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Frock BW, Jnah AJ, Newberry DM. Living with Tricuspid Atresia: Case Report with Review of Literature. Neonatal Netw 2017; 36:218-228. [PMID: 28764825 DOI: 10.1891/0730-0832.36.4.218] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/07/2023]
Abstract
Tricuspid atresia (TA) is a rare congenital heart defect in which the right atrioventricular connection, the tricuspid valve, is absent. As a result, there is no direct communication between the right atrium and right ventricle. Surgical treatment, including the Fontan procedure, is indicated yet palliative, leaving patients with various lifelong complications. A comprehensive literature review revealed a paucity of evidence-based education on the identification, evaluation, management, treatment, and life span implications of TA. We present a case of TA from birth through adulthood, while simultaneously assessing the literature, to report the most current evidence relative to living with TA after surgical palliation. In addition, the embryology, methods of prenatal and postnatal diagnosis, potential complications, management, anticipatory guidance, and educational needs of both parents and patient are discussed.
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Koehne de Gonzalez AK, Lefkowitch JH. Heart Disease and the Liver: Pathologic Evaluation. Gastroenterol Clin North Am 2017; 46:421-435. [PMID: 28506373 DOI: 10.1016/j.gtc.2017.01.012] [Citation(s) in RCA: 36] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/15/2023]
Abstract
Liver injury due to acute and chronic heart failure has long been recognized. This article discusses the concepts of acute cardiogenic liver injury (ACLI) and cardiac or congestive hepatopathy (CH) along with their clinical manifestations and sequelae. Histologically, ACLI manifests as centrilobular hepatocellular necrosis, whereas CH is associated with centrilobular hepatocyte atrophy, dilated sinusoids, and perisinusoidal fibrosis, progressing to bridging fibrosis and ultimately cirrhosis. ACLI is associated with marked increases in aminotransferase levels, whereas CH is associated with a cholestatic pattern of laboratory tests. Certain cardiac medications have also been implicated as a cause of liver fibrosis.
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Affiliation(s)
- Anne Knoll Koehne de Gonzalez
- Department of Pathology and Cell Biology, Columbia University, 630 West 168th Street, PH 15 West, Rm 1574, New York, NY 10032-3725, USA
| | - Jay H Lefkowitch
- Department of Pathology and Cell Biology, Columbia University, 630 West 168th Street, PH 15 West, Rm 1574, New York, NY 10032-3725, USA.
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Fidai A, Dallaire F, Alvarez N, Balon Y, Clegg R, Connelly M, Dicke F, Fruitman D, Harder J, Myers K, Patton DJ, Prieur T, Vorhies E, Myers RP, Martin SR, Greenway SC. Non-invasive Investigations for the Diagnosis of Fontan-Associated Liver Disease in Pediatric and Adult Fontan Patients. Front Cardiovasc Med 2017; 4:15. [PMID: 28396861 PMCID: PMC5366328 DOI: 10.3389/fcvm.2017.00015] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2017] [Accepted: 03/09/2017] [Indexed: 12/18/2022] Open
Abstract
Fontan-associated liver disease (FALD) is a serious complication related to the chronically elevated venous pressure and low cardiac output of this abnormal circulation. However, diagnostic markers for this condition are limited. We hypothesized that specific tests for fibrosis developed for other chronic liver diseases would identify a higher prevalence of FALD than ultrasound and standard laboratory tests and that identified abnormalities would correlate with time post-Fontan. In this cross-sectional study, we assessed 19 children (average age 8.4 ± 4.3 and 5.4 ± 4.1 years post-Fontan) and 8 adults (average age 31.5 ± 8.9 and 21.1 ± 4 years post-Fontan) using standard serum laboratory investigations assessing hepatic integrity and function, the FibroTest, liver ultrasound, and transient elastography (FibroScan). In adult Fontan patients, hemoglobin, C-reactive protein, and gamma-glutamyl transpeptidase were significantly increased, and white blood cell and platelet counts were significantly decreased in comparison to the pediatric cohort. International normalized ratio was mildly elevated in both children and adults. FibroTest results were suggestive of fibrosis regardless of time post-Fontan. FibroScan measurements were significantly correlated with time post-Fontan, but the incidence of ultrasound-detected liver abnormalities was variable. No cases of hepatocellular carcinoma were identified. Abnormalities suggestive of FALD occur in both children and adults post-Fontan. Select laboratory tests, and possibly ultrasound and FibroScan in some patients, appear to have the most promise for the non-invasive detection of FALD.
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Affiliation(s)
- Amyna Fidai
- Department of Paediatrics, Cumming School of Medicine, Alberta Children’s Hospital Research Institute, University of Calgary, Calgary, AB, Canada
| | - Frederic Dallaire
- Division of Pediatric Cardiology, University of Sherbrooke, Centre de Recherche du Centre Hospitalier Universitaire de Sherbrooke, Sherbrooke, QC, Canada
| | - Nanette Alvarez
- Libin Cardiovascular Institute of Alberta, University of Calgary, Calgary, AB, Canada
| | - Yvonne Balon
- Libin Cardiovascular Institute of Alberta, University of Calgary, Calgary, AB, Canada
| | - Robin Clegg
- Department of Paediatrics, Cumming School of Medicine, Alberta Children’s Hospital Research Institute, University of Calgary, Calgary, AB, Canada
- Libin Cardiovascular Institute of Alberta, University of Calgary, Calgary, AB, Canada
| | - Michael Connelly
- Libin Cardiovascular Institute of Alberta, University of Calgary, Calgary, AB, Canada
| | - Frank Dicke
- Department of Paediatrics, Cumming School of Medicine, Alberta Children’s Hospital Research Institute, University of Calgary, Calgary, AB, Canada
| | - Deborah Fruitman
- Department of Paediatrics, Cumming School of Medicine, Alberta Children’s Hospital Research Institute, University of Calgary, Calgary, AB, Canada
| | - Joyce Harder
- Department of Paediatrics, Cumming School of Medicine, Alberta Children’s Hospital Research Institute, University of Calgary, Calgary, AB, Canada
| | - Kimberley Myers
- Department of Paediatrics, Cumming School of Medicine, Alberta Children’s Hospital Research Institute, University of Calgary, Calgary, AB, Canada
| | - David J. Patton
- Department of Paediatrics, Cumming School of Medicine, Alberta Children’s Hospital Research Institute, University of Calgary, Calgary, AB, Canada
- Libin Cardiovascular Institute of Alberta, University of Calgary, Calgary, AB, Canada
| | - Tim Prieur
- Libin Cardiovascular Institute of Alberta, University of Calgary, Calgary, AB, Canada
| | - Erika Vorhies
- Department of Paediatrics, Cumming School of Medicine, Alberta Children’s Hospital Research Institute, University of Calgary, Calgary, AB, Canada
| | - Robert P. Myers
- Liver Unit, Division of Gastroenterology, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
| | - Steven R. Martin
- Department of Paediatrics, Cumming School of Medicine, Alberta Children’s Hospital Research Institute, University of Calgary, Calgary, AB, Canada
| | - Steven C. Greenway
- Department of Paediatrics, Cumming School of Medicine, Alberta Children’s Hospital Research Institute, University of Calgary, Calgary, AB, Canada
- Libin Cardiovascular Institute of Alberta, University of Calgary, Calgary, AB, Canada
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Hilscher MB, Johnson JN, Cetta F, Driscoll DJ, Poterucha JJ, Sanchez W, Connolly HM, Kamath PS. Surveillance for liver complications after the Fontan procedure. CONGENIT HEART DIS 2017; 12:124-132. [DOI: 10.1111/chd.12446] [Citation(s) in RCA: 48] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/26/2016] [Revised: 11/01/2016] [Accepted: 12/26/2016] [Indexed: 12/30/2022]
Affiliation(s)
- Moira B. Hilscher
- Department of Medicine/Division of Gastroenterology and Hepatology; Mayo Clinic; Rochester Minnesota USA
| | - Jonathan N. Johnson
- Department of Pediatrics and Adolescent Medicine/Division of Pediatric Cardiology; Mayo Clinic; Rochester Minnesota USA
- Department of Cardiovascular Diseases; Mayo Clinic; Rochester Minnesota USA
| | - Frank Cetta
- Department of Pediatrics and Adolescent Medicine/Division of Pediatric Cardiology; Mayo Clinic; Rochester Minnesota USA
- Department of Cardiovascular Diseases; Mayo Clinic; Rochester Minnesota USA
| | - David J. Driscoll
- Department of Pediatrics and Adolescent Medicine/Division of Pediatric Cardiology; Mayo Clinic; Rochester Minnesota USA
- Department of Cardiovascular Diseases; Mayo Clinic; Rochester Minnesota USA
| | - John J. Poterucha
- Department of Medicine/Division of Gastroenterology and Hepatology; Mayo Clinic; Rochester Minnesota USA
| | - William Sanchez
- Department of Medicine/Division of Gastroenterology and Hepatology; Mayo Clinic; Rochester Minnesota USA
| | - Heidi M. Connolly
- Department of Cardiovascular Diseases; Mayo Clinic; Rochester Minnesota USA
| | - Patrick S. Kamath
- Department of Medicine/Division of Gastroenterology and Hepatology; Mayo Clinic; Rochester Minnesota USA
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The impact of liver disorders on perioperative management of reoperative cardiac surgery: a retrospective study in adult congenital heart disease patients. J Anesth 2017; 31:170-177. [PMID: 28091794 DOI: 10.1007/s00540-017-2308-4] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2015] [Accepted: 01/05/2017] [Indexed: 10/20/2022]
Abstract
PURPOSE We evaluated the preoperative prevalence of risk factors for liver disorders and the relationship between the liver disorders and perioperative outcomes in adult congenital heart disease (ACHD) patients. METHODS This retrospective study included 32 ACHD patients who underwent reoperative cardiac surgery. RESULTS Preoperatively, 38% of the study patients had risk factors, including congestive liver (CL) due to right heart failure (31%), chronic hepatitis C (HC) (22%), and both CL and HC (16%). The numbers of patients with Child-Pugh scores 5, 6, 7 and 8 were 22, 7, 2 and 1. Median (range) preoperative platelet count and fibrinogen values were 155 (61-330) × 103/μl and 250 (145-367) mg/dl, respectively. The patients with higher Child-Pugh scores tended to have longer duration of anesthesia and surgery (p = 0.078, 0.078, respectively), and had significantly higher platelet transfusion (p = 0.031). Lower platelet count was associated with longer duration of anesthesia, surgery and cardio pulmonary bypass (CPB), and larger amount of blood loss and platelet transfusion (p = 0.01, 0.011, 0.024, 0.033, 0.021). Lower fibrinogen value was associated with longer duration of anesthesia, surgery and CPB, and larger amount of platelet transfusion (p = 0.015, 0.009, 0.009, 0.023). CONCLUSION ACHD patients who underwent reoperative cardiac surgery had a high prevalence of risk factors for liver disorders preoperatively, and liver disorders aggravated some intraoperative outcomes. These findings suggest that the prevention of liver disorders is important for reducing the occurrence of poor outcomes, and that ACHD patients with liver disorders need attentive perioperative management.
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Al-Radi OO. What is the status of liver health in adults living with the Fontan circulation? Now that is a good question. J Thorac Cardiovasc Surg 2016; 153:665-666. [PMID: 27998609 DOI: 10.1016/j.jtcvs.2016.11.011] [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: 11/01/2016] [Accepted: 11/02/2016] [Indexed: 10/20/2022]
Affiliation(s)
- Osman O Al-Radi
- Department of Surgery, Abdullah Bakhsh Children's Heart Center, Faculty of Medicine, King Abdulaziz University, Jeddah, Saudi Arabia.
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Wu FM, Kogon B, Earing MG, Aboulhosn JA, Broberg CS, John AS, Harmon A, Sainani NI, Hill AJ, Odze RD, Johncilla ME, Ukomadu C, Gauvreau K, Valente AM, Landzberg MJ. Liver health in adults with Fontan circulation: A multicenter cross-sectional study. J Thorac Cardiovasc Surg 2016; 153:656-664. [PMID: 27955914 DOI: 10.1016/j.jtcvs.2016.10.060] [Citation(s) in RCA: 93] [Impact Index Per Article: 11.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/12/2015] [Revised: 09/19/2016] [Accepted: 10/12/2016] [Indexed: 11/28/2022]
Abstract
OBJECTIVES Liver disease is an important contributor to morbidity and mortality in patients after Fontan surgery. There has been no large-scale survey of liver health in this population. We sought to explore the prevalence and predictors of liver disease in a multicenter cohort of adults with Fontan physiology. METHODS Subjects were recruited from 6 adult congenital heart centers. Demographics; clinical history; and laboratory, imaging, and histopathology data were obtained. RESULTS Of 241 subjects (median age 25.8 years [11.8-59.4], median time since Fontan 20.3 years [5.4-34.5]), more than 94% of those who underwent testing (208 of 221) had at least 1 abnormal liver-related finding. All hepatic imaging (n = 54) and liver histology (n = 68) was abnormal. Subjects with abnormal laboratory values had higher sinusoidal fibrosis stage (2 vs 1, P = .007) and higher portal fibrosis stage (3 vs 1, P = .003) compared with those with all normal values. Low albumin correlated with lower sinusoidal fibrosis stage (1 vs 2; P = .02) and portal fibrosis stage (0 vs 3, P = .002); no other liver studies correlated with fibrosis. Regenerative nodules were seen on 33% of histology specimens. CONCLUSIONS Regardless of modality, findings of liver disease are common among adults with Fontan circulation, even those appearing clinically well. Cirrhosis is present in up to one-third of subjects. Correlations between hepatic fibrosis stage and clinical history or findings on noninvasive testing are few. Further research is needed to identify patients at risk for more severe liver disease and to determine the best methods for assessing liver health in this population.
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Affiliation(s)
- Fred M Wu
- Department of Cardiology, Boston Children's Hospital, Harvard Medical School, Boston, Mass; Division of Cardiology, Brigham and Women's Hospital, Harvard Medical School, Boston, Mass.
| | - Brian Kogon
- Division of Cardiothoracic Surgery, Emory University School of Medicine and Children's Healthcare of Atlanta, Atlanta, Ga
| | - Michael G Earing
- Department of Pediatric Cardiology, Children's Hospital of Wisconsin, Medical College of Wisconsin, Milwaukee, Wis
| | - Jamil A Aboulhosn
- Ahmanson/UCLA Adult Congenital Heart Disease Center, Los Angeles, Calif
| | - Craig S Broberg
- Department of Cardiology, Oregon Health and Science University, Portland, Ore
| | - Anitha S John
- Division of Cardiology, Children's National Medical Center, George Washington University School of Medicine, Washington, DC
| | - Amy Harmon
- Department of Cardiology, Boston Children's Hospital, Harvard Medical School, Boston, Mass
| | - Nisha I Sainani
- Department of Radiology, Brigham and Women's Hospital, Harvard Medical School, Boston, Mass
| | - Andrew J Hill
- Department of Radiology, Brigham and Women's Hospital, Harvard Medical School, Boston, Mass
| | - Robert D Odze
- Department of Pathology, Brigham and Women's Hospital, Harvard Medical School, Boston, Mass
| | - Melanie E Johncilla
- Department of Pathology, Brigham and Women's Hospital, Harvard Medical School, Boston, Mass
| | - Chinweike Ukomadu
- Division of Gastroenterology, Brigham and Women's Hospital, Harvard Medical School, Boston, Mass
| | - Kimberlee Gauvreau
- Department of Cardiology, Boston Children's Hospital, Harvard Medical School, Boston, Mass
| | - Anne Marie Valente
- Department of Cardiology, Boston Children's Hospital, Harvard Medical School, Boston, Mass; Division of Cardiology, Brigham and Women's Hospital, Harvard Medical School, Boston, Mass
| | - Michael J Landzberg
- Department of Cardiology, Boston Children's Hospital, Harvard Medical School, Boston, Mass; Division of Cardiology, Brigham and Women's Hospital, Harvard Medical School, Boston, Mass
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Oh C, Youn JK, Han JW, Kim GB, Kim HY, Jung SE. Hepatocellular carcinoma after the Fontan procedure in a 16-year-old girl: A case report. Medicine (Baltimore) 2016; 95:e4823. [PMID: 27741102 PMCID: PMC5072929 DOI: 10.1097/md.0000000000004823] [Citation(s) in RCA: 39] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/11/2023] Open
Abstract
INTRODUCTION The Fontan procedure (FP) has become the standard operation for patients with single ventricle physiology. However, a long period of elevated systemic venous pressure and low cardiac output after the procedure result in chronic inflammation and liver cirrhosis, which may eventually lead to the occurrence of hepatocellular carcinoma (HCC). CLINICAL FINDINGS We described the case of a 16-year-old female who developed HCC after the FP. At 21 months, the patient received a lateral tunnel FP, and 14 years later, she began complaining of abdominal distension, telangiectasia, and fatigue. Imaging studies revealed a large hepatic mass involving most of the right lobe and multiple masses in the left lobe. Evidence suggested severe liver cirrhosis, and the presence of ascites, hepatosplenomegaly, paraesophageal gastric varices reflecting the severity of the disease. In addition, tumor thrombosis was found in the right hepatic vein, middle hepatic vein, and inferior vena cava, as well as multiple metastatic nodules in both lungs. The patient received an incisional biopsy and the diagnosis of HCC was pathologically confirmed. After treatment with 1 cycle of systemic chemotherapy, she received ongoing supportive care for disease-related complications, and died 2 months after chemotherapy due to hematemesis. CONCLUSION With the advances in medicine, the incidence of Fontan physiology-related complications is likely to increase, and the incidence of HCC will also increase accordingly. As early diagnosis of HCC results in better patient outcomes, a surveillance guideline for HCC after the FP should be developed.
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Affiliation(s)
| | | | | | - Gi Beom Kim
- Department of Pediatrics, Seoul National University College of Medicine, Seoul, Korea
| | - Hyun-Young Kim
- Department of Surgery
- Correspondence: Hyun-Young Kim, Department of Pediatric Surgery, Seoul National University Children's Hospital, Seoul, Korea (e-mail: )
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Sakamoto T, Nagashima M, Hiramatsu T, Matsumura G, Park IS, Yamazaki K. Fontan circulation over 30 years. What should we learn from those patients? Asian Cardiovasc Thorac Ann 2016; 24:765-771. [DOI: 10.1177/0218492316667771] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
Background This study aimed to evaluate Fontan circulation which was observed over 30 years. Methods Forty patients who underwent a Fontan operation between 1974 and 1986 and survived (group S, n = 20) or died in the late period (group LD, n = 20) were evaluated. The median age at operation was 10 years (range 2–32 years). The diagnoses were tricuspid atresia in 21, single ventricle in 9, and others in 10. The Fontan procedure was a right atrium-pulmonary artery graft in 2, atriopulmonary connection in 28, and right atrium-right ventricle anastomosis in 10 (Björk in 4, graft in 6). Results Causes of late death were congestive heart failure in 6, sudden death in 4, arrhythmia in 4, and others in 6. Sixteen patients underwent reoperation 23.3 ± 6.5 years after Fontan. Cardiac catheterization was performed at 1 month and 12 years. There were no significant differences in central venous pressure, ventricular ejection fraction, or pulmonary vascular resistance between the two groups. However, changes in ventricular end-diastolic volume suggested volume and pressure overload in group LD. In group S, the latest chest radiographs showed cardiothoracic ratio 51.3% ± 7.6%, oxygen saturation 94% ± 2%, brain natriuretic peptide 153 ± 111 pg ċ mL−1, and Holter monitoring revealed sinus rhythm in 10 patients. New York Heart Association class was I in 12 patients, II in 6, and III in 2. Conclusions For long-term Fontan survival, timely total cavopulmonary connection conversion and medication to decrease ventricular volume and pressure load might be important.
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Affiliation(s)
- Takahiko Sakamoto
- Division of Pediatric Cardiovascular Surgery, The Heart Institute of Japan, Tokyo Women’s Medical University, Tokyo, Japan
- Department of Cardiovascular Surgery, The Heart Institute of Japan, Tokyo Women’s Medical University, Tokyo, Japan
| | - Mitsugi Nagashima
- Division of Pediatric Cardiovascular Surgery, The Heart Institute of Japan, Tokyo Women’s Medical University, Tokyo, Japan
- Department of Cardiovascular Surgery, The Heart Institute of Japan, Tokyo Women’s Medical University, Tokyo, Japan
| | - Takeshi Hiramatsu
- Division of Pediatric Cardiovascular Surgery, The Heart Institute of Japan, Tokyo Women’s Medical University, Tokyo, Japan
- Department of Cardiovascular Surgery, The Heart Institute of Japan, Tokyo Women’s Medical University, Tokyo, Japan
| | - Goki Matsumura
- Division of Pediatric Cardiovascular Surgery, The Heart Institute of Japan, Tokyo Women’s Medical University, Tokyo, Japan
- Department of Cardiovascular Surgery, The Heart Institute of Japan, Tokyo Women’s Medical University, Tokyo, Japan
| | - In-Sam Park
- Department of Pediatric Cardiology, The Heart Institute of Japan, Tokyo Women’s Medical University, Tokyo, Japan
| | - Kenji Yamazaki
- Department of Cardiovascular Surgery, The Heart Institute of Japan, Tokyo Women’s Medical University, Tokyo, Japan
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Gerardin J, Rodriguez F, Saraf A, Book WM. Heart transplantation in adults for Fontan failure. PROGRESS IN PEDIATRIC CARDIOLOGY 2016. [DOI: 10.1016/j.ppedcard.2016.02.003] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
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Lewis M, Ginns J, Schulze C, Lippel M, Chai P, Bacha E, Mancini D, Rosenbaum M, Farr M. Outcomes of Adult Patients With Congenital Heart Disease After Heart Transplantation: Impact of Disease Type, Previous Thoracic Surgeries, and Bystander Organ Dysfunction. J Card Fail 2016; 22:578-82. [DOI: 10.1016/j.cardfail.2015.09.002] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2015] [Revised: 09/08/2015] [Accepted: 09/09/2015] [Indexed: 11/25/2022]
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Greuter T, Shah VH. Hepatic sinusoids in liver injury, inflammation, and fibrosis: new pathophysiological insights. J Gastroenterol 2016; 51:511-9. [PMID: 26939970 DOI: 10.1007/s00535-016-1190-4] [Citation(s) in RCA: 93] [Impact Index Per Article: 11.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/20/2016] [Accepted: 02/16/2016] [Indexed: 02/04/2023]
Abstract
Changes of hepatic sinusoids are crucial in the pathogenesis of liver cirrhosis and portal hypertension. Liver injury leads to distinct morphological abnormalities such as loss of sinusoidal fenestration, vasoconstriction, and angiogenesis as well as molecular changes. Communication between the two key cells in this hepatic microenvironment-hepatic stellate cells (HSC) and sinusoidal endothelial cells (SEC)-has been studied for many years and several canonical pathways have been elucidated, such as decreased eNOS activity or increased PDGF and TGF-β production leading to activation and migration of HSC. In recent studies, alternative pathways of intercellular communication in liver diseases have been described such as cell-derived extracellular vesicles called exosomes, which deliver cell compounds to their target cells. Moreover, such extracellular vesicles may link injury to inflammation in alcoholic hepatitis. While inflammation leading to liver fibrosis has been studied in detail, in some circumstances pathways other than the known canonical inflammatory pathways may contribute to hepatic fibrogenesis. For example, in congestive hepatopathy, sinusoidal dilatation and fibrosis have been shown to be mediated by non-inflammatory mechanisms and associated with sinusoidal thrombi. A recently developed murine model further enables experimental studies of this disease entity. Increasing knowledge about these alternative disease pathways in liver injury, inflammation, and fibrosis may reveal possible target molecules for future therapies. This article builds upon a seminar given at the recent 3rd JSGE International Topic Conference in Sendai, Japan, and reviews the areas outlined above.
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Affiliation(s)
- Thomas Greuter
- Division of Gastroenterology and Hepatology, University Hospital Zurich, Zurich, Switzerland
| | - Vijay H Shah
- Gastroenterology Research Unit, Department of Gastroenterology and Hepatology, Mayo Clinic and Foundation, 200 First St. SW, Rochester, MN, 55905, USA.
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Lin SN, Huang SC, Chen YS, Chih NH, Wang CH, Chou NK, Yu HY, Wu IH, Shun CT, Wang SS. Case Series: Heart Transplantation After Fontan Operation-Single-Center Experience. Transplant Proc 2016; 48:959-64. [PMID: 27234779 DOI: 10.1016/j.transproceed.2016.01.037] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2015] [Accepted: 01/14/2016] [Indexed: 11/30/2022]
Abstract
BACKGROUND Fontan failure (FF) occurs rarely. In patients with Fontan failure, heart transplantation is believed to be the most effective therapy. We review our experience in heart transplantations after the Fontan operation. METHODS From July 1987 to December 2014, 4 of 513 patients underwent orthotopic heart transplantation (OHT). Among them, 4 were due to FF. We reviewed these 4 cases via retrospective chart review. Clinical history, laboratory data, surgical technique, perioperative variables, and outcomes of long-term follow-up are presented herein. The primary outcomes were hospital mortality, 1-year-survival rate, and 4-year-survival rate. The secondary outcome is the improvement in patients with protein-losing enteropathy. RESULTS The hospital mortality rate was 0% in the 4 FF patients receiving OHT. No surgically related hemorrhage or infection was observed. The 1-year-survival rate was 100% (n = 4) and the 4-year-survival rate 50% (n = 2). One patient died of posttransplantation lymphoproliferative disorder. Hypoalbuminemia improved in 1 of 3 patients 4 months after OHT. CONCLUSIONS Despite technical challenges, heart transplantation can be performed successfully in patients with Fontan operation. However, protein-losing enteropathy might not be resolved quickly after heart transplantation.
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Affiliation(s)
- S-N Lin
- Department of Surgery, National Taiwan University Hospital, Taipei, Taiwan
| | - S-C Huang
- Department of Surgery, National Taiwan University Hospital, Taipei, Taiwan
| | - Y-S Chen
- Department of Surgery, National Taiwan University Hospital, Taipei, Taiwan
| | - N-H Chih
- Department of Surgery, National Taiwan University Hospital, Taipei, Taiwan
| | - C-H Wang
- Department of Surgery, National Taiwan University Hospital, Taipei, Taiwan
| | - N-K Chou
- Department of Surgery, National Taiwan University Hospital, Taipei, Taiwan
| | - H-Y Yu
- Department of Surgery, National Taiwan University Hospital, Taipei, Taiwan
| | - I-H Wu
- Department of Surgery, National Taiwan University Hospital, Taipei, Taiwan
| | - C-T Shun
- Department of Pathology, National Taiwan University Hospital, Taipei, Taiwan
| | - S-S Wang
- Department of Surgery, National Taiwan University Hospital, Taipei, Taiwan; Department of Surgery, Fu Jen Catholic University Hospital, and Fu Jen Catholic University College of Medicine, New Taipei City, Taiwan.
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Gaeta SA, Ward C, Krasuski RA. Extra-cardiac manifestations of adult congenital heart disease. Trends Cardiovasc Med 2016; 26:627-36. [PMID: 27234354 DOI: 10.1016/j.tcm.2016.04.004] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/04/2016] [Revised: 04/05/2016] [Accepted: 04/11/2016] [Indexed: 12/28/2022]
Abstract
Advancement in correction or palliation of congenital cardiac lesions has greatly improved the lifespan of congenital heart disease patients, resulting in a rapidly growing adult congenital heart disease (ACHD) population. As this group has increased in number and age, emerging science has highlighted the systemic nature of ACHD. Providers caring for these patients are tasked with long-term management of multiple neurologic, pulmonary, hepatic, renal, and endocrine manifestations that arise as syndromic associations with congenital heart defects or as sequelae of primary structural or hemodynamic abnormalities. In this review, we outline the current understanding and recent research into these extra-cardiac manifestations.
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Affiliation(s)
- Stephen A Gaeta
- Division of Cardiology, Duke University Medical Center, Durham, NC
| | - Cary Ward
- Division of Cardiology, Duke University Medical Center, Durham, NC
| | - Richard A Krasuski
- Division of Cardiology, Duke University Medical Center, Durham, NC; Duke Clinical Research Institute, Durham, NC.
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Whiteside W, Tan M, Ostlund RE, Yu S, Ma L, Rocchini A. Altered Cholesterol Metabolism and Hypocholesterolemia in Patients with Single Ventricle following Fontan Palliation. J Pediatr 2016; 171:73-7. [PMID: 26806364 PMCID: PMC5166701 DOI: 10.1016/j.jpeds.2015.12.038] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/10/2015] [Revised: 11/12/2015] [Accepted: 12/15/2015] [Indexed: 11/28/2022]
Abstract
OBJECTIVE To assess whether an abnormality in cholesterol absorption or synthesis may be associated with hypocholesterolemia in patients with single ventricle anatomy following Fontan palliation. STUDY DESIGN This is a cross-sectional study of 21 patients with hypocholesterolemia following Fontan procedure and age/sex-matched healthy controls, with median age of 13.4 (IQR 10.6-16.1) years. Laboratory values of several biomarkers, including phytosterols and 5-α-cholestanol (for cholesterol absorption) and lathosterol (for cholesterol biosynthesis), as well as cholesterol levels, inflammatory markers, and indices of liver function were compared between patients following Fontan procedure and controls. RESULTS The Fontan cohort had significantly lower total cholesterol (mean 117 ± SD 13.9, vs 128 ± 19.2 mg/dL, P = .03) and free cholesterol (35.5 ± 4.5 vs 39.2 ± 5.4 mg/dL, P = .02) compared with control patients. There was an increase in normalized 5-α-cholestanol (1.51 ± 0.6 vs 1.14 ± 0.37 μg/mL, P = .02), and a significantly lower lathosterol/5-α-cholestanol ratio (0.70 ± 0.38 vs 1.11 ± 0.76, P = .04). There was a strong correlation (r = 0.78, P < .0001) between lathosterol and cholesterol levels in the Fontan cohort, not seen in controls (r = 0.47, P = .04). The Fontan cohort also had significantly higher C-reactive protein, transaminases, total bilirubin, and gamma-glutamyl transferase levels. CONCLUSIONS Patients with hypocholesterolemia following Fontan procedure have evidence of increased cholesterol absorption and decreased cholesterol synthesis. As cholesterol absorption efficiency is a regulated process, this finding suggests an upregulation of cholesterol absorption as a result of decreased cholesterol production. In the setting of elevated liver indices and possible inflammation, this finding supports a growing body of data suggesting development of liver disease in patients receiving Fontan.
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Affiliation(s)
- Wendy Whiteside
- The Heart Institute, Cincinnati Children's Hospital Medical Center, Cincinnati, OH.
| | - Meng Tan
- Division of Metabolism Endocrinology and Diabetes, Department of Internal Medicine, University of Michigan, Ann Arbor, MI
| | - Richard E. Ostlund
- School of Medicine Division of Endocrinology, Metabolism & Lipid Research, Washington University, St. Louis, MO
| | - Sunkyung Yu
- Division of Pediatric Cardiology, Department of Pediatrics and Communicable Disease, University of Michigan, Ann Arbor, MI
| | - Lina Ma
- School of Medicine Division of Endocrinology, Metabolism & Lipid Research, Washington University, St. Louis, MO
| | - Albert Rocchini
- Division of Pediatric Cardiology, Department of Pediatrics and Communicable Disease, University of Michigan, Ann Arbor, MI
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Kutty SS, Zhang M, Danford DA, Hasan R, Duncan KF, Kugler JD, Quiros-Tejeira RE, Kutty S. Hepatic stiffness in the bidirectional cavopulmonary circulation: The Liver Adult-Pediatric-Congenital-Heart-Disease Dysfunction Study group. J Thorac Cardiovasc Surg 2016; 151:678-684. [DOI: 10.1016/j.jtcvs.2015.09.079] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/12/2015] [Revised: 08/23/2015] [Accepted: 09/12/2015] [Indexed: 10/23/2022]
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Stout KK, Broberg CS, Book WM, Cecchin F, Chen JM, Dimopoulos K, Everitt MD, Gatzoulis M, Harris L, Hsu DT, Kuvin JT, Law Y, Martin CM, Murphy AM, Ross HJ, Singh G, Spray TL. Chronic Heart Failure in Congenital Heart Disease. Circulation 2016; 133:770-801. [DOI: 10.1161/cir.0000000000000352] [Citation(s) in RCA: 219] [Impact Index Per Article: 27.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
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Bae JM, Jeon TY, Kim JS, Kim S, Hwang SM, Yoo SY, Kim JH. Fontan-associated liver disease: Spectrum of US findings. Eur J Radiol 2016; 85:850-6. [PMID: 26971434 DOI: 10.1016/j.ejrad.2016.02.002] [Citation(s) in RCA: 38] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2015] [Revised: 01/25/2016] [Accepted: 02/02/2016] [Indexed: 10/22/2022]
Abstract
PURPOSE To describe ultrasonography (US) findings of Fontan-associated liver disease (FALD) and to determine whether screening US examinations can identify FALD before biochemical hepatic dysfunction. METHODS This retrospective study included 55 patients who underwent Fontan procedure over a 20-year period. Hepatobiliary US findings (n=55), CT or MRI findings (n=19), biochemical hepatic function tests (n=49), and histopathological results (n=4) were analyzed. Images were reviewed focusing on the hepatic parenchymal changes, presence of focal lesions, and signs of portal hypertension. RESULTS Hepatic parenchymal changes (either heterogeneous echotexture or surface nodularity) evident on US were present in 67% (37/55) and showed positive correlation with the Fontan duration. Hyper-echoic lesions were noted in 35% (19/55) and showed a predilection for multiplicity, small size, right lobe location, and irregular margin on high-frequency transducer. These lesions were not demonstrated by CT or MRI or by low-frequency transducer. Histopathological results of targeted biopsy for hyper-echoic lesions revealed lesser degree of patchy sinusoidal and portal fibrosis than seen in cases with surface nodularity. Abnormal parenchymal enhancement was commonly seen with CT or MRI in 63% (12/19) and hypervascular nodules in 21% (4/19). Most patients (82%, 40/49) showed normal biochemical hepatic function tests, despite the presence of hepatic parenchymal changes on imaging. CONCLUSION The common US findings of FALD included heterogeneous parenchymal echotexture, surface nodularity, and hyper-echoic lesions. We suggest that hyper-echoic lesions without surface nodularity detected by high-frequency transducer may represent the early stage of fibrosis. US examination may be useful for identifying the progression of FALD before biochemical hepatic dysfunction.
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Affiliation(s)
- Jung Min Bae
- Department of Radiology and Center for Imaging Science, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul 135-710, South Korea
| | - Tae Yeon Jeon
- Department of Radiology and Center for Imaging Science, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul 135-710, South Korea.
| | - Jung Sun Kim
- Department of Pathology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul 135-710, South Korea
| | - Seokhwi Kim
- Department of Pathology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul 135-710, South Korea
| | - Sook Min Hwang
- Department of Radiology and Center for Imaging Science, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul 135-710, South Korea
| | - So-Young Yoo
- Department of Radiology and Center for Imaging Science, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul 135-710, South Korea
| | - Ji Hye Kim
- Department of Radiology and Center for Imaging Science, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul 135-710, South Korea
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Hill KD, Sampson MR, Li JS, Tunks RD, Schulman SR, Cohen-Wolkowiez M. Pharmacokinetics of intravenous sildenafil in children with palliated single ventricle heart defects: effect of elevated hepatic pressures. Cardiol Young 2016; 26:354-62. [PMID: 26197839 PMCID: PMC4591210 DOI: 10.1017/s1047951115000359] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
UNLABELLED Aims Sildenafil is frequently prescribed to children with single ventricle heart defects. These children have unique hepatic physiology with elevated hepatic pressures, which may alter drug pharmacokinetics. We sought to determine the impact of hepatic pressure on sildenafil pharmacokinetics in children with single ventricle heart defects. METHODS A population pharmacokinetic model was developed using data from 20 single ventricle children receiving single-dose intravenous sildenafil during cardiac catheterisation. Non-linear mixed effect modelling was used for model development, and covariate effects were evaluated based on estimated precision and clinical significance. RESULTS The analysis included a median (range) of 4 (2-5) pharmacokinetic samples per child. The final structural model was a two-compartment model for sildenafil with a one-compartment model for des-methyl-sildenafil (active metabolite), with assumed 100% sildenafil to des-methyl-sildenafil conversion. Sildenafil clearance was unaffected by hepatic pressure (clearance=0.62 L/hour/kg); however, clearance of des-methyl-sildenafil (1.94×(hepatic pressure/9)(-1.33) L/hour/kg) was predicted to decrease ~7-fold as hepatic pressure increased from 4 to 18 mmHg. Predicted drug exposure was increased by ~1.5-fold in subjects with hepatic pressures ⩾10 versus <10 mmHg (median area under the curve=533 versus 792 µg*h/L). Discussion Elevated hepatic pressure delays clearance of the sildenafil metabolite - des-methyl-sildenafil - and increases drug exposure. We speculate that this results from impaired biliary clearance. Hepatic pressure should be considered when prescribing sildenafil to children. These data demonstrate the importance of pharmacokinetic assessments in patients with unique cardiovascular physiology that may affect drug metabolism.
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Affiliation(s)
- Kevin D. Hill
- Department of Pediatrics, Duke University Medical Center, Durham, North Carolina, USA
- The Duke Clinical Research Institute, Durham, North Carolina, USA
| | - Mario R. Sampson
- The Duke Clinical Research Institute, Durham, North Carolina, USA
- University of North Carolina Eshelman School of Pharmacy, Chapel Hill, North Carolina, USA
| | - Jennifer S. Li
- The Duke Clinical Research Institute, Durham, North Carolina, USA
| | - Robert D. Tunks
- Department of Pediatrics, Duke University Medical Center, Durham, North Carolina, USA
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Normal and Fibrotic Rat Livers Demonstrate Shear Strain Softening and Compression Stiffening: A Model for Soft Tissue Mechanics. PLoS One 2016; 11:e0146588. [PMID: 26735954 PMCID: PMC4703410 DOI: 10.1371/journal.pone.0146588] [Citation(s) in RCA: 77] [Impact Index Per Article: 9.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2015] [Accepted: 12/18/2015] [Indexed: 12/19/2022] Open
Abstract
Tissues including liver stiffen and acquire more extracellular matrix with fibrosis. The relationship between matrix content and stiffness, however, is non-linear, and stiffness is only one component of tissue mechanics. The mechanical response of tissues such as liver to physiological stresses is not well described, and models of tissue mechanics are limited. To better understand the mechanics of the normal and fibrotic rat liver, we carried out a series of studies using parallel plate rheometry, measuring the response to compressive, extensional, and shear strains. We found that the shear storage and loss moduli G’ and G” and the apparent Young's moduli measured by uniaxial strain orthogonal to the shear direction increased markedly with both progressive fibrosis and increasing compression, that livers shear strain softened, and that significant increases in shear modulus with compressional stress occurred within a range consistent with increased sinusoidal pressures in liver disease. Proteoglycan content and integrin-matrix interactions were significant determinants of liver mechanics, particularly in compression. We propose a new non-linear constitutive model of the liver. A key feature of this model is that, while it assumes overall liver incompressibility, it takes into account water flow and solid phase compressibility. In sum, we report a detailed study of non-linear liver mechanics under physiological strains in the normal state, early fibrosis, and late fibrosis. We propose a constitutive model that captures compression stiffening, tension softening, and shear softening, and can be understood in terms of the cellular and matrix components of the liver.
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72
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Greenway SC, Crossland DS, Hudson M, Martin SR, Myers RP, Prieur T, Hasan A, Kirk R. Fontan-associated liver disease: Implications for heart transplantation. J Heart Lung Transplant 2016; 35:26-33. [DOI: 10.1016/j.healun.2015.10.015] [Citation(s) in RCA: 87] [Impact Index Per Article: 10.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2015] [Revised: 09/26/2015] [Accepted: 10/14/2015] [Indexed: 01/19/2023] Open
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Fontan Liver Disease: Review of an Emerging Epidemic and Management Options. CURRENT TREATMENT OPTIONS IN CARDIOVASCULAR MEDICINE 2015; 17:51. [PMID: 26407544 DOI: 10.1007/s11936-015-0412-z] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
OPINION STATEMENT Adults with complex congenital heart disease that resulted in a Fontan procedure frequently experience late cardiac failure. Increasingly, liver disease is recognized as an important complication of single-ventricle anatomy and Fontan physiology; however, there is no consensus regarding liver evaluation in this population. Here, we review what is known about liver disease in this unique group and propose screening and prevention measures. We also review controversial treatment areas including assist devices and transplantation, with a review of outcomes in isolated heart and combined heart-liver transplant.
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Poterucha JT, Johnson JN, Qureshi MY, O'Leary PW, Kamath PS, Lennon RJ, Bonnichsen CR, Young PM, Venkatesh SK, Ehman RL, Gupta S, Smyrk TC, Dearani JA, Warnes CA, Cetta F. Magnetic Resonance Elastography: A Novel Technique for the Detection of Hepatic Fibrosis and Hepatocellular Carcinoma After the Fontan Operation. Mayo Clin Proc 2015; 90:882-94. [PMID: 26059757 PMCID: PMC4500048 DOI: 10.1016/j.mayocp.2015.04.020] [Citation(s) in RCA: 85] [Impact Index Per Article: 9.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/21/2015] [Revised: 04/01/2015] [Accepted: 04/15/2015] [Indexed: 12/25/2022]
Abstract
OBJECTIVE To evaluate the utility of magnetic resonance elastography (MRE) in screening patients for hepatic fibrosis, cirrhosis, and hepatocellular carcinoma after the Fontan operation. PATIENTS AND METHODS Hepatic MRE was performed in conjunction with cardiac magnetic resonance imaging in patients who had undergone a Fontan operation between 2010 and 2014. Liver stiffness was calculated using previously reported techniques. Comparisons to available clinical, laboratory, imaging, and histopathologic data were made. RESULTS Overall, 50 patients at a median age of 25 years (range, 21-33 years) who had undergone a Fontan operation were evaluated. The median interval between Fontan operation and MRE was 22 years (range, 16-26 years). The mean liver stiffness values were increased: 5.5 ± 1.4 kPa relative to normal participants. Liver stiffness directly correlated with liver biopsy-derived total fibrosis score, time since operation, mean Fontan pressure, γ-glutamyltransferase level, Model for End-Stage Liver Disease score, creatinine level, and pulmonary vascular resistance index. Liver stiffness was inversely correlated with cardiac index. All 3 participants with hepatic nodules exhibiting decreased contrast uptake on delayed postcontrast imaging and increased nodule stiffness had biopsy-proven hepatocellular carcinoma. CONCLUSION The association between hepatic stiffness and fibrosis scores, Model for End-Stage Liver Disease scores, and γ-glutamyltransferase level suggests that MRE may be useful in detecting (and possibly quantifying) hepatic cirrhosis in patients after the Fontan operation. The correlation between stiffness and post-Fontan time interval, mean Fontan pressure, pulmonary vascular resistance index, and reduced cardiac index suggests a role for long-term hepatic congestion in creating these hepatic abnormalities. Magnetic resonance elastography was useful in detecting abnormal nodules ultimately diagnosed as hepatocellular carcinoma. The relationship between stiffness with advanced fibrosis and hepatocellular carcinoma provides a strong argument for additional study and broader application of MRE in these patients.
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Affiliation(s)
- Joseph T Poterucha
- Division of Pediatric Cardiology, Department of Pediatric and Adolescent Medicine, Mayo Clinic, Rochester, MN.
| | - Jonathan N Johnson
- Division of Pediatric Cardiology, Department of Pediatric and Adolescent Medicine, Mayo Clinic, Rochester, MN
| | - M Yasir Qureshi
- Division of Pediatric Cardiology, Department of Pediatric and Adolescent Medicine, Mayo Clinic, Rochester, MN
| | - Patrick W O'Leary
- Division of Pediatric Cardiology, Department of Pediatric and Adolescent Medicine, Mayo Clinic, Rochester, MN
| | - Patrick S Kamath
- Division of Gastroenterology and Hepatology, Department of Medicine, Mayo Clinic, Rochester, MN
| | - Ryan J Lennon
- Division of Biomedical Statistics and Informatics, Department of Health Sciences Research, Mayo Clinic, Rochester, MN
| | - Crystal R Bonnichsen
- Division of Cardiovascular Diseases, Department of Medicine, Mayo Clinic, Rochester, MN
| | | | | | | | - Sounak Gupta
- Department of Pathology, Mayo Clinic, Rochester, MN
| | | | - Joseph A Dearani
- Division of Cardiac Surgery, Department of Surgery, Mayo Clinic, Rochester, MN
| | - Carole A Warnes
- Division of Cardiovascular Diseases, Department of Medicine, Mayo Clinic, Rochester, MN
| | - Frank Cetta
- Division of Pediatric Cardiology, Department of Pediatric and Adolescent Medicine, Mayo Clinic, Rochester, MN; Division of Cardiovascular Diseases, Department of Medicine, Mayo Clinic, Rochester, MN
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Wu FM, Jonas MM, Opotowsky AR, Harmon A, Raza R, Ukomadu C, Landzberg MJ, Singh MN, Valente AM, Egidy Assenza G, Perez-Atayde AR. Portal and centrilobular hepatic fibrosis in Fontan circulation and clinical outcomes. J Heart Lung Transplant 2015; 34:883-91. [DOI: 10.1016/j.healun.2015.01.993] [Citation(s) in RCA: 55] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2014] [Revised: 01/19/2015] [Accepted: 01/31/2015] [Indexed: 10/24/2022] Open
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Kempny A, Diller GP, Alonso-Gonzalez R, Uebing A, Rafiq I, Li W, Swan L, Hooper J, Donovan J, Wort SJ, Gatzoulis MA, Dimopoulos K. Hypoalbuminaemia predicts outcome in adult patients with congenital heart disease. Heart 2015; 101:699-705. [PMID: 25736048 PMCID: PMC4413739 DOI: 10.1136/heartjnl-2014-306970] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/13/2014] [Revised: 01/31/2015] [Accepted: 02/02/2015] [Indexed: 12/17/2022] Open
Abstract
BACKGROUND In patients with acquired heart failure, hypoalbuminaemia is associated with increased risk of death. The prevalence of hypoproteinaemia and hypoalbuminaemia and their relation to outcome in adult patients with congenital heart disease (ACHD) remains, however, unknown. METHODS Data on patients with ACHD who underwent blood testing in our centre within the last 14 years were collected. The relation between laboratory, clinical or demographic parameters at baseline and mortality was assessed using Cox proportional hazards regression analysis. RESULTS A total of 2886 patients with ACHD were included. Mean age was 33.3 years (23.6-44.7) and 50.1% patients were men. Median plasma albumin concentration was 41.0 g/L (38.0-44.0), whereas hypoalbuminaemia (<35 g/L) was present in 13.9% of patients. The prevalence of hypoalbuminaemia was significantly higher in patients with great complexity ACHD (18.2%) compared with patients with moderate (11.3%) or simple ACHD lesions (12.1%, p<0.001). During a median follow-up of 5.7 years (3.3-9.6), 327 (11.3%) patients died. On univariable Cox regression analysis, hypoalbuminaemia was a strong predictor of outcome (HR 3.37, 95% CI 2.67 to 4.25, p<0.0001). On multivariable Cox regression, after adjusting for age, sodium and creatinine concentration, liver dysfunction, functional class and disease complexity, hypoalbuminaemia remained a significant predictor of death. CONCLUSIONS Hypoalbuminaemia is common in patients with ACHD and is associated with a threefold increased risk of risk of death. Hypoalbuminaemia, therefore, should be included in risk-stratification algorithms as it may assist management decisions and timing of interventions in the growing ACHD population.
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Affiliation(s)
- Aleksander Kempny
- Adult Congenital Heart Centre and National Centre for Pulmonary Hypertension, Royal Brompton Hospital, London, UK
- NIHR Cardiovascular Biomedical Research Unit, Royal Brompton Hospital and National Heart and Lung Institute, Imperial College London, London, UK
- National Heart and Lung Institute, Imperial College School of Medicine, London, UK
- Department of Cardiology and Angiology, Adult Congenital and Valvular Heart Disease Center, University Hospital of Münster, Muenster, Germany
| | - Gerhard-Paul Diller
- Adult Congenital Heart Centre and National Centre for Pulmonary Hypertension, Royal Brompton Hospital, London, UK
- NIHR Cardiovascular Biomedical Research Unit, Royal Brompton Hospital and National Heart and Lung Institute, Imperial College London, London, UK
- National Heart and Lung Institute, Imperial College School of Medicine, London, UK
- Department of Cardiology and Angiology, Adult Congenital and Valvular Heart Disease Center, University Hospital of Münster, Muenster, Germany
| | - Rafael Alonso-Gonzalez
- Adult Congenital Heart Centre and National Centre for Pulmonary Hypertension, Royal Brompton Hospital, London, UK
- NIHR Cardiovascular Biomedical Research Unit, Royal Brompton Hospital and National Heart and Lung Institute, Imperial College London, London, UK
- National Heart and Lung Institute, Imperial College School of Medicine, London, UK
| | - Anselm Uebing
- Adult Congenital Heart Centre and National Centre for Pulmonary Hypertension, Royal Brompton Hospital, London, UK
- NIHR Cardiovascular Biomedical Research Unit, Royal Brompton Hospital and National Heart and Lung Institute, Imperial College London, London, UK
- National Heart and Lung Institute, Imperial College School of Medicine, London, UK
| | - Isma Rafiq
- Adult Congenital Heart Centre and National Centre for Pulmonary Hypertension, Royal Brompton Hospital, London, UK
- NIHR Cardiovascular Biomedical Research Unit, Royal Brompton Hospital and National Heart and Lung Institute, Imperial College London, London, UK
| | - Wei Li
- Adult Congenital Heart Centre and National Centre for Pulmonary Hypertension, Royal Brompton Hospital, London, UK
- NIHR Cardiovascular Biomedical Research Unit, Royal Brompton Hospital and National Heart and Lung Institute, Imperial College London, London, UK
- National Heart and Lung Institute, Imperial College School of Medicine, London, UK
| | - Lorna Swan
- Adult Congenital Heart Centre and National Centre for Pulmonary Hypertension, Royal Brompton Hospital, London, UK
- NIHR Cardiovascular Biomedical Research Unit, Royal Brompton Hospital and National Heart and Lung Institute, Imperial College London, London, UK
- National Heart and Lung Institute, Imperial College School of Medicine, London, UK
| | - James Hooper
- Adult Congenital Heart Centre and National Centre for Pulmonary Hypertension, Royal Brompton Hospital, London, UK
- NIHR Cardiovascular Biomedical Research Unit, Royal Brompton Hospital and National Heart and Lung Institute, Imperial College London, London, UK
- National Heart and Lung Institute, Imperial College School of Medicine, London, UK
| | - Jackie Donovan
- Adult Congenital Heart Centre and National Centre for Pulmonary Hypertension, Royal Brompton Hospital, London, UK
- NIHR Cardiovascular Biomedical Research Unit, Royal Brompton Hospital and National Heart and Lung Institute, Imperial College London, London, UK
- National Heart and Lung Institute, Imperial College School of Medicine, London, UK
| | - Stephen J Wort
- Adult Congenital Heart Centre and National Centre for Pulmonary Hypertension, Royal Brompton Hospital, London, UK
- NIHR Cardiovascular Biomedical Research Unit, Royal Brompton Hospital and National Heart and Lung Institute, Imperial College London, London, UK
- National Heart and Lung Institute, Imperial College School of Medicine, London, UK
| | - Michael A Gatzoulis
- Adult Congenital Heart Centre and National Centre for Pulmonary Hypertension, Royal Brompton Hospital, London, UK
- NIHR Cardiovascular Biomedical Research Unit, Royal Brompton Hospital and National Heart and Lung Institute, Imperial College London, London, UK
- National Heart and Lung Institute, Imperial College School of Medicine, London, UK
| | - Konstantinos Dimopoulos
- Adult Congenital Heart Centre and National Centre for Pulmonary Hypertension, Royal Brompton Hospital, London, UK
- NIHR Cardiovascular Biomedical Research Unit, Royal Brompton Hospital and National Heart and Lung Institute, Imperial College London, London, UK
- National Heart and Lung Institute, Imperial College School of Medicine, London, UK
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Ofei SY, Gariepy C, Hanje J, Sisk T, Daniels CJ, Zaidi AN. Liver fibrosis in adults with Fontan palliation: Do common screening studies predict disease severity? Int J Cardiol 2014; 181:174-5. [PMID: 25528305 DOI: 10.1016/j.ijcard.2014.12.031] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/30/2014] [Accepted: 12/02/2014] [Indexed: 11/27/2022]
Affiliation(s)
- Sylvia Y Ofei
- Nationwide Children's Hospital/The Ohio State University, Department of Pediatrics, Division of Gastroenterology, Hepatology and Nutrition, 700 Children's Drive, Columbus, OH 43205, USA.
| | - Cheryl Gariepy
- Nationwide Children's Hospital/The Ohio State University, Department of Pediatrics, Division of Gastroenterology, Hepatology and Nutrition, 700 Children's Drive, Columbus, OH 43205, USA.
| | - James Hanje
- Wexner Medical Center/The Ohio State University, Department of Internal Medicine, Division of Gastroenterology, Hepatology and Nutrition, 370 West 9th Avenue, Columbus, OH 43210, USA.
| | - Tracey Sisk
- Nationwide Children's Hospital/The Ohio State University, The Columbus Ohio Adult Congenital Heart Disease Program (COACH), The Heart Center, Division of Pediatric Cardiology, 700 Children's Drive, Columbus, OH 43205, USA.
| | - Curt J Daniels
- Nationwide Children's Hospital/The Ohio State University, The Columbus Ohio Adult Congenital Heart Disease Program (COACH), The Heart Center, Division of Pediatric Cardiology, 700 Children's Drive, Columbus, OH 43205, USA; Wexner Medical Center/The Ohio State University, Department of Internal Medicine, Division of Cardiovascular Medicine, 370 West 9th Avenue, Columbus, OH 43210, USA.
| | - Ali N Zaidi
- Nationwide Children's Hospital/The Ohio State University, The Columbus Ohio Adult Congenital Heart Disease Program (COACH), The Heart Center, Division of Pediatric Cardiology, 700 Children's Drive, Columbus, OH 43205, USA; Wexner Medical Center/The Ohio State University, Department of Internal Medicine, Division of Cardiovascular Medicine, 370 West 9th Avenue, Columbus, OH 43210, USA.
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78
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Ford RM, Book W, Spivey JR. Liver disease related to the heart. Transplant Rev (Orlando) 2014; 29:33-7. [PMID: 25510577 DOI: 10.1016/j.trre.2014.11.003] [Citation(s) in RCA: 55] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2014] [Accepted: 11/13/2014] [Indexed: 12/20/2022]
Abstract
In this article, we review both acute and chronic liver diseases that occur as a result of heart or circulatory system failure. Ischemic hepatitis, congestive hepatopathy, cardiac cirrhosis, and Fontan liver disease are reviewed. We review clinical presentation, diagnostic data, prognosis, and available therapeutic strategies for these entities. We aim to increase awareness about cardio-hepatic disease as the prevalence of this disorder in adults is increasing. Due to advances in medical and surgical care, patients with heart disease are living longer and thus exposing long-term effects on the liver that are clinically relevant. There may be a role for dual organ transplantation in some cases, but this is a very challenging endeavor, and newer ideas about treatment or prevention are needed.
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Affiliation(s)
- Ryan M Ford
- Department of Digestive Diseases, Emory Transplant Center, Emory University, Atlanta, GA, USA.
| | - Wendy Book
- Department of Cardiology, Director of Adult Congenital Heart Disease, Emory University, Atlanta, GA, USA
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Evans WN, Winn BJ, Yumiaco NS, Galindo A, Rothman A, Acherman RJ, Restrepo H. Transvenous hepatic biopsy in stable Fontan patients undergoing cardiac catheterization. Pediatr Cardiol 2014; 35:1273-8. [PMID: 24817681 DOI: 10.1007/s00246-014-0928-0] [Citation(s) in RCA: 32] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/11/2014] [Accepted: 04/25/2014] [Indexed: 10/25/2022]
Abstract
Liver pathology complicates Fontan palliation. Previous reports established that both hepatic sinusoidal and portal fibrosis occur in patients after Fontan procedures. Past studies predominantly included symptomatic patient cohorts. Thus, the authors of this study aimed to characterize hepatic pathology via transvenous hepatic biopsies in 21 asymptomatic patients at the time of elective cardiac catheterization. Seven of these patients (33 %) were accompanied by an interventional procedure. Hepatic biopsies showed evidence of either sinusoidal or portal fibrosis or both in all but one patient. The findings showed a statistically significant (p = 0.005) moderately strong positive correlation between fibrosis scores and time since Fontan surgery. Additionally, no significant correlation was found between fibrosis scores and inferior vena cava pressure, pulmonary vascular resistance, platelet counts, or serum laboratory testing of hepatic function.
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Affiliation(s)
- William N Evans
- Children's Heart Center-Nevada, 3006 S. Maryland Parkway Suite 690, Las Vegas, NV, 89109, USA,
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Elder RW, McCabe NM, Veledar E, Kogon BE, Jokhadar M, Rodriguez FH, McConnell ME, Book WM. Risk factors for major adverse events late after Fontan palliation. CONGENIT HEART DIS 2014; 10:159-68. [PMID: 25130602 DOI: 10.1111/chd.12212] [Citation(s) in RCA: 56] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 07/04/2014] [Indexed: 11/26/2022]
Abstract
OBJECTIVE Risk factors for major adverse events late after Fontan palliation are unknown. Prior studies have suggested ventricular function and morphology as important risk factors. The aim of this study is to (1) characterize the late major adverse event profile in adult Fontan patients and (2) identify additional risk factors that may contribute to adverse outcomes. DESIGN AND SETTING A retrospective review of all adult patients >15 years post-Fontan seen at a tertiary academic center was conducted. Clinical, laboratory, cardiac data, and abdominal imaging were collected via chart review. Major adverse events (death, cardiac transplantation, or listing) were identified, and timing of events was plotted using Kaplan-Meier methods. Univariate and multivariate logistic regression was used to determine independent predictors of late-term events. RESULTS A total of 123 adult Fontan patients were identified (mean time post-Fontan 22.4 years [±4.4]). Major adverse events occurred in 19/123 patients (15%). In this 15-year survivor cohort, transplant-free survival rates were 94.6%, 82.9%, and 59.8% at 20, 25, and 30 years postoperation, respectively. Modes of death were Fontan failure with preserved function (4), congestive heart failure with decreased function (2), sudden death (2), thromboembolic event (1), post-Fontan conversion (2), and posttransplant (2). No differences in adverse outcomes were found based on morphology of the systemic ventricle, Fontan type, or systolic ventricular function. On the other hand, features of portal hypertension (OR 19.0, CI 4.7-77.3, P < .0001), presence of a pacemaker (OR 13.4, CI 2.6-69.8, P = .002), and systemic oxygen desaturation (OR 0.86, CI 0.75-0.98, P = .02) were risk factors for major adverse events in the multivariate analysis. CONCLUSIONS In adult Fontan patients surviving >15 years post-Fontan, portal hypertension, oxygen desaturation, and need for pacemaker were predictive of adverse events. Traditional measures may not predict late-term outcomes in adult survivors; further study of the liver's role in late outcomes is warranted.
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Affiliation(s)
- Robert W Elder
- Section of Cardiology, Pediatrics and Internal Medicine, Yale School of Medicine, New Haven, Conn, USA
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MR assessment of abdominal circulation in Fontan physiology. Int J Cardiovasc Imaging 2014; 30:1065-72. [PMID: 24752955 DOI: 10.1007/s10554-014-0424-x] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/31/2014] [Accepted: 04/11/2014] [Indexed: 01/09/2023]
Abstract
The Fontan operation allows for longer survival of those born with functionally single ventricle physiology. Although it effectively eliminates cyanosis, increased systemic venous pressure is an unavoidable consequence and low cardiac output is frequent. The abdomen is particularly vulnerable to these alterations in hemodynamics because the hepatic blood flow consists predominantly of portal venous flow, which relies on a low pressure gradient between the portal and hepatic veins. Therefore, any subtle increase in systemic venous pressure will adversely affect the hemodynamic balance of the liver as well as the intestine. As the clinical manifestations and routine laboratory findings of abdominal complications can lag behind the hemodynamic and pathologic changes in the abdominal organs, regular imaging surveillance is critical. Magnetic resonance (MR) provides excellent visualization of both cardiovascular and abdominal systems. It provides robust anatomic and hemodynamic data which can be used for timely implementation of treatment options. In this review paper, we discuss the pathogenesis and MR findings of abdominal complications following the Fontan operation. Specifically we explore the utility of phase-contrast MR for assessment of the abdominal circulation in children following the Fontan palliation.
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Yoo BW, Choi JY, Eun LY, Park HK, Park YH, Kim SU. Congestive hepatopathy after Fontan operation and related factors assessed by transient elastography. J Thorac Cardiovasc Surg 2014; 148:1498-505. [PMID: 24823284 DOI: 10.1016/j.jtcvs.2014.04.010] [Citation(s) in RCA: 43] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/16/2013] [Revised: 03/28/2014] [Accepted: 04/04/2014] [Indexed: 02/07/2023]
Abstract
OBJECTIVE Congestive hepatopathy after a Fontan operation can have a major effect on long-term morbidity. We evaluated congestive hepatopathy in patients with Fontan circulation using transient elastography to determine which risk factors for hepatopathy are related to liver stiffness (LS). METHODS We evaluated 46 patients with Fontan circulation and 26 with right side heart failure (RHF) and hepatic congestion using laboratory tests, the aspartate aminotransferase-to-platelet ratio index, ultrasonography, and transient elastography. RESULTS The LS value was significantly greater in the Fontan group (21.1±8.0 kPa) than in the RHF group (10.0±9.0 kPa). The total bilirubin and albumin serum levels, white blood cell count, and aspartate aminotransferase to platelet ratio index correlated significantly with LS in the Fontan group. Of the risk factors, age at evaluation (r=0.42, P=.004), age at Fontan completion (r=0.51, P<.001), inferior vena cava diameter (r=0.35, P=.02), and spleen size (r=0.53, P=.002) correlated significantly with LS. Nineteen patients in the Fontan group (41.3%) had abnormal ultrasound findings, and the frequency of abnormal findings increased with increasing LS (P=.002). In the subgroup with the greatest LS value (≥30 kPa), 88.9% had abnormal ultrasound findings and 44.4% liver cirrhosis. Multivariate analysis revealed that age at Fontan procedure completion and total bilirubin were independent risk factors for hepatopathy. CONCLUSIONS The present study revealed that congestive hepatopathy developed in a significant fraction of patients with long-term Fontan circulation and that transient elastography could be an easy and useful method to assess congestive hepatopathy in these patients.
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Affiliation(s)
- Byung Won Yoo
- Department of Clinical Pharmacology, Clinical Trial Center, Severance Hospital, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Jae Young Choi
- Division of Pediatric Cardiology, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Lucy Youngmin Eun
- Division of Pediatric Cardiology, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Han Ki Park
- Division of Cardiovascular Surgery, Congenital Heart Disease Center, Severance Cardiovascular Hospital, and Department of Thoracic and Cardiovascular Surgery, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Young Hwan Park
- Division of Cardiovascular Surgery, Congenital Heart Disease Center, Severance Cardiovascular Hospital, and Department of Thoracic and Cardiovascular Surgery, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Seung Up Kim
- Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Republic of Korea; Institute of Gastroenterology, Yonsei University College of Medicine, Seoul, Republic of Korea; Liver Cirrhosis Clinical Research Center, Seoul, Republic of Korea.
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Beyond a broken heart: circulatory dysfunction in the failing Fontan. Pediatr Cardiol 2014; 35:569-79. [PMID: 24531876 DOI: 10.1007/s00246-014-0881-y] [Citation(s) in RCA: 54] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/16/2013] [Accepted: 02/05/2014] [Indexed: 02/07/2023]
Abstract
The role of ventricular dysfunction in late morbidity and mortality of univentricular hearts has been described previously. However, a significant proportion of adult Fontan patients who die or require heart transplantation do so with preserved ventricular function. The clinical deterioration in patients who have undergone Fontan palliation requires a broader view of circulatory dysfunction, one that takes into account the complex interaction of regulatory systems affecting hepatic, renal, and pulmonary blood flow, in addition to cardiac function. This review focuses primarily on the pathophysiology of multiple organ involvement in this circulatory dysfunction, with particular focus on the consequences of hepatic dysfunction and portal hypertension. The authors discuss hepatic perfusion, both in health and disease, and review the current understanding of liver histopathology and liver disease in adult Fontan patients and similar clinicopathologic states. They compare and contrast features of postsinusoidal portal hypertension with more typical adult cirrhotic disease. Finally, they delineate the related effects of portal hypertensive physiology on the systemic and pulmonary vasculature, the kidney, and the heart itself and discuss how these changes affect the care of the adult Fontan patient.
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Iyengar AJ, Winlaw DS, Galati JC, Wheaton GR, Gentles TL, Grigg LE, Justo RN, Radford DJ, Weintraub RG, Bullock A, Celermajer DS, d'Udekem Y. The extracardiac conduit Fontan procedure in Australia and New Zealand: hypoplastic left heart syndrome predicts worse early and late outcomes. Eur J Cardiothorac Surg 2014; 46:465-73; discussion 473. [PMID: 24578409 DOI: 10.1093/ejcts/ezu015] [Citation(s) in RCA: 86] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
OBJECTIVES To identify factors associated with hospital and long-term outcomes in a binational cohort of extracardiac conduit (ECC) Fontan recipients. METHODS All patients who underwent an ECC Fontan procedure from 1997 to 2010 in Australia and New Zealand were identified, and perioperative, follow-up, echocardiographic and reintervention data collected. Risk factors for early and late mortality, failure and adverse outcomes were analysed. RESULTS A total of 570 patients were identified, and late follow-up was available in 529 patients. The mean follow-up was 6.7 years (standard deviation: 3.5) and completeness of the follow-up was 98%. There were seven hospital mortalities (1%) and 21 patients (4%) experienced early failure (death, Fontan takedown/revision or mechanical circulatory support). Prolonged length of stay occurred in 10% (57 patients), and prolonged effusions in 9% (51 patients). Overall survival at 14 years was 96% (95% confidence interval [CI]: 93-98%), and late survival for patients discharged with intact Fontan was 98% (95% CI: 94-99%). The rates of late failure (late death, transplantation, takedown, New York Heart Association class III/IV or protein-losing enteropathy) and adverse events (late failure, reoperation, percutaneous intervention, pacemaker, thromboembolic event or supraventricular tachycardia) per 100 patient-years were 0.8 and 3.8, and their 14-year freedoms were 83% (95% CI: 70-91%) and 53% (95% CI: 41-64%), respectively. After adjustment for confounders, hypoplastic left heart syndrome (HLHS) was strongly associated with prolonged effusions (OR: 2.9, 95% CI: 1.4-5.9), late failure (hazard ratio [HR]: 2.8, 95% CI: 1.1-7.5) and adverse events (HR: 3.6, 95% CI: 1.3-7.5). CONCLUSIONS The extracardiac Fontan procedure provides excellent survival into the second decade of life, but half of patients will suffer a late adverse event by 14 years. Patients with HLHS are at higher risk of late adverse events than other morphological groups, but their survival is still excellent.
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Affiliation(s)
- Ajay J Iyengar
- Department of Cardiac Surgery, Royal Children's Hospital, Melbourne, VIC, Australia Murdoch Childrens Research Institute, Melbourne, VIC, Australia Department of Paediatrics, Faculty of Medicine, The University of Melbourne, Melbourne, VIC, Australia
| | - David S Winlaw
- Heart Centre for Children, The Children's Hospital at Westmead, Sydney, NSW, Australia University of Sydney, Sydney, Australia
| | - John C Galati
- Murdoch Childrens Research Institute, Melbourne, VIC, Australia Department of Mathematics and Statistics, La Trobe University, Melbourne, VIC, Australia
| | - Gavin R Wheaton
- Department of Cardiology, Women's and Children's Hospital, Adelaide, SA, Australia
| | - Thomas L Gentles
- Green Lane Paediatric and Congenital Cardiac Service, Starship Children's Hospital, Auckland, New Zealand
| | - Leeanne E Grigg
- Department of Cardiology, The Royal Melbourne Hospital, Melbourne, VIC, Australia
| | - Robert N Justo
- Paediatric Cardiology, Queensland Paediatric Cardiac Service, Mater Children's Hospital, Brisbane, QLD, Australia
| | - Dorothy J Radford
- Adult Congenital Heart Unit, The Prince Charles Hospital, Brisbane, QLD, Australia
| | - Robert G Weintraub
- Murdoch Childrens Research Institute, Melbourne, VIC, Australia Department of Paediatrics, Faculty of Medicine, The University of Melbourne, Melbourne, VIC, Australia Department of Cardiology, Royal Children's Hospital, Melbourne, VIC, Australia
| | - Andrew Bullock
- Children's Cardiac Centre, Princess Margaret Hospital for Children, Perth, WA, Australia
| | - David S Celermajer
- University of Sydney, Sydney, Australia Department of Cardiology, Royal Prince Alfred Hospital, Sydney, NSW, Australia
| | - Yves d'Udekem
- Department of Cardiac Surgery, Royal Children's Hospital, Melbourne, VIC, Australia Murdoch Childrens Research Institute, Melbourne, VIC, Australia Department of Paediatrics, Faculty of Medicine, The University of Melbourne, Melbourne, VIC, Australia
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Wu FM, Opotowsky AR, Raza R, Harney S, Ukomadu C, Landzberg MJ, Valente AM, Breitbart RE, Singh MN, Gauvreau K, Jonas MM. Transient elastography may identify Fontan patients with unfavorable hemodynamics and advanced hepatic fibrosis. CONGENIT HEART DIS 2014; 9:438-47. [PMID: 24418160 DOI: 10.1111/chd.12159] [Citation(s) in RCA: 73] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 12/02/2013] [Indexed: 01/12/2023]
Abstract
BACKGROUND Transient elastography (TE) offers a noninvasive correlate with the degree of hepatic fibrosis. However, factors other than fibrosis affect liver stiffness. We sought to determine whether hepatic congestion related to hemodynamics in Fontan circulation influences liver stiffness measurement (LSM) assessed by TE. METHODS We studied 45 subjects with Fontan circulation undergoing cardiac catheterization with or without simultaneous liver biopsy. Subjects underwent TE within 5 days before catheterization. Clinical history, hemodynamic and biopsy data, and hepatic biomarkers were collected. Five subjects who had previously undergone liver biopsy and TE were also included. RESULTS Median age was 13.1 years (range 2.4-57.8); median time since Fontan was 9.9 years (range 0.1-32.5). No subject had known hepatitis C. Mean LSM for the entire cohort was 21.4 ± 10.8 kPa. Univariate regression analysis using LSM as a continuous outcome variable shows significant correlations with age (R = 0.35, P = .01), time since Fontan (R = 0.41, P = .003), Fontan pressure (R = 0.31, P = .04), cardiac index (R = 0.33, P = .03), pulmonary vascular resistance (R = 0.34, P = .03), systemic arterial oxygen saturation (R = 0.31, P = .04), and platelet count (R = 0.29, P = .05). On multiple regression analysis, Fontan pressure (β = 0.901, P = .03) and cardiac index (β = 2.703, P = .02) were significant predictors of LSM with overall model R(2) = 0.206. Univariate analysis shows LSM to be associated with more severe centrilobular fibrosis (P = .05). CONCLUSIONS Higher LSM is associated with unfavorable Fontan hemodynamics and advanced centrilobular hepatic fibrosis. TE may be a useful tool for identifying Fontan patients who warrant invasive testing.
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Affiliation(s)
- Fred M Wu
- Department of Cardiology, Boston Children's Hospital, Harvard Medical School, Boston, Mass, USA; Division of Cardiology, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Mass, USA
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Kutty SS, Peng Q, Danford DA, Fletcher SE, Perry D, Talmon GA, Scott C, Kugler JD, Duncan KF, Quiros-Tejeira RE, Kutty S. Increased hepatic stiffness as consequence of high hepatic afterload in the Fontan circulation: a vascular Doppler and elastography study. Hepatology 2014; 59:251-60. [PMID: 23913702 DOI: 10.1002/hep.26631] [Citation(s) in RCA: 92] [Impact Index Per Article: 9.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/09/2013] [Revised: 07/08/2013] [Accepted: 07/11/2013] [Indexed: 12/13/2022]
Abstract
UNLABELLED Hepatic dysfunction is a recognized complication after Fontan palliation of congenital heart disease. We sought to quantitatively measure hepatic stiffness and vascular Doppler indices using ultrasound (US) and shear wave elastography (SWE) in a Fontan cohort. Subjects were prospectively recruited for echocardiography and real-time hepatic duplex US with SWE for hepatic stiffness (kPa). Doppler peak velocities, velocity time integral, resistive, pulsatility, acceleration indices (RI, PI, AI), and flow volume were measured in celiac artery, superior mesenteric artery, and main portal vein (MPV). A subset underwent cardiac catheterizations with liver biopsy. Correlations were explored between SWE, duplex, hemodynamic, and histopathologic data. In all, 106 subjects were studied including 41 patients with Fontan physiology (age 13.8 ± 6 years, weight 45.4 ± 23 kg) and 65 controls (age 15.0 ± 8.4 years, weight 47.9 ± 22 kg). Patients with Fontan physiology had significantly higher hepatic stiffness (15.6 versus 5.5 kPa, P < 0.0001), higher celiac RI (0.78 versus 0.73, P = 0.04) superior mesenteric artery RI (0.89 versus 0.84, P = 0.005), and celiac PI (1.87 versus 1.6, P = 0.034); while MPV flow volume (287 versus 420 mL/min in controls, P = 0.007) and SMA AI (829 versus 1100, P = 0.002) were lower. Significant correlation was seen for stiffness with ventricular end-diastolic pressure (P = 0.001) and pulmonary artery wedge pressure (P = 0.009). Greater stiffness correlated with greater degrees of histopathologic fibrosis. No significant change was seen in stiffness or other duplex indices with age, gender, time since Fontan, or ventricular morphology. CONCLUSION Elevated hepatic afterload in Fontan, manifested by high ventricular end-diastolic pressures and pulmonary arterial wedge pressures, is associated with remarkably increased hepatic stiffness, abnormal vascular flow patterns, and fibrotic histologic changes. The MPV is dilated and carries decreased flow volume, while the celiac and superior mesenteric arterial RI is increased. SWE is feasible in this population and shows promise as a means for predicting disease severity on liver biopsy.
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Affiliation(s)
- Shaija S Kutty
- Department of Pediatric Gastroenterology, University of Nebraska College of Medicine and Children's Hospital and Medical Center, Omaha, NE
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Simpson KE, Esmaeeli A, Khanna G, White F, Turnmelle Y, Eghtesady P, Boston U, Canter CE. Liver cirrhosis in Fontan patients does not affect 1-year post-heart transplant mortality or markers of liver function. J Heart Lung Transplant 2013; 33:170-7. [PMID: 24365764 DOI: 10.1016/j.healun.2013.10.033] [Citation(s) in RCA: 78] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2013] [Revised: 08/29/2013] [Accepted: 10/23/2013] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND Liver cirrhosis is recognized with long-term follow-up of patients after the Fontan procedure. The effect of liver cirrhosis on the use of heart transplant (HT) and on post-HT outcomes is unknown. METHODS We reviewed Fontan patients evaluated for HT from 2004 to 2012 with hepatic computed tomography (CT) imaging, classified as normal, non-cirrhotic changes, or cirrhosis. The primary outcome was 1-year all-cause mortality, and the secondary outcome was differences in serial post-HT liver evaluation. RESULTS CT imaging in 32 Fontan patients evaluated for HT revealed 20 (63%) with evidence of liver disease, including 13 (41%) with cirrhosis. Twenty underwent HT, including 5 non-cirrhotic and 7 cirrhosis patients. Characteristics at listing between normal or non-cirrhotic (n = 13) and cirrhosis (n = 7) groups were similar, except cirrhosis patients were older (median 17.6 vs 9.6 years, p = 0.002) and further from Fontan (median 180 vs 50 months, p < 0.05). Serial liver evaluation was similar, including aspartate aminotransferase, alanine aminotransferase, bilirubin, albumin, and tacrolimus dose at 1, 3, 6, 9, and 12 months. Overall patient survival was 80% at 1 year, with no difference between cirrhosis and non-cirrhosis patients (86% vs 77%, p = 0.681). Liver biopsies were performed in 7 patients before HT, and all specimens showed architectural changes with bridging fibrosis. CONCLUSIONS Most patients evaluated for HT had abnormal liver findings by CT, with cirrhosis in 41%. One-year mortality and serial liver evaluation were similar between groups after HT. Liver cirrhosis identified by CT imaging may not be an absolute contraindication to HT alone in this population.
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Affiliation(s)
- Kathleen E Simpson
- Department of Pediatrics, Washington University School of Medicine, Saint Louis, Missouri.
| | - Amir Esmaeeli
- School of Medicine, Washington University School of Medicine, Saint Louis, Missouri
| | - Geetika Khanna
- Department of Radiology, Washington University School of Medicine, Saint Louis, Missouri
| | - Francis White
- Department of Pathology, Washington University School of Medicine, Saint Louis, Missouri
| | - Yumirle Turnmelle
- Department of Pediatrics, Washington University School of Medicine, Saint Louis, Missouri
| | - Pirooz Eghtesady
- Department of Surgery, Washington University School of Medicine, Saint Louis, Missouri
| | - Umar Boston
- Department of Surgery, Washington University School of Medicine, Saint Louis, Missouri
| | - Charles E Canter
- Department of Pediatrics, Washington University School of Medicine, Saint Louis, Missouri
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Lastinger L, Zaidi AN. The adult with a fontan: a panacea without a cure? Review of long-term complications. Circ J 2013; 77:2672-81. [PMID: 24152723 DOI: 10.1253/circj.cj-13-1105] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
The univentricular heart includes a spectrum of complex cardiac defects that are managed by staged palliative surgical procedures, ultimately resulting in a Fontan procedure. Since 1971, when it was first developed, the procedure has undergone several variations. These patients require lifelong management, including a thorough knowledge of their anatomic substrate, hemodynamic status, management of rhythm and ventricular function, together with multi-organ evaluation. As these patients enter middle age, there is increasing awareness of long-term complications and mortality. This review highlights the concept behind the staged surgical palliations, the unique single ventricle physiology and the long-term complications in this complex cohort of patients.
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Affiliation(s)
- Lauren Lastinger
- Division of Pediatrics and Internal Medicine, Nationwide Children's Hospital and the Ohio State University
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91
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Single ventricle anatomy is associated with increased frequency of nonalcoholic cirrhosis. Int J Cardiol 2013; 167:1918-23. [DOI: 10.1016/j.ijcard.2012.05.002] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/06/2012] [Revised: 04/24/2012] [Accepted: 05/03/2012] [Indexed: 01/19/2023]
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Abstract
There is a mutual interaction between the function of the heart and the liver and a broad spectrum of acute and chronic entities that affect both the heart and the liver. These can be classified into heart diseases affecting the liver, liver diseases affecting the heart, and conditions affecting the heart and the liver at the same time. In chronic and acute cardiac hepatopathy, owing to cardiac failure, a combination of reduced arterial perfusion and passive congestion leads to cardiac cirrhosis and cardiogenic hypoxic hepatitis. These conditions may impair the liver function and treatment should be directed towards the primary heart disease and seek to secure perfusion of vital organs. In patients with advanced cirrhosis, physical and/or pharmacological stress may reveal a reduced cardiac performance with systolic and diastolic dysfunction and electrophysical abnormalities termed cirrhotic cardiomyopathy. Electrophysiological abnormalities include prolonged QT interval, chronotropic incompetance, and electromechanical uncoupling. No specific therapy can be recommended, but it should be supportive and directed against the heart failure. Numerous conditions affect both the heart and the liver such as infections, inflammatory and systemic diseases, and chronic alcoholism. The risk and prevalence of coronary artery disease are increasing in cirrhotic patients and since the perioperative mortality is high, a careful cardiac evaluation of such patients is required prior to orthotopic liver transplantation.
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Affiliation(s)
- Søren Møller
- Centre of Functional and Diagnostic Imaging and Research, Department of Clinical Physiology and Nuclear Medicine, Hvidovre Hospital, The Faculty of Health Sciences, University of Copenhagen, Copenhagen, Denmark
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Features of portal hypertension are associated with major adverse events in Fontan patients: the VAST study. Int J Cardiol 2013; 168:3764-9. [PMID: 23849105 DOI: 10.1016/j.ijcard.2013.06.008] [Citation(s) in RCA: 136] [Impact Index Per Article: 12.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/24/2013] [Revised: 05/02/2013] [Accepted: 06/15/2013] [Indexed: 12/31/2022]
Abstract
BACKGROUND Chronic congestive hepatopathy is known to cause hepatic fibrosis and portal hypertension in patients post-Fontan operation for single ventricle palliation. The clinical significance of these findings is not clear. We hypothesized that features of portal hypertension would be significantly related to major adverse events. METHODS A retrospective review of 73 adult and pediatric post-Fontan patients referred for a liver evaluation from 2001 to 2011 was performed. The relationship between features of portal hypertension (VAST score ≥2, 1 point each for Varices, Ascites, Splenomegaly or Thrombocytopenia) and a major adverse event (death, need for transplant, or hepatocellular carcinoma) was examined using logistic regression. RESULTS 73 post-Fontan patients (30% female, 73% Caucasian, 66% systemic left ventricle (SLV), mean age 24±11 years, mean interval from Fontan 17±6 years) were included in analysis. Features of portal hypertension (VAST score ≥2) were present in 26 (36%), and there were 19 major adverse events: death (n=12), transplant (n=6), and HCC (n=1). A significant relationship was found between VAST score ≥2 and major adverse events (OR=9.8, 95% CI [2.9-32.7]). After adjusting for time since Fontan, SLV, age, hemoglobin and type of failure, VAST score ≥2 remained significant (OR=9.1, 95% CI [1.4-57.6]). CONCLUSION Fontan patients with features of portal hypertension have a 9-fold increased risk for a major adverse event. Therapies targeted to manage clinical manifestations of portal hypertension, and early referral to heart transplant may help delay major adverse events. Future prospective studies are needed to confirm these findings.
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Whiteside W, Tan M, Yu S, Rocchini A. Low total, low-density lipoprotein, high-density lipoprotein, and non-high-density lipoprotein cholesterol levels in patients with complex congenital heart disease after Fontan palliation. J Pediatr 2013; 162:1199-204. [PMID: 23312682 DOI: 10.1016/j.jpeds.2012.11.073] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/19/2012] [Revised: 10/22/2012] [Accepted: 11/26/2012] [Indexed: 11/24/2022]
Abstract
OBJECTIVE To test the hypothesis that patients with complex congenital heart disease who have undergone Fontan palliation have low total cholesterol, low-density lipoprotein cholesterol (LDL-C), and high-density lipoprotein cholesterol (HDL-C) levels. STUDY DESIGN We retrospectively reviewed the random serum lipid profiles obtained at cardiology clinic visits between May 2010 and November 2011 in patients who had undergone the Fontan procedure. We compared these serum lipid levels against age- and sex-matched established normal data from the Third National Health and Nutrition Examination Survey. RESULTS Eighty-eight patients who had undergone the Fontan procedure also had laboratory test data obtained during their visits. Median total cholesterol level in the Fontan group was 127 mg/dL (IQR, 116-144 mg/dL), median HDL-C was 40 mg/dL (IQR, 33-45 mg/dL), median non-HDL-C was 86 mg/dL (IQR, 76-109 mg/dL), and median LDL-C was 66 mg/dL (IQR, 57-83 mg/dL). Total cholesterol, LDL-C, non-HDL-C, and HDL-C levels were significantly lower in patients who had undergone a Fontan procedure compared with age- and sex-matched normal individuals (mean z-score, -1.4, -1.2, -1.0, and -1.0 respectively; all P<.0001). Cholesterol levels were below the 25th percentile for age and sex for total cholesterol in 82% of patients, for LDL-C in 76%, for non-HDL-C in 67%, and for HDL-C in 57%. CONCLUSION Patients who have undergone the Fontan procedure have significantly lower serum total cholesterol, LDL-C, HDL-C and non-HDL-C levels than age- and sex-matched normal individuals. Although the implications of this finding are unknown, it raises the possibility of abnormalities in cholesterol absorption, synthesis, or catabolism in this patient population.
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Affiliation(s)
- Wendy Whiteside
- Division of Pediatric Cardiology, Department of Pediatrics and Communicable Diseases, University of Michigan, Ann Arbor, MI, USA.
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Kaulitz R, Haber P, Sturm E, Schäfer J, Hofbeck M. Serial evaluation of hepatic function profile after Fontan operation. Herz 2013; 39:98-104. [DOI: 10.1007/s00059-013-3811-5] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2012] [Revised: 01/14/2013] [Accepted: 03/15/2013] [Indexed: 11/28/2022]
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Schwartz MC, Sullivan LM, Glatz AC, Rand E, Russo P, Goldberg DJ, Rome JJ, Cohen MS. Portal and sinusoidal fibrosis are common on liver biopsy after Fontan surgery. Pediatr Cardiol 2013; 34:135-42. [PMID: 22695765 DOI: 10.1007/s00246-012-0402-9] [Citation(s) in RCA: 87] [Impact Index Per Article: 7.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/09/2012] [Accepted: 05/17/2012] [Indexed: 10/28/2022]
Abstract
Hepatic fibrosis is an important complication after Fontan surgery in patients with single-ventricle congenital heart disease. Few reports of hepatic histology in these patients exist, and sinusoidal fibrosis has been described. We aimed to characterize fibrosis at liver biopsy procedure in patients with previous Fontan surgery and to identify patient variables associated with the degree of fibrosis. All patients who had previous Fontan surgery and who subsequently underwent liver biopsy at our institution between January 1990 and July 2010 were identified. For each biopsy specimen, portal and sinusoidal fibrosis were graded and medical records reviewed. Biopsy specimens from 13 patients were examined; the median time from Fontan surgery to liver biopsy procedure was 16.9 years (range 6.9-25). At the most recent biopsy procedure, 12 patients (92 %) had evidence of portal fibrosis, including 1 patient with portal-based cirrhosis. Thirteen patients (100 %) had at least some degree of sinusoidal fibrosis, including 1 patient with centrilobular-based cirrhosis. Lower platelet count was associated with greater degree of portal fibrosis by ordinal regression (odds ratio 0.84, P = 0.04), and patients with no or mild portal fibrosis had significantly higher platelet counts compared with those with moderate or severe portal disease (278 ± 78 K vs. 160 ± 46 K, P = 0.005). Four patients underwent serial biopsy procedures; portal fibrosis was progressed in 3 patients, and sinusoidal fibrosis was progressed in 3 patients. After Fontan surgery, portal and sinusoidal fibrosis are common at liver biopsy and can progress over time. Lower platelet count may represent a marker of portal-based disease in these patients.
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Affiliation(s)
- Matthew C Schwartz
- Division of Cardiology, The Children's Hospital of Philadelphia, Philadelphia, PA 19104, USA.
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97
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Buelow MW, Dall A, Bartz PJ, Tweddell JS, Sowinski J, Rudd N, Katzmark L, Earing MG. Renal dysfunction is common among adults after palliation for previous tetralogy of Fallot. Pediatr Cardiol 2013; 34:165-9. [PMID: 22673967 DOI: 10.1007/s00246-012-0408-3] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/28/2012] [Accepted: 05/23/2012] [Indexed: 01/24/2023]
Abstract
Long-term survival after tetralogy of Fallot (TOF) repair is excellent. However, little is published regarding late noncardiac complications. This study aimed to determine the prevalence and risk factors for renal dysfunction among adults after TOF repair. For this study, 56 adult patients with complete repair of TOF were identified, and their charts were retrospectively reviewed. An estimated glomerular filtration rate (eGFR) for each patient was calculated using the Modification of Diet in Renal Disease formula (MDRD). Using each patient's eGFR, he or she was classified into stages based on the National Kidney Foundation chronic kidney disease (CKD) staging. Clinical parameters were compared among patients with and those without renal dysfunction to identify risk factors for renal impairment. The median estimated eGFR rate for the cohort was 78 ml/min/1.73 m(2). Based on the National Kidney Foundation CKD staging system, 54 % of the patients had at least stage 2 chronic renal disease. The risk factors identified were hypertension (p < 0.01), type 2 diabetes mellitus (p < 0.05), longer follow-up evaluation (p < 0.005), older age at complete repair (p < 0.05), and use of daily diuretics (p < 0.05). After repair of TOF, renal dysfunction is common at late follow-up evaluation. The study findings show the importance of routine assessment of renal function and the need to limit or avoid future episodes of acute kidney injury in this at-risk population.
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Affiliation(s)
- Matthew W Buelow
- Department of Pediatrics, Medical College of Wisconsin, 9000 W Wisconsin Avenue, Milwaukee, WI 53226, USA
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98
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Asrani SK, Asrani NS, Freese DK, Phillips SD, Warnes CA, Heimbach J, Kamath PS. Congenital heart disease and the liver. Hepatology 2012; 56:1160-9. [PMID: 22383293 DOI: 10.1002/hep.25692] [Citation(s) in RCA: 144] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/31/2011] [Accepted: 02/19/2012] [Indexed: 01/05/2023]
Abstract
There are approximately 1 million adult patients with congenital heart disease (CHD) in the United States, and the number is increasing. Hepatic complications are common and may occur secondary to persistent chronic passive venous congestion or decreased cardiac output resulting from the underlying cardiac disease or as a result of palliative cardiac surgery; transfusion or drug-related hepatitis may also occur. The unique physiology of Fontan circulation is particularly prone to the development of hepatic complications and is, in part, related to the duration of the Fontan procedure. Liver biochemical test abnormalities may be related to cardiac failure, resulting from intrinsic liver disease, secondary to palliative interventions, or drug related. Complications of portal hypertension and, rarely, hepatocellular carcinoma (HCC) may also occur. Abnormalities such as hypervascular nodules are often observed; in the presence of cirrhosis, surveillance for HCC is necessary. Judicious perioperative support is required when cardiac surgery is performed in patients with advanced hepatic disease. Traditional models for liver disease staging may not fully capture the severity of disease in patients with CHD. The effectiveness or safety of isolated liver transplantation in patients with significant CHD is limited in adults; combined heart-liver transplantation may be required in those with decompensated liver disease or HCC, but experience is limited in the presence of significant CHD. The long-term sequelae of many reparative cardiac surgical procedures are not yet fully realized; understanding the unique and diverse hepatic associations and the role for early cardiac transplantation in this population is critical. Because this population continues to grow and age, consideration should be given to developing consensus guidelines for a multidisciplinary approach to optimize management of this vulnerable population.
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Affiliation(s)
- Sumeet K Asrani
- Division of Gastroenterology and Hepatology, Mayo Clinic College of Medicine, Rochester, MN 55905, USA
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99
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McCabe N, Farris AB, Hon H, Ford R, Book WM. Hepatocellular carcinoma in an adult with repaired tetralogy of fallot. CONGENIT HEART DIS 2012; 8:E139-44. [PMID: 22897884 DOI: 10.1111/j.1747-0803.2012.00700.x] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/09/2012] [Indexed: 12/13/2022]
Abstract
Liver fibrosis is a growing concern among adults with congenital heart disease, particularly for those who have undergone a Fontan operation. Liver fibrosis leads to cirrhosis, a precursor of hepatocellular carcinoma. A few cases of hepatocellular carcinoma in patients with prior palliative surgery for congenital heart disease have been identified in the literature. The current case reports the first known case of hepatocellular carcinoma in a 45-year-old male with repaired tetralogy of Fallot.
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Affiliation(s)
- Nancy McCabe
- Nell Hodgson Woodruff School, Department of Medicine, Emory University, Atlanta, Ga, USA
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100
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Windram JD, Oechslin EN. Comprehensive patient care best serves the adult with congenital heart disease. PROGRESS IN PEDIATRIC CARDIOLOGY 2012. [DOI: 10.1016/j.ppedcard.2012.05.014] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
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