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Ohuchi H, Watanabe K, Kishiki K, Nii M, Wakisaka Y, Yagihara T, Echigo S. Comparison of late post-operative cardiopulmonary responses in the Fontan versus ventricular septation for double-inlet left ventricular repair. Am J Cardiol 2007; 99:1757-61. [PMID: 17560890 DOI: 10.1016/j.amjcard.2007.01.063] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/18/2006] [Revised: 01/22/2007] [Accepted: 01/22/2007] [Indexed: 11/26/2022]
Abstract
Ventricular septation (VS) and the Fontan procedure are alternatives for definitive repair in patients with double-inlet left ventricle; although VS is theoretically preferable, the current preference in practice is the Fontan procedure. However, the long-term outcomes of both procedures remain unclear. To address this issue, cardiopulmonary responses during exercise were measured in patients with double-inlet left ventricle, and the impact of the type of procedure performed, Fontan or VS, on long-term exercise capacity and late postoperative clinical profiles was assessed. Fourteen post-Fontan patients (mean age 17+/-6 years) and 13 VS patients (mean age 19+/-4 years) underwent exercise testing. Of the 13 VS patients, 5 required atrioventricular valve replacement (AVVR), and 7 required pacemaker implantation. Although no difference in peak oxygen uptake was found between the VS and Fontan patients, peak oxygen uptake was higher in VS patients without AVVR (30+/-8 ml/kg/min) than in VS patients with AVVR (19+/-1 ml/kg/min) and Fontan patients (22+/-6 ml/kg/min) (p<0.01). There was no significant difference in peak oxygen uptake between the VS patients with and without pacemaker implantation (p=0.09). The clinical profiles of the VS and Fontan patients were similar in terms of medication and freedom from tachyarrhythmias or reoperations during the follow-up period. In conclusion, the data suggest that VS without AVVR provides excellent future exercise capacity in selected patients with double-inlet left ventricle.
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Affiliation(s)
- Hideo Ohuchi
- Department of Pediatrics, National Cardiovascular Center, Osaka, Japan.
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Ohuchi H, Miyazaki A, Watanabe T, Yamada O, Yagihara T, Echigo S. Hemodynamic deterioration during simulated supraventricular tachycardia in patients after the Fontan operation. Int J Cardiol 2007; 117:381-7. [PMID: 16875748 DOI: 10.1016/j.ijcard.2006.05.024] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/04/2006] [Revised: 04/19/2006] [Accepted: 05/18/2006] [Indexed: 11/21/2022]
Abstract
BACKGROUND Supraventricular tachycardia (SVT) is becoming of great concern for patients long after the Fontan operation and arterial blood pressure (BP) decreases during SVT may be associated with their morbidity and mortality. METHODS We investigated the BP during supraventricular pacing (SVP) to simulate SVT in these patients. We measured femoral venous pressure (FVP) and plasma norepinephrine (NE) during SVP at 150 and 180 per minute in 20 Fontan patients and recorded the initial BP fall, its recovery and steady-state BP. RESULTS Wide QRS duration had a significant impact on a greater BP decline and increases in steady-state FVP and NE at 150 SVP. Changes in BP, FVP and NE were greater at 180 SVP and in adult patients. In addition to a greater impact of baseline BP and age on the initial BP drop and steady-state BP (p<0.01); older age at Fontan repair, lower ventricular ejection fraction and heart rate variability were major determinants of greater BP fluctuation during 180 SVP (p<0.05). Patients with a history of SVT (n=5) exhibited a greater initial BP drop and increase in FVP during 180 SVP (p<0.01). The type of Fontan procedure had no influence on BP dynamics during SVP. CONCLUSIONS In Fontan patients, wide QRS duration causes a greater hemodynamic fluctuation at slower SVT. Higher baseline BP and age, impaired ventricular function, late Fontan repair and a history of SVT were major determinants of hemodynamic deterioration during faster SVT.
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Affiliation(s)
- Hideo Ohuchi
- Department of Pediatrics, National Cardiovascular Center, 5-7-1, Fujishiro-dai, Suita, Osaka, Japan.
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Abstract
Long-term survival of patients with congenital heart disease has dramatically improved during the last 50 years and the number of adults with congenital heart disease is therefore increasing in all developed countries. Grown-up patients with congenital heart disease (GUCH) often present difficult and challenging problems. Patients with both native unoperated and operated malformations contribute to the GUCH population. Survivors without surgical treatment mainly have simple malformations; but a few have complex diseases, and some have survived with secondary pulmonary hypertension. Among operated malformations there are patients with a 'complete' repair (anatomical and physiological), others with a definitive palliation (physiological repair) and some with a simple palliation. The clinical spectrum is obviously diversified, depending on the underlying anomaly, surgical outcome, presence of residua, sequelae and/or complications, length of follow-up, comorbidities. Arrhythmias, bacterial endocarditis, cyanosis, polycythemia, heart failure, anomalies of pulmonary circulation, deterioration or malfunction of devices, need of cardiac and non-cardiac surgery, intercurrent non-cardiac diseases, and a need for cardiac and non-cardiac diagnostic procedures are common problems of adults with congenital heart disease. Physiological events such as pregnancy and childbearing deserve a careful multidisciplinary approach. While most simple native and well corrected GUCH do not require very specialized treatments throughout their life, the abnormalities and complexities of postoperative anatomy are often beyond the expertise of the adult cardiologist, requiring multidisciplinary competence in specialized tertiary centers. The problem is still unresolved and involves cultural, medical, technological and economically relevant issues.
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MESH Headings
- Adult
- Anti-Bacterial Agents/therapeutic use
- Arrhythmias, Cardiac/etiology
- Arrhythmias, Cardiac/therapy
- Cardiac Care Facilities
- Cardiac Output, Low/etiology
- Cardiac Output, Low/surgery
- Cardiac Pacing, Artificial/methods
- Cardiac Surgical Procedures/adverse effects
- Cardiac Surgical Procedures/methods
- Death, Sudden, Cardiac/etiology
- Eisenmenger Complex/complications
- Eisenmenger Complex/therapy
- Endocarditis, Bacterial/drug therapy
- Endocarditis, Bacterial/etiology
- Heart Defects, Congenital/complications
- Heart Defects, Congenital/drug therapy
- Heart Defects, Congenital/surgery
- Heart Defects, Congenital/therapy
- Heart Transplantation
- Humans
- Hypertension, Pulmonary/etiology
- Hypertension, Pulmonary/therapy
- Italy
- Long-Term Care
- Patient Care Team
- Survivors
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Affiliation(s)
- Adele Borghi
- Centro per la diagnosi e il trattamento delle cardiopatie congenite, Dipartimento cardiovascolare, A.O. Ospedali Riuniti, Largo Barozzi, 1, I-24128 Bergamo, Italy.
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Meyer DB, Zamora G, Wernovsky G, Ittenbach RF, Gallagher PR, Tabbutt S, Gruber PJ, Nicolson SC, Gaynor JW, Spray TL. Outcomes of the Fontan Procedure Using Cardiopulmonary Bypass with Aortic Cross-Clamping. Ann Thorac Surg 2006; 82:1611-8; discussion 1618-20. [PMID: 17062214 DOI: 10.1016/j.athoracsur.2006.05.106] [Citation(s) in RCA: 38] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/31/2006] [Revised: 05/19/2006] [Accepted: 05/22/2006] [Indexed: 11/24/2022]
Abstract
BACKGROUND Avoidance of cardiopulmonary bypass (CPB) and aortic cross-clamping during the Fontan procedure has been advocated to improve outcomes. We continue to use CPB with aortic cross-clamping for the Fontan procedure. METHODS We performed a review of patients undergoing the Fontan procedure between January 1, 2000 and December 31, 2004. RESULTS The Fontan procedure was performed in 160 patients. The median age was 2.2 years (range, 1.0 to 29.1 years). Hypoplastic left heart syndrome or a variant was present in 114 patients (71%), and heterotaxy was present in 19 (12%). CPB and modified ultrafiltration were used in all patients. Aortic cross-clamping was used in 154 (96%) of 160 patients and deep hypothermic circulatory arrest (DHCA) in 132 (83%). A lateral tunnel Fontan was performed in 69 patients (43%) and an extracardiac Fontan in 91 (57%). A fenestration was created in 144 patients (90%). Two patients died. Freedom from death or takedown was 98% (157/160). Median duration of pleural drainage was 2 days (range, 1 to 44 days) and was more than 14 days in 16 patients. Median duration of hospitalization was 6 days (range, 3 to 55 days). The small number of deaths precluded assessment of risk factors for mortality. By multivariable analysis, risk factors for pleural drainage longer than 3 days were extracardiac connection (p < 0.001) and increasing mean pulmonary artery pressure before the Fontan procedure (p = 0.033). By multivariable analysis, risk factors for hospitalization for more than 7 days were extracardiac connection (p = 0.003), increasing duration of total support (CPB and DHCA, p = 0.027), and decreasing systemic oxygen saturation before the Fontan procedure (p = 0.048). CONCLUSIONS The Fontan procedure can be performed using CPB and aortic cross-clamping with low morbidity and mortality.
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Affiliation(s)
- David B Meyer
- Department of Cardiothoracic Surgery, New York University, New York, New York, USA
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Pizarro C, Mroczek T, Gidding SS, Murphy JD, Norwood WI. Fontan Completion in Infants. Ann Thorac Surg 2006; 81:2243-8; discussion 2248-9. [PMID: 16731161 DOI: 10.1016/j.athoracsur.2006.01.016] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/04/2004] [Revised: 01/04/2006] [Accepted: 01/04/2006] [Indexed: 11/19/2022]
Abstract
BACKGROUND Since the implementation of the Fontan procedure, several clinical factors have been linked to outcome. A study of the outcome after Fontan completion was undertaken with particular attention to the influence of age and cardiac diagnosis. METHODS Review of all patients (n = 107) undergoing Fontan completion between January 1998 and July 2005 to identify predictors of outcome: early death, prolonged effusions, and prolonged hospital stay. RESULTS Median age was 13 months (range, 11 to 35) and median weight was 9.4 kgs (6.7 to 15.1). Hypoplastic left heart syndrome was present in 61 patients, and stage I Norwood was the initial palliation in 69. An interim superior cavopulmonary connection was performed in all. A lateral tunnel was used, and a deliberate right to left shunt was created in 99 patients. Mean transpulmonary gradient and pulmonary artery pressure were 5.7 +/- 1.5 mm Hg and 11.6 +/- 2.2 mm Hg, respectively. Median time to extubation was 5 hours (range, 2.5 to 184). Median duration of pleural effusion was 3 days (1 to 58) and was greater or equal to 14 days in 13 patients (12%). Overall mortality was 4.5% (5 of 107). Variables associated with poor outcome included associated noncardiac diagnosis (p < 0.05), elevated transpulmonary gradient (p = 0.03), and pulmonary artery pressure (p < 0.02). Hypoplastic left heart syndrome was the only variable associated with prolonged effusive complications. CONCLUSIONS Fontan completion can be performed with good results in the first year of life independent of anatomic diagnosis. Significant noncardiac pathology, and a higher pulmonary artery pressure were predictive of worse outcome. Hypoplastic left heart syndrome was associated with prolonged effusions.
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Affiliation(s)
- Christian Pizarro
- Nemours Cardiac Center, Alfred I. duPont Hospital for Children, Wilmington, Delaware, USA.
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Engelfriet P, Boersma E, Oechslin E, Tijssen J, Gatzoulis MA, Thilén U, Kaemmerer H, Moons P, Meijboom F, Popelová J, Laforest V, Hirsch R, Daliento L, Thaulow E, Mulder B. The spectrum of adult congenital heart disease in Europe: morbidity and mortality in a 5 year follow-up period. Eur Heart J 2005; 26:2325-33. [PMID: 15996978 DOI: 10.1093/eurheartj/ehi396] [Citation(s) in RCA: 285] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
AIMS To describe clinical and demographic characteristics at baseline of a European cohort of adults with congenital heart disease (CHD) and to assess mortality and morbidity in a 5 year follow-up period. METHODS AND RESULTS Data collected as part of the Euro Heart Survey on adult CHD was analysed. This entailed information transcribed from the files of 4110 patients diagnosed with one of eight congenital heart conditions ('defects'), who consecutively visited the outpatient clinics of one of the participating centres in 1998. The patients were included retrospectively and followed until the end of 2003 for a median follow-up of 5.1 years. Notwithstanding their overall relatively good functional class and low mortality over the follow-up period, a considerable proportion of the patients had a history of endocarditis, arrhythmias, or vascular events. There were major differences between the eight defects, both in morbidity and regarding specific characteristics. Outcomes were worst in cyanotic defects and in the Fontan circulation, but a considerable proportion of the other patients also suffer from cardiac symptoms. In particular, arrhythmias are common. CONCLUSION The spectrum of adult CHD in Europe emerging from this survey is one of a predominantly young population with substantial morbidity but relatively low mortality in a 5 year period.
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Affiliation(s)
- Peter Engelfriet
- Department of Cardiology, Academic Medical Centre, Amsterdam, The Netherlands
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Rosenthal D, Chrisant MRK, Edens E, Mahony L, Canter C, Colan S, Dubin A, Lamour J, Ross R, Shaddy R, Addonizio L, Beerman L, Berger S, Bernstein D, Blume E, Boucek M, Checchia P, Dipchand A, Drummond-Webb J, Fricker J, Friedman R, Hallowell S, Jaquiss R, Mital S, Pahl E, Pearce FB, Pearce B, Rhodes L, Rotondo K, Rusconi P, Scheel J, Pal Singh T, Towbin J. International Society for Heart and Lung Transplantation: Practice guidelines for management of heart failure in children. J Heart Lung Transplant 2005; 23:1313-33. [PMID: 15607659 DOI: 10.1016/j.healun.2004.03.018] [Citation(s) in RCA: 178] [Impact Index Per Article: 9.4] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
Affiliation(s)
- David Rosenthal
- International Society for Heart and Lung Transplantation, Addison, Texas.
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Gupta A, Daggett C, Behera S, Ferraro M, Wells W, Starnes V. Risk factors for persistent pleural effusions after the extracardiac Fontan procedure. J Thorac Cardiovasc Surg 2004; 127:1664-9. [PMID: 15173721 DOI: 10.1016/j.jtcvs.2003.09.011] [Citation(s) in RCA: 75] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
OBJECTIVE Pleural effusions after the Fontan operation contribute significantly to morbidity and prolonged hospitalization. This study investigates the association between selected preoperative, operative, and postoperative variables and persistent pleural effusions after the extracardiac Fontan procedure. METHODS We conducted a retrospective study of extracardiac Fontan procedures. The variables analyzed as potential risk factors included age and weight at the time of the operation, anatomic diagnosis, preoperative oxygen saturation, mean pulmonary artery pressure, ventricular end-diastolic pressure, presence of an accessory source of pulmonary blood flow, presence of significant aortopulmonary collateral vessels, presence of fenestration, cardiopulmonary bypass time, conduit size, postoperative pulmonary artery pressure, use of angiotensin-converting enzyme inhibitors, and presence of postoperative infection. The outcome measures evaluated were duration and volume of chest tube drainage after surgical intervention. RESULTS From June 1997 to August 2002, 100 consecutive patients underwent the extracardiac Fontan procedure. The median age at operation was 3.1 years. The median duration of chest tube drainage was 10 days, and the median volume of drainage was 14.7 mL.kg(-1).d(-1). As determined by means of multivariate analysis, significant risk factors for pleural effusions lasting more than 2 weeks were lower preoperative oxygen saturation (P =.011) and the presence of postoperative infections (P =.003). Significant risk factors for pleural effusions draining at more than 20 mL.kg(-1).d(-1) were lower preoperative oxygen saturation (P =.005), smaller conduit size (P =.04), and longer duration of cardiopulmonary bypass (P =.004). CONCLUSIONS Lower preoperative oxygen saturation, presence of postoperative infection, smaller conduit size, and longer duration of cardiopulmonary bypass were associated with persistent pleural effusions after the extracardiac Fontan procedure. Modifications of some of these risk factors might influence the duration and volume of pleural drainage after surgical intervention.
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Affiliation(s)
- Anuja Gupta
- Division of Cardiology, Children's Hospital Los Angeles, University of Southern California, 90024, USA.
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