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Jassal YR, Slomowitz R, Everitt MD, Christofferson ES, von Alvensleben JC, Di Maria M, Wolfe KR. A Preliminary Study of One Year Safety and Tolerability of Attention-Deficit/Hyperactivity Disorder Medications in Youth with Fontan Palliation or Heart Transplant. Pediatr Cardiol 2024; 45:673-680. [PMID: 36809419 DOI: 10.1007/s00246-023-03128-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/14/2022] [Accepted: 02/06/2023] [Indexed: 02/23/2023]
Abstract
There are no published studies that examine the safety and tolerability of medication to treat attention-deficit/hyperactivity disorder (ADHD) in children with histories of Fontan palliation (Fontan) or heart transplant (HT), despite the high prevalence of ADHD in these populations. To address this gap, we examined the cardiac course, somatic growth, and incidence of side effects for one year after medication initiation amongst children with Fontan or HT and comorbid ADHD. The final sample comprised 24 children with Fontan (12 medication-treated, 12 control) and 20 children with HT (10 medication-treated, 10 control). Demographic, somatic growth (height and weight percentile-for age), and cardiac data (blood pressure, heart rate, results of 24 h Holter monitoring, electrocardiograms) were extracted from electronic medical records. Medication-treated and control subjects were matched by cardiac diagnosis (Fontan or HT), age, and sex. Nonparametric statistical tests were utilized to compare between- and within-group differences prior to, and one year post, medication initiation. There were no differences in somatic growth or cardiac data when comparing medication-treated participants to matched controls, regardless of cardiac diagnosis. Within the medication group, a statistically significant increase in blood pressure was observed, though the group average remained within clinically acceptable limits. While results are preliminary in nature due to our very limited sample size, our findings suggest that ADHD medications can be tolerated with minimal cardiac or somatic growth effects amongst complex cardiac patients. Our preliminary results favor treating ADHD with medication, which has considerable implications for long-term academic/employment outcomes and quality of life for this population. Close collaboration between pediatricians, psychologists, and cardiologists is essential to individualizing and optimizing interventions and outcomes for children with Fontan or HT.
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Affiliation(s)
- Yasmine R Jassal
- Children's Hospital Colorado, 13123 East 16Th Avenue, Aurora, CO, 80045, USA.
- University of Colorado School of Medicine, Aurora, CO, USA.
| | - Rebecca Slomowitz
- Children's Hospital Colorado, 13123 East 16Th Avenue, Aurora, CO, 80045, USA
| | - Melanie D Everitt
- Children's Hospital Colorado, 13123 East 16Th Avenue, Aurora, CO, 80045, USA
- University of Colorado School of Medicine, Aurora, CO, USA
| | - Elizabeth S Christofferson
- Children's Hospital Colorado, 13123 East 16Th Avenue, Aurora, CO, 80045, USA
- University of Colorado School of Medicine, Aurora, CO, USA
| | - Johannes C von Alvensleben
- Children's Hospital Colorado, 13123 East 16Th Avenue, Aurora, CO, 80045, USA
- University of Colorado School of Medicine, Aurora, CO, USA
| | - Michael Di Maria
- Children's Hospital Colorado, 13123 East 16Th Avenue, Aurora, CO, 80045, USA
- University of Colorado School of Medicine, Aurora, CO, USA
| | - Kelly R Wolfe
- Children's Hospital Colorado, 13123 East 16Th Avenue, Aurora, CO, 80045, USA
- University of Colorado School of Medicine, Aurora, CO, USA
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Fetcu S, Osawa T, Klawonn F, Schaeffer T, Röhlig C, Staehler H, Di Padua C, Heinisch PP, Piber N, Hager A, Ewert P, Hörer J, Ono M. Longitudinal analysis of systemic ventricular function and atrioventricular valve function after the Norwood procedure. Eur J Cardiothorac Surg 2024; 65:ezae058. [PMID: 38383053 DOI: 10.1093/ejcts/ezae058] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/14/2023] [Revised: 11/20/2023] [Accepted: 02/20/2024] [Indexed: 02/23/2024] Open
Abstract
OBJECTIVES To evaluate longitudinal systemic ventricular function and atrioventricular valve regurgitation in patients after the neonatal Norwood procedure. METHODS Serial postoperative echocardiographic images before Fontan completion were assessed in neonates who underwent the Norwood procedure between 2001 and 2020. Ventricular function and atrioventricular valve regurgitation were compared between patients with modified Blalock-Taussig shunt and right ventricle to pulmonary artery conduit. RESULTS A total of 335 patients were identified including 273 hypoplastic left heart syndrome and 62 of its variants. Median age at Norwood was 8 (7-12) days. Modified Blalock-Taussig shunt was performed in 171 patients and the right ventricle to pulmonary artery conduit in 164 patients. Longitudinal ventricular function and atrioventricular valve regurgitation were evaluated using a total of 4352 echocardiograms. After the Norwood procedure, ventricular function was initially worse (1-30 days) but thereafter better (30 days to stage II) in the right ventricle to pulmonary artery conduit group (P < 0.001). After stage II, the ventricular function was inferior in the right ventricle to the pulmonary artery conduit group (P < 0.001). Atrioventricular valve regurgitation between the Norwood procedure and stage II was more frequent in the modified Blalock-Taussig shunt group (P < 0.001). After stage II, there was no significant difference in atrioventricular valve regurgitation between the groups (P = 0.171). CONCLUSIONS The effect of shunt type on haemodynamics after the Norwood procedure seems to vary according to the stage of palliation. After the Norwood, the modified Blalock-Taussig shunt is associated with poorer ventricular function and worse atrioventricular valve regurgitation compared to right ventricle to pulmonary artery conduit. Whereas, after stage II, modified Blalock-Taussig shunt is associated with better ventricular function and comparable atrioventricular valve regurgitation, compared to the right ventricle to pulmonary artery conduit.
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Affiliation(s)
- Stefan Fetcu
- Department of Congenital and Pediatric Heart Surgery, German Heart Center Munich, Technische Universität München, Munich, Germany
- Division of Congenital and Pediatric Heart Surgery, University Hospital of Munich, Ludwig-Maximilians-Universität, Munich, Germany
| | - Takuya Osawa
- Department of Congenital and Pediatric Heart Surgery, German Heart Center Munich, Technische Universität München, Munich, Germany
- Division of Congenital and Pediatric Heart Surgery, University Hospital of Munich, Ludwig-Maximilians-Universität, Munich, Germany
| | - Frank Klawonn
- Department of Biostatistics, Helmholtz Center for Infection Research, Braunschweig, Germany
- Department of Computer Science, Ostfalia University, Wolfenbüttel, Germany
| | - Thibault Schaeffer
- Department of Congenital and Pediatric Heart Surgery, German Heart Center Munich, Technische Universität München, Munich, Germany
- Division of Congenital and Pediatric Heart Surgery, University Hospital of Munich, Ludwig-Maximilians-Universität, Munich, Germany
| | - Christoph Röhlig
- Department of Congenital Heart Disease and Pediatric Cardiology, German Heart Center Munich, Technische Universität München, Munich, Germany
| | - Helena Staehler
- Department of Congenital and Pediatric Heart Surgery, German Heart Center Munich, Technische Universität München, Munich, Germany
- Division of Congenital and Pediatric Heart Surgery, University Hospital of Munich, Ludwig-Maximilians-Universität, Munich, Germany
| | - Chiara Di Padua
- Department of Congenital and Pediatric Heart Surgery, German Heart Center Munich, Technische Universität München, Munich, Germany
- Division of Congenital and Pediatric Heart Surgery, University Hospital of Munich, Ludwig-Maximilians-Universität, Munich, Germany
| | - Paul Philipp Heinisch
- Department of Congenital and Pediatric Heart Surgery, German Heart Center Munich, Technische Universität München, Munich, Germany
- Division of Congenital and Pediatric Heart Surgery, University Hospital of Munich, Ludwig-Maximilians-Universität, Munich, Germany
| | - Nicole Piber
- Department of Cardiovascular Surgery, German Heart Center Munich, Technische Universität München, Munich, Germany
| | - Alfred Hager
- Department of Congenital Heart Disease and Pediatric Cardiology, German Heart Center Munich, Technische Universität München, Munich, Germany
| | - Peter Ewert
- Department of Congenital Heart Disease and Pediatric Cardiology, German Heart Center Munich, Technische Universität München, Munich, Germany
| | - Jürgen Hörer
- Department of Congenital and Pediatric Heart Surgery, German Heart Center Munich, Technische Universität München, Munich, Germany
- Division of Congenital and Pediatric Heart Surgery, University Hospital of Munich, Ludwig-Maximilians-Universität, Munich, Germany
| | - Masamichi Ono
- Department of Congenital and Pediatric Heart Surgery, German Heart Center Munich, Technische Universität München, Munich, Germany
- Division of Congenital and Pediatric Heart Surgery, University Hospital of Munich, Ludwig-Maximilians-Universität, Munich, Germany
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Ravndal M, Idorn L, Nielsen KG, Hjortdal V. Lung Function in Fontan Patients Over a Ten-Year Period: Is the Fontan Circulation Impairing Lung Development? Pediatr Cardiol 2024; 45:500-512. [PMID: 38273050 PMCID: PMC10891202 DOI: 10.1007/s00246-023-03389-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/14/2023] [Accepted: 12/18/2023] [Indexed: 01/27/2024]
Abstract
Few studies have investigated how the Fontan circulation affects lung function, and no studies have investigated the development of lung function over longer time in these patients. We aimed to describe the development of lung function in Fontan patients over a 10-year period. Pulmonary function tests (PFT), including spirometry and diffusion capacity for Carbon Monoxide (DLCO) and Nitric Oxide (DLNO), were conducted in a Danish Fontan cohort in 2011 (PFT-I). In 2021, re-investigations were performed (PFT-II). We investigated changes in percent predicted (%pred) lung function from PFT-I to PFT-II. Patients were categorized into a pediatric group (age under 18 at PFT-I) and an adult group (age 18 or older at PFT-I). Out of the 81 patients completing PFT-I, 48 completed PFT-II. In the pediatric group (32 patients), there were significant declines in %pred forced expiratory volume in 1s (99.7 (92.4, 104.4)-89.3 (84.9, 97.2), p < 0,001), forced vital capacity (98.3 (87.8, 106.1)-96.7 (86.7, 100.6), p = 0.008), and alveolar volume (95.5 (89.5, 101.6)-89.5 (79.7, 93.2), p < 0.001). The corresponding measurements remained stable in the adult group. However, the median %pred DLNO significantly declined in the adult group (58.4 (53.3, 63.5)-53.7 (44.1, 57.3), p = 0.005). Over a 10-year period, several lung function parameters declined significantly in the younger Fontan patients, suggesting possible impairments in lung development during growth. The decline in %pred DLNO in the adult patient group indicates deterioration of the membrane component of diffusion capacity, implying that the Fontan circulation might negatively affect the alveolar membrane over time.
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Affiliation(s)
- Maren Ravndal
- Department of Cardiothoracic Surgery, Copenhagen University Hospital Rigshospitalet, Copenhagen, Denmark.
| | - Lars Idorn
- Section of Pediatric Cardiology, Department of Pediatrics and Adolescent Medicine, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - Kim Gjerum Nielsen
- Pediatric Pulmonary Service, Department of Pediatrics and Adolescent Medicine, Copenhagen University Hospital, Copenhagen, Denmark
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Vibeke Hjortdal
- Department of Cardiothoracic Surgery, Copenhagen University Hospital Rigshospitalet, Copenhagen, Denmark
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
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Madan N, Aly D, Kathol M, Buddhavarapu A, Rieth T, Sherman A, Forsha D. Relationship Between Obesity and Global Longitudinal Strain in the Pediatric Single Ventricle Fontan Population Across Ventricular Morphologies. J Am Heart Assoc 2024; 13:e028616. [PMID: 38240220 PMCID: PMC11056151 DOI: 10.1161/jaha.122.028616] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/01/2022] [Accepted: 11/27/2023] [Indexed: 02/07/2024]
Abstract
BACKGROUND Obesity is associated with diminished myocardial function as measured by strain echocardiography in children and young adults with normal cardiac anatomy. Data are lacking about the effect of obesity on myocardial strain in patients with a single ventricle. In this study, the relationship between body mass index (BMI) and single ventricle myocardial strain in the Fontan population was assessed. METHODS AND RESULTS Thirty-eight abnormal BMI Fontan cases (21 overweight and 17 obese) and 30 normal BMI Fontan controls matched based on single ventricular morphology, age, and sex were included in the study. Ventricular morphology was categorized as single right ventricle, single left ventricle, or biventricular. Single ventricle global longitudinal peak systolic strain (GLS) and other echocardiographic measurements were performed and compared between groups, with a P≤0.05 defined as significant. The abnormal BMI group demonstrated diminished GLS (-15.7±3.6% versus -17.2±3.2%, [P=0.03]) and elevated systolic blood pressure (P=0.04) compared with the normal BMI group. On subgroup analysis of those with single right ventricle morphology, the abnormal BMI group demonstrated diminished GLS compared with controls. There was no significant difference in GLS between the abnormal BMI and control groups in the single left ventricle and biventricular subgroups. Analyzed by ventricular morphology, no other variables were statistically different in the abnormal BMI group including systolic blood pressure. Inter-reader reproducibility for GLS and strain rate were excellent for both measures. CONCLUSIONS Obesity has an adverse relationship with myocardial strain in the young Fontan population, with the most maladaptive response seen in the single right ventricle.
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Affiliation(s)
- Nitin Madan
- Ward Family Heart Center, Children’s Mercy Kansas CityKansas CityMOUSA
- University of Missouri‐Kansas CityKansas CityMOUSA
| | - Doaa Aly
- Ward Family Heart Center, Children’s Mercy Kansas CityKansas CityMOUSA
- University of Missouri‐Kansas CityKansas CityMOUSA
| | - Melanie Kathol
- Ward Family Heart Center, Children’s Mercy Kansas CityKansas CityMOUSA
| | | | - Thomas Rieth
- University of Missouri‐Kansas CityKansas CityMOUSA
| | - Ashley Sherman
- Health Services and Outcomes Research, Children’s Mercy Kansas CityKansas CityMOUSA
| | - Daniel Forsha
- Ward Family Heart Center, Children’s Mercy Kansas CityKansas CityMOUSA
- University of Missouri‐Kansas CityKansas CityMOUSA
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Van den Eynde J, Westenberg JJM, Hazekamp MG, Lamb HJ, Jongbloed MRM, Wentzel JJ, Kenjeres S, Dekkers IA, Van De Bruaene A, Rijnberg FM, Roest AAW. Noninvasive Advanced Cardiovascular Magnetic Resonance-Derived Fontan Hemodynamics Are Associated With Reduced Kidney Function But Not Albuminuria. J Am Heart Assoc 2024; 13:e033122. [PMID: 38293946 PMCID: PMC11056124 DOI: 10.1161/jaha.123.033122] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/21/2023] [Accepted: 12/01/2023] [Indexed: 02/01/2024]
Abstract
BACKGROUND Kidney disease is the most important predictor of death in patients with a Fontan circulation, yet its clinical and hemodynamic correlates have not been well established. METHODS AND RESULTS A total of 53 ambulatory patients with a Fontan circulation (median age, 16.2 years, 52.8% male patients) underwent advanced cardiovascular magnetic resonance assessment, including 4-dimensional flow imaging and computational fluid dynamics. Estimated glomerular filtration rate (eGFR) <90 mL/min per 1.73 m2 was observed in 20.8% and albumin-to-creatinine ratio >3 mg/mmol in 39.6%. The average eGFR decline rate was -1.83 mL/min per 1.73 m2 per year (95% CI, -2.67 to -0.99; P<0.001). Lower eGFR was associated with older age, larger body surface area at examination, longer time since Fontan procedure, and lower systemic ventricular ejection fraction. Higher albumin-to-creatinine ratio was associated with absence of fenestration at the Fontan operation, and older age and lower systemic ventricular ejection fraction at the assessment. Lower cross-sectional area of the Fontan conduit indexed to flow (r=0.32, P=0.038), higher inferior vena cava-conduit velocity mismatch factor (r=-0.35, P=0.022), higher kinetic energy indexed to flow in the total cavopulmonary connection (r=-0.59, P=0.005), and higher total cavopulmonary connection resistance (r=-0.42, P=0.005 at rest; r=-0.43, P=0.004 during exercise) were all associated with lower eGFR but not with albuminuria. CONCLUSIONS Kidney dysfunction and albuminuria are common among clinically well adolescents and young adults with a Fontan circulation. Advanced cardiovascular magnetic resonance-derived metrics indicative of declining Fontan hemodynamics are associated with eGFR and might serve as targets to improve kidney health. Albuminuria might be driven by other factors that need further investigation.
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Affiliation(s)
- Jef Van den Eynde
- Department of Pediatrics, Division of Pediatric CardiologyLeiden University Medical CenterLeidenThe Netherlands
- Department of Cardiothoracic SurgeryLeiden University Medical CenterLeidenThe Netherlands
- Congenital and Structural CardiologyUniversity Hospitals LeuvenLeuvenBelgium
- Department of Cardiovascular SciencesCatholic University LeuvenLeuvenBelgium
| | - Jos J. M. Westenberg
- CardioVascular Imaging Group, Department of RadiologyLeiden University Medical CenterLeidenThe Netherlands
| | - Mark G. Hazekamp
- Department of Cardiothoracic SurgeryLeiden University Medical CenterLeidenThe Netherlands
| | - Hildo J. Lamb
- CardioVascular Imaging Group, Department of RadiologyLeiden University Medical CenterLeidenThe Netherlands
| | - Monique R. M. Jongbloed
- Department of CardiologyLeiden University Medical CenterLeidenThe Netherlands
- Department of Anatomy & EmbryologyLeiden University Medical CenterLeidenThe Netherlands
| | - Jolanda J. Wentzel
- Department of CardiologyBiomechanical Engineering, Erasmus MCRotterdamThe Netherlands
| | - Sasa Kenjeres
- Department of Chemical Engineering, Faculty of Applied SciencesDelft University of TechnologyDelftThe Netherlands
- J.M. Burgers Centrum Research School for Fluid MechanicsDelftThe Netherlands
| | - Ilona A. Dekkers
- CardioVascular Imaging Group, Department of RadiologyLeiden University Medical CenterLeidenThe Netherlands
| | - Alexander Van De Bruaene
- Congenital and Structural CardiologyUniversity Hospitals LeuvenLeuvenBelgium
- Department of Cardiovascular SciencesCatholic University LeuvenLeuvenBelgium
| | - Friso M. Rijnberg
- Department of Cardiothoracic SurgeryLeiden University Medical CenterLeidenThe Netherlands
| | - Arno A. W. Roest
- Department of Pediatrics, Division of Pediatric CardiologyLeiden University Medical CenterLeidenThe Netherlands
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Dib N, Samuel M, Levesque S, Zaidi A, Cohen S, Opotowsky AR, Mongeon FP, Mondésert B, Kay J, Ibrahim R, Hamilton RM, Fournier A, Jameson SM, Dore A, Cook SC, Cohen S, Chaix MA, Broberg CS, Aboulhosn J, Poirier N, Khairy P. Impact of Fontan Fenestration on Adverse Cardiovascular Outcomes: A Multicentre Study. Can J Cardiol 2024:S0828-282X(24)00079-5. [PMID: 38309467 DOI: 10.1016/j.cjca.2024.01.031] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2023] [Revised: 01/24/2024] [Accepted: 01/26/2024] [Indexed: 02/05/2024] Open
Abstract
BACKGROUND Fenestrating a Fontan baffle has been associated with improved perioperative outcomes in patients with univentricular hearts. However, longer-term potential adverse effects remain debated. We sought to assess the impact of a fenestrated Fontan baffle on adverse cardiovascular events including all-cause mortality, cardiac transplantation, atrial arrhythmias, and thromboemboli. METHODS A multicentre North American retrospective cohort study was conducted on patients with total cavopulmonary connection Fontan baffle, with and without fenestration. All components of the composite outcome were independently adjudicated. Potential static and time-varying confounders were taken into consideration, along with competing risks. RESULTS A total of 407 patients were followed for 10.4 (7.1-14.4) years; 70.0% had fenestration of their Fontan baffle. The fenestration spontaneously closed or was deliberately sealed in 79.9% of patients a median of 2.0 years after Fontan completion. In multivariable analysis in which a persistent fenestration was modelled as a time-dependent variable, an open fenestration did not confer a higher risk of the composite outcome (hazard ratio, 1.18; 95% confidence interval, 0.71-1.97; P = 0.521). In secondary analyses, an open fenestration was not significantly associated with components of the primary outcome: that is, mortality or transplantation, atrial arrhythmias, or thromboemboli. However, sensitivity analyses to assess the possible range of error resulting from imprecise dates for spontaneous fenestration closures could not rule out significant associations between an open fenestration and atrial arrhythmias or thromboemboli. CONCLUSIONS In this multicentre study, no significant association was identified between an open fenestration in the Fontan baffle and major adverse cardiovascular events.
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Affiliation(s)
- Nabil Dib
- Montreal Heart Institute, Université de Montréal, Montréal, Québec, Canada
| | - Michelle Samuel
- Montreal Heart Institute, Université de Montréal, Montréal, Québec, Canada
| | - Sylvie Levesque
- Montreal Health Innovations Coordinating Center, Montréal, Québec, Canada
| | - Ali Zaidi
- Nationwide Children's Hospital, Ohio State University, Columbus, Ohio, USA
| | - Sarah Cohen
- Hôpital Marie-Lannelongue, Groupe Hospitalier Saint-Joseph, Le Plessis Robinson, Paris, France
| | - Alexander R Opotowsky
- Boston Adult Congenital Heart Service, Boston Children's Hospital and Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA; The Cincinnati Adult Congenital Heart Disease Program, Cincinnati Children's Hospital, Cincinnati, Ohio, USA
| | | | - Blandine Mondésert
- Montreal Heart Institute, Université de Montréal, Montréal, Québec, Canada
| | - Joseph Kay
- University of Colorado Denver, Aurora, Colorado, USA
| | - Reda Ibrahim
- Montreal Heart Institute, Université de Montréal, Montréal, Québec, Canada
| | - Robert M Hamilton
- The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
| | - Anne Fournier
- Hôpital Sainte-Justine, Université de Montréal, Montréal, Québec, Canada
| | - Susan M Jameson
- Stanford Adult Congenital Heart Program, Lucile Packard Children's Hospital Stanford and Stanford Health Care, Stanford University School of Medicine, Palo Alto, California, USA
| | - Annie Dore
- Montreal Heart Institute, Université de Montréal, Montréal, Québec, Canada
| | - Stephen C Cook
- Indiana University Health Medical Center, Indianapolis, Indiana, USA
| | - Scott Cohen
- The Wisconsin Adult Congenital Heart (WAtCH) Program, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | - Marie-A Chaix
- Montreal Heart Institute, Université de Montréal, Montréal, Québec, Canada
| | | | - Jamil Aboulhosn
- Ahmanson/UCLA Adult Congenital Heart Program, University of California, Los Angeles, California, USA
| | - Nancy Poirier
- Montreal Heart Institute, Université de Montréal, Montréal, Québec, Canada
| | - Paul Khairy
- Montreal Heart Institute, Université de Montréal, Montréal, Québec, Canada.
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Clode M, Tran D, Majumdar A, Ayer J, Ferrie S, Cordina R. Nutritional considerations for people living with a Fontan circulation: a narrative review. Cardiol Young 2024; 34:238-249. [PMID: 38258459 DOI: 10.1017/s1047951123004389] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/24/2024]
Abstract
The population of people living with a Fontan circulation are highly heterogenous, including both children and adults, who have complex health issues and comorbidities associated with their unique physiology throughout life. Research focused on nutritional considerations and interventions in the Fontan population is extremely limited beyond childhood. This review article discusses the current literature examining nutritional considerations in the setting of Fontan physiology and provides an overview of the available evidence to support nutritional management strategies and future research directions. Protein-losing enteropathy, growth deficits, bone mineral loss, and malabsorption are well-recognised nutritional concerns within this population, but increased adiposity, altered glucose metabolism, and skeletal muscle deficiency are also more recently identified issues. Emergencing evidence suggets that abnormal body composition is associated with poor circulatory function and health outcomes. Many nutrition-related issues, including the impact of congenital heart disease on nutritional status, factors contributing to altered body composition and comorbidities, as well as the role of the microbiome and metabolomics, remain poodly understood.
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Affiliation(s)
- Melanie Clode
- The University of Sydney, Sydney Medical School, Camperdown, NSW, Australia
- Heart Research Group, Murdoch Children's Research Institute, Melbourne, VIC, Australia
| | - Derek Tran
- The University of Sydney, Sydney Medical School, Camperdown, NSW, Australia
- Heart Research Institute, Newtown, NSW, Australia
- Department of Cardiology, Royal Prince Alfred Hospital, Camperdown, NSW, Australia
| | - Avik Majumdar
- The University of Sydney, Sydney Medical School, Camperdown, NSW, Australia
| | - Julian Ayer
- The University of Sydney, Sydney Medical School, Camperdown, NSW, Australia
- The Heart Centre for Children, The Sydney Children's Hospital Network, Westmead, NSW, Australia
| | - Suzie Ferrie
- The University of Sydney, Sydney Medical School, Camperdown, NSW, Australia
- Department of Nutrition and Dietetics, Royal Prince Alfred Hospital, Camperdown, NSW, Australia
| | - Rachael Cordina
- The University of Sydney, Sydney Medical School, Camperdown, NSW, Australia
- Heart Research Group, Murdoch Children's Research Institute, Melbourne, VIC, Australia
- Heart Research Institute, Newtown, NSW, Australia
- Department of Cardiology, Royal Prince Alfred Hospital, Camperdown, NSW, Australia
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58
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Yang EL, Evers PD, Long MJ, Mostafavifar M, Balaji S. Impact of Atrial Pacing in Fontan Patients with Junctional Rhythm: A Prospective Echocardiographic Study. Pediatr Cardiol 2024; 45:361-367. [PMID: 38062259 DOI: 10.1007/s00246-023-03345-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/28/2023] [Accepted: 11/03/2023] [Indexed: 01/28/2024]
Abstract
Sinus node dysfunction (SND) with junctional rhythm (JR) is common after the Fontan operation. Atrial pacing (AP) restores atrioventricular (AV) synchrony, but the placement of a pacemaker carries significant morbidity. To study the impact of AP on echocardiographic parameters of function in Fontan patients with SND and JR. Nine Fontan patients with AP for SND and JR were prospectively studied with echocardiography in the following conditions-baseline paced rhythm, underlying JR and, if possible, slow-paced rhythm below their baseline paced rate (~ 10 bpm faster than their JR rate). Cardiac index was significantly lower in JR (3 ± 1.1 L/min/m2) vs AP (4.2 ± 1.4 L/min/m2; p = 0.002). Diastolic function also significantly worsened with increased ratio of early diastolic systemic AV valve inflow velocity to early diastolic systemic AV valve annulus velocity (E/e' ratio) by tissue Doppler imaging (TDI) in JR (11.6 ± 4.6) vs AP (8.8 ± 2.2, p = 0.016). Pulmonary venous flow reversal was present in 7/9 patients in JR vs 0/9 in AP (p = 0.016). There were no significant differences in these echocardiographic measurements between the paced and slow-paced conditions. When compared to AP, JR was associated with a significant reduction in cardiac output and diastolic function, and an increased prevalence of pulmonary vein flow reversal. There were no differences between paced and slow-paced conditions, suggesting that AV synchrony rather than heart rate was primarily contributing to cardiac output. Further studies are needed to understand the chronic impact of JR on Fontan outcomes.
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Affiliation(s)
- Emily L Yang
- Division of Pediatric Cardiology, Oregon Health and Science University, 707 SW Gaines Street, Mail code: CDRC-P, Portland, OR, 97239, USA.
| | - Patrick D Evers
- Division of Pediatric Cardiology, Oregon Health and Science University, 707 SW Gaines Street, Mail code: CDRC-P, Portland, OR, 97239, USA
| | - Mia J Long
- Division of Pediatric Cardiology, Oregon Health and Science University, 707 SW Gaines Street, Mail code: CDRC-P, Portland, OR, 97239, USA
| | - Mina Mostafavifar
- Division of Pediatric Cardiology, Oregon Health and Science University, 707 SW Gaines Street, Mail code: CDRC-P, Portland, OR, 97239, USA
| | - Seshadri Balaji
- Division of Pediatric Cardiology, Oregon Health and Science University, 707 SW Gaines Street, Mail code: CDRC-P, Portland, OR, 97239, USA
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Dipchand AI, Webber SA. Pediatric heart transplantation: Looking forward after five decades of learning. Pediatr Transplant 2024; 28:e14675. [PMID: 38062996 DOI: 10.1111/petr.14675] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/09/2023] [Revised: 11/17/2023] [Accepted: 11/24/2023] [Indexed: 02/07/2024]
Abstract
Heart transplantation has become the standard of care for pediatric patients with end-stage heart disease throughout the world. Since the first transplant was performed in 1967, the number of transplants has grown dramatically with 13 449 pediatric heart transplants being reported to The International Society of Heart and Lung Transplant (ISHLT) between January 1992 and June 30, 2018. Outcomes have consistently improved over the last few decades, specifically short-term outcomes. Most recent survival data demonstrate that recipients who survive to 1-year post-transplant have excellent long-term survival with more than 60% of those who were transplanted as infants being alive 25 years later. Nonetheless, the rates of graft loss beyond the first year have remained relatively constant over time; driven primarily by our poor understanding and lack of treatments for chronic allograft vasculopathy (CAV). Acute rejection, CAV, graft failure, and infection continue to be the major causes of death within the first 5 years post-transplant. In addition, renal dysfunction, malignancy, and the need for re-transplantation remain as significant issues that require close follow-up. Looking forward, key challenges include improving donor utilization rates (including donation after cardiac death (DCD) and the use of ex vivo perfusion devices), the development of non-invasive biomarkers for rejection, efforts to mitigate the long-term effects of immunosuppression, and prevention of CAV. It is not possible to cover the entire evolution of pediatric heart transplantation over the last five decades, but in this review, we hope to touch on key observations, lessons learned, and practice changes that have advanced the field, as well as glance ahead to the next decade.
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Affiliation(s)
- Anne I Dipchand
- Department of Paediatrics, Head, Heart Transplant, Labatt Family Heart Centre, Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
| | - Steven A Webber
- Department of Pediatrics, Vanderbilt University School of Medicine, Pediatrician-in-Chief, Monroe Carell Jr. Children's Hospital at Vanderbilt, Nashville, Tennessee, USA
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Sethasathien S, Leemasawat K, Silvilairat S, Sittiwangkul R, Makonkawkeyoon K, Leerapun A, Kongkarnka S, Inmutto N, Suksai S, Apaijai N, Chattipakorn SC, Chattipakorn N. Mitochondrial dysfunction is associated with the severity of liver fibrosis in patients after the Fontan operation. J Cell Mol Med 2024; 28:e18035. [PMID: 37966270 PMCID: PMC10826431 DOI: 10.1111/jcmm.18035] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2023] [Revised: 10/26/2023] [Accepted: 10/30/2023] [Indexed: 11/16/2023] Open
Abstract
The gold standard for determining the severity of liver disease in Fontan patients is now liver biopsy. Since it is an invasive procedure, this study determined the possibility of applying mitochondrial function from isolated peripheral blood mononuclear cells (PBMCs) as a non-invasive indicator of liver fibrosis. Fontan patients (n = 37) without known liver disease were analysed cross-sectionally. Patients were classified according to their histology using the METAVIR score as follows; F0/F1-no/mild fibrosis; F2-moderate fibrosis; and F3/F4-cirrhosis. Peripheral blood mononuclear cells were assessed for mitochondrial activity and apoptosis. This study did not find any significant differences in cardiac function among the groups according to liver histology. Interestingly, our findings indicated a significant decrease in maximal respiration and spare respiratory capacity, in both the moderate (F2) and cirrhosis (F3/F4) groups compared with the group without significant fibrosis (F0/F1). Moreover, the cirrhosis group exhibited higher levels of apoptosis and lower levels of live cells, compared with both the moderate and no significant fibrosis groups. In conclusion, the degree of liver fibrosis in Fontan patients is strongly correlated with mitochondrial dysfunction in PBMCs. Mitochondrial function and apoptosis could potentially serve as novel markers for tracking the progression of liver fibrosis in these patients.
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Affiliation(s)
- Saviga Sethasathien
- Division of Pediatric Cardiology, Department of Pediatrics, Faculty of MedicineChiang Mai UniversityChiang MaiThailand
| | - Krit Leemasawat
- Division of Cardiovascular Diseases, Department of Medicine, Faculty of MedicineChiang Mai UniversityChiang MaiThailand
| | - Suchaya Silvilairat
- Division of Pediatric Cardiology, Department of Pediatrics, Faculty of MedicineChiang Mai UniversityChiang MaiThailand
| | - Rekwan Sittiwangkul
- Division of Pediatric Cardiology, Department of Pediatrics, Faculty of MedicineChiang Mai UniversityChiang MaiThailand
| | - Krit Makonkawkeyoon
- Division of Pediatric Cardiology, Department of Pediatrics, Faculty of MedicineChiang Mai UniversityChiang MaiThailand
| | - Apinya Leerapun
- Division of Gastroenterology Diseases, Department of Medicine, Faculty of MedicineChiang Mai UniversityChiang MaiThailand
| | - Sarawut Kongkarnka
- Department of Pathology, Faculty of MedicineChiang Mai UniversityChiang MaiThailand
| | - Nakarin Inmutto
- Department of Radiology, Faculty of MedicineChiang Mai UniversityChiang MaiThailand
| | - Supanai Suksai
- Cardiac Electrophysiology Research and Training Center, Faculty of MedicineChiang Mai UniversityChiang MaiThailand
- Center of Excellence in Cardiac Electrophysiology ResearchChiang Mai UniversityChiang MaiThailand
| | - Nattayaporn Apaijai
- Cardiac Electrophysiology Research and Training Center, Faculty of MedicineChiang Mai UniversityChiang MaiThailand
- Center of Excellence in Cardiac Electrophysiology ResearchChiang Mai UniversityChiang MaiThailand
- Cardiac Electrophysiology Unit, Department of Physiology, Faculty of MedicineChiang Mai UniversityChiang MaiThailand
| | - Siriporn C. Chattipakorn
- Cardiac Electrophysiology Research and Training Center, Faculty of MedicineChiang Mai UniversityChiang MaiThailand
- Center of Excellence in Cardiac Electrophysiology ResearchChiang Mai UniversityChiang MaiThailand
- Department of Oral Biology and Diagnostic Sciences, Faculty of DentistryChiang Mai UniversityChiang MaiThailand
| | - Nipon Chattipakorn
- Cardiac Electrophysiology Research and Training Center, Faculty of MedicineChiang Mai UniversityChiang MaiThailand
- Center of Excellence in Cardiac Electrophysiology ResearchChiang Mai UniversityChiang MaiThailand
- Cardiac Electrophysiology Unit, Department of Physiology, Faculty of MedicineChiang Mai UniversityChiang MaiThailand
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Jokhadar M, Hardin JT. Congenital Heart Disease in the Adult Cardiac Intensive Care Unit. Crit Care Clin 2024; 40:179-191. [PMID: 37973353 DOI: 10.1016/j.ccc.2023.09.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2023]
Abstract
This article provides a broad overview of key concepts and more commonly encountered critical illness presentations in adult congenital heart disease (ACHD) patients. General principles are discussed, and the need for ACHD subspecialty consultation is emphasized. ACHD is categorized based on hemodynamic profile, and common clinical presentations are reviewed, including common pitfalls. Many ACHD lesions are associated with predictable complications, and awareness of these associations can guide evaluation and management, which are listed in this article.
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Affiliation(s)
- Maan Jokhadar
- Department of Cardiology, Mayo Clinic, 200 First Street Southwest, Rochester, MN 55905, USA.
| | - Joel T Hardin
- Emory Adult Congenital Heart Center, Emory University, 1365 A Clifton Road Northeast, Atlanta, GA 30322, USA
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Elder RW, Valente AM, Davey B, Wu F, Drucker N, Lombardi K, Lee S, McCollum S, Shabanova V, St. Clair N, Azcue N, Toro-Salazar OH, Rathod RH. How Good Are Cardiologists at Predicting Major Adverse Events in Fontan Patients? JACC. ADVANCES 2024; 3:100736. [PMID: 38939804 PMCID: PMC11198720 DOI: 10.1016/j.jacadv.2023.100736] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/28/2023] [Revised: 09/20/2023] [Accepted: 10/12/2023] [Indexed: 06/29/2024]
Abstract
Background It is unknown how well cardiologists predict which Fontan patients are at risk for major adverse events (MAEs). Objectives The purpose of this study was to examine the accuracy of cardiologists' ability to identify the "good Fontan" patient, free from MAE within the following year, and compare that predicted risk cohort to patients who experienced MAE. Methods This prospective, multicenter study included patients ≥10 years with lateral tunnel or extracardiac Fontan. The cardiologist was asked the yes/no "surprise" question: would you be surprised if your patient has a MAE in the next year? After 12 months, the cardiologist was surveyed to assess MAE. Agreement between cardiologist predictions of MAE and observed MAE was determined using the simple kappa coefficient. Multivariable generalized linear mixed effects models were performed to identify factors associated with MAE. Results Overall, 146 patients were enrolled, and 99/146 (68%) patients w`ere predicted to be a "good Fontan." After 12 months, 17 (12%) experienced a MAE. The simple kappa coefficient of cardiologists' prediction was 0.17 (95% CI: 0.02-0.32), suggesting prediction of MAE was 17% better than random chance. In the multivariable cardiologist-predicted MAE (N = 47) model, diuretic/beta-blocker use (P ≤ 0.001) and systolic dysfunction (P = 0.005) were associated with MAE. In the observed multivariable MAE (N = 17) model, prior unplanned cardiac admission (P = 0.006), diuretic/beta-blocker use (P = 0.028), and ≥moderate atrioventricular valve regurgitation (P = 0.049) were associated with MAE. Conclusions Cardiologists are marginally able to predict which Fontan patients are at risk for MAE over a year. There was overlap between factors associated with a cardiologist's prediction of risk and observed MAE, namely the use of diuretic/beta-blocker.
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Affiliation(s)
- Robert W. Elder
- Department of Pediatrics and Internal Medicine (Cardiology), Yale University School of Medicine, New Haven, Connecticut, USA
| | - Anne Marie Valente
- Department of Cardiology, Boston Children’s Hospital, Harvard Medical School, Boston, Massachusetts, USA
- Division of Cardiology, Department of Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Brooke Davey
- Division of Cardiology, Connecticut Children’s Hospital, Hartford, Connecticut, USA
| | - Fred Wu
- Department of Cardiology, Boston Children’s Hospital, Harvard Medical School, Boston, Massachusetts, USA
- Division of Cardiology, Department of Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Nancy Drucker
- Division of Pediatric Cardiology, The University of Vermont Children’s Hospital, Burlington, Vermont, USA
| | - Kristin Lombardi
- Department of Pediatrics, Warren Alpert Medical School of Brown University, Providence, Rhode Island, USA
| | - Seohyuk Lee
- Department of Pediatrics and Internal Medicine (Cardiology), Yale University School of Medicine, New Haven, Connecticut, USA
| | - Sarah McCollum
- Department of Pediatrics and Internal Medicine (Cardiology), Yale University School of Medicine, New Haven, Connecticut, USA
- Department of Biostatistics, Yale School of Public Health, New Haven, Connecticut, USA
| | - Veronika Shabanova
- Department of Pediatrics and Internal Medicine (Cardiology), Yale University School of Medicine, New Haven, Connecticut, USA
- Department of Biostatistics, Yale School of Public Health, New Haven, Connecticut, USA
| | - Nicole St. Clair
- Department of Cardiology, Boston Children’s Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Nina Azcue
- Department of Cardiology, Boston Children’s Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Olga H. Toro-Salazar
- Division of Cardiology, Connecticut Children’s Hospital, Hartford, Connecticut, USA
| | - Rahul H. Rathod
- Department of Cardiology, Boston Children’s Hospital, Harvard Medical School, Boston, Massachusetts, USA
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Seckeler MD. FUELing Improved Treatment for Patients with Fontan Physiology. Am J Cardiol 2024; 210:309-310. [PMID: 37879384 DOI: 10.1016/j.amjcard.2023.10.057] [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: 10/17/2023] [Accepted: 10/19/2023] [Indexed: 10/27/2023]
Affiliation(s)
- Michael D Seckeler
- Department of Pediatrics (Cardiology), University of Arizona, Tucson, Arizona.
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Balaji S, Evers PD, Batra AS, Moore J. Management of Junctional Rhythm in Patients After the Fontan Operation: A Multicenter Congenital Cardiology Survey. Pediatr Cardiol 2024; 45:63-67. [PMID: 37740738 DOI: 10.1007/s00246-023-03296-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/25/2023] [Accepted: 09/05/2023] [Indexed: 09/25/2023]
Abstract
Sinus node dysfunction with concomitant junctional rhythm (JR) is frequently observed among Fontan patients and has been recognized as a contributor to heart failure. The impact and management of JR is unclear. A survey was mailed to all members of the Pediatric and Congenital Electrophysiology society (PACES) and members were asked to forward the questionnaire to their non-electrophysiology colleagues. Responses were received from 154 physicians (88 electrophysiologists (EP's) and 66 non-EP's (46 pediatric cardiologists and 20 adult congenital cardiologists). There were few differences in the response between EP's and non-EP's. Overall, 57% recommended an annual ambulatory ECG (AECG). A significant majority (80%) opted to continue to follow patients with significant periods of JR on AECG as long as the patients were asymptomatic, and showed no echocardiographic signs of cardiac decompensation. However, 84% would place a pacemaker in a patient with JR who was having open chest surgery for other reasons. Finally, pacemaker placement would be performed by 91% if a patient with JR showed signs of heart failure. Most congenital cardiologists would not recommend pacemaker placement in asymptomatic Fontan patients with JR. Further studies are needed on the Fontan population to determine the impact of SND and JR on longer term outcomes and to determine the role and optimal timing of pacemaker placement in these patients.
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Affiliation(s)
- Seshadri Balaji
- Division of Cardiology, Department of Pediatrics, Oregon Health & Science University, 707, SW Gaines Street, Mailcode: CDRC-P, Portland, OR, 97239, USA.
| | - Patrick D Evers
- Division of Cardiology, Department of Pediatrics, Oregon Health & Science University, 707, SW Gaines Street, Mailcode: CDRC-P, Portland, OR, 97239, USA
| | - Anjan S Batra
- Division of Cardiology, Department of Pediatrics, University of California, Irvine, CA, USA
| | - Jeremy Moore
- Division of Cardiology, Department of Pediatrics, University of California, Los Angeles, CA, USA
- Ahmanson/UCLA Adult Congenital Heart Disease Program, University of California, Los Angeles, CA, USA
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Şişli E, Yıldırım C, Aka İB, Tuncer ON, Atay Y, Özbaran M, Pekkan K. Switching the Left and the Right Hearts: A Novel Bi-ventricle Mechanical Support Strategy with Spared Native Single-Ventricle. Ann Biomed Eng 2023; 51:2853-2872. [PMID: 37635154 DOI: 10.1007/s10439-023-03348-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2023] [Accepted: 08/09/2023] [Indexed: 08/29/2023]
Abstract
End-stage Fontan patients with single-ventricle (SV) circulation are often bridged-to-heart transplantation via mechanical circulatory support (MCS). Donor shortage and complexity of the SV physiology demand innovative MCS. In this paper, an out-of-the-box circulation concept, in which the left and right ventricles are switched with each other is introduced as a novel bi-ventricle MCS configuration for the "failing" Fontan patients. In the proposed configuration, the systemic circulation is maintained through a conventional mechanical ventricle assist device (VAD) while the venous circulation is delegated to the native SV. This approach spares the SV and puts it to a new use at the right-side providing the most-needed venous flow pulsatility to the failed Fontan circulation. To analyze its feasibility and performance, eight SV failure modes have been studied via an established multi-compartmental lumped parameter cardiovascular model (LPM). Here the LPM model is experimentally validated against the corresponding pulsatile mock-up flow loop measurements of a representative 15-year-old Fontan patient employing a clinically-approved VAD (Medtronic-HeartWare). The proposed surgical configuration maintained the healthy cardiac index (3-3.5 l/min/m2) and the normal mean systemic arterial pressure levels. For a failed SV with low ejection fraction (EF = 26%), representing a typical systemic Fontan failure, the proposed configuration enabled a ~ 28 mmHg amplitude in the venous/pulmonary waveforms and a 2 mmHg decrease in the central venous pressure (CVP) together with acceptable mean pulmonary artery pressures (17.5 mmHg). The pulmonary vascular resistance (PVR)-SV failure case provided a ~ 5 mmHg drop in the CVP, with venous/pulmonary pulsatility reaching to ~ 22 mmHg. For the high PVR failure case with a healthy SV (EF = 44%) pulmonary hypertension is likely to occur as expected. While this condition is routinely encountered during the heart transplantation and managed through pulmonary vasodilators a need for precise functional assessment of the spared failed-ventricle is recommended if utilized in the PVR failure mode. Comprehensive in vitro and in silico results encourage this novel concept as a low-cost, more physiological alternative to the conventional bi-ventricle MCS pending animal experiments.
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Affiliation(s)
- Emrah Şişli
- Pediatric Cardiovascular Surgery, Department of Cardiovascular Surgery, Osmangazi University Faculty of Medicine, Büyükdere District, Campus of Meşelik, Tepebaşı, 26480, Eskisehir, Turkey.
| | - Canberk Yıldırım
- Department of Biomedical Sciences and Engineering, Koç University, Istanbul, Turkey
| | - İbrahim Başar Aka
- Department of Mechatronics Engineering, İstanbul Bilgi University, Istanbul, Turkey
| | - Osman Nuri Tuncer
- Pediatric Cardiovascular Surgery, Department of Cardiovascular Surgery, Ege University Faculty of Medicine, Izmir, Turkey
| | - Yüksel Atay
- Pediatric Cardiovascular Surgery, Department of Cardiovascular Surgery, Ege University Faculty of Medicine, Izmir, Turkey
| | - Mustafa Özbaran
- Heart Transplantation, Department of Cardiovascular Surgery, Ege University Faculty of Medicine, Izmir, Turkey
| | - Kerem Pekkan
- Department of Mechanical Engineering, Koç University, Rumeli Feneri Campus, Sarıyer, Istanbul, Turkey.
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Schäfer M, Di Maria MV, Jaggers J, Stone ML, Campbell DN, Ivy DD, Mitchell MB. Hemi-Fontan and bidirectional Glenn operations result in flow-mediated viscous energy loss at the time of stage II palliation. JTCVS OPEN 2023; 16:836-843. [PMID: 38204687 PMCID: PMC10775100 DOI: 10.1016/j.xjon.2023.09.030] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/20/2023] [Revised: 08/24/2023] [Accepted: 09/08/2023] [Indexed: 01/12/2024]
Abstract
Background Superior cavopulmonary connection (SCPC) for stage II palliation of hypoplastic left heart syndrome (HLHS) is achieved most frequently by either a bidirectional Glenn (BDG) or hemi-Fontan (HF) operation. The comparison of flow hemodynamic efficiency at the region of surgical reconstruction and in proximal pulmonary arteries has been evaluated primarily using computational modeling techniques with conflicting reports. The purpose of this descriptive study was to compare flow hemodynamics following stage II (BDG vs HF) using 4-dimensional flow magnetic resonance imaging (4D-Flow MRI) with particular focus on flow-mediated viscous energy loss (EL') under matched hemodynamic conditions. Methods Patients with hypoplastic left heart syndrome (HLHS) who underwent either HF or BDG as part of stage II palliation underwent pre-Fontan 4D-Flow MRI. Patients were matched by the pulmonary vascular resistance index, net superior vena cava (SVC) flow, right pulmonary artery (RPA) and left pulmonary artery (LPA) size, and age. Maximum EL' throughout the cardiac cycle was calculated along the SVC-RPA and SVC-LPA tracts. Results Eight patients who underwent HF as part of their stage II single ventricle palliation were matched with 8 patients who underwent BDG. There were no differences between the 2 groups in median volumetric indices, including end-diastolic volume (P = .278) and end-systolic volume (P = .213). Moreover, no differences were observed in ejection fraction (P = .091) and cardiac index (P = .324). There also were no differences in peak EL' measured along the SVC-RPA tract (median, 0.05 mW for HF vs 0.04 mW for BDG; P = .365) or along the SVC-LPA tract (median, 0.05 mW vs 0.04 mW; P = .741). Conclusions The second stage of surgical palliation of HLHS using either HF or BDG results in similar flow-mediated viscous energy loss throughout the SCPC junction. 4D-Flow MRI and computational methods should be applied together to investigate flow hemodynamic patterns throughout the Fontan palliation and overall efficiency of the Fontan circuit.
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Affiliation(s)
- Michal Schäfer
- Division of Cardiothoracic Surgery, University of Colorado Denver, Anschutz Medical Campus, Aurora, Colo
| | - Michael V. Di Maria
- Division of Pediatric Cardiology, Children's Hospital Colorado, University of Colorado Denver, Anschutz Medical Campus, Aurora, Colo
| | - James Jaggers
- Division of Cardiothoracic Surgery, University of Colorado Denver, Anschutz Medical Campus, Aurora, Colo
| | - Matthew L. Stone
- Division of Cardiothoracic Surgery, University of Colorado Denver, Anschutz Medical Campus, Aurora, Colo
| | - David N. Campbell
- Division of Cardiothoracic Surgery, University of Colorado Denver, Anschutz Medical Campus, Aurora, Colo
| | - D. Dunbar Ivy
- Division of Pediatric Cardiology, Children's Hospital Colorado, University of Colorado Denver, Anschutz Medical Campus, Aurora, Colo
| | - Max B. Mitchell
- Division of Cardiothoracic Surgery, University of Colorado Denver, Anschutz Medical Campus, Aurora, Colo
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Kumthekar R, Webster G. Prediction of Sudden Death Risk in Patients with Congenital Heart Diseases. Card Electrophysiol Clin 2023; 15:493-503. [PMID: 37865522 DOI: 10.1016/j.ccep.2023.07.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2023]
Abstract
Risk stratification for sudden death should be discussed with patients with congenital heart disease at each stage of personal and cardiac development. For most patients, risk is low through teenage years and the critical factors to consider are anatomy, ventricular function, and symptoms. By adulthood, these are supplemented by screening for atrial arrhythmias, ventricular arrhythmias, and pulmonary hypertension. Therapies include medication, ablation, and defibrillator placement.
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Affiliation(s)
- Rohan Kumthekar
- Division of Cardiology, Nationwide Children's Hospital, 700 Children's Drive, Columbus, OH 43205, USA; Department of Pediatrics, The Ohio State University College of Medicine, 370 W. 9th Avenue, Columbus, OH, USA
| | - Gregory Webster
- Division of Cardiology, Ann & Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine, 225 East Chicago Avenue, Box 21, Chicago, IL 60611, USA.
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Chen S, Shezad MF, Lorts A, McCormick AD, Mao CY, Simpson KE, O'Connor MJ, Barnes A, Lubert AM, Castleberry C, Schmidt J, Schroeder K, Joong A, Bearl DW, Lal AK, Mokshagundam D, Conway J, Cedars A, Schumacher KR. Outcomes after initial heart failure consultation in Fontan patients. Cardiol Young 2023:1-8. [PMID: 38014551 DOI: 10.1017/s1047951123003852] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2023]
Abstract
BACKGROUND Patients with Fontan failure are high-risk candidates for heart transplantation and other advanced therapies. Understanding the outcomes following initial heart failure consultation can help define appropriate timing of referral for advanced heart failure care. METHODS This is a survey study of heart failure providers seeing any Fontan patient for initial heart failure care. Part 1 of the survey captured data on clinical characteristics at the time of heart failure consultation, and Part 2, completed 30 days later, captured outcomes (death, transplant evaluation outcome, and other interventions). Patients were classified as "too late" (death or declined for transplant due to being too sick) and/or "care escalation" (ventricular assist device implanted, inotrope initiated, and/or listed for transplant), within 30 days. "Late referral" was defined as those referred too late and/or had care escalation. RESULTS Between 7/2020 and 7/2022, 77 Fontan patients (52% inpatient) had an initial heart failure consultation. Ten per cent were referred too late (6 were too sick for heart transplantation with one subsequent death, and two others died without heart transplantation evaluation, within 30 days), and 36% had care escalation (21 listed ± 5 ventricular assist device implanted ± 6 inotrope initiated). Overall, 42% were late referrals. Heart failure consultation < 1 year after Fontan surgery was strongly associated with late referral (OR 6.2, 95% CI 1.8-21.5, p=0.004). CONCLUSIONS Over 40% of Fontan patients seen for an initial heart failure consultation were late referrals, with 10% dying or being declined for transplant within a month of consultation. Earlier referral, particularly for those with heart failure soon after Fontan surgery, should be encouraged.
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Affiliation(s)
- Sharon Chen
- Lucile Packard Children's Hospital at Stanford, Palo Alto, CA, USA
| | | | - Angela Lorts
- Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | | | - Chad Y Mao
- Children's Healthcare of Atlanta, Atlanta, GA, USA
| | | | | | | | - Adam M Lubert
- Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | | | - Julie Schmidt
- Lucile Packard Children's Hospital at Stanford, Palo Alto, CA, USA
| | | | - Anna Joong
- Ann and Robert H. Lurie Children's Hospital of Chicago, Chicago, IL, USA
| | - David W Bearl
- Monroe Carell Jr. Children's Hospital at Vanderbilt, Nashville, TN, USA
| | - Ashwin K Lal
- Primary Children's Hospital, Salt Lake City, UT, USA
| | | | | | - Ari Cedars
- Johns Hopkins Hospital, Baltimore, MD, USA
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Schamroth Pravda N, Richter I, Blieden L, Dadashev A, Vig S, Yehuda D, Razon Y, Machtei A, Sudri O, Schwartz E, Schamroth Pravda M, Kolker S, Kornowski R, Hirsch R. Long-Term Outcomes and Characteristics Associated With Mortality of Adult Patients Post Fontan Surgery: 27-Year Single-Center Experience. Am J Cardiol 2023; 207:392-398. [PMID: 37782970 DOI: 10.1016/j.amjcard.2023.08.176] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/09/2023] [Revised: 08/27/2023] [Accepted: 08/27/2023] [Indexed: 10/04/2023]
Abstract
Data on the characteristics and long-term outcomes of patients who underwent Fontan surgery and surviving into adulthood are limited. We aimed to describe our center's long-term experience with this unique patient population. Included were adult patients who had undergone Fontan surgery and were followed up at our Adult Congenital Heart Disease clinic between the years 1994 and 2021. We describe cardiac and noncardiac morbidities, medical treatment, laboratory data, echocardiographic characteristics, and all-cause mortality. The primary outcome was a composite of heart failure hospitalizations or death. A total of 107 patients who underwent Fontan surgery were followed up during the study period; 46.7% were male. The mean age at time of Fontan was 7.4 ± 6.2 years and the mean age at the last follow-up or at the time of an outcome event was 35.0 ± 8.0 years (range 21.1 to 62.8). At the last documented follow-up, 74.7% of the cohort were in New York Heart Association functional class I/II. The common morbidities included atrial arrythmias (37%) and stroke (17%). The primary outcome occurred in 17.7%. By the end of the study period, 9.3% of the patients in the cohort died. In a multivariate logistic regression analysis, controlling for gender, age, and Fontan type, worse functional class at the last follow-up (New York Heart Association III/IV vs I/II) was significantly associated with the risk of the primary outcome (odds ratio 34.57, 95% confidence interval 6.728 to 177.623, p <0.001). In conclusion, long-term outcomes of patients surviving into adulthood with a Fontan circulation is encouraging. Most of these patients achieve good functional cardiovascular status, despite the complex anatomy and a substantial burden of co-morbid conditions, specifically, atrial arrythmias and thrombotic events. Functional class was independently associated with heart failure hospitalizations and mortality.
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Affiliation(s)
- Nili Schamroth Pravda
- Adult Congenital Heart Disease Unit, Department of Cardiology, Rabin Medical Center, Petach Tikva, Israel; The Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel.
| | - Ilan Richter
- The Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel; Department of Cardiology & Interventional Cardiology Unit, Rabin Medical Center, Petach Tikva, Israel
| | - Leonard Blieden
- Adult Congenital Heart Disease Unit, Department of Cardiology, Rabin Medical Center, Petach Tikva, Israel; The Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Alexander Dadashev
- Adult Congenital Heart Disease Unit, Department of Cardiology, Rabin Medical Center, Petach Tikva, Israel; The Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Shahar Vig
- Adult Congenital Heart Disease Unit, Department of Cardiology, Rabin Medical Center, Petach Tikva, Israel; The Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Daniel Yehuda
- Internal medicine B, Beilinson Hospital, Petach Tikva, Israel
| | - Yaron Razon
- The Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel; Department of Paediatric Cardiology, Assuta Ashdod Medical Center, Ashdod, Israel
| | - Ayelet Machtei
- The Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel; The Schneider Children's Hospital, Petach Tikva, Israel
| | - Omri Sudri
- The Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Eyal Schwartz
- The Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | | | - Shimon Kolker
- Adult Congenital Heart Disease Unit, Department of Cardiology, Rabin Medical Center, Petach Tikva, Israel; The Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Ran Kornowski
- The Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel; Department of Cardiology & Interventional Cardiology Unit, Rabin Medical Center, Petach Tikva, Israel
| | - Rafael Hirsch
- Adult Congenital Heart Disease Unit, Department of Cardiology, Rabin Medical Center, Petach Tikva, Israel; The Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
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70
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Konduri A, West C, Lowery R, Hunter T, Jarosz A, Yu S, Lim HM, McCormick AD, Schumacher KR, Peng DM. Experience with SGLT2 Inhibitors in Patients with Single Ventricle Congenital Heart Disease and Fontan Circulatory Failure. Pediatr Cardiol 2023:10.1007/s00246-023-03332-5. [PMID: 37919530 DOI: 10.1007/s00246-023-03332-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/01/2023] [Accepted: 10/17/2023] [Indexed: 11/04/2023]
Abstract
Heart failure is the leading cause of morbidity and mortality in patients with Fontan circulation. Sodium-glucose-cotransporter 2 inhibitors (SGLT2i) have become a mainstay of heart failure therapy in adult patients, however, there remains a paucity of literature to describe its use in pediatric heart failure patients, especially those with single ventricle physiology. We describe our early experience using SGLT2i in patients with single ventricle congenital heart disease surgically palliated to the Fontan circulation. We conducted a single-center retrospective chart review of all patients with Fontan circulation who were initiated on an SGLT2i from January 1, 2022 to March 1, 2023. Patient demographics, diagnoses, clinical status, and other therapies were collected from the electronic medical record. During the study period, 14 patients (median age 14.5 years, range 2.0-26.4 years) with Fontan circulation were started on a SGLT2i. Mean weight was 54 kg (range 11.6-80.4 kg). Median follow-up since SGLT2i initiation was 4.1 months (range 13 days-7.7 months). Four patients had a systemic left ventricle and 10 had a systemic right ventricle. Half the patients had Fontan Circulatory Failure with reduced Ejection Fraction (FCFrEF) of the systemic ventricle and the other half had Fontan Circulatory Failure with preserved Ejection Fraction (FCFpEF) of the systemic ventricle. In addition, 3 patients experienced Protein Losing Enteropathy (PLE) and 2 patients had plastic bronchitis, one of whom also was diagnosed with chylothorax. There were no genitourinary infections, hypoglycemia, ketoacidosis, hypotension or other significant adverse effects noted in our patient population. One patient experienced significant diuresis and transient acute kidney injury. Patients with FCFrEF showed a decrease in natriuretic peptide levels. Given the lack of proven therapies, demonstrated benefits of SGLT2i in other populations, and some suggestion of efficacy in Fontan circulation, further study of SGTLT2i in patients with Fontan circulation is warranted.
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Affiliation(s)
- Anusha Konduri
- University of Michigan Congenital Heart Center, Ann Arbor, MI, USA.
| | - Caroline West
- University of Michigan Congenital Heart Center, Ann Arbor, MI, USA
| | - Ray Lowery
- University of Michigan Congenital Heart Center, Ann Arbor, MI, USA
| | - Tiffany Hunter
- University of Michigan Congenital Heart Center, Ann Arbor, MI, USA
| | - Audrey Jarosz
- University of Michigan Congenital Heart Center, Ann Arbor, MI, USA
| | - Sunkyung Yu
- University of Michigan Congenital Heart Center, Ann Arbor, MI, USA
| | - Heang M Lim
- University of Michigan Congenital Heart Center, Ann Arbor, MI, USA
| | | | | | - David M Peng
- University of Michigan Congenital Heart Center, Ann Arbor, MI, USA
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71
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Hammer V, Schaeffer T, Staehler H, Heinisch PP, Burri M, Piber N, Lemmer J, Hager A, Ewert P, Hörer J, Ono M. Protein-Losing Enteropathy and Plastic Bronchitis Following the Total Cavopulmonary Connections. World J Pediatr Congenit Heart Surg 2023; 14:691-698. [PMID: 37551120 DOI: 10.1177/21501351231185111] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/09/2023]
Abstract
BACKGROUND We aimed to evaluate incidence, outcomes, and predictors of protein-losing enteropathy (PLE) and plastic bronchitis (PB) in a cohort of total cavopulmonary connection (TCPC). METHODS We included 620 consecutive patients undergoing TCPC between 1994 and 2021. Prevalence and predictors for onset of PLE/PB were evaluated. Death and heart transplantation after onset of PLE/PB were examined. RESULTS A total of 41 patients presented with PLE/PB (31 with PLE, 15 with PB, and 5 developed both PLE and PB). Their median age at TCPC was 2.2 (interquartile ranges [IQRs], 1.7-3.7) years, and time period to onset for PLE was 2.6 (IQR: 1.0-6.6) years and for PB was 1.1 (IQR: 0.3-4.1) years after TCPC. Independent factors for developing PLE/PB were dominant right ventricle (RV, hazard ratio [HR], 2.243; 95% confidence interval [CI], 1.129-4.458, P = .021) and prolonged pleural effusion after TCPC (HR, 2.101; 95% CI, 1.090-4.049, P = .027). In PLE/PB population, freedom from death or transplantation after PLE/PB diagnosis at 5 and 10 years were 88.7% and 76.4%, respectively. Eleven surgical interventions were performed in 10 patients, comprising atrioventricular valve repairs (n = 4), Fontan pathway revisions (n = 2), pacemaker implantation (n = 2), secondary fenestration (n = 1), diaphragm plication (n = 1), and ventricular assist device implantation (n = 1). In nine patients, a recovery from PLE with the resolution of PLE symptoms and normal protein levels was achieved. Eight patients died and the remaining continued to have challenging protein loss. CONCLUSIONS Protein-losing enteropathy and PB remain severe complications in the cohort of TCPC. Patients with dominant RV, and prolonged pleural effusions, were at risk for PLE/PB.
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Affiliation(s)
- Veronika Hammer
- Department of Congenital and Pediatric Heart Surgery, German Heart Center Munich, Technische Universität München, Munich, Germany
- Division of Congenital and Pediatric Heart Surgery, University Hospital of Munich, Ludwig-Maximilians-Universität, Munich, Germany
| | - Thibault Schaeffer
- Department of Congenital and Pediatric Heart Surgery, German Heart Center Munich, Technische Universität München, Munich, Germany
- Division of Congenital and Pediatric Heart Surgery, University Hospital of Munich, Ludwig-Maximilians-Universität, Munich, Germany
| | - Helena Staehler
- Department of Congenital and Pediatric Heart Surgery, German Heart Center Munich, Technische Universität München, Munich, Germany
- Division of Congenital and Pediatric Heart Surgery, University Hospital of Munich, Ludwig-Maximilians-Universität, Munich, Germany
| | - Paul Philipp Heinisch
- Department of Congenital and Pediatric Heart Surgery, German Heart Center Munich, Technische Universität München, Munich, Germany
- Division of Congenital and Pediatric Heart Surgery, University Hospital of Munich, Ludwig-Maximilians-Universität, Munich, Germany
| | - Melchior Burri
- Department of Cardiovascular Surgery, German Heart Center Munich, Technische Universität München, Munich, Germany
| | - Nicole Piber
- Department of Cardiovascular Surgery, German Heart Center Munich, Technische Universität München, Munich, Germany
| | - Julia Lemmer
- Department of Congenital Heart Disease and Pediatric Cardiology, German Heart Center Munich at the Technical University of Munich, Munich, Germany
| | - Alfred Hager
- Department of Congenital Heart Disease and Pediatric Cardiology, German Heart Center Munich at the Technical University of Munich, Munich, Germany
| | - Peter Ewert
- Department of Congenital Heart Disease and Pediatric Cardiology, German Heart Center Munich at the Technical University of Munich, Munich, Germany
| | - Jürgen Hörer
- Department of Congenital and Pediatric Heart Surgery, German Heart Center Munich, Technische Universität München, Munich, Germany
- Division of Congenital and Pediatric Heart Surgery, University Hospital of Munich, Ludwig-Maximilians-Universität, Munich, Germany
| | - Masamichi Ono
- Department of Congenital and Pediatric Heart Surgery, German Heart Center Munich, Technische Universität München, Munich, Germany
- Division of Congenital and Pediatric Heart Surgery, University Hospital of Munich, Ludwig-Maximilians-Universität, Munich, Germany
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72
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Tedla BA, Kim YY, Vaikunth S. Novel Approaches to the Failing Congenital Heart. Curr Cardiol Rep 2023; 25:1633-1647. [PMID: 37889420 DOI: 10.1007/s11886-023-01979-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 10/04/2023] [Indexed: 10/28/2023]
Abstract
PURPOSE OF REVIEW Heart failure is the leading cause of morbidity and mortality in adults with congenital heart disease and is characterized by a variety of underlying mechanisms. Here, we aim to elaborate on the medical and technological advancements in the management of heart failure in adult patients with congenital heart disease and highlight the use of imaging modalities to guide therapy. RECENT FINDINGS There have been several advances over the past decade with angiotensin receptor neprilysin and sodium-glucose cotransporter-2 inhibitors, atrioventricular valve clips, transcatheter pulmonary valves, catheter ablation, and cardiac resynchronization therapy, as well as the introduction of lymphatic interventions. Expanded use of echocardiography, cardiac magnetic resonance imaging, and cardiac computed tomography has guided many of these therapies. Significant innovations in the management of heart failure in adults with congenital heart disease have evolved with advancements in imaging modalities playing a critical role in guiding treatment therapies.
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Affiliation(s)
- Bruke A Tedla
- Philadelphia Adult Congenital Heart Center, Penn Medicine & Children's Hospital of Philadelphia, University of Pennsylvania, Philadelphia, PA, USA
| | - Yuli Y Kim
- Philadelphia Adult Congenital Heart Center, Penn Medicine & Children's Hospital of Philadelphia, University of Pennsylvania, Philadelphia, PA, USA
| | - Sumeet Vaikunth
- Philadelphia Adult Congenital Heart Center, Penn Medicine & Children's Hospital of Philadelphia, University of Pennsylvania, Philadelphia, PA, USA.
- Perelman Center for Advanced Medicine, 11th Floor, South Pavilion, 3400 Civic Center Boulevard, Philadelphia, PA, 19104-5127, USA.
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73
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Téllez L, Payancé A, Tjwa E, Del Cerro MJ, Idorn L, Ovroutski S, De Bruyne R, Verkade HJ, De Rita F, de Lange C, Angelini A, Paradis V, Rautou PE, García-Pagán JC. EASL-ERN position paper on liver involvement in patients with Fontan-type circulation. J Hepatol 2023; 79:1270-1301. [PMID: 37863545 DOI: 10.1016/j.jhep.2023.07.013] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/06/2023] [Accepted: 07/06/2023] [Indexed: 10/22/2023]
Abstract
Fontan-type surgery is the final step in the sequential palliative surgical treatment of infants born with a univentricular heart. The resulting long-term haemodynamic changes promote liver damage, leading to Fontan-associated liver disease (FALD), in virtually all patients with Fontan circulation. Owing to the lack of a uniform definition of FALD and the competitive risk of other complications developed by Fontan patients, the impact of FALD on the prognosis of these patients is currently debatable. However, based on the increasing number of adult Fontan patients and recent research interest, the European Association for The Study of the Liver and the European Reference Network on Rare Liver Diseases thought a position paper timely. The aims of the current paper are: (1) to provide a clear definition and description of FALD, including clinical, analytical, radiological, haemodynamic, and histological features; (2) to facilitate guidance for staging the liver disease; and (3) to provide evidence- and experience-based recommendations for the management of different clinical scenarios.
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Affiliation(s)
- Luis Téllez
- Gastroenterology and Hepatology Department, Hospital Universitario Ramón y Cajal, Madrid, Spain; Instituto Ramón y Cajal de Investigación Sanitaria (IRYCIS), CIBEREHD (Centro de Investigación Biomédica en Red Enfermedades Hepáticas y Digestivas), University of Alcalá, Madrid, Spain
| | - Audrey Payancé
- DHU Unity, Pôle des Maladies de l'Appareil Digestif, Service d'Hépatologie, Hôpital Beaujon, AP-HP, Clichy, France; Université Denis Diderot-Paris 7, Sorbonne Paris Cité, Paris, France
| | - Eric Tjwa
- Department of Gastroenterology and Hepatology, Radboud University Medical Center, Nijmegen, The Netherlands
| | - María Jesús Del Cerro
- Pediatric Cardiology Department, Hospital Universitario Ramón y Cajal, Madrid, Spain; Instituto Ramón y Cajal de Investigación Sanitaria (IRYCIS), University of Alcalá, Madrid, Spain
| | - Lars Idorn
- Department of Pediatrics, Section of Pediatric Cardiology, Rigshospitalet, Copenhagen, Denmark
| | - Stanislav Ovroutski
- Department of Congenital Heart Disease/Pediatric Cardiology, Deutsches Herzzentrum Berlin, Berlin, Germany
| | - Ruth De Bruyne
- Department of Pediatric Gastroenterology, Hepatology and Nutrition, Ghent University Hospital, Belgium
| | - Henkjan J Verkade
- Department of Pediatrics, Beatrix Children's Hospital/University Medical Center Groningen, The Netherlands
| | - Fabrizio De Rita
- Adult Congenital and Paediatric Heart Unit, Freeman Hospital, Newcastle Upon Tyne Hospitals NHS Foundation Trust, Newcastle Upon Tyne, UK
| | - Charlotte de Lange
- Department of Pediatric Radiology, Queen Silvia Childrens' Hospital, Sahlgrenska University Hospital, Behandlingsvagen 7, 41650 Göteborg, Sweden
| | - Annalisa Angelini
- Pathology of Cardiac Transplantation and Regenerative Medicine Unit, Department of Cardiac, Thoracic and Vascular Sciences and Public Health, University of Padua, Padua, Italy
| | - Valérie Paradis
- Centre de recherche sur l'inflammation, INSERM1149, Université Paris Cité, Paris, France; Pathology Department, Beaujon Hospital, APHP.Nord, Clichy, France
| | - Pierre Emmanuel Rautou
- AP-HP, Service d'Hépatologie, Hôpital Beaujon, DMU DIGEST, Centre de Référence des Maladies Vasculaires du Foie, FILFOIE, Clichy, France; Université Paris-Cité, Inserm, Centre de recherche sur l'inflammation, UMR 1149, Paris, France
| | - Juan Carlos García-Pagán
- Barcelona Hepatic Hemodynamic Laboratory, Liver Unit, Hospital Clínic, Institut de Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Departament de Medicina i Ciències de la Salut, University of Barcelona, Barcelona, Spain; CIBEREHD (Centro de Investigación Biomédica en Red Enfermedades Hepáticas y Digestivas), Health Care Provider of the European Reference Network on Rare Liver Disorders (ERN-Liver), Spain.
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74
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Karner B, Escher A, Schorn T, Narayanaswamy K, Sachweh J, Laufer G, Hübler M, Zimpfer D, Granegger M. Anatomical Compliance of Cavopulmonary Assist Device Designs: A Virtual Fitting Study in Fontan Patients. ASAIO J 2023; 69:1016-1024. [PMID: 37902686 DOI: 10.1097/mat.0000000000002013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/31/2023] Open
Abstract
Several device designs for cavopulmonary mechanical circulatory support (MCS) are under investigation, however, challenged by the Fontan population's heterogeneity in size, cardiovascular and thoracic anatomy. This study aimed to preclinically assess the anatomical compliance of proposed device designs in silico. Representative double- and single-outlet cavopulmonary assist device (CPAD) designs were virtually implanted into CT imaging data of 10 patients previously palliated with total cavopulmonary connection (TCPC) for functionally univentricular hearts. Anatomical device compatibility was characterized concerning pump proximity to cardiovascular, respiratory and thoracic structures, as well as pump in- and outflow graft configuration. In 10 Fontan patients with a median age of 10.4 years (interquartile range [IQR] 5.0-15.3 years) and a median body surface area of 1.09 m2 (IQR 0.76-1.28 m2), implantation of a double-outlet CPAD was feasible in 1 patient (10%). In all other, adverse device intersection with the trachea and (neo-)aorta, or posterior pulmonary artery outflow graft kinking were observed. A single-outlet design permitted enhanced device mobilization adapting to individual anatomical conditions, resulting in device fit in nine of 10 patients (90%). Despite vast anatomical variations among single ventricle patients, a single-outlet device design may provide intracorporeal cavopulmonary MCS to a broad spectrum of failing Fontan patients.
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Affiliation(s)
- Barbara Karner
- From the Department of Cardiac Surgery, Medical University of Vienna, Vienna, Austria
- Division of Cardiac Surgery, Department of Surgery, Medical University Graz, Graz, Austria
| | - Andreas Escher
- From the Department of Cardiac Surgery, Medical University of Vienna, Vienna, Austria
| | - Therese Schorn
- From the Department of Cardiac Surgery, Medical University of Vienna, Vienna, Austria
| | | | - Jörg Sachweh
- Department of Congenital and Pediatric Heart Surgery, Children's Heart Clinic, University Heart & Vascular Center, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Günther Laufer
- From the Department of Cardiac Surgery, Medical University of Vienna, Vienna, Austria
| | - Michael Hübler
- Department of Congenital and Pediatric Heart Surgery, Children's Heart Clinic, University Heart & Vascular Center, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Daniel Zimpfer
- From the Department of Cardiac Surgery, Medical University of Vienna, Vienna, Austria
- Division of Cardiac Surgery, Department of Surgery, Medical University Graz, Graz, Austria
| | - Marcus Granegger
- From the Department of Cardiac Surgery, Medical University of Vienna, Vienna, Austria
- Biofluid Mechanics Laboratory, Charité-Universitätsmedizin Berlin, Berlin, Germany
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75
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Hyer E, Alexander C, Rand EB, Diamond T. Liver Biopsy Leads to Serendipitous Diagnosis of Glycogen Storage Disease Type IX in a Patient With Fontan-Associated Liver Disease. JPGN REPORTS 2023; 4:e377. [PMID: 38034453 PMCID: PMC10684236 DOI: 10.1097/pg9.0000000000000377] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/02/2023] [Accepted: 08/16/2023] [Indexed: 12/02/2023]
Abstract
Fontan-associated liver disease (FALD) is a form of congestive hepatopathy resulting from Fontan palliation procedures in patients with single ventricle physiology. Although there is variation between pediatric centers, the surveillance for FALD may include liver biopsies for assessment of degree of fibrosis. Our report describes a 7-year-old girl with hypoplastic left heart syndrome who underwent Fontan palliation at age 2, and presented with disproportionate hepatomegaly, elevated liver enzymes, and increased stiffness on liver elastography. Liver biopsy showed diffuse hepatocellular cytoplasmic glycogenation, leading to the diagnosis of glycogen storage disease IX. This case demonstrates the importance of investigating unexpected physical exam findings and the potential for serendipitous benefit of liver biopsy in FALD.
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Affiliation(s)
- Erin Hyer
- From the Division of Gastroenterology, Hepatology and Nutrition, Children’s Hospital of Philadelphia, Philadelphia, PA
- Drexel University College of Medicine, Philadelphia, PA
| | - Caitlin Alexander
- Department of Anatomic Pathology, Children’s Hospital of Philadelphia, Philadelphia, PA
| | - Elizabeth B. Rand
- From the Division of Gastroenterology, Hepatology and Nutrition, Children’s Hospital of Philadelphia, Philadelphia, PA
- Department of Pediatrics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Tamir Diamond
- From the Division of Gastroenterology, Hepatology and Nutrition, Children’s Hospital of Philadelphia, Philadelphia, PA
- Department of Pediatrics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
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76
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Adamson GT, Yu J, Ramamoorthy C, Peng LF, Taylor A, Lennig M, Schmidt AR, Feinstein JA, Navaratnam M. Acute Hemodynamics in the Fontan Circulation: Open-Label Study of Vasopressin. Pediatr Crit Care Med 2023; 24:952-960. [PMID: 37462430 DOI: 10.1097/pcc.0000000000003326] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/03/2023]
Abstract
OBJECTIVE To describe the acute hemodynamic effect of vasopressin on the Fontan circulation, including systemic and pulmonary pressures and resistances, left atrial pressure, and cardiac index. DESIGN Prospective, open-label, nonrandomized study (NCT04463394). SETTING Cardiac catheterization laboratory at Lucile Packard Children's Hospital, Stanford. PATIENTS Patients 3-50 years old with a Fontan circulation who were referred to the cardiac catheterization laboratory for hemodynamic assessment and/or intervention. INTERVENTIONS A 0.03 U/kg IV (maximum dose 1 unit) bolus of vasopressin was administered over 5 minutes, followed by a maintenance infusion of 0.3 mU/kg/min (maximum dose 0.03 U/min). MEASUREMENTS AND MAIN RESULTS Comprehensive cardiac catheterization measurements before and after vasopressin administration. Measurements included pulmonary artery, atrial, and systemic arterial pressures, oxygen saturations, and systemic and pulmonary flows and resistances. There were 28 patients studied. Median age was 13.5 (9.1, 17) years, and 16 (57%) patients had a single or dominant right ventricle. Following vasopressin administration, systolic blood pressure and systemic vascular resistance (SVR) increased by 17.5 (13.0, 22.8) mm Hg ( Z value -4.6, p < 0.001) and 3.8 (1.8, 7.5) Wood Units ( Z value -4.6, p < 0.001), respectively. The pulmonary vascular resistance (PVR) decreased by 0.4 ± 0.4 WU ( t statistic 6.2, p < 0.001), and the left atrial pressure increased by 1.0 (0.0, 2.0) mm Hg ( Z value -3.5, p < 0.001). The PVR:SVR decreased by 0.04 ± 0.03 ( t statistic 8.1, p < 0.001). Neither the pulmonary artery pressure (median difference 0.0 [-1.0, 1.0], Z value -0.4, p = 0.69) nor cardiac index (0.1 ± 0.3, t statistic -1.4, p = 0.18) changed significantly. There were no adverse events. CONCLUSIONS In Fontan patients undergoing cardiac catheterization, vasopressin administration resulted in a significant increase in systolic blood pressure, SVR, and left atrial pressure, decrease in PVR, and no change in cardiac index or pulmonary artery pressure. These findings suggest that in Fontan patients vasopressin may be an option for treating systemic hypotension during sedation or general anesthesia.
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Affiliation(s)
- Gregory T Adamson
- Division of Pediatric Cardiology, Department of Pediatrics, Stanford University School of Medicine, Palo Alto, CA
| | - Jane Yu
- Division of Pediatric Anesthesiology, Department of Anesthesia, Stanford University School of Medicine, Palo Alto, CA
| | - Chandra Ramamoorthy
- Division of Pediatric Anesthesiology, Department of Anesthesia, Stanford University School of Medicine, Palo Alto, CA
| | - Lynn F Peng
- Division of Pediatric Cardiology, Department of Pediatrics, Stanford University School of Medicine, Palo Alto, CA
| | - Anne Taylor
- Division of Pediatric Cardiology, Department of Pediatrics, Stanford University School of Medicine, Palo Alto, CA
| | - Michael Lennig
- Division of Pediatric Anesthesiology, Department of Anesthesia, Stanford University School of Medicine, Palo Alto, CA
| | - Alexander R Schmidt
- Division of Pediatric Anesthesiology, Department of Anesthesia, Stanford University School of Medicine, Palo Alto, CA
| | - Jeffrey A Feinstein
- Division of Pediatric Cardiology, Department of Pediatrics, Stanford University School of Medicine, Palo Alto, CA
| | - Manchula Navaratnam
- Division of Pediatric Anesthesiology, Department of Anesthesia, Stanford University School of Medicine, Palo Alto, CA
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Bauer C, Scala M, Sekyra P, Fellner F, Tulzer G. Non-Contrast MR Lymphography and Intranodal Dynamic Contrast MR Lymphangiography in Children with Congenital Heart Disease-Imaging Findings as well as Impact on Patient Management and Outcome. Int J Mol Sci 2023; 24:14827. [PMID: 37834274 PMCID: PMC10573489 DOI: 10.3390/ijms241914827] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2023] [Revised: 09/15/2023] [Accepted: 09/25/2023] [Indexed: 10/15/2023] Open
Abstract
Lymphatic flow disorders are rare but devastating complications in children with congenital heart disease. T2-weighted magnetic resonance lymphography and intranodal dynamic contrast magnetic resonance lymphangiography are imaging modalities that can depict central lymphatic anatomy and flow pattern. Our objective was to describe the technical aspects and our imaging findings of central lymphatic abnormalities and their impact on patient management and outcomes: We conducted a retrospective review of 26 children with congenital heart disease who presented for lymphatic imaging between 2015 and 2020 at our institution. Eleven had postoperative chylothorax, six had plastic bronchitis, seven had protein-losing enteropathy and three had Noonan syndrome. Our lymphatic imaging demonstrated severely abnormal lymphatic flow in all of the children, but only minor abnormalities in protein-losing enteropathy. No major procedure-related complication occurred. Lymphatic interventions were performed in six patients, thoracic duct decompression in two patients and chylothorax revision in three patients. This led to symptomatic improvements in all of the patients: Lymphatic imaging is safe and essential for the diagnosis of lymphatic flow disorders and therapy planning. Our intranodal lymphangiography depicts an abnormal lymphatic flow pattern from the central lymphatics but failed to demonstrate an abnormal lymphatic flow in protein-losing enteropathy. These imaging techniques are the basis for selective lymphatic interventions, which are promising to treat lymphatic flow disorders.
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Affiliation(s)
- Christoph Bauer
- Department of Paediatric Cardiology, Kepler University Hospital GmbH, Krankenhausstrasse 26–30, 4020 Linz, Austria (G.T.)
- Johannes Kepler University Linz, Altenbergerstrasse 68, 4040 Linz, Austria; (P.S.); (F.F.)
| | - Mario Scala
- Johannes Kepler University Linz, Altenbergerstrasse 68, 4040 Linz, Austria; (P.S.); (F.F.)
- Central Radiology Institute, Kepler University Hospital GmbH, Krankenhausstrasse 9, 4020 Linz, Austria
| | - Pavel Sekyra
- Johannes Kepler University Linz, Altenbergerstrasse 68, 4040 Linz, Austria; (P.S.); (F.F.)
- Central Radiology Institute, Kepler University Hospital GmbH, Krankenhausstrasse 9, 4020 Linz, Austria
| | - Franz Fellner
- Johannes Kepler University Linz, Altenbergerstrasse 68, 4040 Linz, Austria; (P.S.); (F.F.)
- Central Radiology Institute, Kepler University Hospital GmbH, Krankenhausstrasse 9, 4020 Linz, Austria
| | - Gerald Tulzer
- Department of Paediatric Cardiology, Kepler University Hospital GmbH, Krankenhausstrasse 26–30, 4020 Linz, Austria (G.T.)
- Johannes Kepler University Linz, Altenbergerstrasse 68, 4040 Linz, Austria; (P.S.); (F.F.)
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78
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Vaikunth S, Sundaravel S, Saef J, Ortega-Legaspi J. Novel Therapeutic Strategies in Heart Failure in Adult Congenital Heart Disease: of Medicines and Devices. Curr Heart Fail Rep 2023; 20:401-416. [PMID: 37582901 DOI: 10.1007/s11897-023-00621-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 07/18/2023] [Indexed: 08/17/2023]
Abstract
PURPOSE OF REVIEW This paper reviews the latest literature on the growing field of heart failure in the adult congenital heart disease population. RECENT FINDINGS After highlighting the increasing prevalence and a few of the unique potential causes, including the concept of early senescence, this review begins with novel medical management strategies such as the angiotensin II receptor blocker and neprilysin inhibitors and sodium glucose cotransporter-2 inhibitors. Then, it addresses the latest applications of percutaneous techniques like implantable hemodynamic monitoring, transcatheter pulmonary and aortic valve replacement, and mitral clips. Cardiac resynchronization therapy and novel lymphatic system imaging and intervention are then described. Finally, the use of mechanical support devices, temporary and durable, is discussed as well as heart and combined heart and liver transplantation. There have been recent exciting advances in the strategies used to manage adult congenital heart disease patients with heart failure. As this population continues to grow, it is likely we will see further rapid evolution in this field.
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Affiliation(s)
- Sumeet Vaikunth
- Philadelphia Adult Congenital Heart Center, Penn Medicine & Children's Hospital of Philadelphia, University of Pennsylvania, Philadelphia, PA, USA.
| | - Swethika Sundaravel
- Advanced Heart Failure Section, Cardiovascular Medicine Division, Hospital of the University of Pennsylvania, Philadelphia, PA, USA
| | - Joshua Saef
- Philadelphia Adult Congenital Heart Center, Penn Medicine & Children's Hospital of Philadelphia, University of Pennsylvania, Philadelphia, PA, USA
| | - Juan Ortega-Legaspi
- Advanced Heart Failure Section, Cardiovascular Medicine Division, Hospital of the University of Pennsylvania, Philadelphia, PA, USA
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79
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McGovern E. Fontan Pathway Stenting: For Whom and When Can We Change Outcomes? A Call for a Large Prospective Multicentre Study. Can J Cardiol 2023; 39:1366-1368. [PMID: 37295612 DOI: 10.1016/j.cjca.2023.06.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2023] [Revised: 05/29/2023] [Accepted: 06/04/2023] [Indexed: 06/12/2023] Open
Affiliation(s)
- Eimear McGovern
- Department of Pediatrics, University of Kentucky Children's Hospital, University of Kentucky, Lexington, Kentucky, USA
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80
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Najashi KA, Najashi NA, Ahmed T, Abdelnaeem R, Alolit S, Zuaybir AA, Atiyah M, Trout AT, Alsaied T, Veldtman GR. The prognostic role of liver volumetry in Fontan patients. Cardiol Young 2023; 33:1834-1839. [PMID: 36258282 DOI: 10.1017/s1047951122002992] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
BACKGROUND AND HYPOTHESES High venous pressures and associated hepatic congestion are important drivers for Fontan-associated liver disease. The prognostic significance of hepatomegaly as a marker of congestion however is not well defined and is further explored in this research study. METHODS Fontan patients who have had liver ultrasound scans were identified from the Prince Sultan Cardiac Centre Fontan Database and had their anatomic, surgical, clinical histories abstracted from the electronic medical records following institutional ethics approval. Liver volumes were determined retrospectively from reviewing individual US images, and these, divided into tertiles, were analysed in the context of the predefined endpoints of (i) Primary - death or heart or liver transplantation, or (ii) Secondary - combined endpoint of death, transplantation, arrhythmia, or protein-losing enteropathy. RESULTS Mean indexed liver volumes for the entire cohort (n = 199) were 1065.1 ± 312.1 ml/m2, range 387 to 2071 ml/m2. Patients with the largest liver volumes (highest tertile) were less likely to have a functioning fenestration compared to those in the lowest tertile 44% versus 56% p = 0.016 and experienced the highest burden of mortality and heart or heart-liver transplantation, p = 0.016, and were more likely to reach the composite endpoint of death, protein-losing enteropathy, arrhythmia, or transplantation, p = 0.010. Liver volumes had an overall predictive accuracy for the combined outcome of 61% (CI 53%, 67%, p = 0.009). CONCLUSIONS Liver volumetry may serve as a potentially important congestion biomarker for adverse outcomes after the Fontan operation.
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Affiliation(s)
- Khalid Al Najashi
- Pediatric Cardiology Department, Prince Sultan Cardiac Center, Riyadh, Saudi Arabia
| | - Nejoud Al Najashi
- Radiology Department, Prince Sultan Medical Military City, Riyadh, Saudi Arabia
| | - Taghreed Ahmed
- Pediatric Cardiology Department, Prince Sultan Cardiac Center, Riyadh, Saudi Arabia
| | - Rayan Abdelnaeem
- Pediatric Cardiology Department, Prince Sultan Cardiac Center, Riyadh, Saudi Arabia
| | - Sultan Alolit
- Radiology Department, Prince Sultan Medical Military City, Riyadh, Saudi Arabia
| | - Amani Al Zuaybir
- Radiology Department, Prince Sultan Medical Military City, Riyadh, Saudi Arabia
| | - Merna Atiyah
- Pediatric Cardiology Department, Prince Sultan Cardiac Center, Riyadh, Saudi Arabia
| | - Andrew T Trout
- Department of Radiology, Cincinnati Children's Hospital Medical Center and University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Tarek Alsaied
- Paediatric Cardiology, UPMC Children's Hospital of Pittsburgh, PA, USA
| | - Gruschen R Veldtman
- Scottish Adult Congenital Cardiac Service, Golden Jubilee National Hospital, Glasgow, Scotland, UK
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81
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Agasthi P, Jain CC, Egbe AC, Hagler DJ, Cabalka AK, Taggart NW, Anderson JH, Cetta F, Connolly HM, Burchill LJ, Kamath PS, Miranda WR. Clinical Outcomes of Percutaneous Fontan Stenting in Adults. Can J Cardiol 2023; 39:1358-1365. [PMID: 37141988 DOI: 10.1016/j.cjca.2023.04.023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2023] [Revised: 04/20/2023] [Accepted: 04/26/2023] [Indexed: 05/06/2023] Open
Abstract
BACKGROUND Fontan pathway stenosis is a well-known complication after palliation. Percutaneous stenting is effective for angiographic/hemodynamic relief of Fontan obstruction, but its clinical impact in adults remains unknown. METHODS This was a retrospective cohort of 26 adults undergoing percutaneous stenting for Fontan obstruction from 2014 to 2022. Procedural details, functional capacity, and liver parameters were reviewed at baseline and during follow-up. RESULTS Median age was 22.5 years (interquartile range [IQR] 19-28.8 y); 69% were male. After stenting, Fontan gradient significantly decreased (2.0 ± 1.9 vs 0 [IQR 0-1] mm Hg; P < 0.005), and minimal Fontan diameter increased (11.3 ± 2.9 vs 19.3 [IQR 17-20] mm; P < 0.001). One patient developed acute kidney injury periprocedurally. During a follow-up of 2.1 years (IQR 0.6-3.7 y), 1 patient had thrombosis of the Fontan stent and 2 underwent elective Fontan re-stenting. New York Heart Association functional class improved in 50% of symptomatic patients. Changes in functional aerobic capacity on exercise testing were directly related to pre-stenting Fontan gradient (n = 7; r = 0.80; P = 0.03) and inversely related to pre-stenting minimal Fontan diameter (r = -0.79; P = 0.02). Thrombocytopenia (platelet count < 150 109/L) was present in 42.3% of patients before and in 32% after the procedure (P = 0.08); splenomegaly (spleen size > 13 cm) was present in 58.3% and 58.8% (P = 0.57), respectively. Liver fibrosis (aspartate transaminase to platelet ratio index and Fibrosis-4) scores were unchanged after the procedure compared with baseline. CONCLUSIONS Percutaneous stenting in adults is safe and effective in relieving Fontan obstruction, resulting in subjective improvement in functional capacity in some. A subset of patients demonstrated improvement in markers of portal hypertension, suggesting that Fontan stenting could improve Fontan-associated liver disease in select individuals.
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Affiliation(s)
- Pradyumna Agasthi
- Department of Cardiovascular Diseases, Mayo Clinic, Rochester, Minnesota, USA
| | - C Charles Jain
- Department of Cardiovascular Diseases, Mayo Clinic, Rochester, Minnesota, USA
| | - Alexander C Egbe
- Department of Cardiovascular Diseases, Mayo Clinic, Rochester, Minnesota, USA
| | - Donald J Hagler
- Department of Cardiovascular Diseases, Mayo Clinic, Rochester, Minnesota, USA; Division of Pediatric Cardiology, Department of Pediatric and Adolescent Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Allison K Cabalka
- Department of Cardiovascular Diseases, Mayo Clinic, Rochester, Minnesota, USA; Division of Pediatric Cardiology, Department of Pediatric and Adolescent Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Nathaniel W Taggart
- Department of Cardiovascular Diseases, Mayo Clinic, Rochester, Minnesota, USA; Division of Pediatric Cardiology, Department of Pediatric and Adolescent Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Jason H Anderson
- Department of Cardiovascular Diseases, Mayo Clinic, Rochester, Minnesota, USA; Division of Pediatric Cardiology, Department of Pediatric and Adolescent Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Frank Cetta
- Department of Cardiovascular Diseases, Mayo Clinic, Rochester, Minnesota, USA; Division of Pediatric Cardiology, Department of Pediatric and Adolescent Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Heidi M Connolly
- Division of Pediatric Cardiology, Department of Pediatric and Adolescent Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Luke J Burchill
- Department of Cardiovascular Diseases, Mayo Clinic, Rochester, Minnesota, USA
| | - Patrick S Kamath
- Division of Gastroenterology and Hepatology, Department of Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - William R Miranda
- Department of Cardiovascular Diseases, Mayo Clinic, Rochester, Minnesota, USA.
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Gagnon J, Martin M, Gosselin L, Chetaille P. Home-Based Resistance Training Programme in Fontan Patients: It Is Feasible, Safe, and Efficient. CJC PEDIATRIC AND CONGENITAL HEART DISEASE 2023; 2:240-246. [PMID: 37970214 PMCID: PMC10642132 DOI: 10.1016/j.cjcpc.2023.08.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/07/2023] [Accepted: 08/15/2023] [Indexed: 11/17/2023]
Abstract
Background Fontan physiology is characterized by a single functional systemic ventricle that reduces cardiac output adaptation and exercise capacity. Peripheral muscle pump is crucial for venous return, and resistance training of the peripheral muscles may be particularly beneficial for cardiac function in these patients. This study explores the feasibility of a training programme including safety and effectiveness, maximal exercise capacity, cardiorespiratory endurance, and quality of life in a Fontan population. Methods Twelve Fontan patients (18-32 years old) with New York Heart Association functional classes I and II were recruited. The intervention was 12 weeks of home-based exercise programme of 3 sessions per week supervised online by a physiotherapist. Pre- and postintervention evaluations assessed lean body mass, segmental forces with a hand-held dynamometer, maximal oxygen consumption (VO2max), cardiovascular endurance, leg endurance with a 1-minute-sit-to-stand test, and quality of life with a 36-item Short-Form Survey. Results A total of 11 of 12 participants completed 35 of 36 workouts, exceeding our 80% threshold for completion. No adverse events were reported. Leg muscle strength increased significantly (knee extensors improved by 22.8 ± 22.8 N m [17.7%], P = 0.019). Despite no change in VO2max, endurance time showed a significant improvement of 5.3 minutes (72%). Perceived physical condition evaluated with a self-perception scale improved significantly. There was no significant difference in the lean body mass and in quality of life. Conclusion In this small group of post-Fontan patients with mild functional impairments, we describe a structured, accessible, and feasible home-based resistance training programme that seems safe and show improvements in strength and perceived physical condition.
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Affiliation(s)
- Joanie Gagnon
- Centre de recherche du CHU de Québec-Université Laval, Québec, Québec, Canada
| | - Mickaël Martin
- Centre de recherche du CHU de Québec-Université Laval, Québec, Québec, Canada
| | - Louise Gosselin
- Centre de recherche du CHU de Québec-Université Laval, Québec, Québec, Canada
| | - Philippe Chetaille
- Département de pédiatrie, service de cardiologie, CHU de Québec-Université Laval, Québec, Québec, Canada
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83
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Karahalios DS, Sehgal S. High Time to Consider the Role of Thyroid Function in Single Ventricle Heart Disease. Pediatr Cardiol 2023; 44:1587-1590. [PMID: 37272993 DOI: 10.1007/s00246-023-03201-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/16/2023] [Accepted: 05/27/2023] [Indexed: 06/06/2023]
Abstract
Herein we respond to the controversial United States Food and Drug Administration (FDA) recommendation to perform thyroid function testing in children up to 3 years of age within 3 weeks of exposure to iodinated contrast media (ICM). Considering the many effects of thyroid hormone on the cardiovascular system, the increased risk of thyroid disease in patients with congenital heart disease, the hemodynamic consequences of the Fontan circulation on the thyroid gland, and the potential clinical significance of subclinical hypothyroidism, we share our perspective that the cardiovascular effects of thyroid hormone may carry more influence for patients with single ventricle heart disease. In our opinion, the FDA statement prompts us to consider routine thyroid hormone surveillance testing in the long-term management of patients with single ventricle heart disease.
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Affiliation(s)
- Dean S Karahalios
- Central Michigan University and Children's Hospital of Michigan, 3901 Beaubien Boulevard, Detroit, MI, 48201, USA.
| | - Swati Sehgal
- Central Michigan University and Children's Hospital of Michigan, 3901 Beaubien Boulevard, Detroit, MI, 48201, USA
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Gill M, Mudaliar S, Prince D, Than NN, Cordina R, Majumdar A. Poor correlation of 2D shear wave elastography and transient elastography in Fontan-associated liver disease: A head-to-head comparison. JGH Open 2023; 7:690-697. [PMID: 37908293 PMCID: PMC10615175 DOI: 10.1002/jgh3.12967] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2023] [Revised: 08/10/2023] [Accepted: 08/31/2023] [Indexed: 11/02/2023]
Abstract
Background and Aims Fontan-associated liver disease (FALD) is a long-term complication of the Fontan procedure. Guidelines recommend elastography, but the utility of transient elastography (TE) and two-dimensional shear wave elastography (2D SWE) is unknown. We aimed to evaluate the relationship between TE and 2D SWE in FALD. Methods This prospective cohort study included 25 patients managed in a specialist clinic between January 2018 and August 2021. Trained clinicians performed 2D SWE (GE Logiq-E9) and TE (FibroScan 503 Touch) on the same day under the same conditions. Laboratory, echocardiography, and imaging data were collected. The atrioventricular systolic-to-diastolic duration (AVV S/D ratio) was calculated as a measure of cardiac diastolic function. Results We analyzed 40 paired measurements. Median age was 22 years. Median liver stiffness measurement (LSM) was 15.4 kPa (12.1-19.6) by TE and 8.0 kPa (7.0-10.3) (P = 0.001) by 2D SWE. There was weak correlation between the modalities (r = 0.41, P = 0.004). There was no correlation between time since Fontan and LSM by TE (r = 0.15, P = 0.19) or 2D SWE (r = 0.19, P = 0.13). There was no difference in LSM irrespective of whether sonographic cirrhosis was present or absent by TE (17.4 kPa [15.9-23.6] vs. 14.9 kPa [12.0-19.4], respectively, P = 0.6) or 2D SWE (9.0 kPa [2.8-10.5] vs. 8.0 kPa [6.7-10.1], P = 0.46). There was no correlation between AVV S/D ratio and LSM by TE (r = 0.16, P = 0.18) or 2D SWE (r = 0.02, P = 0.45). Conclusions In FALD, TE and 2D SWE are poorly correlated. LSM by either modality was not associated with known risk factors for liver fibrosis or Fontan function. Based on these data, the role of elastography in FALD is uncertain.
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Affiliation(s)
- Madeleine Gill
- Australian National Liver Transplant UnitRoyal Prince Alfred HospitalSydneyNew South WalesAustralia
- Faculty of Medicine and HealthThe University of SydneySydneyNew South WalesAustralia
- Centenary Institute of Cancer Medicine and Cell BiologySydneyNew South WalesAustralia
| | - Sanjivan Mudaliar
- Australian National Liver Transplant UnitRoyal Prince Alfred HospitalSydneyNew South WalesAustralia
| | - David Prince
- Australian National Liver Transplant UnitRoyal Prince Alfred HospitalSydneyNew South WalesAustralia
- Centenary Institute of Cancer Medicine and Cell BiologySydneyNew South WalesAustralia
| | - Nwe Ni Than
- Department of Gastroenterology and HepatologyUniversity Hospital CoventryCoventryUK
| | - Rachel Cordina
- Faculty of Medicine and HealthThe University of SydneySydneyNew South WalesAustralia
- Department of CardiologyRoyal Prince Alfred HospitalSydneyNew South WalesAustralia
| | - Avik Majumdar
- Faculty of Medicine and HealthThe University of SydneySydneyNew South WalesAustralia
- Victorian Liver Transplant Unit, Austin HospitalHeidelbergVictoriaAustralia
- Division of Medicine, Dentistry and Health ScienceThe University of MelbourneMelbourneVictoriaAustralia
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Hassan A, Chegondi M, Porayette P. Five decades of Fontan palliation: What have we learned? What should we expect? J Int Med Res 2023; 51:3000605231209156. [PMID: 37910851 PMCID: PMC10621298 DOI: 10.1177/03000605231209156] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2023] [Accepted: 10/04/2023] [Indexed: 11/03/2023] Open
Abstract
The Fontan procedure is the final palliative surgery in a series of staged surgeries to reroute the systemic venous blood flow directly to the lungs, with the ventricle(s) pumping oxygenated blood to the body. Advances in medical and surgical techniques have improved patients' overall survival after the Fontan procedure. However, Fontan-associated chronic comorbidities are common. In addition to chronic cardiac dysfunction and arrhythmias, complications involving other organs such as the liver, lungs, intestine, lymphatic system, brain, and blood frequently occur. This narrative review focuses on the immediate and late consequences in children, pregnant women, and other adults with Fontan circulation. In addition, we describe the technical advancements that might change the way single-ventricle patients are managed in future.
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Affiliation(s)
- Adil Hassan
- Department of Internal Medicine, University of Iowa, Iowa City, IA 52242, USA
| | - Madhuradhar Chegondi
- Division of Pediatric Critical Care Medicine, Stead Family Children’s Hospital, University of Iowa, Iowa City, IA 52242, USA
| | - Prashob Porayette
- Division of Pediatric Cardiology, Stead Family Children’s Hospital, University of Iowa, Iowa City, IA 52242, USA
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86
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Ferrari MR, Schäfer M, Hunter KS, Di Maria MV. Central Venous Waveform Patterns in the Fontan Circulation Independently Contribute to the Prediction of Composite Survival. Pediatr Cardiol 2023:10.1007/s00246-023-03268-w. [PMID: 37773462 DOI: 10.1007/s00246-023-03268-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/03/2023] [Accepted: 08/07/2023] [Indexed: 10/01/2023]
Abstract
It is well appreciated that the Fontan circulation perturbs central venous hemodynamics, with elevated pressure being the clearest change associated with Fontan comorbidities, such as Fontan-associated liver disease (FALD) and protein-losing enteropathy (PLE). Our group has better quantity of these venous perturbations through single- and multi-location analyses of flow waveforms obtained from magnetic resonance imaging of Fontan patients. Here, we determine if such analyses, which yield principal components (PC) that describe flow features, are associated with Fontan survival. Patients with a Fontan circulation (N = 140) that underwent free-breathing and mechanically ventilated cardiac MRI were included in this study. Standard volumetric and functional hemodynamics, as well as flow analysis principal components, were subjected to univariate and bivariate Cox regression analyses to determine composite clinical outcome, including plastic bronchitis, PLE, and referral and receipt of transplant. Unsurprisingly, ventricular function measures of ejection fraction (EF; HR = 0.88, p < 0.0001), indexed end-systolic volume (ESVi; HR 1.02, p < 0.0001), and indexed end-diastolic volume (EDVi; HR = 1.02, p = 0.0007) were found as specific predictors of clinical events, with specificities uniformly > 0.75. Additionally a feature of IVC flow (PC2) indicating increased flow in systole was found as a highly sensitive predictor (HR = 0.851, p = 0.027, sensitivity 0.93). In bivariate prediction, combinations of ventricular function (EF, ESVi, EDVi) with this IVC flow feature yielded best overall prediction of composite outcome. This suggests that central venous waveform analysis relays additional information about Fontan patient survival and that coupling sensitive and specific measures in bivariate analysis is a useful approach for obtaining superior prediction of survival.
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Affiliation(s)
- Margaret R Ferrari
- Department of Bioengineering, University of Colorado Anschutz Medical Campus, Aurora, CO, 80045, USA
| | - Michal Schäfer
- Division of Cardiology, Heart Institute, Children's Hospital Colorado, University of Colorado Anschutz Medical Campus, 13123 East 16Th Ave, Aurora, CO, 80045, USA
| | - Kendall S Hunter
- Department of Bioengineering, University of Colorado Anschutz Medical Campus, Aurora, CO, 80045, USA
| | - Michael V Di Maria
- Division of Cardiology, Heart Institute, Children's Hospital Colorado, University of Colorado Anschutz Medical Campus, 13123 East 16Th Ave, Aurora, CO, 80045, USA.
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87
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Laubham M, Blais B, Kamp AN. Atrial Arrhythmias in Adults with Fontan Palliation. Cardiol Ther 2023; 12:473-487. [PMID: 37495769 PMCID: PMC10423191 DOI: 10.1007/s40119-023-00326-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2023] [Accepted: 07/14/2023] [Indexed: 07/28/2023] Open
Abstract
Single ventricle physiology is a rare form of congenital heart disease and was, historically, a uniformly lethal condition. However, the atriopulmonary Fontan operation, and its successive iterations, the lateral tunnel and extracardiac conduit Fontan, became the fundamental approach to treating single ventricle heart disease. Over time, dysrhythmias are some of the most common complications with Fontan physiology, compounding morbidity and mortality. Atrial arrhythmias are prevalent in the Fontan population and occur in about 15-60% of patients with Fontan palliation, increasingly with age. Diagnosing atrial arrhythmias in patients with Fontan palliation may be challenging because of low voltage amplitudes arising from myopathic atrial tissue making it difficult to clearly assess atrial depolarization on surface electrocardiograms (ECG), vague symptoms not suggestive of tachyarrhythmia, or atrial arrhythmia with ventricular rates below 100 beats per minute. Intra-atrial reentrant tachycardia (IART) is the most common type of supraventricular tachycardia in adults with Fontan palliation. Acute management of atrial arrhythmias in patients with Fontan palliation involves prompt assessment of a patient's hemodynamic stability, anticoagulation and thrombosis risk, systemic ventricular function, and risk of sedation or anesthesia if needed. Long-term management of atrial arrhythmias is often multifactorial and may include long-term anti-arrhythmic therapy, permanent pacing, and ablation. The best approach for the management of atrial arrhythmias in adults with Fontan palliation is patient-specific and involves collaboration between congenital electrophysiologists, adult congenital cardiologists, and the patient.
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Affiliation(s)
- Matthew Laubham
- Nationwide Children's Hospital, 700 Children's Drive, Columbus, OH, 43205, USA.
| | - Ben Blais
- Nationwide Children's Hospital, 700 Children's Drive, Columbus, OH, 43205, USA
- The Ohio State University School of Medicine, Columbus, OH, USA
| | - Anna N Kamp
- Nationwide Children's Hospital, 700 Children's Drive, Columbus, OH, 43205, USA
- The Ohio State University School of Medicine, Columbus, OH, USA
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Bhat DP, Graziano JN, Garn BJ, Franklin WJ. Safety and utility of CardioMEMS device for remote pulmonary artery monitoring in paediatric Fontan patients: a case series. Eur Heart J Case Rep 2023; 7:ytad422. [PMID: 37705945 PMCID: PMC10497180 DOI: 10.1093/ehjcr/ytad422] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2023] [Revised: 08/04/2023] [Accepted: 08/24/2023] [Indexed: 09/15/2023]
Abstract
Background Patients with single ventricle congenital heart disease who undergo total cavo-pulmonary anastomosis (Fontan surgery) suffer from elevated pulmonary artery pressure (PAP), which leads to multiple adverse sequelae. Traditionally, the Fontan pressures are assessed via invasive haemodynamic catheterization that exposes these medically fragile patients to the risks of vascular injury and anaesthesia. While the CardioMEM remote PAP monitor has been extensively used in adults with heart failure, the safety of this device has not been established in children. Case summary We report safety and utility of this device in eight paediatric Fontan patients. Our patients ranged from 9 to 18 years of age. There were no reported complications related to the implantation of the CardioMEMS device in our population. Discussion This is the first case series of safety of CardioMEMS device in paediatric Fontan Powered by Editorial Manager® and ProduXion Manager® from Aries Systems Corporation patients. Our experience indicates that the device may be safely utilized for the management of Fontan-related complications in this vulnerable population.
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Affiliation(s)
- Deepti P Bhat
- The Fontan Clinic, Division of Cardiology, Phoenix Children's Hospital and University of Arizona, 1919, E Thomas Road, Phoenix, AZ 85016, USA
| | - Joseph N Graziano
- The Fontan Clinic, Division of Cardiology, Phoenix Children's Hospital and University of Arizona, 1919, E Thomas Road, Phoenix, AZ 85016, USA
| | - Byron J Garn
- The Fontan Clinic, Division of Cardiology, Phoenix Children's Hospital and University of Arizona, 1919, E Thomas Road, Phoenix, AZ 85016, USA
| | - Wayne J Franklin
- The Fontan Clinic, Division of Cardiology, Phoenix Children's Hospital and University of Arizona, 1919, E Thomas Road, Phoenix, AZ 85016, USA
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Cindik N, Gökdemir M, Varan B, Ulubay G, Ozkan M, Tokel NK. Comparison of serum N-terminal pro-brain natriuretic peptide levels, conventional echocardiography, exercise parameters, and dyssynchrony measurements in Fontan patients. Cardiol Young 2023; 33:1706-1712. [PMID: 37675568 DOI: 10.1017/s1047951123003256] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 09/08/2023]
Abstract
INTRODUCTION Little data are available concerning the methods used in the long-term follow-up of Fontan patients. We analyzed the association between serum N-terminal pro-brain natriuretic peptide levels, conventional echocardiography findings, exercise parameters, and dyssynchrony measurements in patients who underwent Fontan surgery. METHODS This study included 28 patients who underwent Fontan surgery (mean age 12.8 ± 4.36 years) and 27 healthy controls (mean age 12.5 ± 3.76 years). Echocardiography examinations and exercise tests were performed in both groups. The systemic ventricle was examined via echocardiography, dyssynchrony measurement was performed, the systemic ventricular myocardial performance index was calculated, and serum N-terminal pro-brain natriuretic peptide levels were measured for all subjects. RESULTS Lower cardiac output, stroke volume, maximal work, chronotropic index, maximal oxygen uptake, and higher N-terminal pro-brain natriuretic peptide levels were observed in the Fontan group than in the control group (p < 0.05). A negative correlation was found between physical exercise parameters and N-terminal pro-brain natriuretic peptide levels and dyssynchrony measurements. CONCLUSION Measurements of exercise capacity, serum N-terminal pro-brain natriuretic peptide levels, and dyssynchrony measurement were more valuable than conventional methods for assessing patients' clinical and functional status. Dyssynchrony measurements provided better information about ventricular status than did conventional echocardiography studies. While patients' systolic function determined by conventional echocardiography was normal, dyssynchrony measurements showed the opposite result. The negative relationship between serum N-terminal pro-brain natriuretic peptide levels, dyssynchrony measurements, and exercise capacity suggests that these parameters should be investigated further in Fontan patients.
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Affiliation(s)
- Nimet Cindik
- Department of Pediatric Cardiology, Baskent University, Konya, TR, Turkey
| | - Mahmut Gökdemir
- Department of Pediatric Cardiology, Baskent University, Konya, TR, Turkey
| | - Birgül Varan
- Pediatric cardiology, Baskent University Faculty of Medicine, Ankara, TR, Turkey
| | - Gaye Ulubay
- Department of Pulmonary Diseases, Baskent University Faculty of Medicine, Ankara, TR, Turkey
| | - Murat Ozkan
- Cardiovascular Surgery, Baskent University Faculty of Medicine, Ankara, TR, Turkey
| | - Niyazi Kürşad Tokel
- Pediatric cardiology, Baskent University Faculty of Medicine, Ankara, TR, Turkey
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Timofeeva M, Lav C, Cheung MMH, Ooi A. Numerical simulation of the cavopulmonary connection flow with conduit stenoses of varying configurations. Comput Biol Med 2023; 164:107358. [PMID: 37598480 DOI: 10.1016/j.compbiomed.2023.107358] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2023] [Revised: 06/18/2023] [Accepted: 08/12/2023] [Indexed: 08/22/2023]
Abstract
The circulation in the total cavopulmonary connection (TCPC) is a low-energy system which operation and efficiency are subjected to multiple factors. Some retrospective studies report that the abnormal narrowing of vessels in the system, i.e. stenosis, is one of the most dangerous geometric factors which can result in heart failure. In the present study, the effect of varying extracardiac conduit (ECC) stenosis on the hemodynamics in a surrogate TCPC model is investigated using high-fidelity numerical simulations. The efficiency of the surrogate TCPC model was quantified according to the power loss, relative perfusion in lungs and the percentage of conduit surface area with abnormally low and high wall shear stress for venous flow. Additionally, the impact of respiration and asymmetry in the stenosis geometry to the system was examined. The results show that the flow in the TCPC model exhibits pronounced unsteadiness even under the steady initial boundary conditions, while the uneven pulmonary flow distribution and the presence of the ECC stenosis amplify the chaotic nature of the flow. Energy efficiency of the system is shown to strongly correlate with amount of vortical structures in the model and their range of scales. Finally, the study demonstrates that the presence of respiration in the model adds to perturbations in the flow which causes increase in the power loss. Results obtained in the study provide valuable insights on how the ECC stenosis effect the flow in the surrogate TCPC model under different flow conditions.
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Affiliation(s)
- Mariia Timofeeva
- The Faculty of Engineering and Information Technology, The University of Melbourne, 700 Swanston Street, Carlton, VIC, 3053, Australia.
| | - Chitrarth Lav
- The Faculty of Engineering and Information Technology, The University of Melbourne, 700 Swanston Street, Carlton, VIC, 3053, Australia; Scuderia AlphaTauri F1, Bicester, OX26 4LD, United Kingdom
| | - Michael M H Cheung
- Department of Cardiology, Royal Children's Hospital, Melbourne, Australia; Heart Research Group, Murdoch Children's Research Institute, Melbourne, Australia; Department of Paediatrics, The University of Melbourne, VIC, 3052, Australia
| | - Andrew Ooi
- The Faculty of Engineering and Information Technology, The University of Melbourne, 700 Swanston Street, Carlton, VIC, 3053, Australia
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91
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Arrigoni SC, Berger RMF, Ebels T, Postmus D, Hoendermis ES, Schoof PH, Willems TP, van Melle JP. Cardiac output drop reflects circulatory attrition after Fontan completion: serial cardiac magnetic resonance study. EUROPEAN HEART JOURNAL. IMAGING METHODS AND PRACTICE 2023; 1:qyad039. [PMID: 39045076 PMCID: PMC11195729 DOI: 10.1093/ehjimp/qyad039] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 09/27/2023] [Accepted: 11/23/2023] [Indexed: 07/25/2024]
Abstract
Aims Cardiac magnetic resonance (CMR) imaging is a main diagnostic tool in the follow-up of Fontan patients. However, the value of serial CMR for the evaluation of Fontan attrition is unknown. The aim of this prospective study of serial CMR is to describe the analysis of time-dependent evolution of blood flow distribution, ventricular volumes, and function in patients after Fontan completion. Methods and results In this prospective single-centre study, between 2012 and 2022, 281 CMR examinations were performed in 88 Fontan patients with distribution of blood flows, measurements of ventricular volumes, and ejection fraction. Linear mixed model regression for repeated measurements was used to analyse changes of measurements across serial CMR examinations. During a time interval of 10 years, the median number of CMR per patient was 3 (range 1-5). Indexed flow of ascending aorta, caval veins, and pulmonary arteries decreased significantly across serial CMR examinations. Although a decrease of mean indexed aortic flow (3.03 ± 0.10 L/min/m2 at first CMR vs. 2.36 ± 0.14 L/min/m2 at fourth CMR, P < 0.001) was observed, ejection fraction did not decline (50 ± 1% at first CMR vs. 54 ± 2% at fourth CMR, P = 0.070). Indexed ventricular volumes did not differ significantly across serial CMR examinations. Conclusion The decrease of indexed aortic and cavopulmonary flows reflects the attrition of univentricular circulation and can be detected by means of serial CMR. Ventricular systolic dysfunction does not contribute significantly to this attrition. In order to detect significant change of indexed aortic flow, we recommend performing serial CMR as routine practice in the Fontan population.
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Affiliation(s)
- Sara C Arrigoni
- Department of Cardiothoracic Surgery, University of Groningen, University Medical Center Groningen, Hanzeplein 1, PO Box 30.001, Groningen 9700 RB, The Netherlands
| | - Rolf M F Berger
- Department of Pediatric Cardiology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Tjark Ebels
- Department of Cardiothoracic Surgery, University of Groningen, University Medical Center Groningen, Hanzeplein 1, PO Box 30.001, Groningen 9700 RB, The Netherlands
| | - Douwe Postmus
- Department of Epidemiology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Elke S Hoendermis
- Department of Cardiology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Paul H Schoof
- Department of Pediatric Cardiac Surgery, University of Utrecht, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Tineke P Willems
- Department of Radiology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Joost P van Melle
- Department of Cardiology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
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92
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Thornton SW, Meza JM, Prabhu NK, Kang L, Moya-Mendez ME, Parker LE, Fleming GA, Turek JW, Andersen ND. Impact of Ventricular Dominance on Long-Term Fontan Outcomes: A 25-year Single-institution Study. Ann Thorac Surg 2023; 116:508-515. [PMID: 36543280 DOI: 10.1016/j.athoracsur.2022.11.039] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/09/2022] [Revised: 11/14/2022] [Accepted: 11/28/2022] [Indexed: 12/23/2022]
Abstract
BACKGROUND The long-term impact of ventricular dominance on Fontan outcomes is controversial. This study examined this issue in a 25-year cohort. METHODS Patients undergoing the Fontan operation at a single institution (Duke University Medical Center, Durham, NC) from October 1998 to February 2022 were reviewed. Primary outcomes were transplant-free survival and Fontan failure (death, heart transplantation, takedown, protein-losing enteropathy, or plastic bronchitis). Secondary outcomes included hospital and intensive care lengths of stay. Kaplan-Meier methodology compared outcomes by ventricular dominance. Multiphase parametric risk hazard analysis identified risk factors for primary outcomes. RESULTS There were 195 patients (104 right ventricular dominant) included in the study. Baseline characteristics were comparable. Perioperative survival was similar (right ventricular dominant, 98%; non-right ventricular dominant, 100%; P = .51). The proportion of patients experiencing death or heart transplantation was 8.7%, and the rate of Fontan failure was 11.8% during a median follow-up of 4.5 years (interquartile range, 0.3-9.8 years). Right ventricular-dominant patients had reduced transplant-free survival (10-year estimates: 80% [95% CI, 70%-91%] vs 92% [95% CI, 83%-100%]; P = .04) and freedom from Fontan failure (73% [95% CI, 62%-86%] vs 92% [95% CI, 83%-100%]; P = .04). Multiphase hazard modeling resolved 2 risk phases. The early phase spanned from surgery to approximately 6 months afterward. The late phase spanned from approximately 6 months after surgery onward. In multivariable analysis, right ventricular dominance was an independent risk factor for death or heart transplantation (parameter estimate, 1.3 ± 0.6; P = .04) and Fontan failure (1.1 ± 0.5; P = .04) during the second phase, with no significant first-phase risk factors. CONCLUSIONS Right ventricular dominance was associated with long-term complications after Fontan procedures, including mortality, heart transplantation, and Fontan failure. This cohort may benefit from heightened surveillance in a multidisciplinary Fontan clinic after the perioperative period.
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Affiliation(s)
- Steven W Thornton
- Duke University School of Medicine, Durham, North Carolina; Duke Congenital Heart Surgery Research and Training Laboratory, Durham, North Carolina.
| | - James M Meza
- Duke Congenital Heart Surgery Research and Training Laboratory, Durham, North Carolina; Division of Cardiovascular and Thoracic Surgery, Duke University Hospitals, Durham, North Carolina
| | - Neel K Prabhu
- Duke University School of Medicine, Durham, North Carolina; Duke Congenital Heart Surgery Research and Training Laboratory, Durham, North Carolina
| | - Lillian Kang
- Department of Surgery, Duke University Hospitals, Durham, North Carolina; Duke Congenital Heart Surgery Research and Training Laboratory, Durham, North Carolina
| | - Mary E Moya-Mendez
- Duke University School of Medicine, Durham, North Carolina; Duke Congenital Heart Surgery Research and Training Laboratory, Durham, North Carolina
| | - Lauren E Parker
- Duke University School of Medicine, Durham, North Carolina; Duke Congenital Heart Surgery Research and Training Laboratory, Durham, North Carolina
| | - Gregory A Fleming
- Department of Pediatrics, Duke University Hospitals, Durham, North Carolina; Duke Congenital Heart Surgery Research and Training Laboratory, Durham, North Carolina
| | - Joseph W Turek
- Duke Congenital Heart Surgery Research and Training Laboratory, Durham, North Carolina; Division of Cardiovascular and Thoracic Surgery, Duke University Hospitals, Durham, North Carolina
| | - Nicholas D Andersen
- Duke Congenital Heart Surgery Research and Training Laboratory, Durham, North Carolina; Division of Cardiovascular and Thoracic Surgery, Duke University Hospitals, Durham, North Carolina
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93
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Meyer Z, Haas N, Mühlberg R, Braun A, Fischer M, Mandilaras G. Transient liver elastography in the follow-up of Fontan patients: results of a nation wide survey in Germany. Front Pediatr 2023; 11:1194641. [PMID: 37711600 PMCID: PMC10499538 DOI: 10.3389/fped.2023.1194641] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/27/2023] [Accepted: 07/24/2023] [Indexed: 09/16/2023] Open
Abstract
Introduction Fontan-palliated patients are at risk for the development of Fontan-associated liver disease (FALD). Currently, there is no consensus on how to stage FALD. Transient elastography (TE) is a rapid, non-invasive method to assess FALD and liver fibrosis. Method To assess the availability and conditions of using TE to monitor liver disease in Fontan patients in german centers for pediatric cardiology and to propose the introduction of a standardized national protocol for the monitoring of liver disease, we developed a questionnaire. Results In total, 95 valid questionnaires were collected. Only 20% of the centers offer the TE investigation directly. Most of the centers transfer the patients to another department or center (40%) or didńt offer TE (40%). In only 2.6% of the centers TE is performed directly by the cardiologist. Most of the centers transfer the patients to a other department. In 29.2% TE is performed only at a certain age of the patients and in 27.7% it is performed if the patients present symptoms of failing Fontan. In only 13.9% of the centers TE is proposed in all the Fontan patients on a routine basis. Most often TE is performed only from the beginning of the adolescence. In the majority of answers it was not known if the patients are fasting for the examination (68%) or not and if the TE examination had to be performed in a specific breathing phase during TE (Inspiration/Expiration, 90%). In the majority, TE is not offered routinely (46.9%). Discussion To date in Germany, TE is only used in a few numbers of centers specialized in Fontan follow-up. A standardized protocol to use TE is currently not existing. With regard to the feasibility of the examination, it is evident that TE is a quick, cheap and easy method to distinguish between cases with and without progressive FALD. This makes TE a useful and prognostic tool for screening of liver disease and to failing Fontan circulation. Conclusion We propose a systematic TE evaluation of possible liver congestion and fibrosis, as a part of the routine follow-up of Fontan patients.
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Affiliation(s)
- Zora Meyer
- Ludwig Maximilian University of Munich, Munich, Germany
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94
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Renaud D, Scholl-Bürgi S, Karall D, Michel M. Comparative Metabolomics in Single Ventricle Patients after Fontan Palliation: A Strong Case for a Targeted Metabolic Therapy. Metabolites 2023; 13:932. [PMID: 37623876 PMCID: PMC10456471 DOI: 10.3390/metabo13080932] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2023] [Revised: 07/28/2023] [Accepted: 08/03/2023] [Indexed: 08/26/2023] Open
Abstract
Most studies on single ventricle (SV) circulation take a physiological or anatomical approach. Although there is a tight coupling between cardiac contractility and metabolism, the metabolic perspective on this patient population is very recent. Early findings point to major metabolic disturbances, with both impaired glucose and fatty acid oxidation in the cardiomyocytes. Additionally, Fontan patients have systemic metabolic derangements such as abnormal glucose metabolism and hypocholesterolemia. Our literature review compares the metabolism of patients with a SV circulation after Fontan palliation with that of patients with a healthy biventricular (BV) heart, or different subtypes of a failing BV heart, by Pubmed review of the literature on cardiac metabolism, Fontan failure, heart failure (HF), ketosis, metabolism published in English from 1939 to 2023. Early evidence demonstrates that SV circulation is not only a hemodynamic burden requiring staged palliation, but also a metabolic issue with alterations similar to what is known for HF in a BV circulation. Alterations of fatty acid and glucose oxidation were found, resulting in metabolic instability and impaired energy production. As reported for patients with BV HF, stimulating ketone oxidation may be an effective treatment strategy for HF in these patients. Few but promising clinical trials have been conducted thus far to evaluate therapeutic ketosis with HF using a variety of instruments, including ketogenic diet, ketone esters, and sodium-glucose co-transporter-2 (SGLT2) inhibitors. An initial trial on a small cohort demonstrated favorable outcomes for Fontan patients treated with SGLT2 inhibitors. Therapeutic ketosis is worth considering in the treatment of Fontan patients, as ketones positively affect not only the myocardial energy metabolism, but also the global Fontan physiopathology. Induced ketosis seems promising as a concerted therapeutic strategy.
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Affiliation(s)
- David Renaud
- Fundamental and Biomedical Sciences, Paris-Cité University, 75006 Paris, France
- Health Sciences Faculty, Universidad Europea Miguel de Cervantes, 47012 Valladolid, Spain
- Fundacja Recover, 05-124 Skrzeszew, Poland
| | - Sabine Scholl-Bürgi
- Department of Child and Adolescent Health, Division of Pediatrics I—Inherited Metabolic Disorders, Medical University of Innsbruck, 6020 Innsbruck, Austria
| | - Daniela Karall
- Department of Child and Adolescent Health, Division of Pediatrics I—Inherited Metabolic Disorders, Medical University of Innsbruck, 6020 Innsbruck, Austria
| | - Miriam Michel
- Department of Child and Adolescent Health, Division of Pediatrics III—Cardiology, Pulmonology, Allergology and Cystic Fibrosis, Medical University of Innsbruck, 6020 Innsbruck, Austria
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95
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Ishida H, Maeda J, Uchida K, Yamagishi H. Unique Pulmonary Hypertensive Vascular Diseases Associated with Heart and Lung Developmental Defects. J Cardiovasc Dev Dis 2023; 10:333. [PMID: 37623346 PMCID: PMC10455332 DOI: 10.3390/jcdd10080333] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2023] [Revised: 07/10/2023] [Accepted: 08/01/2023] [Indexed: 08/26/2023] Open
Abstract
Although pediatric pulmonary hypertension (PH) shares features and mechanisms with adult PH, there are also some significant differences between the two conditions. Segmental PH is a unique pediatric subtype of PH with unclear and/or multifactorial pathophysiological mechanisms, and is often associated with complex congenital heart disease (CHD), pulmonary atresia with ventricular septal defect, and aortopulmonary collateral arteries. Some cases of complex CHD, associated with a single ventricle after Fontan operation, show pathological changes in the small peripheral pulmonary arteries and pulmonary vascular resistance similar to those observed in pulmonary arterial hypertension (PAH). This condition is termed as the pediatric pulmonary hypertensive vascular disease (PPHVD). Recent advances in genetics have identified the genes responsible for PAH associated with developmental defects of the heart and lungs, such as TBX4 and SOX17. Targeted therapies for PAH have been developed; however, their effects on PH associated with developmental heart and lung defects remain to be established. Real-world data analyses on the anatomy, pathophysiology, genetics, and molecular biology of unique PPHVD cases associated with developmental defects of the heart and lungs, using nationwide and/or international registries, should be conducted in order to improve the treatments and prognosis of patients with these types of pediatric PH.
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Affiliation(s)
- Hidekazu Ishida
- Department of Pediatrics, Osaka University Graduate School of Medicine, 2-2 Yamadaoka, Suita 565-0871, Osaka, Japan;
| | - Jun Maeda
- Department of Cardiology, Tokyo Metropolitan Children’s Medical Center, 2-8-29 Musashidai, Fuchu 183-8561, Tokyo, Japan;
| | - Keiko Uchida
- Department of Pediatrics, Keio University of Medicine, 35 Shinanomachi, Shinjuku-ku 160-8582, Tokyo, Japan;
- Keio University Health Center, 4-1-1 Hiyoshi, Kohoku-ku, Yokohama 223-8521, Kanagawa, Japan
| | - Hiroyuki Yamagishi
- Department of Pediatrics, Keio University of Medicine, 35 Shinanomachi, Shinjuku-ku 160-8582, Tokyo, Japan;
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Acosta Izquierdo L, Rai A, Saprungruang A, Chavhan GB, Kamath BM, Dipchand AI, Seed M, Yoo SJ, Lam CZ. Assessment of liver fibrosis using a 3-dimensional high-resolution late gadolinium enhancement sequence in children and adolescents with Fontan circulation. Eur Radiol 2023; 33:5446-5454. [PMID: 36786904 DOI: 10.1007/s00330-023-09452-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2022] [Revised: 12/05/2022] [Accepted: 02/03/2023] [Indexed: 02/15/2023]
Abstract
OBJECTIVES To assess abnormal liver enhancement on 15-20 min delayed 3D high-resolution late gadolinium enhancement (3D HR LGE) sequence in patients with Fontan circulation. METHODS Retrospective study of pediatric Fontan patients (< 18 years old) with combined cardiac-liver MRI from January 2018 to August 2021. Abnormal hepatic enhancement was graded (0-3) for each lobe, summed for a total liver enhancement score (0-6), and compared to repaired tetralogy of Fallot (rTOF) patients. Correlations with other hepatic imaging biomarkers were performed. Temporal relationships of enhancement compared to traditional early portal venous and 5-7-min delayed phase liver imaging were analyzed. RESULTS The Fontan group (n = 35, 13 ± 3.4 years old, median time from Fontan 10 (9-12) years) had 23/35 (66%) with delayed 3D HR LGE total liver enhancement score > 0 (range 0-5), with greater involvement of the right lobe (1 (0-1) vs 0 (0-1), p < 0.01). The rTOF group (n = 35, 14 ± 2.6 years old) had no abnormal enhancement. In the Fontan group, total liver enhancement was 3 (2-4) in the early portal venous phase, lower at 1 (1-2) in the 5-7-min delayed phase (p < 0.01), and lowest at 1 (0-2) in the 15-20-min delayed phase (p = 0.03). 3D HR LGE enhancement correlated inversely with portal vein flow (rs = - 0.42, p = 0.01) and positively with left lobe stiffness (rs = 0.51, p < 0.01). The enhancement score decreased in 13/35 (37%) between the 5-7- and 15-20-min delayed phases. CONCLUSIONS Liver fibrosis can be assessed on 3D HR LGE sequences in patients with Fontan circulation, correlates with other imaging biomarkers of Fontan liver disease, and may add information for hepatic surveillance in this population. KEY POINTS • Abnormal liver enhancement on 3D HR LGE sequences in Fontan patients likely represents liver fibrosis and is seen in up to 66% of children and adolescents with variable distribution and severity. • The degree of 3D HR LGE liver enhancement correlates with decreased portal vein flow and increased left hepatic lobe stiffness.
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Affiliation(s)
- Laura Acosta Izquierdo
- Department of Diagnostic Imaging, Hospital for Sick Children, 555 University Avenue, Toronto, Ontario, M5G 1X8, Canada
- Department of Medical Imaging, University of Toronto, Toronto, Ontario, Canada
| | - Archana Rai
- Department of Diagnostic Imaging, Hospital for Sick Children, 555 University Avenue, Toronto, Ontario, M5G 1X8, Canada
- Department of Medical Imaging, University of Toronto, Toronto, Ontario, Canada
| | - Ankavipar Saprungruang
- Department of Diagnostic Imaging, Hospital for Sick Children, 555 University Avenue, Toronto, Ontario, M5G 1X8, Canada
- Division of Cardiology, Department of Paediatrics, Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
| | - Govind B Chavhan
- Department of Diagnostic Imaging, Hospital for Sick Children, 555 University Avenue, Toronto, Ontario, M5G 1X8, Canada
- Department of Medical Imaging, University of Toronto, Toronto, Ontario, Canada
| | - Binita M Kamath
- Division of Gastroenterology, Hepatology and Nutrition, Department of Paediatrics, Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
| | - Anne I Dipchand
- Division of Cardiology, Department of Paediatrics, Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
| | - Mike Seed
- Department of Diagnostic Imaging, Hospital for Sick Children, 555 University Avenue, Toronto, Ontario, M5G 1X8, Canada
- Department of Medical Imaging, University of Toronto, Toronto, Ontario, Canada
- Division of Cardiology, Department of Paediatrics, Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
| | - Shi-Joon Yoo
- Department of Diagnostic Imaging, Hospital for Sick Children, 555 University Avenue, Toronto, Ontario, M5G 1X8, Canada
- Department of Medical Imaging, University of Toronto, Toronto, Ontario, Canada
| | - Christopher Z Lam
- Department of Diagnostic Imaging, Hospital for Sick Children, 555 University Avenue, Toronto, Ontario, M5G 1X8, Canada.
- Department of Medical Imaging, University of Toronto, Toronto, Ontario, Canada.
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Menachem JN, Clark D, Cedars A. Austin Powers' Steamroller: Lessons Learned to Benefit Patients with Congenital Heart Disease. J Card Fail 2023; 29:1222-1224. [PMID: 34974182 DOI: 10.1016/j.cardfail.2021.12.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2021] [Accepted: 12/15/2021] [Indexed: 11/12/2022]
Abstract
A structural crisis is brewing in advanced care for patients with congenital heart disease (CHD)-specifically, single-ventricle patients palliated by the Fontan procedure. The largest study evaluating management practices in pediatric cardiac teams found that 93% of providers believe that after the Fontan procedure, patients "will eventually have signs/symptoms of heart failure (HF) and will need a heart transplant (HT) at some point in their lives."1 Despite this, the majority either disagreed about (45%) or were undecided about (24%) "whether routine evaluation by a HF/HT cardiologist is needed." This may be, in part, attributable to the lack of an HF/HT subspecialty in the American College of Pediatrics, but these findings highlight a concerning disconnect in the minds of providers caring for patients undergoing the Fontan procedure, for whom the providers' preparation seems incongruous in terms of the anticipated endpoint. This disconnect would likely be even worse had the survey been conducted in adult providers, given that the providers of care for adults with congenital heart disease (ACHD) have limited required HF/HT training, and adult HF/HT cardiologists have little required training in CHD.
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Affiliation(s)
- Jonathan N Menachem
- Division of Cardiovascular Medicine, Vanderbilt University Medical Center, Nashville, Tennessee.
| | - Daniel Clark
- Division of Cardiovascular Medicine, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Ari Cedars
- Departments of Medicine and Pediatrics, Johns Hopkins School of Medicine, Baltimore, Maryland
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98
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Teng C, Shrestha R, Phillips J. Challenges in diagnosing pulmonary embolism in an adult with Fontan physiology: a case report. Eur Heart J Case Rep 2023; 7:ytad330. [PMID: 37554959 PMCID: PMC10405353 DOI: 10.1093/ehjcr/ytad330] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2022] [Revised: 06/26/2023] [Accepted: 07/19/2023] [Indexed: 08/10/2023]
Abstract
BACKGROUND With the increasing longevity of congenital heart disease patients and limited number of adult congenital heart disease specialists, it is becoming increasingly imperative for general cardiologists to understand not only the unique physiology of Fontan patients but also imaging protocol considerations when treating this group of patients. CASE SUMMARY Here, we present a patient with a history of congenital tricuspid atresia status after the Fontan procedure who presented for gut translocation-related bacteraemia. Importantly, the patient was falsely diagnosed with pulmonary embolism resulting from inaccurate acquisition of computed tomography imaging. DISCUSSION This case illustrates the complex intricacies that clinicians should consider when facing the challenge of treating Fontan patients.
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Affiliation(s)
- Catherine Teng
- Division of Cardiology, Department of Medicine, University of Texas Health Science Center San Antonio, TX, USA
| | - Ribesh Shrestha
- Division of Cardiology, Department of Medicine, University of Texas Health Science Center San Antonio, TX, USA
- Department of Internal Medicine, University of Texas Health Science Center, San Antonio, TX, USA
| | - Jason Phillips
- Division of Cardiology, Department of Medicine, University of Texas Health Science Center San Antonio, TX, USA
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Gagliardi MG, Formigari R, Perrone MA, Pomiato E, Fanisio F, Panebianco M, Barracano R, Guccione P, Palmieri R, Raponi M, Galletti L. Changes in the Cath Lab in the Treatment of Adult Patients with Congenital Heart Disease: A 12-Year Experience in a Single Referral Center with the Establishment of a Dedicated Working Group. J Cardiovasc Dev Dis 2023; 10:314. [PMID: 37623327 PMCID: PMC10455676 DOI: 10.3390/jcdd10080314] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2023] [Revised: 07/16/2023] [Accepted: 07/20/2023] [Indexed: 08/26/2023] Open
Abstract
BACKGROUND Adults with congenital heart disease (ACHD) are a growing population needing ongoing care. The aim of this study was to investigate if a dedicated ACHD team impacted the timing and indication of invasive cardiology procedures in these patients at our hospital. METHODS Our retrospective single-center study enrolled adult patients with moderate or complex congenital heart disease and with at least one cardiac catheterization between January 2010 and December 2021. According to the period, procedures were labeled as group A (2010 to 2015) or group B (2016 to 2021) and further divided into diagnostic (DCC) and interventional cardiac catheterizations (ICC). RESULTS 594 patients were eligible for the study. Both DCC (p < 0.05) and ICC increased between groups A and B (p < 0.05). In group B: Fontan patients accounted for the majority of DCC (p < 0.001), while DCC decreased in arterial switch repair (p < 0.001). In Fontan patients, conduit stenting was prevalent (p < 0.001), while fenestration closures dropped (p < 0.01). In patients with tetralogy of Fallot and native outflow tract, percutaneous pulmonary valve implantations (PPVI) increased, with a concurrent reduction in pulmonary valve replacements (p < 0.001 vs. surgical series). In right ventricular conduits, ICC increased (p < 0.01), mainly due to PPVI. Among Mustard/Senning patients, baffle stenting increased from Group A to Group B (p < 0.001). In patients with pulmonary atresia and biventricular repair, ICC often increased for pulmonary artery stenting. CONCLUSIONS A dedicated working group could improve ACHD patients' indications for interventional procedures, leading to tailored treatment, better risk stratification and optimizing time until heart transplantation.
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Affiliation(s)
- Maria Giulia Gagliardi
- Department of Cardiac Surgery, Cardiology and Heart Lung Transplant, Bambino Gesù Children’s Hospital IRCCS, 00165 Rome, Italy; (R.F.); (E.P.); (F.F.); (M.P.); (R.B.); (P.G.); (R.P.); (L.G.)
| | - Roberto Formigari
- Department of Cardiac Surgery, Cardiology and Heart Lung Transplant, Bambino Gesù Children’s Hospital IRCCS, 00165 Rome, Italy; (R.F.); (E.P.); (F.F.); (M.P.); (R.B.); (P.G.); (R.P.); (L.G.)
| | - Marco Alfonso Perrone
- Department of Cardiac Surgery, Cardiology and Heart Lung Transplant, Bambino Gesù Children’s Hospital IRCCS, 00165 Rome, Italy; (R.F.); (E.P.); (F.F.); (M.P.); (R.B.); (P.G.); (R.P.); (L.G.)
- Division of Cardiology and Cardio Lab, Department of Clinical Sciences and Translational Medicine, University of Rome Tor Vergata, 00133 Rome, Italy
| | - Elettra Pomiato
- Department of Cardiac Surgery, Cardiology and Heart Lung Transplant, Bambino Gesù Children’s Hospital IRCCS, 00165 Rome, Italy; (R.F.); (E.P.); (F.F.); (M.P.); (R.B.); (P.G.); (R.P.); (L.G.)
| | - Francesca Fanisio
- Department of Cardiac Surgery, Cardiology and Heart Lung Transplant, Bambino Gesù Children’s Hospital IRCCS, 00165 Rome, Italy; (R.F.); (E.P.); (F.F.); (M.P.); (R.B.); (P.G.); (R.P.); (L.G.)
| | - Mario Panebianco
- Department of Cardiac Surgery, Cardiology and Heart Lung Transplant, Bambino Gesù Children’s Hospital IRCCS, 00165 Rome, Italy; (R.F.); (E.P.); (F.F.); (M.P.); (R.B.); (P.G.); (R.P.); (L.G.)
| | - Rosaria Barracano
- Department of Cardiac Surgery, Cardiology and Heart Lung Transplant, Bambino Gesù Children’s Hospital IRCCS, 00165 Rome, Italy; (R.F.); (E.P.); (F.F.); (M.P.); (R.B.); (P.G.); (R.P.); (L.G.)
| | - Paolo Guccione
- Department of Cardiac Surgery, Cardiology and Heart Lung Transplant, Bambino Gesù Children’s Hospital IRCCS, 00165 Rome, Italy; (R.F.); (E.P.); (F.F.); (M.P.); (R.B.); (P.G.); (R.P.); (L.G.)
| | - Rosalinda Palmieri
- Department of Cardiac Surgery, Cardiology and Heart Lung Transplant, Bambino Gesù Children’s Hospital IRCCS, 00165 Rome, Italy; (R.F.); (E.P.); (F.F.); (M.P.); (R.B.); (P.G.); (R.P.); (L.G.)
| | - Massimiliano Raponi
- Medical Directorate, Bambino Gesù Children’s Hospital IRCCS, 00165 Rome, Italy;
| | - Lorenzo Galletti
- Department of Cardiac Surgery, Cardiology and Heart Lung Transplant, Bambino Gesù Children’s Hospital IRCCS, 00165 Rome, Italy; (R.F.); (E.P.); (F.F.); (M.P.); (R.B.); (P.G.); (R.P.); (L.G.)
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Misra A, Desai AS, Valente AM. Valvular Regurgitation in Adults with Congenital Heart Disease and Heart Failure: Current Status and Potential Interventions. Heart Fail Clin 2023; 19:345-356. [PMID: 37230649 DOI: 10.1016/j.hfc.2023.02.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/27/2023]
Abstract
The great majority of patients born with congenital heart disease (CHD) are living well into adulthood, yet they often have residual hemodynamic lesions, including valvar regurgitation. As these complex patients grow older, they are at risk of developing heart failure, which can be exacerbated by the underlying valvular regurgitation. In this review, we describe the etiologies of heart failure related to valvular regurgitation in the CHD population and discuss potential interventions.
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Affiliation(s)
- Amrit Misra
- Department of Cardiology, Boston Children's Hospital, Harvard Medical School, 300 Longwood, Boston, MA 02115, USA; Department of Cardiology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA.
| | - Akshay S Desai
- Department of Cardiology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Anne Marie Valente
- Department of Cardiology, Boston Children's Hospital, Harvard Medical School, 300 Longwood, Boston, MA 02115, USA; Department of Cardiology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
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