87%). Patients without intraoperative tranexamic acid (TXA) had a 67% complication rate (8/12) versus 36% (4/11) in those with intraoperative TXA (P = 0.29). There was a significant difference in estimated blood loss by weight (cc/kg) between non-TXA and TXA patients (P = 0.016). Twelve patients experienced complications (52%), all of which occurred postoperatively. There were no deaths, cerebrovascular events, adverse perioperative cardiac or hemodynamic complications, or wound infections. Using the Clavien-Dindo-Sink classification for postoperative complications, four patients had serious adverse events, including one permanent neurologic deficit. CONCLUSION Spinal surgery for scoliosis has been performed in selected patients with single ventricle physiology at a single institution without mortality for 25 years. Operative blood loss may be reduced by routine use of TXA. Complications occur most commonly in the postoperative period, and can include pleural effusion.Level of Evidence: 4.
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Affiliation(s)
- Lara L Cohen
- Department of Orthopedic Surgery, Boston Children's Hospital, Boston, MA
| | | | | | - John B Emans
- Department of Orthopedic Surgery, Boston Children's Hospital, Boston, MA
| | - Daniel J Hedequist
- Department of Orthopedic Surgery, Boston Children's Hospital, Boston, MA
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Gasparrini F, Lenci I, Gagliardi MG, Spada M, Salimei F, Orlacchio A. Repeated TACE in HCC after Fontan surgery and situs viscerum inversus: A case report. Radiol Case Rep 2021; 16:2564-2569. [PMID: 34306288 PMCID: PMC8283149 DOI: 10.1016/j.radcr.2021.06.031] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2021] [Revised: 06/11/2021] [Accepted: 06/12/2021] [Indexed: 12/12/2022] Open
Abstract
We describe the case of a 32-year-old man who developed a liver neoplasm due to previous Fontan surgery (FS) for a single ventricle anomaly and situs viscerum inversus. He was admitted to our hospital for suspected hepatocellular carcinoma during an Ultrasound (US) follow up. Computed tomography (CT) showed features of chronic liver disease and 7 cm hepatic nodule with arterial enhancement. Laboratory analyses documented preserved liver function and increased levels of alpha-fetoprotein. Trans-arterial-chemoembolization (TACE) was performed obtaining complete necrosis at 4 weeks of follow up and significant reduction of alpha-fetoprotein. The patient is currently in follow-up, being evaluated for further treatments and/or combined liver-heart transplantation. TACE is a therapeutic option for the treatment of patients with unresectable hepatocellular carcinoma (HCC) and with severe heart disease, like those submitted to FS and with also other vascular abnormalities like those correlated to situs viscerum inversus.
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Key Words
- CM, Contrast Medium
- CT, Computed Tomography, EDVi, End- Diastolic Volume index, EF, Ejection Fraction
- Cardiac cirrhosis
- Congenital heart disease
- FALD, Fontan-associated liver disease
- Fontan surgery
- HCC, hepatocellular carcinoma
- HR, Heart Rate
- IVC-PA, Inferior Vena Cava-Pulmonary Artery
- MRI, Magnetic Resonance Imaging
- SI, Situs inversus
- SMA, Superior Mesenteric Artery
- Situs viscerum inversus
- TACE, Trans Arterial ChemoEmbolization
- TACE, trans-arterial-chemoembolization
- US, Ultrasound
- bpm, beats per minute
- ceCT, Contrast Enhanced CT
- ceCT, contrast enhanced Computed Tomography
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Affiliation(s)
- Fulvio Gasparrini
- Department of Diagnostic and Interventional Radiology, University Hospital Tor Vergata, Rome, Italy
| | - Ilaria Lenci
- Liver Unit, University Hospital Tor Vergata, Rome, Italy
| | - Maria Giulia Gagliardi
- Department of Cardiology, Division of Grow Up Congenital Heart, Bambino Gesù Children's Hospital IRCCS, Rome, Italy
| | - Marco Spada
- Department of Abdominal Transplantation and Hepatobiliopancreatic Surgery, Bambino Gesù Children's Hospital IRCCS, Rome, Italy
| | - Fabio Salimei
- Department of Diagnostic and Interventional Radiology, University Hospital Tor Vergata, Rome, Italy
| | - Antonio Orlacchio
- Department of Diagnostic and Interventional Radiology, University Hospital Tor Vergata, Rome, Italy
- Corresponding author: Viale Oxford, 81 - 00133 Rome, Italy.
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Anesthetic considerations for Fontan circulation and pregnancy. Int Anesthesiol Clin 2021; 59:52-59. [PMID: 34029248 DOI: 10.1097/aia.0000000000000329] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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71
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Bichell DP. Commentary: Cardiac surgery in the developing world: Matching patient selection to longitudinal care. J Thorac Cardiovasc Surg 2021; 163:424-425. [PMID: 34134891 DOI: 10.1016/j.jtcvs.2021.05.039] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/25/2021] [Revised: 05/25/2021] [Accepted: 05/25/2021] [Indexed: 11/19/2022]
Affiliation(s)
- David P Bichell
- Department of Cardiac Surgery, Monroe Carell, Jr, Children's Hospital, Vanderbilt University Medical Center, Nashville, Tenn.
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Winlaw DS, Opotowsky AR, Tweddell JS. Commentary: Time for a new maxim. J Thorac Cardiovasc Surg 2021; 163:1225-1226. [PMID: 34088498 DOI: 10.1016/j.jtcvs.2021.05.025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/11/2021] [Revised: 05/11/2021] [Accepted: 05/12/2021] [Indexed: 10/21/2022]
Affiliation(s)
- David S Winlaw
- Department of Cardiothoracic Surgery, Heart Institute, Cincinnati Children's Hospital, Cincinnati, Ohio.
| | - Alexander R Opotowsky
- Department of Cardiothoracic Surgery, Heart Institute, Cincinnati Children's Hospital, Cincinnati, Ohio
| | - James S Tweddell
- Department of Cardiothoracic Surgery, Heart Institute, Cincinnati Children's Hospital, Cincinnati, Ohio
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73
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Buratto E, Konstantinov IE. Atrioventricular valve surgery: Restoration of the fibrous skeleton of the heart. J Thorac Cardiovasc Surg 2021; 162:360-365. [PMID: 34059335 DOI: 10.1016/j.jtcvs.2021.03.128] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/13/2021] [Revised: 03/13/2021] [Accepted: 03/16/2021] [Indexed: 10/21/2022]
Affiliation(s)
- Edward Buratto
- Department of Cardiac Surgery, Royal Children's Hospital, Melbourne, Australia; Department of Paediatrics, University of Melbourne, Melbourne, Australia; Heart Research Group, Murdoch Children's Research Institute, Melbourne, Australia
| | - Igor E Konstantinov
- Department of Cardiac Surgery, Royal Children's Hospital, Melbourne, Australia; Department of Paediatrics, University of Melbourne, Melbourne, Australia; Heart Research Group, Murdoch Children's Research Institute, Melbourne, Australia; Melbourne Children's Centre for Cardiovascular Genomics and Regenerative Medicine, Melbourne, Australia.
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Abstract
A Fontan circulation requires a series of three-staged operations aimed to palliate patients with single-ventricle CHD. Currently, the most frequent technique is the extracardiac total cavopulmonary connection, an external conduit connecting the IVC and right pulmonary artery, bypassing the right side of the heart. Fontan candidates must meet strict criteria; they are assessed utilising both cardiac catheterisation and cardiac magnetic resonance. Postoperatively, treatment protocols prioritise antibiotic prophylaxis, diuretics, angiotensin-converting enzyme inhibitors, anticoagulation, and oxygen therapy with fluid restriction and a low-fat diet. These measures aim to reduce length of stay in the ICU and hospital by preventing acute complications such as infection, venous thromboembolism, low cardiac output, pleural effusion, and acute kidney injury. Late complications of a Fontan procedure include circulation failure, protein-losing enteropathy, plastic bronchitis, and Fontan-associated liver disease. The definitive management is cardiac transplantation, with promising innovations in selective embolisation of lymphatic vessels and Fontan-specific ventricular assist devices. Further research assessing current protocols in the perioperative management of Fontan patients would be beneficial for standardising current practice and improving outcomes.
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Hraska V, Mitchell ME, Woods RK, Hoffman GM, Kindel SJ, Ginde S. Innominate Vein Turn-down Procedure for Failing Fontan Circulation. Semin Thorac Cardiovasc Surg Pediatr Card Surg Annu 2021; 23:34-40. [PMID: 32354545 DOI: 10.1053/j.pcsu.2020.01.002] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2019] [Revised: 01/06/2020] [Accepted: 01/25/2020] [Indexed: 12/16/2022]
Abstract
After the Fontan, systemic venous hypertension induces pathophysiologic changes in the lymphatic system that can result in complications of pleural effusion, ascites, plastic bronchitis, and protein losing enteropathy. Advances in medical therapy and novel interventional approaches have not substantially improved the poor prognosis of these complications. A more physiological approach has been developed by decompression of the thoracic duct to the lower pressure common atrium with a concomitant increase of preload. Diverting the innominate vein to the common atrium increases the transport capacity of the thoracic duct, which in most patients enters the circulation at the left subclavian-jugular vein junction. Contrary to the fenestrated Fontan circulation, in which the thoracic duct is drained into the high pressure Fontan circulation, turn down of the innominate vein to the common atrium effectively decompresses the thoracic duct to the lower pressure system with "diastolic suctioning" of lymph. Innominate vein turn-down may be considered for medical-refractory post-Fontan lymphatic complications of persistent chylothorax, plastic bronchitis, and protein losing enteropathy. Prophylactic innominate vein turn-down may also be considered at time of the Fontan operation for patients that are higher risk for lymphatic complications.
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Affiliation(s)
- Viktor Hraska
- Division of Congenital Heart Surgery; Department of Surgery, Herma Heart Institute, Medical College of Wisconsin, Milwaukee, Wisconsin.
| | - Michael E Mitchell
- Division of Congenital Heart Surgery; Department of Surgery, Herma Heart Institute, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Ronald K Woods
- Division of Congenital Heart Surgery; Department of Surgery, Herma Heart Institute, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - George M Hoffman
- Department of Anesthesia, Herma Heart Institute, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Steven J Kindel
- Division of Pediatric Cardiology, Department of Pediatrics, Herma Heart Institute, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Salil Ginde
- Division of Pediatric Cardiology, Department of Pediatrics, Herma Heart Institute, Medical College of Wisconsin, Milwaukee, Wisconsin
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Lin HC, Wu MH, Wang JK, Lin MT, Chen CA, Lu CW, Chen YS, Huang SC, Chiu SN. Perioperative outcomes of Fontan operation: Impact of heterotaxy syndrome. J Formos Med Assoc 2021; 121:89-97. [PMID: 33549407 DOI: 10.1016/j.jfma.2021.01.014] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2020] [Revised: 12/16/2020] [Accepted: 01/15/2021] [Indexed: 11/26/2022] Open
Abstract
BACKGROUND/PURPOSE Fontan operation is the standard surgical procedure for achieving long-term survival in single-ventricular complex congenital heart diseases (SV-CHD). We aim to identify the perioperative outcomes and impact of heterotaxy syndrome (HS) after Fontan operation in a tertiary pediatric cardiology center. METHODS Medical records were reviewed for all patients who received Fontan operation and who were born between 1997 and 2017 in our institution. Preoperative, operative, and postoperative risk factors for perioperative mortality and morbidity were analyzed. RESULTS Totally, 154 patients were enrolled (103 SV-CHD and 51 HS), and the male to female ratio was 92:62. The mean age of Fontan operation was 5.1 years, and extracardiac conduit comprised the majority (90.9%) of Fontan operation. Overall perioperative event-free survival to discharge was 91.6% (84.3% in HS and 95.1% in other SV-CHD, P = 0.032). For secondary outcomes, length of intensive care stay and duration of pleural effusion drainage were not significantly different between patients with HS and other SV-CHD, but postoperative arrhythmia was more common in HS group (31.4% vs. 12.6%, P = 0.005). In multivariable regression analysis, preoperative risk factors including operation year before 2007 and high PAP and postoperative factors of elevated postoperative CVP were associated with worse outcomes. HS was not a predictor of worse outcome after adjusting for preoperative PAP and operation era. CONCLUSION Surgical outcome has improved much in current era. Perioperative outcome is poorer in patients with HS than other SV-CHD, but HS is not a predictor of perioperative mortality after adjusting for hemodynamic factors.
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Affiliation(s)
- Hsin-Chia Lin
- Department of Pediatrics, National Taiwan University Children's Hospital, Taipei, Taiwan; Department of Pediatrics, National Taiwan University Hospital Yunlin Branch, Yunlin, 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
| | - Shu-Chien Huang
- 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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Moon J, Shen L, Likosky DS, Sood V, Hobbs RD, Sassalos P, Romano JC, Ohye RG, Bove EL, Si MS. Relationship of Ventricular Morphology and Atrioventricular Valve Function to Long-Term Outcomes Following Fontan Procedures. J Am Coll Cardiol 2021; 76:419-431. [PMID: 32703513 DOI: 10.1016/j.jacc.2020.05.059] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/23/2020] [Revised: 05/27/2020] [Accepted: 05/28/2020] [Indexed: 10/23/2022]
Abstract
BACKGROUND The influence of ventricular morphology on Fontan outcomes is controversial. OBJECTIVES This study hypothesized that dysfunction of the single right ventricle (RV) and right atrioventricular valve regurgitation (AVVR) increases over time and adversely impacts late outcomes following a Fontan operation. A single-center retrospective study was performed. METHODS From 1985 through 2018, 1,162 patients underwent the Fontan procedure at our center and were included in this study. Transplant and takedown free survival, ventricular, and atrioventricular valve dysfunction after Fontan were analyzed. Death or heart transplantation information was obtained from the National Death Index and the Scientific Registry of Transplant Recipients. RESULTS The follow-up rate was 99%. Morphologic RV was present in 58% of patients. Transplant and takedown free survival were 91%, 75%, and 71% at 10 years, 20 years, and 25 years, respectively. Morphologic RV was an independent risk factor for transplant, takedown free survival (hazard ratio: 2.4; p = 0.008). The AVVR, which preceded ventricular dysfunction in most cases, was associated with the development of ventricular dysfunction after Fontan (odds ratio: 4.3; 95% confidence interval: 2.7 to 6.7; p < 0.001). Furthermore, AVVR and ventricular dysfunction progressed over time after Fontan, especially in the RV (AVVR: p < 0.0001, ventricular dysfunction: p < 0.0001). CONCLUSIONS Morphologic RV is negatively associated with the long-term survival following the Fontan, possibly due to a tendency toward progressive AVVR and deterioration of the single ventricle function. Additional volume overload caused by AVVR may be one of the main factors accelerating the dysfunction of the single RV, implying that early valve intervention may be warranted.
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Affiliation(s)
- Jiyong Moon
- Section of Pediatric Cardiovascular Surgery, Department of Cardiac Surgery, University of Michigan Medical School, University of Michigan, C.S. Mott Children's Hospital, Ann Arbor, Michigan; Division of Congenital Heart Surgery, Department of Surgery, Baylor College of Medicine Texas Children's Hospital, Houston, Texas
| | - Li Shen
- Section of Pediatric Cardiovascular Surgery, Department of Cardiac Surgery, University of Michigan Medical School, University of Michigan, C.S. Mott Children's Hospital, Ann Arbor, Michigan; Department of Cardiothoracic Surgery, Shanghai Jiaotong University, Shanghai Children Hospital, Shanghai, China
| | - Donald S Likosky
- Department of Cardiac Surgery, Section of Health Services Research and Quality, University of Michigan Medical School, University of Michigan, Ann Arbor, Michigan
| | - Vikram Sood
- Section of Pediatric Cardiovascular Surgery, Department of Cardiac Surgery, University of Michigan Medical School, University of Michigan, C.S. Mott Children's Hospital, Ann Arbor, Michigan
| | - Reilly D Hobbs
- Section of Pediatric Cardiovascular Surgery, Department of Cardiac Surgery, University of Michigan Medical School, University of Michigan, C.S. Mott Children's Hospital, Ann Arbor, Michigan
| | - Peter Sassalos
- Section of Pediatric Cardiovascular Surgery, Department of Cardiac Surgery, University of Michigan Medical School, University of Michigan, C.S. Mott Children's Hospital, Ann Arbor, Michigan
| | - Jennifer C Romano
- Section of Pediatric Cardiovascular Surgery, Department of Cardiac Surgery, University of Michigan Medical School, University of Michigan, C.S. Mott Children's Hospital, Ann Arbor, Michigan
| | - Richard G Ohye
- Section of Pediatric Cardiovascular Surgery, Department of Cardiac Surgery, University of Michigan Medical School, University of Michigan, C.S. Mott Children's Hospital, Ann Arbor, Michigan
| | - Edward L Bove
- Section of Pediatric Cardiovascular Surgery, Department of Cardiac Surgery, University of Michigan Medical School, University of Michigan, C.S. Mott Children's Hospital, Ann Arbor, Michigan
| | - Ming-Sing Si
- Section of Pediatric Cardiovascular Surgery, Department of Cardiac Surgery, University of Michigan Medical School, University of Michigan, C.S. Mott Children's Hospital, Ann Arbor, Michigan.
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Wolfe KR, Kelly SL, Liptzin DR, Brigham D, Rafferty C, Younoszai AK, Di Maria MV. Patient and Family Experience in a Multidisciplinary Clinic for Children With Single-Ventricle Heart Disease. J Patient Exp 2021; 7:1384-1390. [PMID: 33457591 PMCID: PMC7786718 DOI: 10.1177/2374373520904214] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
Children with single-ventricle heart disease (SVHD) are at risk for morbidity across multiple organ systems. A single-ventricle multidisciplinary clinic (SVMDC) may address complex health-care needs by providing access to, and coordination among, pediatric subspecialties. However, the patient and family experience of multidisciplinary care for SVHD remains unexplored. We e-mailed a 26-question survey to families after an SVMDC visit, which included evaluation with subspecialists from cardiology, pulmonology, gastroenterology, neuropsychology, and pediatric psychology, as well as social activities during clinic. Responses were anonymized to protect privacy, and data were analyzed quantitatively and qualitatively. Over 3 years, 22% (27/122) of families completed the survey. Overall, families’ experiences were positive, with 100% reporting that they would recommend the SVMDC to others. Qualitative themes emerged regarding logistics, multidisciplinary care, key takeaways from clinic, and connection-making with other families. A multidisciplinary clinic demonstrated overall acceptability and perceived benefit to families of children with SVHD. Considerations for mixed experiences regarding financial commitment and connection-making among parents are discussed, as are the benefits of the synergy achieved through multidisciplinary care.
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Affiliation(s)
- Kelly R Wolfe
- Neuroscience Institute, Section of Pediatric Neurology, Department of Pediatrics, University of Colorado School of Medicine, Children's Hospital Colorado, Aurora, CO, USA
| | - Sarah L Kelly
- Heart Institute, Section of Pediatric Cardiology, Department of Pediatrics, University of Colorado School of Medicine, Children's Hospital Colorado, Aurora, CO, USA
| | - Deborah R Liptzin
- Breathing Institute, Section of Pulmonary Medicine, Department of Pediatrics, University of Colorado School of Medicine, Children's Hospital Colorado, Aurora, CO, USA
| | - Dania Brigham
- Digestive Health Institute, Section of Pediatric Gastroenterology, Hepatology and Nutrition, Department of Pediatrics, University of Colorado School of Medicine, Children's Hospital Colorado Aurora, CO, USA
| | - Carey Rafferty
- Heart Institute, Section of Pediatric Cardiology, Department of Pediatrics, University of Colorado School of Medicine, Children's Hospital Colorado, Aurora, CO, USA
| | - Adel K Younoszai
- Heart Institute, Section of Pediatric Cardiology, Department of Pediatrics, University of Colorado School of Medicine, Children's Hospital Colorado, Aurora, CO, USA
| | - Michael V Di Maria
- Heart Institute, Section of Pediatric Cardiology, Department of Pediatrics, University of Colorado School of Medicine, Children's Hospital Colorado, Aurora, CO, USA
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Moosmann J, Schroeder C, Cesnjevar R, Rottermann K, Weigelt A, Dittrich S. Neutrophil-to-Lymphocyte and Platelet-to-Lymphocyte Ratio in Univentricular Patients From Birth to Follow-Up After Fontan-Predicting Lymphatic Abnormalities. Front Pediatr 2021; 9:740951. [PMID: 34956972 PMCID: PMC8692875 DOI: 10.3389/fped.2021.740951] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/14/2021] [Accepted: 11/17/2021] [Indexed: 11/13/2022] Open
Abstract
Background: Reliable laboratory parameters identifying complications after Fontan surgery including the lymphatic abnormalities and the development of protein-losing enteropathy (PLE) are rare. Neutrophil-to-lymphocyte ratio (NLR) and platelet-to-lymphocte ratio (PLR) are inflammatory markers and have been studied to predict outcome and prognosis in various diseases. The aim of this study was to investigate NLR and PLR from birth to follow-up after Fontan and evaluate their use as prognostic parameters for single ventricle patients regarding the development of lymphatic malformations during follow-up. Materials and Methods: Sixty-six univentricular patients who underwent Fontan surgery and had 6-month follow-up magnetic resonance imaging (MRI) with T2 weighted lymphatic imaging after total cavopulmonary connection (TCPC) surgery were included in the study. NLR and PLR were determined at specific time points, from neonatal age to follow-up after Fontan operation and correlated to data from the MRI 6 months after Fontan. Results: NLR and PLR increase significantly over time from the first surgery during infancy to the follow-up after Fontan (both p < 0.0001), with a significant increase after the Glenn surgery for both ratios (each p < 0.0001). Higher NLR (p = 0.002) and higher PLR (p = 0.004) correlated with higher-grade classification of lymphatic abnormalities in T2-weighted imaging 6 months after Fontan surgery and higher NLR correlated with higher transpulmonary gradient prior to Fontan surgery (p = 0.035) Both ratios showed a significant correlation to total protein at follow-up (NLR p = 0.0038; PLR<0.0001). Conclusion: Increased NLR and PLR correlate with higher degree lymphatic malformations after TCPC and therefore might contribute as valuable additional biomarker during follow-up after TCPC. NLR and PLR are simple, inexpensive and easily available parameters to complement diagnostics after TCPC.
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Affiliation(s)
- Julia Moosmann
- Department of Pediatric Cardiology, University of Erlangen-Nürnberg, Erlangen, Germany
| | - Christian Schroeder
- Department of Pediatric Cardiology, University of Erlangen-Nürnberg, Erlangen, Germany
| | - Robert Cesnjevar
- Department of Pediatric Cardiac Surgery, University of Erlangen-Nürnberg, Erlangen, Germany
| | - Kathrin Rottermann
- Department of Pediatric Cardiology, University of Erlangen-Nürnberg, Erlangen, Germany
| | - Annika Weigelt
- Department of Pediatric Cardiology, University of Erlangen-Nürnberg, Erlangen, Germany
| | - Sven Dittrich
- Department of Pediatric Cardiology, University of Erlangen-Nürnberg, Erlangen, Germany
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80
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Rodriguez De Santiago E, Téllez L, Guerrero A, Albillos A. Hepatocellular carcinoma after Fontan surgery: A systematic review. Hepatol Res 2021; 51:116-134. [PMID: 33037858 DOI: 10.1111/hepr.13582] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/10/2020] [Revised: 09/29/2020] [Accepted: 10/01/2020] [Indexed: 02/08/2023]
Abstract
AIM Fontan surgery is often the procedure of choice for patients with congenital single effective ventricle. In the long term, elevated systemic venous pressure and chronic ischemia following this procedure could lead to advanced chronic liver disease and there is also a risk of hepatocellular carcinoma (HCC). This review systematically summarizes the characteristics and outcomes of this rare condition. METHODS PubMed and Embase databases were searched from inception to January 2020 for studies reporting on HCC after Fontan surgery. The factors analyzed were clinical presentation, histology, imaging findings, treatments, and survival. Our primary analysis was based on biopsy-proven HCC. RESULTS The records selected were 26 observational studies (19 case reports/case series and seven cohort studies) including 65 biopsy-proven HCC. Age at the time of HCC diagnosis ranged from 12 to 52 years, and 62% of the patients were female. Only one case occurred earlier than 10 years after Fontan surgery. Twenty patients had no imaging or histological evidence of liver cirrhosis and 78.3% had elevated α-fetoprotein levels. Advanced stage was the most common at diagnosis. The most frequent treatments were transarterial chemoembolization (n = 18) and surgery (n = 12). One-year survival was 50% and only four patients (6.2%) were under liver imaging surveillance. We also analyzed 17 patients with non-biopsy-proven HCC. CONCLUSIONS After Fontan surgery, HCC usually occurs at least 10 years later and can develop in the absence of cirrhosis. Biopsy is mandatory to confirm the diagnosis. Patients were diagnosed at a late stage and survival outcomes were poor, highlighting a need for liver surveillance.
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Affiliation(s)
- Enrique Rodriguez De Santiago
- Department of Gastroenterology and Hepatology, Ramón y Cajal University Hospital, University of Alcala, Ramón y Cajal Health Research Institute (IRYCIS), Madrid, Spain
| | - Luis Téllez
- Department of Gastroenterology and Hepatology, Ramón y Cajal University Hospital, University of Alcala, Ramón y Cajal Health Research Institute (IRYCIS), Madrid, Spain
| | - Antonio Guerrero
- Department of Gastroenterology and Hepatology, Ramón y Cajal University Hospital, University of Alcala, Ramón y Cajal Health Research Institute (IRYCIS), Madrid, Spain
| | - Agustín Albillos
- Department of Gastroenterology and Hepatology, Ramón y Cajal University Hospital, University of Alcala, Ramón y Cajal Health Research Institute (IRYCIS), Madrid, Spain
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81
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Pollack MM, Banks R, Holubkov R, Meert KL. Long-Term Outcome of PICU Patients Discharged With New, Functional Status Morbidity. Pediatr Crit Care Med 2021; 22:27-39. [PMID: 33027242 PMCID: PMC7790876 DOI: 10.1097/pcc.0000000000002590] [Citation(s) in RCA: 31] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVES To determine the long-term (> 6 mo) functional status of PICU patients with significant new functional morbidities at hospital discharge. DESIGN Longitudinal cohort followed-up using structured chart reviews of electronic health records. SETTING Electronic health records of former PICU patients at seven sites. PATIENTS Randomly selected patients from the Trichotomous Outcome Prediction in Critical Care study discharged from the hospital with new functional status morbidity who had sufficient electronic health record data to determine functional status. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Long-term functional status was measured with the Functional Status Scale and categorized by comparison to hospital discharge Functional Status Scale. Improvement or new morbidity was based on a change in Functional Status Scale of greater than or equal to 2 in a single domain. Overall, 56% (n = 71) improved, 15% (n = 19) did not change, 9% (n = 11) developed a new morbidity, and 21% (n = 26) died. The shortest median follow-up time from PICU discharge was 1.4 years for those who died and the longest was 4.0 years for those improved. Functional status at baseline (pre-acute illness) was different among the outcome groups with those that improved having the highest frequency of baseline normal status or only mild dysfunction. Of the long-term survivors with improvement, 82% (n = 58) improved to normal status or mild dysfunction, 11% (n = 8) improved to moderate dysfunction, and 7% (n = 5) improved to severe dysfunction. Trauma patients improved and cancer patients died more frequently than other diagnoses. The long-term outcome groups were not associated with hospital discharge functional status. CONCLUSIONS A majority of PICU survivors discharged with significant new functional morbidity with follow-up after 6 or more months improved, many to normal status or only mild dysfunction, while 29% died or developed new morbidity. Of the long-term survivors, 70% had significant improvement after a median follow-up time of 4.0 years.
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Affiliation(s)
- Murray M Pollack
- Department of Pediatrics, Children's National Hospital and the George Washington University School of Medicine and Health Sciences, Washington, DC
| | - Russell Banks
- Department of Pediatrics, University of Utah School of Medicine, Salt Lake City, UT
| | - Richard Holubkov
- Department of Pediatrics, University of Utah School of Medicine, Salt Lake City, UT
| | - Kathleen L Meert
- Department of Pediatrics, Children's Hospital of Michigan, Detroit, MI
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Goldberg DJ, Zak V, McCrindle BW, Ni H, Gongwer R, Rhodes J, Garofano RP, Kaltman JR, Lambert LM, Mahony L, Margossian R, Spector ZZ, Williams RV, Atz AM, Paridon SM. Exercise Capacity and Predictors of Performance After Fontan: Results from the Pediatric Heart Network Fontan 3 Study. Pediatr Cardiol 2021; 42:158-168. [PMID: 32975603 PMCID: PMC7867583 DOI: 10.1007/s00246-020-02465-1] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/23/2020] [Accepted: 09/16/2020] [Indexed: 12/22/2022]
Abstract
Impaired exercise following Fontan is a surrogate of morbidity. Single-center longitudinal data exist, but there is a lack of contemporary multi-center data. Ramp cycle ergometry was re-performed in consented participants who had originally participated in the Pediatric Heart Network's Fontan cross-sectional study. Annualized change was evaluated at maximal and submaximal exercise. Associations between these outcomes and patient characteristics were analyzed. There were 336 participants in Fontan 3, mean age 23.2 years. Paired measurements of peak oxygen consumption (peak VO2) were available for 95; peak exercise data at Fontan 3 were available for 275. Percent-predicted peak VO2 declined by 0.8 ± 1.7% per year (p < 0.001). At Fontan 3, the lowest performing peak VO2 tertile had the highest rate of overweight and obesity (p < 0.001). Female gender was more prevalent in the highest performing tertile (p = 0.004). Paired data at the ventilatory anaerobic threshold (VO2 at VAT) were available for 196; VAT data at Fontan 3 were available for 311. Percent-predicted VO2 at VAT decreased by 0.8 ± 2.6% per year (p < 0.001). At Fontan 3, VO2 at VAT was better preserved than peak VO2 across all tertiles, with higher rates of overweight and obesity in the lower performing group (p = 0.001). Female gender (p < 0.001) and left ventricular morphology (p = 0.03) were associated with better performance. Submaximal exercise is better preserved than maximal in the Fontan population, but declined at the same rate over the study period. The overall longitudinal rate of decline in exercise performance is slower than what has been described previously.
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Affiliation(s)
- David J. Goldberg
- Division of Cardiology, The Children’s Hospital of Philadelphia, Perelman School of Medicine, 34th Street and Civic Center Blvd, Philadelphia, PA 19104, USA
| | | | - Brian W. McCrindle
- The Hospital for Sick Children, University of Toronto, Toronto, ON M5G 1X8, Canada
| | - Hua Ni
- Healthcore, Watertown, MA 02472, USA
| | | | - Jonathan Rhodes
- Children’s Hospital Boston, Harvard Medical School, Boston, MA 02115, USA
| | - Robert P. Garofano
- Morgan Stanley Children’s Hospital, Columbia University Medical Center, New York, NY 10032, USA
| | - Jonathan R. Kaltman
- Division of Cardiovascular Sciences, National Heart, Lung, and Blood Institute, NIH, Bethesda, MD 20892, USA
| | - Linda M. Lambert
- Primary Children’s Hospital, University of Utah, Salt Lake City, UT 84132, USA
| | - Lynn Mahony
- Children’s Health Dallas, University of Texas Southwestern Medical School, Dallas, TX 75390, USA
| | - Renee Margossian
- Children’s Hospital Boston, Harvard Medical School, Boston, MA 02115, USA
| | | | - Richard V. Williams
- Primary Children’s Hospital, University of Utah, Salt Lake City, UT 84132, USA
| | - Andrew M. Atz
- Medical University of South Carolina, Charleston, SC 29425, USA
| | - Stephen M. Paridon
- Division of Cardiology, The Children’s Hospital of Philadelphia, Perelman School of Medicine, 34th Street and Civic Center Blvd, Philadelphia, PA 19104, USA
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83
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Chiu P, Emani S. Left Ventricular Recruitment in Patients With Hypoplastic Left Heart Syndrome. Semin Thorac Cardiovasc Surg Pediatr Card Surg Annu 2021; 24:30-36. [PMID: 34116780 DOI: 10.1053/j.pcsu.2021.03.001] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2020] [Revised: 02/22/2021] [Accepted: 03/05/2021] [Indexed: 11/11/2022]
Abstract
Hypoplastic left heart complex with "borderline left ventricle" and intact ventricular septum is a clinical conundrum for the congenital heart surgeon. The choice between neonatal biventricular repair and single ventricle palliation can be challenging, and the current tools to aid in the decision-making process fail to account for the morbidity associated with intermediate and late diastolic dysfunction. Staged ventricular recruitment, consisting of valvular repair techniques, resection of endocardial fibroelastosis, atrial septal restriction, and augmentation of pulmonary blood flow, has been shown to improve left ventricular size and function culminating in eventual biventricular circulation. Despite staged ventricular recruitment, some patients cannot undergo biventricular conversion. Strategies to address these complex patients, including the "reverse" double switch, are the next frontier in biventricular repair.
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Affiliation(s)
- Peter Chiu
- Department of Cardiac Surgery, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Sitaram Emani
- Department of Cardiac Surgery, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts.
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84
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Daley M, d'Udekem Y. The optimal Fontan operation: Lateral tunnel or extracardiac conduit? J Thorac Cardiovasc Surg 2020; 162:1825-1834. [PMID: 33581907 DOI: 10.1016/j.jtcvs.2020.11.179] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/13/2020] [Revised: 11/09/2020] [Accepted: 11/26/2020] [Indexed: 01/14/2023]
Affiliation(s)
- Michael Daley
- Department of Cardiac Surgery, The Royal Children's Hospital, Melbourne, Australia; Department of Paediatrics, The University of Melbourne, Melbourne, Australia; Murdoch Children's Research Institute, Melbourne, Australia
| | - Yves d'Udekem
- Department of Paediatrics, The University of Melbourne, Melbourne, Australia; Murdoch Children's Research Institute, Melbourne, Australia; Division of Cardiac Surgery, Children's National Hospital, Washington, DC.
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85
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Weinreb SJ, Dodds KM, Burstein DS, Huang J, Rand EB, Mancilla E, Heimall JR, McBride MG, Paridon SM, Goldberg DJ, Rychik J. End-Organ Function and Exercise Performance in Patients With Fontan Circulation: What Characterizes the High Performers? J Am Heart Assoc 2020; 9:e016850. [PMID: 33317366 PMCID: PMC7955385 DOI: 10.1161/jaha.120.016850] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Background The physiologic hallmarks of the Fontan circulation-chronically elevated central venous pressures and low cardiac output-have significant effects not only on cardiovascular status but also impact other organ systems. Exercise capacity is limited in many and declines with age, accelerating in adolescence, but with wide variability. We explore the relationship between exercise performance and end-organ function in outpatient subjects with a Fontan circulation. Methods and Results This is a cross-sectional analysis of subject end-organ characterization from our outpatient Fontan circulation clinic with peak oxygen consumption (peak Vo2) at cardiopulmonary exercise testing as the primary outcome. We perform linear regression to assess associations between clinical characteristics and peak Vo2 as well as the magnitude of the association of clinical characteristics with peak Vo2. Of 265 subjects age 12.8 (9.5-16.4) years, there is a negative correlation between age and peak Vo2 (-0.49, P<0.001). Of those undergoing ramp cycle exercise testing, 34% perform above 80% predicted peak Vo2. Variables positively associated with peak Vo2 and their effect size include vitamin D sufficiency (+3.00, P=0.020) and absolute lymphocyte count (+0.23, P=0.005). Status as overweight/obese (-3.91, P=0.003) and hemoglobin (-0.77, P=0.003) are negatively associated. Neither ventricular morphology, timing of Fontan palliation, nor Fontan circulation type affect peak Vo2. Conclusions Higher peak Vo2 in those with a Fontan circulation is associated with younger age, vitamin D sufficiency, absence of overweight/obese, lower hemoglobin, and a healthier hepatic profile. Whether exercise training or other initiatives can modify organ characteristics in those with a Fontan circulation is worthy of exploration.
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Affiliation(s)
- Scott J Weinreb
- Division of Cardiology Department of Pediatrics Children's Hospital of Philadelphia PA
| | - Kathryn M Dodds
- Division of Cardiology Department of Pediatrics Children's Hospital of Philadelphia PA
| | - Danielle S Burstein
- Division of Cardiology Department of Pediatrics Children's Hospital of Philadelphia PA
| | - Jing Huang
- Department of Biostatistics, Epidemiology and Informatics University of Pennsylvania Perelman School of Medicine Philadelphia PA
| | - Elizabeth B Rand
- Division of Gastroenterology, Hepatology and Nutrition Department of Pediatrics Children's Hospital of Philadelphia PA
| | - Edna Mancilla
- Division of Endocrinology Department of Pediatrics Children's Hospital of Philadelphia PA
| | - Jennifer R Heimall
- Division of Allergy and Immunology Department of Pediatrics Children's Hospital of Philadelphia PA
| | - Michael G McBride
- Division of Cardiology Department of Pediatrics Children's Hospital of Philadelphia PA
| | - Stephen M Paridon
- Division of Cardiology Department of Pediatrics Children's Hospital of Philadelphia PA
| | - David J Goldberg
- Division of Cardiology Department of Pediatrics Children's Hospital of Philadelphia PA
| | - Jack Rychik
- Division of Cardiology Department of Pediatrics Children's Hospital of Philadelphia PA
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86
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Wolfe KR, Liptzin DR, Brigham D, Kelly SL, Rafferty C, Albertz M, Younoszai AK, Di Maria MV. Relationships between Physiologic and Neuropsychologic Functioning after Fontan. J Pediatr 2020; 227:239-246. [PMID: 32687915 DOI: 10.1016/j.jpeds.2020.07.043] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/27/2020] [Revised: 06/12/2020] [Accepted: 07/14/2020] [Indexed: 11/18/2022]
Abstract
OBJECTIVE To investigate potential relationships between neuropsychologic functioning and cardiac, gastroenterologic/hepatologic, and pulmonary complications in the single ventricle heart disease (SVHD) post-Fontan population. STUDY DESIGN Following the initiation of a Fontan Multidisciplinary Clinic, patients with SVHD were evaluated systematically according to a clinical care pathway, and data from multiple subspecialty evaluations were collected prospectively from 2016 to 2019. Biomarkers of cardiology, pulmonary, and hepatology/gastroenterology functioning were abstracted, along with neuropsychologic testing results. Bivariate correlations and regression analyses examined cross-sectional relationships between physiologic predictors and neuropsychologic outcomes. RESULTS The sample included a cohort of 68 youth with SVHD age 3-19 years, after Fontan palliation. Sleep-disordered breathing was related to poorer visual-motor integration skills (r = -0.33; P < .05) and marginally related to poorer executive functioning (r = -0.33; P = .05). Lower arterial blood oxygen content was related to poorer executive functioning (r = .45; P < .05). Greater atrioventricular valve regurgitation was related to lower parent-rated adaptive functioning (ρ = -0.34; P < .01). These results were maintained in regression analyses controlling for history of stroke and/or seizures. CONCLUSIONS We demonstrated associations between neuropsychologic functioning and potentially modifiable aspects of physiologic functioning in a prospectively evaluated cohort of patients with SVHD with Fontan physiology. Our findings emphasize the importance of multidisciplinary screening and care after a Fontan procedure and suggest avenues for intervention that may improve patient outcomes and quality of life.
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Affiliation(s)
- Kelly R Wolfe
- Section of Neurology, Department of Pediatrics, University of Colorado School of Medicine, Aurora, CO.
| | - Deborah R Liptzin
- Section of Pulmonology, Department of Pediatrics, University of Colorado School of Medicine, Aurora, CO
| | - Dania Brigham
- Section of Gastroenterology, Department of Pediatrics, University of Colorado School of Medicine, Aurora, CO
| | - Sarah L Kelly
- Section of Cardiology, Department of Pediatrics, University of Colorado School of Medicine, Aurora, CO
| | - Carey Rafferty
- Section of Cardiology, Department of Pediatrics, University of Colorado School of Medicine, Aurora, CO
| | - Megan Albertz
- Section of Anesthesiology, University of Colorado School of Medicine, Aurora, CO
| | - Adel K Younoszai
- Section of Cardiology, Department of Pediatrics, University of Colorado School of Medicine, Aurora, CO
| | - Michael V Di Maria
- Section of Cardiology, Department of Pediatrics, University of Colorado School of Medicine, Aurora, CO
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88
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Tan W, Small A, Gallotti R, Moore J, Aboulhosn J. Peripheral venous pressure accurately predicts central venous pressure in the adult Fontan circulation. Int J Cardiol 2020; 326:77-80. [PMID: 33189798 DOI: 10.1016/j.ijcard.2020.11.007] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/06/2020] [Revised: 10/19/2020] [Accepted: 11/03/2020] [Indexed: 11/16/2022]
Abstract
BACKGROUND Patients with the Fontan circulation lack a subpulmonary ventricular pump and thus the main driver for pulmonary blood flow is a high central venous pressure. Peripheral venous pressure (PVP) measurement has been shown to be a reproducible and fairly accurate surrogate for central venous pressure (CVP), but not specifically for the adult Fontan circulation. This study aims to determine the relationship of PVP to CVP in adult Fontan patients. METHODS All adult patients (≥18 yo) with a Fontan circulation undergoing cardiac catheterization were included. Both CVP and PVP were measured during the catheterization. The relationship between the peripheral venous and central venous pressures was assessed using simple linear regression and the Bland-Altman plot analysis for differences. RESULTS Thirty-eight adult Fontan patients (mean age 30.7 ± 8.5, range 18-52 years) undergoing 43 cardiac catheterizations were analyzed. The mean CVP was 17.3 +/- 4.7 mmHg. The mean PVP was 18.4 +/- 5 mmHg. CVP and PVP were highly correlated, with an R2 value of 0.83 (p < 0.001). The CVP can be estimated with PVP measurements using the formula CVP = (0.86 * PVP) + 1.3. A Bland-Altman plot for PVP and CVP demonstrated that the PVP overestimated CVP by a mean of 1.2 mmHg, with a 95% limit of agreement of -5.2 mmHg to 2.8 mmHg. CONCLUSIONS In adult Fontan patients, measuring PVP is a reliable, less-invasive, and accurate method of estimating the CVP during cardiac catheterization procedures. These findings may enable outpatient monitoring of Fontan hemodynamics.
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Affiliation(s)
- Weiyi Tan
- Ahmanson/UCLA Adult Congenital Heart Disease Center, Division of Cardiology, Department of Medicine, University of California Los Angeles, Los Angeles, CA, United States of America.
| | - Adam Small
- Adult Congenital Heart Disease, Division of Cardiology, Department of Medicine, NYU Grossman School of Medicine, New York, NY, United States of America; Ahmanson/UCLA Adult Congenital Heart Disease Center, Division of Cardiology, Department of Medicine, University of California Los Angeles, Los Angeles, CA, United States of America
| | - Roberto Gallotti
- Division of Pediatric Cardiology, Department of Pediatrics, University of California Los Angeles, Los Angeles, CA, United States of America
| | - Jeremy Moore
- Ahmanson/UCLA Adult Congenital Heart Disease Center, Division of Cardiology, Department of Medicine, University of California Los Angeles, Los Angeles, CA, United States of America; Division of Pediatric Cardiology, Department of Pediatrics, University of California Los Angeles, Los Angeles, CA, United States of America
| | - Jamil Aboulhosn
- Ahmanson/UCLA Adult Congenital Heart Disease Center, Division of Cardiology, Department of Medicine, University of California Los Angeles, Los Angeles, CA, United States of America
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89
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Abstract
Hypoplastic left heart syndrome (HLHS) is a complex form of congenital heart disease defined by anatomic and functional inadequacy of the left side of the heart with nonviability of the left ventricle to perform systemic perfusion. Lethal if not treated, a strategy for survival currently is well established, with continuing improvement in outcomes over the past 30 years. Prenatal diagnosis, good newborn care, improved surgical skills, specialized postoperative care, and unique strategies for interstage monitoring all have contributed to increasing likelihood of survival. The unique life with a single right ventricle and a Fontan circulation is a focused area of investigation.
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90
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Bockeria L, Carrel T, Lemaire A, Makarenko V, Kim A, Shatalov K, Cox M, Svanidze O. Total cavopulmonary connection with a new restorative vascular graft: results at 2 years. J Thorac Dis 2020; 12:4168-4173. [PMID: 32944328 PMCID: PMC7475567 DOI: 10.21037/jtd-19-739] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/03/2022]
Abstract
Background To present a 2-year follow-up regarding safety and hemodynamic performance of a new restorative vascular graft used as extracardiac cavo-pulmonary connection in patients with univentricular congenital heart malformations. Methods The graft was implanted in five patients (aged 4–12 years) as extracardiac connection between the inferior vena cava and the pulmonary artery. The conduit consists of a bioabsorbable polymer-based implant able to generate endogenous tissue restoration leading to a fully functional neo-vessel while the polymer progressively absorbs. All patients have reached more than 24 months following surgery and underwent echocardiography and magnetic resonance imaging. Results All patients are doing well at 24 months follow-up, with no graft-related serious adverse events. Transthoracic echocardiography demonstrated adequate function of the conduit in all patients while magnetic resonance imaging showed anatomical and functional stability of the restorative grafts. Conclusions The new restorative conduit has been successfully used for the second step of the Fontan procedure as extracardiac total cavopulmonary connection. The results are promising because they suggest that complete transformation of a bioabsorbable polymer and replacement through endogenous tissue may represent a major advantage in the treatment of congenital heart disease patients. Further monitoring will allow to evaluate the long-term behavior of this new graft, in terms of clinical and hemodynamic performance, thrombogenicity and ability to grow.
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Affiliation(s)
- Leo Bockeria
- Department of Cardiovascular Surgery, Bakulev Center, Moscow, Russia
| | - Thierry Carrel
- Department of Cardiovascular Surgery, University of Bern, Bern, Switzerland
| | | | | | - Alex Kim
- Department of Cardiovascular Surgery, Bakulev Center, Moscow, Russia
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The Unique Clinical Phenotype and Exercise Adaptation of Fontan Patients With Normal Exercise Capacity. Can J Cardiol 2020; 36:1499-1507. [DOI: 10.1016/j.cjca.2019.11.006] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2019] [Revised: 11/06/2019] [Accepted: 11/07/2019] [Indexed: 12/24/2022] Open
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92
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Sethasathien S, Silvilairat S, Kraikruan H, Sittiwangkul R, Makonkawkeyoon K, Pongprot Y, Woragidpoonpol S. Survival and predictors of mortality in patients after the Fontan operation. Asian Cardiovasc Thorac Ann 2020; 28:572-576. [PMID: 32777943 DOI: 10.1177/0218492320949655] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND As a result of the surgical techniques now being employed, the survival rate in patients after undergoing the Fontan operation has improved. The aims of this study were focused on determining the survival rate and predictors of early mortality. METHODS In a retrospective cohort study, 117 consecutive patients who underwent the Fontan operation were recruited. Multivariate Cox proportional regression analysis was used to assess the predictors of early mortality, defined as death within 30 days after the Fontan operation. RESULTS The median follow-up time was 6.1 years. The median age at the time of the Fontan operation was 5.7 years. Survival rates in the patients at 5, 10, and 15 years postoperatively were 92%, 87% and 84%, respectively. Using univariate Cox regression analysis, the predictors of early mortality were found to be postoperative mean pulmonary artery pressure ≥23 mm Hg (hazard ratio 26.0), renal failure (hazard ratio 9.5), heterotaxy syndrome (hazard ratio 5.3), and uncorrected moderate or severe atrioventricular valve regurgitation (hazard ratio 9.4). After adjusting for confounding factors using multivariate Cox regression analysis, the predictors of early mortality were found to be postoperative mean pulmonary artery pressure ≥23 mm Hg (hazard ratio 23.2) and uncorrected moderate or severe atrioventricular valve regurgitation (hazard ratio 8.2). CONCLUSIONS Uncorrected moderate or severe atrioventricular valve regurgitation and postoperative mean pulmonary artery pressure ≥23 mm Hg are independent predictors of early mortality after the Fontan operation. Patients with these factors should undergo aggressive management to minimize morbidity and mortality.
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Affiliation(s)
- Saviga Sethasathien
- Department of Pediatrics, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand
| | - Suchaya Silvilairat
- Department of Pediatrics, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand
| | - Hathaiporn Kraikruan
- Department of Pediatrics, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand
| | - Rekwan Sittiwangkul
- Department of Pediatrics, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand
| | - Krit Makonkawkeyoon
- Department of Pediatrics, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand
| | - Yupada Pongprot
- Department of Pediatrics, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand
| | - Surin Woragidpoonpol
- Department of Surgery, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand
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93
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Swanson TM, Patel A, Baxter AJ, Morris SA, Maskatia SA, Lantos JD. Pediatric Cardiology Specialist's Opinions Toward the Acceptability of Comfort Care for Congenital Heart Disease. Pediatr Cardiol 2020; 41:1160-1165. [PMID: 32419096 DOI: 10.1007/s00246-020-02367-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/23/2020] [Accepted: 05/06/2020] [Indexed: 11/29/2022]
Abstract
In order to evaluate physicians' willingness to seek legal action to mandate surgery when parents refuse surgery for various congenital heart lesions, we surveyed pediatric cardiologists and cardiovascular surgeons at 4 children's hospitals. We asked whether physicians would support parental refusal of surgery for specific heart defects and, if not, whether they would seek legal action to mandate surgery. We then analyzed associations between physicians' willingness to mandate surgery and national operative mortality rates for each lesion. We surveyed 126 cardiologists and 9 cardiac surgeons at four tertiary referral centers. Overall response rate was 77%. Greater than 70% of physicians would seek legal action and mandate surgery for the following lesions: ventricular septal defect, coarctation of the aorta, complete atrioventricular canal, transposition of the great arteries, tetralogy of Fallot, and unobstructed total anomalous pulmonary venous return. Surgery for all of these lesions has reported mortality rates of < 5%. Physicians were less likely to seek legal action when parents refused surgery for Shone complex, any single ventricle lesion, or any congenital heart disease accompanied by Trisomy 13 or Trisomy 18. Among experts in pediatric cardiology, there is widespread agreement about the appropriate response to parental refusal of surgery for most congenital heart lesions, and these lesions tended to be heart defects with lower surgical mortality rates. Lesions for which there was greater consensus among experts were those with the best outcomes. There was less consensus for lesions with higher mortality rates. Such surveys, revealing disagreement among expert professionals, can provide an operational definition of the current professional "gray zone" in which parental preferences should determine treatment.
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Affiliation(s)
- Tara M Swanson
- Section of Cardiology, Children's Mercy Hospital, University of Missouri-Kansas City School of Medicine, Kansas City, MO, USA
| | - Angira Patel
- Section of Cardiology, Ann & Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine, 225 E. Chicago Ave., Chicago, IL, 60611, USA.
| | - Austin J Baxter
- Center for Ethics, Children's Mercy Hospital, University of Missouri-Kansas City School of Medicine, Kansas City, MO, USA
| | - Shaine A Morris
- Section of Cardiology, Baylor College of Medicine, Texas Children's Hospital, Houston, TX, USA
| | - Shiraz A Maskatia
- Section of Cardiology, Stanford University School of Medicine, Lucile Packard Children's Hospital, Stanford, CA, USA
| | - John D Lantos
- Center for Ethics, Children's Mercy Hospital, University of Missouri-Kansas City School of Medicine, Kansas City, MO, USA
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94
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Outcomes of the Fontan Operation for Patients With Heterotaxy: A Meta-Analysis of 848 Patients. Ann Thorac Surg 2020; 110:307-315. [DOI: 10.1016/j.athoracsur.2019.11.027] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/23/2019] [Revised: 11/06/2019] [Accepted: 11/15/2019] [Indexed: 11/20/2022]
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95
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Monaco J, Khanna A, Khazanie P. Transplant and mechanical circulatory support in patients with adult congenital heart disease. Heart Fail Rev 2020; 25:671-683. [PMID: 32472522 PMCID: PMC7811764 DOI: 10.1007/s10741-020-09976-2] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
Advances in surgery and pediatric care over the past decades have achieved improved survival for children born with congenital heart disease (CHD) and have produced a large, growing population of patients with adult congenital heart disease (ACHD). Heart failure has emerged as the leading cause of death and a major cause of morbidity among the ACHD population, while as little evidence supports the efficacy of guideline-directed medical therapies in this population. It is increasingly important that clinicians caring for these patients understand how to utilize mechanical circulatory support (MCS) in ACHD. In this review, we summarize the data on transplantation and MCS in the ACHD-heart failure population and provide a framework for how ACHD patients may benefit from advanced heart failure therapies like transplantation and MCS.
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Affiliation(s)
- James Monaco
- Colorado University Hospital, University of Colorado Anschutz Medical Center, Aurora, CO, USA.
| | - Amber Khanna
- Colorado University Hospital, University of Colorado Anschutz Medical Center, Aurora, CO, USA
| | - Prateeti Khazanie
- Colorado University Hospital, University of Colorado Anschutz Medical Center, Aurora, CO, USA
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96
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Arunamata A, Tacy TA, Kache S, Mainwaring RD, Ma M, Maeda K, Punn R. Recent outcomes of the extracardiac Fontan procedure in patients with hypoplastic left heart syndrome. Ann Pediatr Cardiol 2020; 13:186-193. [PMID: 32863652 PMCID: PMC7437630 DOI: 10.4103/apc.apc_5_20] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/12/2020] [Revised: 04/17/2020] [Accepted: 11/05/2020] [Indexed: 11/21/2022] Open
Abstract
Objective: To investigate patient-related factors, echocardiographic, and anatomic variables associated with immediate and long-term clinical outcomes after extracardiac Fontan procedure at our institution. Materials and Methods: Retrospective review of preoperative cardiac catheterizations and echocardiograms as well as medical records of all children with hypoplastic left heart syndrome (HLHS) who underwent Fontan between June 2002 and December 2018. Results: Seventy-seven patients with HLHS were included (age 4 years [1.5–11.7]). Seventy patients (91%) received a nonfenestrated Fontan and 57 patients (74%) underwent Fontan without cardiopulmonary bypass (CPB). Presence of a Fontan fenestration (P = 0.69) and use of CPB (P = 0.79) did not differ between those with <2 weeks compared to those with ≥2 weeks of chest tube drainage. There were no differences in either pre- or intra-operative hemodynamics between patients who weighed <15 kg compared to those who weighed ≥15 kg at time of surgery; incidence of death, transplant, and transplant listing were similar between weight groups. Inferior vena cava (IVC) diameter z-score did not differ among patients with and without chylous chest tube drainage (P = 0.78), with and without development of protein losing enteropathy (P = 0.23), or death/heart transplant/transplant listing compared to survivors without transplant (P = 0.26). Conclusion: In HLHS patients undergoing Fontan, preoperative weight and IVC diameter appeared to have no influence on immediate postoperative outcomes. Performing the Fontan off CPB and with a fenestration also conferred no added clinical benefit. These observations should be considered when deciding optimal timing for Fontan completion.
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Affiliation(s)
- Alisa Arunamata
- Department of Pediatrics, Division of Pediatric Cardiology, Stanford University School of Medicine, Stanford, CA, USA
| | - Theresa A Tacy
- Department of Pediatrics, Division of Pediatric Cardiology, Stanford University School of Medicine, Stanford, CA, USA
| | - Saraswati Kache
- Department of Pediatrics, Division of Critical Care Medicine, Stanford University School of Medicine, Stanford, CA, USA
| | - Richard D Mainwaring
- Department of Cardiothoracic Surgery, Division of Pediatric Cardiac Surgery, Stanford University School of Medicine, Stanford, CA, USA
| | - Michael Ma
- Department of Cardiothoracic Surgery, Division of Pediatric Cardiac Surgery, Stanford University School of Medicine, Stanford, CA, USA
| | - Katsuhide Maeda
- Department of Cardiothoracic Surgery, Division of Pediatric Cardiac Surgery, Stanford University School of Medicine, Stanford, CA, USA
| | - Rajesh Punn
- Department of Pediatrics, Division of Pediatric Cardiology, Stanford University School of Medicine, Stanford, CA, USA
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97
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Talwar S, Marathe SP, Choudhary SK, Airan B. Where are we after 50 years of the Fontan operation? Indian J Thorac Cardiovasc Surg 2020; 37:42-53. [PMID: 33584026 DOI: 10.1007/s12055-019-00906-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2019] [Revised: 11/02/2019] [Accepted: 11/08/2019] [Indexed: 01/11/2023] Open
Abstract
First introduced in 1971, the Fontan procedure is the final common destination for all patients with a functional single ventricle. The procedure itself has evolved tremendously over the last five decades. This review traces this journey and presents the importance, outcomes and future outlook of the procedure in the current era.
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Affiliation(s)
- Sachin Talwar
- Cardiothoracic Centre, All India Institute of Medical Sciences, New Delhi, India
- Department of Cardiothoracic and Vascular Surgery, All India Institute of Medical Sciences, Ansari Nagar, New Delhi, 110029 India
| | | | - Shiv Kumar Choudhary
- Cardiothoracic Centre, All India Institute of Medical Sciences, New Delhi, India
| | - Balram Airan
- Mahatma Gandhi Hospital, Mahatma Gandhi University of Medical Sciences Technology, Jaipur, India
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98
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van den Bosch E, Bossers SSM, Bogers AJJC, Robbers-Visser D, van Dijk APJ, Roos-Hesselink JW, Breur HMPJ, Haas F, Kapusta L, Helbing WA. Staged total cavopulmonary connection: serial comparison of intra-atrial lateral tunnel and extracardiac conduit taking account of current surgical adaptations. Interact Cardiovasc Thorac Surg 2020; 29:453-460. [PMID: 30968115 DOI: 10.1093/icvts/ivz081] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2018] [Revised: 02/01/2019] [Accepted: 02/21/2019] [Indexed: 01/14/2023] Open
Abstract
OBJECTIVES Our goals were to compare the outcome of the intra-atrial lateral tunnel (ILT) and the extracardiac conduit (ECC) techniques for staged total cavopulmonary connection (TCPC) and to compare the current modifications of the TCPC technique, i.e. the prosthetic ILT technique with the current ECC technique with a ≥18-mm conduit. METHODS We included patients who had undergone a staged TCPC between 1988 and 2008. Records were reviewed for patient demographics, operative details and events during follow-up (death, surgical and catheter-based reinterventions and arrhythmias). RESULTS Of the 208 patients included, 103 had the ILT (51 baffle, 52 prosthetic) technique and 105 had the ECC technique. Median follow-up duration was 13.2 years (interquartile range 9.5-16.3). At 15 years after the TCPC, the overall survival rate was comparable (81% ILT vs 89% ECC; P = 0.12). Freedom from late surgical and catheter-based reintervention was higher for patients who had ILT than for those who had ECC (63% vs 44%; P = 0.016). However, freedom from late arrhythmia was lower for patients who had ILT than for those who had ECC (71% vs 85%, P = 0.034). In a subgroup of patients who had the current TCPC technique, when we compared the use of a prosthetic ILT with ≥18-mm ECC, we found no differences in freedom from late arrhythmias (82% vs 86%, P = 0.64) or in freedom from late reinterventions (70% vs 52%, P = 0.14). CONCLUSIONS A comparison between the updated prosthetic ILT and current ≥18-mm ECC techniques revealed no differences in late arrhythmia-free survival or late reintervention-free survival. Overall, outcomes after the staged TCPC were relatively good and reinterventions occurred more frequently in the ECC group, whereas late arrhythmias were more common in the ILT group.
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Affiliation(s)
- Eva van den Bosch
- Division of Paediatric Cardiology, Department of Paediatrics, Erasmus University Medical Center, Rotterdam, Netherlands.,Department of Radiology, Erasmus University Medical Center, Rotterdam, Netherlands.,Netherlands Heart Institute, Utrecht, Netherlands
| | - Sjoerd S M Bossers
- Division of Paediatric Cardiology, Department of Paediatrics, Erasmus University Medical Center, Rotterdam, Netherlands.,Department of Radiology, Erasmus University Medical Center, Rotterdam, Netherlands
| | - Ad J J C Bogers
- Department of Cardiothoracic Surgery, Erasmus University Medical Center, Rotterdam, Netherlands
| | | | - Arie P J van Dijk
- Department of Cardiology, Radboud University Medical Center, Nijmegen, Netherlands
| | | | - Hans M P J Breur
- Department of Paediatric Cardiology, University Medical Center Utrecht, Utrecht, Netherlands
| | - Felix Haas
- Department of Paediatric Cardiothoracic Surgery, University Medical Center Utrecht, Utrecht, Netherlands
| | - Livia Kapusta
- Paediatric Cardiology, Dana-Dwek Children's Hospital, Sourasky Medical Center, Tel Aviv University, Tel Aviv, Israel.,Division of Paediatric Cardiology, Department of Paediatrics, Radboud University Medical Center, Nijmegen, Netherlands
| | - Willem A Helbing
- Division of Paediatric Cardiology, Department of Paediatrics, Erasmus University Medical Center, Rotterdam, Netherlands.,Department of Radiology, Erasmus University Medical Center, Rotterdam, Netherlands.,Division of Paediatric Cardiology, Department of Paediatrics, Radboud University Medical Center, Nijmegen, Netherlands
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99
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Rijnberg FM, Blom NA, Sojak V, Bruggemans EF, Kuipers IM, Rammeloo LAJ, Jongbloed MRM, Bouma BJ, Hazekamp MG. A 45-year experience with the Fontan procedure: tachyarrhythmia, an important sign for adverse outcome. Interact Cardiovasc Thorac Surg 2020; 29:461-468. [PMID: 31038168 DOI: 10.1093/icvts/ivz111] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2019] [Revised: 03/22/2019] [Accepted: 04/07/2019] [Indexed: 11/13/2022] Open
Abstract
OBJECTIVES This study aims to evaluate our 45-year experience with the Fontan procedure and to identify risk factors for late mortality and morbidity. METHODS Demographic, preoperative, perioperative and postoperative characteristics were retrospectively collected for all patients who underwent a Fontan procedure in a single centre between 1972 and 2016. RESULTS The study included 277 Fontan procedures (44 atriopulmonary connections, 28 Fontan-Björk, 42 lateral tunnels and 163 extracardiac conduits). Early failure occurred in 17 patients (6.1%). Median follow-up of the study cohort was 11.9 years (Q1-Q3 7.6-17.5). Longest survival estimates were 31% [95% confidence intervals (CI) 18-44%] at 35 years for atriopulmonary connection/Björk, 87% (95% CI 63-96%) at 20 years for lateral tunnel and 99% (95% CI 96-100%) at 15 years for extracardiac conduit. Estimated freedom from Fontan failure (death, heart transplant, take-down, protein-losing enteropathy, New York Heart Association III-IV) at 15 years was 65% (95% CI 52-76%) for atriopulmonary connection/Björk, 90% (95% CI 73-97%) for lateral tunnel and 90% (95% CI 82-94%) for extracardiac conduit. The development of tachyarrhythmia was an important predictor of Fontan failure [hazard ratio (HR) 2.6, 95% CI 1.2-5.8; P = 0.017], thromboembolic/neurological events (HR 3.6, 95% CI 1.4-9.4; P = 0.008) and pacemaker for sinus node dysfunction (HR 3.7, 95% CI 1.4-9.6; P = 0.008). Prolonged pleural effusion (>21 days) increased the risk of experiencing protein-losing enteropathy (HR 4.7, 95% CI 2.0-11.1; P < 0.001). CONCLUSIONS With modern techniques, survival and freedom from Fontan failure are good. However, Fontan patients remain subject to general attrition. Tachyarrhythmia is an important sign for an adverse outcome. Prevention and early treatment of tachyarrhythmia may, therefore, be paramount in improving the long-term outcome.
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Affiliation(s)
- Friso M Rijnberg
- Department of Cardiothoracic Surgery, Leiden University Medical Center, Leiden, Netherlands
| | - Nico A Blom
- Department of Pediatric Cardiology, Leiden University Medical Center, Leiden, Netherlands.,Department of Pediatric Cardiology, Amsterdam Medical Center, Amsterdam, Netherlands
| | - Vladimir Sojak
- Department of Cardiothoracic Surgery, Leiden University Medical Center, Leiden, Netherlands
| | - Eline F Bruggemans
- Department of Cardiothoracic Surgery, Leiden University Medical Center, Leiden, Netherlands
| | - Irene M Kuipers
- Department of Pediatric Cardiology, Amsterdam Medical Center, Amsterdam, Netherlands
| | - Lukas A J Rammeloo
- Department of Pediatric Cardiology, Free University Medical Center, Amsterdam, Netherlands
| | | | - Berto J Bouma
- Department of Cardiology, Amsterdam Medical Center, Amsterdam, Netherlands
| | - Mark G Hazekamp
- Department of Cardiothoracic Surgery, Leiden University Medical Center, Leiden, Netherlands
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100
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Early Integration of Palliative Care in Families of Children with Single Ventricle Congenital Heart Defects: A Quality Improvement Project to Enhance Family Support. Pediatr Cardiol 2020; 41:114-122. [PMID: 31676955 DOI: 10.1007/s00246-019-02231-y] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/09/2019] [Accepted: 10/17/2019] [Indexed: 10/25/2022]
Abstract
Children with single ventricle congenital heart defects (SVCHD) experience a significant risk of early mortality throughout their lifespan, particularly during their first year of life. Due to the intense care needed for these children and families, pediatric palliative care (PPC) team consults should be routine; however, medical staff are often reluctant to broach the idea of PPC to families. The involvement of PPC for many carries with it an association to end-of-life (EOL) care. Setting the standard of PPC involvement from the time of admission for the first palliative surgery led to increased family support, decreased days to consult, improved acceptance and communication. The purpose of this article is to describe a quality improvement project of early integration of PPC with families of children with SVCHD. Lessons learned will be presented, including the resources needed and the barriers encountered in assimilating PPC into the standard of care for all patients with SVCHD. The single ventricle (SV) and PPC teams collaborated to enhance the support given to SV families. Education was initiated with cardiology and PPC providers to understand the goal of consistent PPC consults beginning after birth for patients with SVCHD. Parents were educated during fetal consultation regarding the involvement of the PPC team. The SV team ensured compliance with the PPC initiative by identifying eligible patients and requesting consult orders from the primary providers. PPC consultation increased significantly over the 40 month study period to nearly 100% compliance for children with SVCHD who are undergoing pre-Fontan surgery. In addition, mean days to consult decreased dramatically during the study to a current average of 3 days into the patient's hospitalization; the data likely suggest that more PPC consults were routinely ordered versus urgently placed for unexpected complications. Data indicate that patients are being followed by the PPC team at an earlier age and stage in their SV journey which allows for more opportunity to provide meaningful support to these patients and families. The early involvement of the PPC team for children with SV physiology was operationally feasible and was accepted by families, thus allowing PPC providers to establish a therapeutic relationship early in the disease trajectory with the family. It allowed more continuity throughout the SV journey in a proactive fashion rather than a reactive manner.
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