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Invasive Hemodynamic Evaluation of the Fontan Circulation: Current Day Practice and Limitations. Curr Cardiol Rep 2022; 24:587-596. [PMID: 35230616 DOI: 10.1007/s11886-022-01679-4] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 02/03/2022] [Indexed: 12/29/2022]
Abstract
PURPOSE OF REVIEW Establishing the Fontan circulation has led to improved survival in patients born with complex congenital heart diseases. Despite early success, the long-term course of Fontan patients is complicated by multi-organ dysfunction, mainly due to a combination of low resting and blunted exercise-augmented cardiac output as well as elevated central venous (Fontan) pressure. Similarly, despite absolute hemodynamic differences compared to the normal population with biventricular circulation, the "normal" ranges of hemodynamic parameters specific to age-appropriate Fontan circulation have not been well defined. With the ever-increasing population of patients requiring Fontan correction, it is of utmost importance that an acceptable range of hemodynamics in this highly complex patient cohort is better defined. RECENT FINDINGS Multiple publications have described hemodynamic limitations and potential management options in patients with Fontan circulation; however, an acceptable range of hemodynamic parameters in this patient population has not been well defined. Identification of "normal" hemodynamic parameters among patients with Fontan circulation will allow physicians to more objectively define indications for intervention, which is a necessary first step to eliminate institutional and regional heterogeneity in Fontan management and potentially improve long-term clinical outcomes.
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Truong VT, Moore RA, Lubert AM, Taylor MD, Mazur W, Alsaied T, Goldstein BH. Association of plasma biomarkers and interstitial myocardial fibrosis in fontan population: A machine learning approach. INTERNATIONAL JOURNAL OF CARDIOLOGY CONGENITAL HEART DISEASE 2022. [DOI: 10.1016/j.ijcchd.2022.100321] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
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Müller MJ, Norozi K, Caroline J, Sedlak N, Bock J, Paul T, Geyer S, Dellas C. Morbidity and mortality in adults with congenital heart defects in the third and fourth life decade. Clin Res Cardiol 2022; 111:900-911. [PMID: 35229166 PMCID: PMC9334441 DOI: 10.1007/s00392-022-01989-1] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/17/2021] [Accepted: 02/07/2022] [Indexed: 12/22/2022]
Abstract
Objectives The population of adults with congenital heart defects (ACHD) is continuously growing. Data on morbidity and mortality of ACHD are limited. This longitudinal observational study examined a group of ACHD with surgically corrected or palliated congenital heart defects (CHD) during a 15-year period. Methods ACHD that had participated in the initial study were invited for a follow-up examination. Mortality and hospitalization data were compared with a healthy control group. Results From 05/2017 to 04/2019 a total of 249/364 (68%) ACHD participated in the follow-up study: 21% had mild, 60% moderate and 19% severe CHD. During the observational period, 290 health incidents occurred (cardiac catheterization 37%, cardiovascular surgery 27%, electrophysiological study/ablation 20%, catheter interventional treatment 14%, non-cardiac surgery 3%). Events were more frequent in ACHD with moderate (53%) and severe (87%) compared to those with mild CHD (p < 0.001). 24 individuals died at a median age of 43 years during the observation period. 29% of them had moderate and 71% severe CHD corresponding to a mortality rate of 0%, 0.29% and 1.68% per patient-year in ACHD with mild, moderate and severe CHD. Long-term survival was significantly reduced in patients with severe CHD in comparison to individuals with mild and moderate CHD (p < 0.001). Conclusion After correction or palliation of CHD, there was remarkable ongoing morbidity and mortality in ACHD patients over the 15-year observation period, particularly in individuals with moderate and severe CHD when compared with the general population. Thus, life-long special care is required for all surgically corrected or palliated ACHD patients. Graphical abstract ![]()
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Affiliation(s)
- Matthias J Müller
- Department of Pediatric Cardiology and Intensive Care Medicine, Georg August University, Robert-Koch-Str. 40, 37075, Goettingen, Germany.
| | - Kambiz Norozi
- Department of Pediatric Cardiology and Intensive Care Medicine, Georg August University, Robert-Koch-Str. 40, 37075, Goettingen, Germany.,Pediatric Cardiology, Western University, London, ON, Canada
| | - Jonas Caroline
- Department of Pediatric Cardiology and Intensive Care Medicine, Georg August University, Robert-Koch-Str. 40, 37075, Goettingen, Germany
| | - Nicole Sedlak
- Department of Pediatric Cardiology and Intensive Care Medicine, Georg August University, Robert-Koch-Str. 40, 37075, Goettingen, Germany
| | - Jonas Bock
- Department of Pediatric Cardiology and Intensive Care Medicine, Georg August University, Robert-Koch-Str. 40, 37075, Goettingen, Germany
| | - Thomas Paul
- Department of Pediatric Cardiology and Intensive Care Medicine, Georg August University, Robert-Koch-Str. 40, 37075, Goettingen, Germany
| | - Siegfried Geyer
- Medical Sociology Unit, Hannover Medical School, Hannover, Germany
| | - Claudia Dellas
- Department of Pediatric Cardiology and Intensive Care Medicine, Georg August University, Robert-Koch-Str. 40, 37075, Goettingen, Germany
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Heart transplant indications, considerations and outcomes in Fontan patients: Age-related nuances, transplant listing and disease-specific indications. THE CANADIAN JOURNAL OF CARDIOLOGY 2022; 38:1072-1085. [PMID: 35240250 DOI: 10.1016/j.cjca.2022.02.019] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Subscribe] [Scholar Register] [Received: 12/20/2021] [Revised: 02/09/2022] [Accepted: 02/21/2022] [Indexed: 11/23/2022]
Abstract
In the current era, 5-10% of Fontan patients die or need a transplant in childhood, and approximately 50% will experience the same fate by age 40 years. Heart transplant (HTx) can be successful for selected children and adults with Fontan circulatory failure (FCF) of any mechanism, with a 1-year post-transplant survival approaching 90% in children and 80% in the largest single-centre adult Fontan HTx experience. Protein losing enteropathy and plastic bronchitis can be expected to resolve post-transplant and limited data suggests patients with FALD who survive HTx can expect improvement in liver health. Early Fontan failure, within 12 months of Fontan completion, is not easily rescued by HTx and late referrals / failure to refer adult patients remains problematic. Very little is known about the numbers of patients not referred, turned down following assessment for HTx, or dying on the waiting list which are needed to understand the complete picture of HTx in the Fontan population and to identify where best to focus quality improvement efforts. Recent revisions to listing prioritization in Canada with considerations specific to the Fontan population aim to mitigate the fact that the status listing criteria are not tailored to the congenital heart population. Transplanting high-risk children prior to Fontan completion, developing ACHD transplant centres of expertise which can also offer combined heart-liver transplant when appropriate, and improving single ventricle mechanical support options and criteria for both adults and children may help mitigate the early post-listing mortality.
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205
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Lubert AM, Opotowsky AR, Palermo JJ, Alsaied T, Szugye C, Anwar N, Tiao GM, Lorts A, Dillman JR, Trout AT. Relation of Liver Volume to Adverse Cardiovascular Events in Adolescents and Adults With Fontan Circulation. Am J Cardiol 2022; 165:88-94. [PMID: 34893302 DOI: 10.1016/j.amjcard.2021.10.045] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/12/2021] [Revised: 10/14/2021] [Accepted: 10/19/2021] [Indexed: 11/26/2022]
Abstract
Elevated central venous pressure in those with Fontan circulation causes liver congestion and hepatomegaly. We assessed if liver volume by magnetic resonance imaging (MRI) is associated with adverse cardiovascular outcomes. Retrospective study of 122 patients with Fontan circulation who were >10 years old and had a liver MRI with magnetic resonance elastography. Liver volume (ml) was measured by manual segmentation from axial T2-weighted images and was indexed to body surface area. The composite outcome included death, heart transplant, ventricular assist device placement, or nonelective cardiovascular hospitalization. The median age at the time of MRI was 18.9 (interquartile range 15.8 to 25.9) years, and 47% of the patients were women. The mean indexed liver volume was 1,133 ± 180 ml/m2. Indexed liver volume was not significantly associated with age, years since Fontan, or with liver stiffness (r = 0.15, p = 0.10), but was positively correlated with Fontan pressure (r = 0.32, p = 0.002). Over a median follow-up of 2.1 (0.8 to 4.2) years, 32 patients (26%) experienced the composite outcome. Higher indexed liver volume was associated with a greater hazard for the composite outcome (hazard ratio per 1 SD increase = 1.74, 95% confidence interval 1.27 to 2.35, p = 0.0004) but increased liver stiffness was not significantly associated with the composite outcome (hazard ratio per 1 SD increase 1.44, 95% confidence interval 0.90 to 2.21, p = 0.11). In conclusion, greater liver volume indexed to body surface area is associated with unfavorable hemodynamics and adverse outcomes in patients with Fontan circulation. Liver volume may be a useful, simple imaging biomarker in adolescents and adults with Fontan circulation.
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Dirks S, Kramer P, Schleiger A, Speck HM, Wolfarth B, Thouet T, Berger F, Sallmon H, Ovroutski S. Home-Based Long-Term Physical Endurance and Inspiratory Muscle Training for Children and Adults With Fontan Circulation—Initial Results From a Prospective Study. Front Cardiovasc Med 2022; 8:784648. [PMID: 35198605 PMCID: PMC8858796 DOI: 10.3389/fcvm.2021.784648] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2021] [Accepted: 12/28/2021] [Indexed: 11/13/2022] Open
Abstract
BackgroundPatients with congenital heart disease (CHD)—including those after Fontan operation—are encouraged to be physically active.AimTo prospectively determine the effects of an individually adapted, home-based cycle ergometer endurance training in combination with inspiratory muscle training (IMT) in pediatric and adult Fontan patients. We, herein, report the results of the initial 10-months follow-up (phase 1).Methods18 patients (median age 16.5 years; range 10-43 years) completed baseline check-ups, and 4 and 10 months follow-up visits, which each included cardiopulmonary exercise testing (CPET), bodyplethysmography (including measurement of respiratory muscle strength), and a quality of life questionnaire (PedsQL™). The training program consisted of a home-based cycle ergometer endurance training on a “Magbike® AM-5i/3i” (DKN Technology®, Clermont-Ferrand, France) and IMT with a handheld “POWERbreathe® Medic plus” device. Patients performed 90 min of endurance training per week in addition to IMT (30 breaths per day, 6-7 times per week). After the first 4 months, patients underwent additional interval training.ResultsAfter 10 months of training, we observed significant increases in maximum relative workload (W/kg, p = 0.003) and in maximum inspiratory (MIP, p = 0.002) and expiratory (MEP, p = 0.008) pressures. Peak VO2 values did not increase significantly as compared to baseline (p = 0.12) in the entire cohort (n = 18), but reached statistical significance in a subgroup analysis of teenage/adult patients (n = 14; p = 0.03). Patients' subjective quality of life did not show any significant changes after 10 months of training.DiscussionIn Fontan patients, an individually adapted home-based training is safe and associated with improvements in some CPET variables. However, these improvements did not translate into an improved QoL after 10 months. With an unclear, but most likely negative, impact of the COVID-19 pandemic, improvements in QoL may become evident during further follow-up (phase 2 of the study).
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Affiliation(s)
- Stefan Dirks
- Department of Congenital Heart Disease—Pediatric Cardiology, Deutsches Herzzentrum Berlin, Berlin, Germany
| | - Peter Kramer
- Department of Congenital Heart Disease—Pediatric Cardiology, Deutsches Herzzentrum Berlin, Berlin, Germany
| | - Anastasia Schleiger
- Department of Congenital Heart Disease—Pediatric Cardiology, Deutsches Herzzentrum Berlin, Berlin, Germany
| | - Hans-Martin Speck
- Department of Congenital Heart Disease—Pediatric Cardiology, Deutsches Herzzentrum Berlin, Berlin, Germany
| | - Bernd Wolfarth
- Department of Sports Medicine, Charité—Universitätsmedizin Berlin, Berlin, Germany
| | - Thomas Thouet
- Department of Sports Medicine, Charité—Universitätsmedizin Berlin, Berlin, Germany
| | - Felix Berger
- Department of Congenital Heart Disease—Pediatric Cardiology, Deutsches Herzzentrum Berlin, Berlin, Germany
- Department of Pediatric Cardiology, Charité—Universitätsmedizin Berlin, Berlin, Germany
- German Centre for Cardiovascular Research (DZHK), Berlin, Germany
| | - Hannes Sallmon
- Department of Congenital Heart Disease—Pediatric Cardiology, Deutsches Herzzentrum Berlin, Berlin, Germany
- Department of Pediatric Cardiology, Charité—Universitätsmedizin Berlin, Berlin, Germany
| | - Stanislav Ovroutski
- Department of Congenital Heart Disease—Pediatric Cardiology, Deutsches Herzzentrum Berlin, Berlin, Germany
- *Correspondence: Stanislav Ovroutski
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Nederend M, Egorova AD, Vliegen HW, Roest AAW, Ruijter BN, Korteweg T, Ninaber MK, Zeppenfeld K, Hazekamp MG, Kiès P, Jongbloed MRM. Case report of the broad spectrum of late complications in an adult patient with univentricular physiology palliated by the Fontan circulation. Eur Heart J Case Rep 2022; 6:ytac067. [PMID: 35224438 PMCID: PMC8867817 DOI: 10.1093/ehjcr/ytac067] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2021] [Revised: 12/14/2021] [Accepted: 01/24/2022] [Indexed: 11/18/2022]
Abstract
Background At the most severe end of the spectrum of congenital heart disease are patients with an univentricular physiology. They comprise a heterogeneous group of congenital heart malformations that have the common characteristic that the cardiac morphology is not equipped for sustaining a biventricular circulation. Case summary Here, we present a case of an adult patient after Fontan palliation, illustrative of the complex clinical course and the broad spectrum of complications that can be encountered during follow-up, highlighting the need for a multidisciplinary approach in the clinical care for these patients. Discussion During the surgical Fontan procedure, the inferior vena cava is connected to the pulmonary circulation, after prior connection of the superior vena cava to the pulmonary arterial circulation. The resulting cavopulmonary connection, thus lacking a subpulmonic ventricle, provides non-pulsatile passive flow of oxygen-poor blood from the systemic venous circulation into the lungs, and the functional monoventricle pumps the oxygen-rich pulmonary venous return blood into the aorta. With an operative mortality of <5% and current 30-year survival rates up to 85%, the adult population of patients with a Fontan circulation is growing. This increase in survival is, however, inevitably accompanied by long-term complications affecting multiple organ systems, resulting in decline in cardiovascular performance. Conclusion For optimal treatment, the evaluation in a multidisciplinary team is mandatory, using the specific expertise of the team members to timely detect and address late complications and to support quality of life.
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Affiliation(s)
- Marieke Nederend
- CAHAL, Center for Congenital Heart Disease Amsterdam Leiden, Leiden University Medical Center, Leiden, the Netherlands
- Department of Cardiology, Leiden University Medical Center, Albinusdreef 2, 2333 ZA Leiden, the Netherlands
| | - Anastasia D Egorova
- CAHAL, Center for Congenital Heart Disease Amsterdam Leiden, Leiden University Medical Center, Leiden, the Netherlands
- Department of Cardiology, Leiden University Medical Center, Albinusdreef 2, 2333 ZA Leiden, the Netherlands
| | - Hubert W Vliegen
- CAHAL, Center for Congenital Heart Disease Amsterdam Leiden, Leiden University Medical Center, Leiden, the Netherlands
- Department of Cardiology, Leiden University Medical Center, Albinusdreef 2, 2333 ZA Leiden, the Netherlands
| | - Arno A W Roest
- CAHAL, Center for Congenital Heart Disease Amsterdam Leiden, Leiden University Medical Center, Leiden, the Netherlands
- Division of Paediatric Cardiology, Department of Paediatrics, Leiden University Medical Center, Albinusdreef 2, 2333 ZA Leiden, the Netherlands
| | - Bastian N Ruijter
- Department of Gastroenterology, Leiden University Medical Center, Leiden, Albinusdreef 2, 2333 ZA Leiden, the Netherlands
| | - Tijmen Korteweg
- Department of Radiology, Leiden University Medical Center, Albinusdreef 2, 2333 ZA Leiden, the Netherlands
| | - Maarten K Ninaber
- Department of Pulmonology, Leiden University Medical Center, Albinusdreef 2, 2333 ZA Leiden, the Netherlands
| | - Katja Zeppenfeld
- Department of Cardiology, Leiden University Medical Center, Albinusdreef 2, 2333 ZA Leiden, the Netherlands
| | - Mark G Hazekamp
- CAHAL, Center for Congenital Heart Disease Amsterdam Leiden, Leiden University Medical Center, Leiden, the Netherlands
- Department of Cardiothoracic Surgery, Leiden University Medical Center, Albinusdreef 2, 2333 ZA Leiden, the Netherlands
| | - Philippine Kiès
- CAHAL, Center for Congenital Heart Disease Amsterdam Leiden, Leiden University Medical Center, Leiden, the Netherlands
- Department of Cardiology, Leiden University Medical Center, Albinusdreef 2, 2333 ZA Leiden, the Netherlands
| | - Monique R M Jongbloed
- CAHAL, Center for Congenital Heart Disease Amsterdam Leiden, Leiden University Medical Center, Leiden, the Netherlands
- Department of Cardiology, Leiden University Medical Center, Albinusdreef 2, 2333 ZA Leiden, the Netherlands
- Department of Anatomy & Embryology, Leiden University Medical Center, Albinusdreef 2, 2333 ZA Leiden, the Netherlands
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Reid CS, Kaiser HA, Heinisch PP, Bruelisauer T, Michel S, Siepe M. Ventricular assist device for Fontan: who, when and why? Curr Opin Anaesthesiol 2022; 35:12-17. [PMID: 34812751 DOI: 10.1097/aco.0000000000001078] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
PURPOSE OF REVIEW Since the advent of the Fontan palliation, survival of patients with univentricular congenital heart disease has increased significantly. These patients will, however, ultimately develop heart failure requiring advanced therapies such as heart transplantation. As wait times are long, mechanical circulatory support (MCS) is an attractive therapy, both for bridge to transplantation and destination therapy in patients not suitable for transplantation. This review aims to summarize current thinking about how to determine which patients would benefit from a ventricular assist device (VAD), the optimal time for implantation and which device should be considered. RECENT FINDINGS VAD implantation in end-stage Fontan is still in its infancy; however, case reports and research interest have increased extensively in the past few years. Mortality is significantly higher than in noncongenital heart disease patients. Implantation in patients with primarily systolic dysfunction is indicated, whereas patients with increased transpulmonary gradient may not benefit from a single-VAD solution. When possible, implantation should occur prior to clinical decompensation with evidence of end-organ damage, as outcomes at this point are worse. SUMMARY Fontan patients demonstrating signs of heart failure should be evaluated early and often for feasibility and optimal timing of VAD implantation. The frequency of this procedure will likely increase significantly in the future.
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Affiliation(s)
- Catherine S Reid
- Department of Anaesthesiology and Pain Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Heiko A Kaiser
- Department of Anaesthesiology and Pain Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
- Centre for Anaesthesiology and Intensive Care Medicine, Hirslanden Klinik Aarau, Hirslanden Group, Aarau, Switzerland
| | - Paul Philipp Heinisch
- Department of Congenital and Pediatric Heart Surgery, German Heart Center Munich, Technische Universität München, Germany
- Division of Congenital and Pediatric Heart Surgery, University Hospital of Munich, Ludwig-Maximilians-Universität, Munich, Germany
| | - Thomas Bruelisauer
- German Heart Center Berlin, Department of Cardiac Anesthesiology and Intensive Care Medicine, Berlin, Germany
| | - Sebastian Michel
- Department of Congenital and Pediatric Heart Surgery, German Heart Center Munich, Technische Universität München, Germany
- Division of Congenital and Pediatric Heart Surgery, University Hospital of Munich, Ludwig-Maximilians-Universität, Munich, Germany
| | - Matthias Siepe
- Department of Cardiovascular Surgery, Heart Center University Freiburg - Bad Krozingen, Bad Krozingen, Germany
- Faculty of Medicine, University of Freiburg, Freiburg, Germany
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Sakamori R, Yamada R, Tahata Y, Kodama T, Hikita H, Tatsumi T, Yamada T, Takehara T. The absence of warfarin treatment and situs inversus are associated with the occurrence of hepatocellular carcinoma after Fontan surgery. J Gastroenterol 2022; 57:111-119. [PMID: 35064829 DOI: 10.1007/s00535-021-01842-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/17/2021] [Accepted: 12/05/2021] [Indexed: 02/04/2023]
Abstract
BACKGROUND Hepatocellular carcinoma (HCC) is a long-term complication of Fontan-associated liver disease (FALD). However, risk factors for HCC in patients with FALD remain unclear. This study aimed to identify factors associated with HCC development post-Fontan procedure. METHODS We retrospectively examined 103 post-Fontan patients who underwent hepatic imaging at our institution. HCC incidence and patient characteristics were analyzed. A Cox proportional hazards model was used to identify risk factors for HCC. RESULTS The median interval between Fontan surgery and final hepatic imaging was 19.6 (1.0-37.7) years. Among 103 patients, nine developed HCC. The cumulative incidence rates of HCC at 10, 20, and 30 years postoperatively were 0%, 7%, and 13%, respectively. In the univariate analysis, age at Fontan surgery, situs inversus, and warfarin absence were associated with HCC occurrence. The multivariate analysis identified the warfarin absence (adjusted hazard ratio [aHR], 22.71; 95% confidence interval: 3.29-507.1; p = 0.0005) and situs inversus (aHR, 14.36; 95% confidence interval: 2.75-105.5; p = 0.002) as risk factors. The prevalence of situs inversus and the warfarin absence was 12% and 50%, respectively. The 20- and 30-year incidence rates of HCC among patients who received warfarin were 0% and 7%, respectively, while those among patients who did not receive warfarin were 14% and 21%, respectively. HCC incidence was significantly higher in the non-warfarin group than in the warfarin group (p = 0.006) and among patients with situs inversus than among those with situs solitus (p = 0.004). CONCLUSIONS Warfarin absence and situs inversus were associated with HCC development post-Fontan procedure.
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Affiliation(s)
- Ryotaro Sakamori
- Department of Gastroenterology and Hepatology, Osaka University Graduate School of Medicine, 2-2 Yamadaoka, Suita, Osaka, 565-0871, Japan
| | - Ryoko Yamada
- Department of Gastroenterology and Hepatology, Osaka University Graduate School of Medicine, 2-2 Yamadaoka, Suita, Osaka, 565-0871, Japan
| | - Yuki Tahata
- Department of Gastroenterology and Hepatology, Osaka University Graduate School of Medicine, 2-2 Yamadaoka, Suita, Osaka, 565-0871, Japan
| | - Takahiro Kodama
- Department of Gastroenterology and Hepatology, Osaka University Graduate School of Medicine, 2-2 Yamadaoka, Suita, Osaka, 565-0871, Japan
| | - Hayato Hikita
- Department of Gastroenterology and Hepatology, Osaka University Graduate School of Medicine, 2-2 Yamadaoka, Suita, Osaka, 565-0871, Japan
| | - Tomohide Tatsumi
- Department of Gastroenterology and Hepatology, Osaka University Graduate School of Medicine, 2-2 Yamadaoka, Suita, Osaka, 565-0871, Japan
| | - Tomomi Yamada
- Department of Medical Innovation, Osaka University Hospital, Suita, Osaka, Japan
| | - Tetsuo Takehara
- Department of Gastroenterology and Hepatology, Osaka University Graduate School of Medicine, 2-2 Yamadaoka, Suita, Osaka, 565-0871, Japan.
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Villa C, Greenberg JW, Morales DL. Mechanical Support for the Failing Single Ventricle After Fontan. JTCVS Tech 2022; 13:174-181. [PMID: 35713590 PMCID: PMC9195612 DOI: 10.1016/j.xjtc.2021.12.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2021] [Accepted: 12/04/2021] [Indexed: 11/30/2022] Open
Affiliation(s)
| | | | - David L.S. Morales
- Address for reprints: David L. S. Morales, MD, Pediatric Cardiothoracic Surgery, The Heart Institute, Cincinnati Children's Hospital Medical Center, The University of Cincinnati College of Medicine, 3333 Burnet Ave – MLC 2004, Cincinnati, OH 45229.
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Psychological functioning in paediatric patients with single ventricle heart disease: a systematic review. Cardiol Young 2022; 32:173-184. [PMID: 35045915 DOI: 10.1017/s1047951122000063] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
BACKGROUND Patients with single ventricle heart disease are living into adulthood due to medical and surgical advancements but have significant physical comorbidities and an increased risk for psychological comorbidities compared to healthy subjects or those with other CHD diagnoses. This study aimed to systematically review psychological functioning in paediatric single ventricle heart disease. METHODS Literature was searched using PubMed, Embase, PsycInfo, CINAHL Complete and Scopus. Peer-reviewed articles that included patients ages 0-25 years with single ventricle heart disease, and quantitative measures of psychological outcomes were included. Meta-analysis using a fixed-effect model was conducted for internalising and externalising t-scores, utilised by the Achenbach Child Behavior Checklist. RESULTS Twenty-nine records met the criteria for inclusion. 13/24 studies demonstrated increased risk for internalising disorders, such as anxiety/depression; 16/22 studies demonstrated risk for externalising disorders, such as attention or behavioural problems. Meta-analysis of four studies revealed that paediatric single ventricle heart disease patients had no significant difference in internalising and externalising t-scores compared to normative values. CONCLUSIONS The current review demonstrates the need for further studies to better understand psychological functioning in patients with single ventricle heart disease, with a majority of studies showing increased risk for psychological problems despite no difference seen in a small meta-analysis. This summary of the literature underscores the need for regular psychological screening, earlier intervention and integrated mental health therapies in paediatric single ventricle heart disease.
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212
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Developing an adolescent and adult Fontan Management Programme. Cardiol Young 2022; 32:230-235. [PMID: 33966676 DOI: 10.1017/s104795112100175x] [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: 11/07/2022]
Abstract
Patients with single-ventricle CHD undergo a series of palliative surgeries that culminate in the Fontan procedure. While the Fontan procedure allows most patients to survive to adulthood, the Fontan circulation can eventually lead to multiple cardiac complications and multi-organ dysfunction. Care for adolescents and adults with a Fontan circulation has begun to transition from a primarily cardiac-focused model to care models, which are designed to monitor multiple organ systems, and using clues from this screening, identify patients who are at risk for adverse outcomes. The complexity of care required for these patients led our centre to develop a multidisciplinary Fontan Management Programme with the primary goals of earlier detection and treatment of complications through the development of a cohesive network of diverse medical subspecialists with Fontan expertise.
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213
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Loke YH, Capuano F, Balaras E, Olivieri LJ. Computational Modeling of Right Ventricular Motion and Intracardiac Flow in Repaired Tetralogy of Fallot. Cardiovasc Eng Technol 2022; 13:41-54. [PMID: 34169460 PMCID: PMC8702579 DOI: 10.1007/s13239-021-00558-3] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/23/2020] [Accepted: 06/08/2021] [Indexed: 02/03/2023]
Abstract
PURPOSE Patients with repaired Tetralogy of Fallot (rTOF) will develop dilation of the right ventricle (RV) from chronic pulmonary insufficiency and require pulmonary valve replacement (PVR). Cardiac MRI (cMRI) is used to guide therapy but has limitations in studying novel intracardiac flow parameters. This pilot study aimed to demonstrate feasibility of reconstructing RV motion and simulating intracardiac flow in rTOF patients, exclusively using conventional cMRI and an immersed-boundary method computational fluid dynamic (CFD) solver. METHODS Four rTOF patients and three normal controls underwent cMRI including 4D flow. 3D RV models were segmented from cMRI images. Feature-tracking software captured RV endocardial contours from cMRI long-axis and short-axis cine stacks. RV motion was reconstructed via diffeomorphic mapping (Deformetrica, deformetrica.org), serving as the domain boundary for CFD. Fully-resolved direct numerical simulations were performed over several cardiac cycles. Intracardiac vorticity, kinetic energy (KE) and turbulent kinetic energy (TKE) was measured. For validation, RV motion was compared to manual tracings, results of KE were compared between CFD and 4D flow. RESULTS Diastolic vorticity and TKE in rTOF patients were 4.12 ± 2.42 mJ/L and 115 ± 27/s, compared to 2.96 ± 2.16 mJ/L and 78 ± 45/s in controls. There was good agreement between RV motion and manual tracings. The difference in diastolic KE between CFD and 4D flow by Bland-Altman analysis was - 0.89910 to 2 mJ/mL (95% limits of agreement: - 1.351 × 10-2 mJ/mL to 1.171 × 10-2 mJ/mL). CONCLUSION This CFD framework can produce intracardiac flow in rTOF patients. CFD has the potential for predicting the effects of PVR in rTOF patients and improve the clinical indications guided by cMRI.
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Affiliation(s)
- Yue-Hin Loke
- Division of Cardiology, Children's National Hospital, 111 Michigan Ave NW W3-200, Washington, DC, 20010, USA.
| | - Francesco Capuano
- Department of Industrial Engineering, Università degli Studi di Napoli "Federico II", 80125, Naples, Italy
- Department of Mechanics, Mathematics and Management, Politecnico di Bari, 70126, Bari, Italy
| | - Elias Balaras
- Department of Mechanical and Aerospace Engineering, George Washington University, Washington, DC, 20052, USA
| | - Laura J Olivieri
- Division of Cardiology, Children's National Hospital, 111 Michigan Ave NW W3-200, Washington, DC, 20010, USA
- Sheikh Zayed Institute for Pediatric Surgical Innovation, Children's National Hospital, 111 Michigan Ave NW, Washington, DC, 20010, USA
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214
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Plappert L, Edwards S, Senatore A, De Martini A. The Epidemiology of Persons Living with Fontan in 2020 and Projections for 2030: Development of an Epidemiology Model Providing Multinational Estimates. Adv Ther 2022; 39:1004-1015. [PMID: 34936056 PMCID: PMC8866255 DOI: 10.1007/s12325-021-02002-3] [Citation(s) in RCA: 19] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2021] [Accepted: 11/16/2021] [Indexed: 12/18/2022]
Abstract
Introduction Fontan surgery is a palliative procedure performed in children with a functionally univentricular heart. Improvements in surgical technique over the past 30 years have increased life expectancy in this rare population. However, the epidemiology of persons living with Fontan is poorly understood. This study aimed to estimate the 2020 and 2030 prevalence of persons living with a Fontan circulation in 11 countries across the US, Europe, Australia and New Zealand, by procedure type: [atriopulmonary connection (AP), lateral tunnel total cavopulmonary connection (LT-TCPC) or extracardiac total cavopulmonary connection (EC-TCPC)]; and age group: [children (< 12 years), adolescents (12–17 years), and adults (≥ 18 years old)] by building an epidemiologic model. Methods The annual number of Fontan surgeries by country in 2010–2020 were extracted from hospital or claims databases, via procedure codes. The epidemiology of persons living with Fontan was modelled by applying these surgery frequencies to mid-year populations from 1972 to 2020 and overlaying an uptake curve. A literature search identified: 30-day mortality rates, long-term survival, and median age at surgery. Averages of these estimates were inputted into the model to project prevalence in 2030. Results The number of persons living with Fontan in 2020 across the 11 countries was estimated to be 47,881 [66 people per million (ppm)], rising to 59,777 (79 ppm) by 2030. In 2020, this population was 55% adults, 17% adolescents and 28% children shifting to 64%, 13% and 23%, respectively, in 2030. Among all persons living with Fontan, 74%/18%/9% are estimated to have EC-TCPC/LT-TCPC/AP, respectively, in 2020, and 83%/14%/4% in 2030. Conclusions According to this epidemiology model, the Fontan population is growing, partly driven by increased survival rates with the more recent LT-TCPC and EC-TCPC procedures (compared with AP). The 2020/2030 prevalence of persons living with Fontan is 66/79 ppm. Supplementary Information The online version contains supplementary material available at 10.1007/s12325-021-02002-3.
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215
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Khoury M, Cordina R. Exercise Training for People Living with a Fontan Circulation: An Underutilized Intervention. Can J Cardiol 2022; 38:1012-1023. [PMID: 35041931 DOI: 10.1016/j.cjca.2022.01.008] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2021] [Revised: 12/31/2021] [Accepted: 01/08/2022] [Indexed: 12/17/2022] Open
Abstract
Surgical repair for children born with single ventricle congenital heart disease, culminating in the Fontan operation, has resulted in dramatic improvements in survival; children born with these lesions are now typically expected to survive well into adulthood. Most, but not all, individuals with a Fontan circulation have reduced exercise capacity compared with the general population that in turn is associated with increased cardiovascular morbidity and mortality. The cause of reduced exercise capacity is multifactorial. A significant contributor is the absence of a subpulmonary ventricular pump, which limits preload and appropriate cardiac output augmentation to meet the increased metabolic demands that occur with exercise. While in its infancy relative to adults with acquired heart disease, the evidence to date suggests that exercise interventions to improve exercise capacity and Fontan physiology in children and adults with Fontan circulation are safe, effective and well tolerated. However, many knowledge gaps remain, including a detailed understanding of the unique physiological adaptations that occur, the optimal approach to exercise in this population and the effectiveness of home-based interventions utilizing telemedicine and remote physiologic monitoring technologies. Furthermore, the long-term impact of such interventions on the Fontan-cardiovascular system, physical activity levels, health-related quality of life, and late cardiovascular morbidity and mortality are not well characterized. In this review, we outline the factors associated with reduced exercise capacity in individuals with Fontan circulation, review the experience to date of dedicated interventions to improve exercise capacity, and highlight the current knowledge gaps in the field and priorities for further study.
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Affiliation(s)
- Michael Khoury
- Division of Pediatric Cardiology, Department of Pediatrics, University of Alberta, Edmonton, Alberta, Canada.
| | - Rachael Cordina
- Sydney Medical School, University of Sydney, Sidney, New South Wales, Australia; Department of Cardiology, Royal Prince Alfred Hospital, Sydney, New South Wales, Australia
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216
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Jalal Z, Gewillig M, Boudjemline Y, Guérin P, Pilati M, Butera G, Malekzadeh-Milani S, Avesani M, Thambo JB. Transcatheter interventions in patients with a Fontan circulation: Current practice and future developments. Front Pediatr 2022; 10:965989. [PMID: 36110107 PMCID: PMC9468446 DOI: 10.3389/fped.2022.965989] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/10/2022] [Accepted: 08/08/2022] [Indexed: 11/24/2022] Open
Abstract
The Fontan operation represents the last of multiple steps that are offered a wide range of congenital cardiac lesions with a single ventricle (SV) physiology. Nowadays this surgical program consists of a total cavopulmonary connection (TCPC), by anastomosing systemic veins to the pulmonary arteries (PAs), excluding the right-sided circulation from the heart. As a result of imaging, surgical, percutaneous, and critical care improvements, survival in this population has steadily increased. However, the Fontan physiology chronically increases systemic venous pressure causing systemic venous congestion and decreased cardiac output, exposing patients to the failure of the Fontan circulation (FC), which is associated with a wide variety of clinical complications such as liver disease, cyanosis, thromboembolism, protein-losing enteropathy (PLE), plastic bronchitis (PB), and renal dysfunction, ultimately resulting in an increased risk of exercise intolerance, arrhythmias, and premature death. The pathophysiology of the failing Fontan is complex and multifactorial; i.e., caused by the single ventricle dysfunction (diastolic/systolic failure, arrhythmias, AV valve regurgitation, etc.) or caused by the specific circulation (conduits, pulmonary vessels, etc.). The treatment is still challenging and may include multiple options and tools. Among the possible options, today, interventional catheterization is a reliable option, through which different procedures can target various failing elements of the FC. In this review, we aim to provide an overview of indications, techniques, and results of transcatheter options to treat cavopulmonary stenosis, collaterals, impaired lymphatic drainage, and the management of the fenestration, as well as to explore the recent advancements and clinical applications of transcatheter cavopulmonary connections, percutaneous valvular treatments, and to discuss the future perspectives of percutaneous therapies in the Fontan population.
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Affiliation(s)
- Zakaria Jalal
- University Hospital of Bordeaux - Department of Pediatric and Adult Congenital Cardiology, Pessac, France.,IHU LIRYC Electrophysiology and Heart Modeling Institute, Fondation Bordeaux Université, Pessac, France.,INSERM, Centre de Recherche Cardio-Thoracique de Bordeaux, U1045, Pessac, France
| | - Marc Gewillig
- Department of Pediatric Cardiology, University Hospitals Leuven, Leuven, Belgium
| | | | - Patrice Guérin
- Interventional Cardiology Unit, Inserm UMR 1229, L'Institut du Thorax, University Hospital of Nantes, Nantes, France
| | - Mara Pilati
- Medical and Surgical Department of Pediatric Cardiology, Bambino Gesù Children Hospital, IRCCS, Rome, Italy
| | - Gianfranco Butera
- Medical and Surgical Department of Pediatric Cardiology, Bambino Gesù Children Hospital, IRCCS, Rome, Italy
| | - Sophie Malekzadeh-Milani
- Department of Congenital and Pediatric Cardiology, Centre de Reference Malformations Cardiaques Congenitales Complexes-M3C, Necker Hospital for Sick Children, Assistance Publique des Hôpitaux de Paris, Pediatric Cardiology, Paris, France
| | - Martina Avesani
- University Hospital of Bordeaux - Department of Pediatric and Adult Congenital Cardiology, Pessac, France.,IHU LIRYC Electrophysiology and Heart Modeling Institute, Fondation Bordeaux Université, Pessac, France.,INSERM, Centre de Recherche Cardio-Thoracique de Bordeaux, U1045, Pessac, France
| | - Jean-Benoit Thambo
- University Hospital of Bordeaux - Department of Pediatric and Adult Congenital Cardiology, Pessac, France.,IHU LIRYC Electrophysiology and Heart Modeling Institute, Fondation Bordeaux Université, Pessac, France.,INSERM, Centre de Recherche Cardio-Thoracique de Bordeaux, U1045, Pessac, France
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217
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Ma J, Chen J, Tan T, Liu X, Liufu R, Qiu H, Zhang S, Wen S, Zhuang J, Yuan H. Complications and management of functional single ventricle patients with Fontan circulation: From surgeon's point of view. Front Cardiovasc Med 2022; 9:917059. [PMID: 35966528 PMCID: PMC9374127 DOI: 10.3389/fcvm.2022.917059] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2022] [Accepted: 07/07/2022] [Indexed: 02/05/2023] Open
Abstract
Fontan surgery by step-wise completing the isolation of originally mixed pulmonary and systemic circulation provides an operative approach for functional single-ventricle patients not amenable to biventricular repair and allows their survival into adulthood. In the absence of a subpulmonic pumping chamber, however, the unphysiological Fontan circulation consequently results in diminished cardiac output and elevated central venous pressure, in which multiple short-term or long-term complications may develop. Current understanding of the Fontan-associated complications, particularly toward etiology and pathophysiology, is extremely incomplete. What's more, ongoing efforts have been made to manage these complications to weaken the Fontan-associated adverse impact and improve the life quality, but strategies are ill-defined. Herein, this review summarizes recent studies on cardiac and non-cardiac complications associated with Fontan circulation, focusing on significance or severity, etiology, pathophysiology, prevalence, risk factors, surveillance, or diagnosis. From the perspective of surgeons, we also discuss the management of the Fontan circulation based on current evidence, including post-operative administration of antithrombotic agents, ablation, pacemaker implantation, mechanical circulatory support, and final orthotopic heart transplantation, etc., to standardize diagnosis and treatment in the future.
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Affiliation(s)
- Jianrui Ma
- Department of Cardiovascular Surgery, Guangdong Cardiovascular Institute, Guangdong Provincial People’s Hospital, Guangdong Academy of Medical Sciences, Guangzhou, China
- Shantou University Medical College, Shantou, China
| | - Jimei Chen
- Department of Cardiovascular Surgery, Guangdong Cardiovascular Institute, Guangdong Provincial People’s Hospital, Guangdong Academy of Medical Sciences, Guangzhou, China
| | - Tong Tan
- Department of Cardiovascular Surgery, Guangdong Cardiovascular Institute, Guangdong Provincial People’s Hospital, Guangdong Academy of Medical Sciences, Guangzhou, China
- Shantou University Medical College, Shantou, China
| | - Xiaobing Liu
- Department of Cardiovascular Surgery, Guangdong Cardiovascular Institute, Guangdong Provincial People’s Hospital, Guangdong Academy of Medical Sciences, Guangzhou, China
| | - Rong Liufu
- Department of Cardiovascular Surgery, Guangdong Cardiovascular Institute, Guangdong Provincial People’s Hospital, Guangdong Academy of Medical Sciences, Guangzhou, China
| | - Hailong Qiu
- Department of Cardiovascular Surgery, Guangdong Cardiovascular Institute, Guangdong Provincial People’s Hospital, Guangdong Academy of Medical Sciences, Guangzhou, China
| | - Shuai Zhang
- Department of Cardiovascular Surgery, Guangdong Cardiovascular Institute, Guangdong Provincial People’s Hospital, Guangdong Academy of Medical Sciences, Guangzhou, China
| | - Shusheng Wen
- Department of Cardiovascular Surgery, Guangdong Cardiovascular Institute, Guangdong Provincial People’s Hospital, Guangdong Academy of Medical Sciences, Guangzhou, China
| | - Jian Zhuang
- Department of Cardiovascular Surgery, Guangdong Cardiovascular Institute, Guangdong Provincial People’s Hospital, Guangdong Academy of Medical Sciences, Guangzhou, China
| | - Haiyun Yuan
- Department of Cardiovascular Surgery, Guangdong Cardiovascular Institute, Guangdong Provincial People’s Hospital, Guangdong Academy of Medical Sciences, Guangzhou, China
- Shantou University Medical College, Shantou, China
- *Correspondence: Haiyun Yuan,
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218
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Lee JY. Protein-losing Enteropathy: A Big Challenge in Fontan Circulation. Korean Circ J 2022; 52:621-622. [PMID: 35929054 PMCID: PMC9353247 DOI: 10.4070/kcj.2022.0166] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2022] [Accepted: 06/21/2022] [Indexed: 11/17/2022] Open
Affiliation(s)
- Jae Young Lee
- Division of Cardiology, Department of Pediatrics, Seoul St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
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219
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De Bruyne R, Vandekerckhove K, Van Overschelde H, Hendricx F, Vande Walle C, De Groote K, Panzer J, De Wolf D, Van Biervliet S, Bové T, François K. Non-invasive assessment of liver abnormalities in pediatric Fontan patients. Eur J Pediatr 2022; 181:159-169. [PMID: 34231051 DOI: 10.1007/s00431-021-04163-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/18/2021] [Revised: 06/01/2021] [Accepted: 06/11/2021] [Indexed: 12/23/2022]
Abstract
Liver abnormalities are well known among long-term survivors of Fontan palliation, which remains the definite surgery for complex congenital heart disease and single ventricle physiology. Pediatric data however are scarce. We assessed the prevalence and degree of liver abnormalities in pediatric Fontan patients through non-invasive investigations suitable for longitudinal follow-up. Thirty-five patients with a median age of 11.8 years (5.2-16.6) and median time since Fontan of 6 years (1.17-13.83) were studied. Each child underwent a blood test, liver Doppler ultrasound (US), and transient elastography (TE). Healthy children were used as controls for TE measurement. AST, ALT, γGT, and direct bilirubin were abnormal in respectively 12 (34%), 5 (14%), 24 (69%), and 7 (20%) patients, while platelet count was decreased in 7 (20%). Splenomegaly was present in 7 (20%) patients. Portal vein mean flow velocity was < 15 cm/s in 19 (54%) patients indicative of portal hypertension. Twenty-two patients (63%) showed inferior vena cava collapsibility index values below 17%, indicating venous congestion. Hepatic artery and superior mesenteric artery resistance index were inversely correlated with time post Fontan (p < 0.05). TE values in Fontan patients were significantly higher than controls, with a median of 12.6 versus 4.6 kPa (p < 0.001) and were already increased shortly after Fontan completion. Conclusion: Liver abnormalities are frequently observed in pediatric Fontan patients. The non-invasive investigations used were not able to confirm liver fibrosis or differentiate hepatic congestion from fibrosis. Based on our findings, we propose a prospective screening protocol with serial measurements of laboratory, (Doppler) US, and TE parameters. What is Known: • Hepatic dysfunction is a well-known consequence of the Fontan circulation. • The natural history of Fontan-associated liver disease in the pediatric age group remains unclear. What is New: • Liver abnormalities are frequently observed in pediatric Fontan patients; however, differentiating liver fibrosis and hepatic congestion with non-invasive investigations remains challenging. Sonographic Doppler measurements may improve our insight in both Fontan-associated liver disease development and the functioning of the Fontan circulation. • A prospective screening protocol is proposed to improve our ability to detect Fontan-associated liver disease early on and understand its natural history.
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Affiliation(s)
- Ruth De Bruyne
- Department of Pediatric Gastroenterology, Hepatology and Nutrition, Ghent University Hospital, Ghent University, Ghent, Belgium.
| | - Kristof Vandekerckhove
- Department of Pediatric Cardiology, Ghent University Hospital, Ghent University, Ghent, Belgium
| | | | - Fabian Hendricx
- Department of Pediatrics, University Hospital Brussels, Brussels, Belgium
| | | | - Katya De Groote
- Department of Pediatric Cardiology, Ghent University Hospital, Ghent University, Ghent, Belgium
| | - Joseph Panzer
- Department of Pediatric Cardiology, Ghent University Hospital, Ghent University, Ghent, Belgium
| | - Daniel De Wolf
- Department of Pediatric Cardiology, Ghent University Hospital, Ghent University, Ghent, Belgium
| | - Stephanie Van Biervliet
- Department of Pediatric Gastroenterology, Hepatology and Nutrition, Ghent University Hospital, Ghent University, Ghent, Belgium
| | - Thierry Bové
- Department of Cardiac Surgery, Ghent University Hospital, Ghent University, Ghent, Belgium
| | - Katrien François
- Department of Cardiac Surgery, Ghent University Hospital, Ghent University, Ghent, Belgium
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220
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Jeong SI. Evaluation of Pulmonary Blood Flow Pulsatility in Patients Undergoing Various Fontan Palliation Techniques. J Cardiovasc Imaging 2022; 30:109-111. [PMID: 35505499 PMCID: PMC9058627 DOI: 10.4250/jcvi.2021.0180] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2021] [Accepted: 01/04/2022] [Indexed: 11/22/2022] Open
Affiliation(s)
- Soo In Jeong
- Department of Pediatrics, Ajou University Hospital, Ajou University School of Medicine, Suwon, Korea
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221
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Hedlund E, Lundell B. Fontan circulation has improved life expectancy for infants born with complex heart disease over the last 50 years but has also resulted in significant morbidity. Acta Paediatr 2022; 111:11-16. [PMID: 34235784 DOI: 10.1111/apa.16023] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/22/2021] [Revised: 06/22/2021] [Accepted: 07/06/2021] [Indexed: 12/17/2022]
Abstract
The prognosis for infants born with complex heart disease improved dramatically with the introduction of the Fontan circulation 50 years ago. With today's carefully designed and staged operations to a Fontan circulation, life expectancy has increased and most children will survive into adult life. The Fontan circulation entails an unphysiological circulation with high risk for multiple organ system dysfunction. Neurodevelopmental disabilities with adverse psychosocial effects are prevalent. The Fontan circulation may eventually fail and necessitate heart transplantation. CONCLUSION: Fifty years development of the Fontan circulation to today's staged surgical procedures has improved survival but also revealed the burden of a high morbidity for a growing number of patients.
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Affiliation(s)
- Eva Hedlund
- Department of Women's and Children's Health Karolinska Institutet Stockholm Sweden
| | - Bo Lundell
- Department of Women's and Children's Health Karolinska Institutet Stockholm Sweden
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222
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Rychik J, Goldberg DJ, Rand E, Mancilla EE, Heimall J, Seivert N, Campbell D, O'Malley S, Dodds KM. A Path FORWARD: Development of a Comprehensive Multidisciplinary Clinic to Create Health and Wellness for the Child and Adolescent with a Fontan Circulation. Pediatr Cardiol 2022; 43:1175-1192. [PMID: 35604474 PMCID: PMC9125546 DOI: 10.1007/s00246-022-02930-z] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/22/2022] [Accepted: 04/28/2022] [Indexed: 12/19/2022]
Abstract
Today, it is anticipated most individuals diagnosed with single-ventricle malformation will survive surgical reconstruction through a successful Fontan operation. As greater numbers of patients survive, so has the recognition that individuals with Fontan circulation face a variety of challenges. The goal of a normal quality and duration of life will not be reached by all. The hurdles fall into a variety of domains. From a cardiovascular perspective, the Fontan circulation is fundamentally flawed by its inherent nature of creating a state of chronically elevated venous pressure and congestion, accompanied by a relatively low cardiac output. Ventricular dysfunction, atrioventricular valve regurgitation, and arrhythmia may directly impact cardiac performance and can progress with time. Problems are not limited to the cardiovascular system. Fontan circulatory physiology impacts a multitude of biological processes and health parameters outside the heart. The lymphatic circulation is under strain manifesting as variable degrees of protein-rich lymph loss and immune system dysregulation. Organ system dysfunction develops through altered perfusion profiles. Liver fibrosis is ubiquitous, and a process of systemic fibrogenesis in response to circulatory stressors may affect other organs as well. Somatic growth and development can be delayed. Behavioral and mental health problems are common, presenting as clinically important levels of anxiety and depression. Most striking is the high variability in prevalence and magnitude of these complications within the population, indicating the likelihood of additional factors enhancing or mitigating their emergence. We propose that optimal care for the individual with single ventricle and a Fontan circulation is ideally offered in a comprehensive multidisciplinary manner, with attention to elements that are beyond cardiac management alone. In this report, we share the concepts, our experiences, and perspectives on development of a clinic model-the "Fontan rehabilitation, wellness and resilience development" or FORWARD program. We provide insights into the mechanics of our multidisciplinary model of care and the benefits offered serving our growing population of individuals with a Fontan circulation and their families.
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Affiliation(s)
- Jack Rychik
- Division of Cardiology, Children's Hospital of Philadelphia, Philadelphia, USA.
- Department of Pediatrics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, USA.
- Fontan FORWARD Program, Cardiac Center at the Children's Hospital of Philadelphia, 3401 Civic Center Boulevard, Philadelphia, PA, 19104, USA.
| | - David J Goldberg
- Division of Cardiology, Children's Hospital of Philadelphia, Philadelphia, USA
- Department of Pediatrics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, USA
| | - Elizabeth Rand
- Division of Gastroenterology, Hepatology and Nutrition, Children's Hospital of Philadelphia, Philadelphia, USA
- Department of Pediatrics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, USA
| | - Edna E Mancilla
- Division of Endocrinology and Diabetes, Children's Hospital of Philadelphia, Philadelphia, USA
- Department of Pediatrics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, USA
| | - Jennifer Heimall
- Division of Allergy and Immunology, Children's Hospital of Philadelphia, Philadelphia, USA
- Department of Pediatrics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, USA
| | - Nicholas Seivert
- Department of Child and Adolescent Psychiatry, and Behavioral Sciences, Children's Hospital of Philadelphia, Philadelphia, USA
- Department of Psychiatry, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, USA
| | - Danielle Campbell
- Clinical Nutrition, Children's Hospital of Philadelphia, Philadelphia, USA
| | - Shannon O'Malley
- Division of Cardiology, Children's Hospital of Philadelphia, Philadelphia, USA
| | - Kathryn M Dodds
- Division of Cardiology, Children's Hospital of Philadelphia, Philadelphia, USA
- Department of Nursing at the University of Pennsylvania, Philadelphia, USA
- Fontan FORWARD Program, Cardiac Center at the Children's Hospital of Philadelphia, 3401 Civic Center Boulevard, Philadelphia, PA, 19104, USA
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Ghelani SJ, Opotowsky AR, Harrild DM, Powell AJ, Azcue N, Ahmad S, Clair NS, Bradwin G, Rathod RH. Characterization of Circulating and Urinary Biomarkers in the Fontan Circulation and Their Correlation With Cardiac Imaging. Am J Cardiol 2022; 162:177-183. [PMID: 34903340 DOI: 10.1016/j.amjcard.2021.08.063] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/14/2021] [Revised: 08/25/2021] [Accepted: 08/30/2021] [Indexed: 12/01/2022]
Abstract
Several circulating biomarkers have been found to play a role in the surveillance and risk stratification of heart failure without congenital heart disease, but these have not been widely studied in patients with single ventricles palliated with a Fontan operation. Imaging predictors of worse outcomes in this population include ventricular dilation and dysfunction. Patients who weighed >30 kg with a Fontan circulation referred for cardiac magnetic resonance imaging were invited to participate in the study. Blood and urine samples were obtained at the time of imaging and multiple conventional and novel biomarkers were measured. A total of 82 patients with a median age of 18 years were enrolled. Among the novel biomarkers, N-terminal pro-B-type natriuretic peptide (NT-proBNP) and high-sensitivity troponin T had the strongest correlation with ventricular dilation and dysfunction. NT-ProBNP >100 pg/ml has a sensitivity of 91% for the detection of significant ventricular dilation (end-diastolic volume >120 ml/body surface area1.3) and 82% for detection of ejection fraction <50%. The urinary neutrophil gelatinase-associated lipocalin-2 to creatinine ratio correlated with ejection fraction and estimated glomerular filteration rate. In conclusion, abnormalities in biomarkers of heart failure are common in ambulatory, largely asymptomatic patients with Fontan circulation. NT-ProBNP may serve as a sensitive marker for the identification of patients with significant ventricular dilation or dysfunction. Further work is needed to understand how these easily measured circulating biomarkers may be integrated into clinical care.
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224
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Van Den Helm S, Sparks CN, Ignjatovic V, Monagle P, Attard C. Increased Risk for Thromboembolism After Fontan Surgery: Considerations for Thromboprophylaxis. Front Pediatr 2022; 10:803408. [PMID: 35419321 PMCID: PMC8996130 DOI: 10.3389/fped.2022.803408] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/27/2021] [Accepted: 02/28/2022] [Indexed: 11/13/2022] Open
Abstract
The Fontan circulation introduces an increased risk of thromboembolism which is associated with substantial mortality and morbidity. Adverse outcomes of thromboembolic complications post-Fontan surgery vary in both nature and severity, ranging from local tissue infarction and pulmonary embolism to Fontan failure and ischemic stroke. Furthermore, recent studies have identified that subclinical stroke is common yet underdiagnosed in Fontan patients. Fontan patients are commonly treated with antiplatelet agents and/or anticoagulants as primary thromboprophylaxis. Optimal thromboprophylaxis management in the Fontan population is still unclear, and clinical consensus remains elusive despite the growing literature on the subject. This perspective will describe the nature of thromboembolism post-Fontan surgery and provide evidence for the use of both current and emerging thromboprophylaxis options for children and adults living with Fontan circulation.
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Affiliation(s)
- Suelyn Van Den Helm
- Haematology Research, Murdoch Children's Research Institute, Melbourne, VIC, Australia.,Department of Paediatrics, The University of Melbourne, Melbourne, VIC, Australia
| | - Christopher Noel Sparks
- Haematology Research, Murdoch Children's Research Institute, Melbourne, VIC, Australia.,Department of Anatomy and Physiology, The University of Melbourne, Melbourne, VIC, Australia
| | - Vera Ignjatovic
- Haematology Research, Murdoch Children's Research Institute, Melbourne, VIC, Australia.,Department of Paediatrics, The University of Melbourne, Melbourne, VIC, Australia
| | - Paul Monagle
- Haematology Research, Murdoch Children's Research Institute, Melbourne, VIC, Australia.,Department of Paediatrics, The University of Melbourne, Melbourne, VIC, Australia.,Kids Cancer Centre, Sydney Children's Hospital, Randwick, NSW, Australia.,Department of Haematology, Royal Children's Hospital, Melbourne, VIC, Australia
| | - Chantal Attard
- Haematology Research, Murdoch Children's Research Institute, Melbourne, VIC, Australia.,Department of Anatomy and Physiology, The University of Melbourne, Melbourne, VIC, Australia
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225
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Alsaied T, Lubert AM, Goldberg DJ, Schumacher K, Rathod R, Katz DA, Opotowsky AR, Jenkins M, Smith C, Rychik J, Amdani S, Lanford L, Cetta F, Kreutzer C, Feingold B, Goldstein BH. Protein losing enteropathy after the Fontan operation. INTERNATIONAL JOURNAL OF CARDIOLOGY CONGENITAL HEART DISEASE 2022. [DOI: 10.1016/j.ijcchd.2022.100338] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
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226
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Gierlinger G, Sames-Dolzer E, Kreuzer M, Mair R, Nawrozi MP, Tulzer A, Bauer C, Tulzer G, Mair R. OUP accepted manuscript. Interact Cardiovasc Thorac Surg 2022; 35:6570592. [PMID: 35438156 PMCID: PMC9419686 DOI: 10.1093/icvts/ivac098] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2022] [Revised: 03/10/2022] [Accepted: 04/12/2022] [Indexed: 11/14/2022] Open
Affiliation(s)
- Gregor Gierlinger
- Division of Pediatric and Congenital Heart Surgery, Kepler University Hospital, Linz, Austria
- Medical Faculty, Johannes Kepler University Linz, Linz, Austria
- Corresponding author. Department für Kinderherzchirurgie, Kepler Universitätsklinik, Med Campus III., Krankenhausstrasse 9, 4020 Linz, Austria. Tel: +43-732-7806-78230; e-mail: (G. Gierlinger)
| | - Eva Sames-Dolzer
- Division of Pediatric and Congenital Heart Surgery, Kepler University Hospital, Linz, Austria
- Medical Faculty, Johannes Kepler University Linz, Linz, Austria
| | - Michaela Kreuzer
- Division of Pediatric and Congenital Heart Surgery, Kepler University Hospital, Linz, Austria
- Medical Faculty, Johannes Kepler University Linz, Linz, Austria
| | - Roland Mair
- Division of Pediatric and Congenital Heart Surgery, Kepler University Hospital, Linz, Austria
- Medical Faculty, Johannes Kepler University Linz, Linz, Austria
| | - Mohammad-Paimann Nawrozi
- Department for Thoracic and Cardiovascular Surgery, Kepler University Hospital, JKU, Linz, Austria
| | - Andreas Tulzer
- Medical Faculty, Johannes Kepler University Linz, Linz, Austria
- Department of Pediatric Cardiology, Kepler University Hospital, JKU, Linz, Austria
| | - Christoph Bauer
- Medical Faculty, Johannes Kepler University Linz, Linz, Austria
- Department of Pediatric Cardiology, Kepler University Hospital, JKU, Linz, Austria
| | - Gerald Tulzer
- Department of Pediatric Cardiology, Kepler University Hospital, JKU, Linz, Austria
| | - Rudolf Mair
- Division of Pediatric and Congenital Heart Surgery, Kepler University Hospital, Linz, Austria
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227
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Kamsheh AM, O'Connor MJ, Rossano JW. Management of circulatory failure after Fontan surgery. Front Pediatr 2022; 10:1020984. [PMID: 36425396 PMCID: PMC9679629 DOI: 10.3389/fped.2022.1020984] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/16/2022] [Accepted: 10/18/2022] [Indexed: 11/11/2022] Open
Abstract
With improvement in survival after Fontan surgery resulting in an increasing number of older survivors, there are more patients with a Fontan circulation experiencing circulatory failure each year. Fontan circulatory failure may have a number of underlying etiologies. Once Fontan failure manifests, prognosis is poor, with patient freedom from death or transplant at 10 years of only about 40%. Medical treatments used include traditional heart failure medications such as renin-angiotensin-aldosterone system blockers and beta-blockers, diuretics for symptomatic management, antiarrhythmics for rhythm control, and phosphodiesterase-5 inhibitors to decrease PVR and improve preload. These oral medical therapies are typically not very effective and have little data demonstrating benefit; if there are no surgical or catheter-based interventions to improve the Fontan circulation, patients with severe symptoms often require inotropic medications or mechanical circulatory support. Mechanical circulatory support benefits patients with ventricular dysfunction but may not be as useful in patients with other forms of Fontan failure. Transplant remains the definitive treatment for circulatory failure after Fontan, but patients with a Fontan circulation face many challenges both before and after transplant. There remains significant room and urgent need for improvement in the management and outcomes of patients with circulatory failure after Fontan surgery.
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Affiliation(s)
- Alicia M Kamsheh
- Division of Cardiology, Children's Hospital of Philadelphia, United States
| | - Matthew J O'Connor
- Division of Cardiology, Children's Hospital of Philadelphia, United States
| | - Joseph W Rossano
- Division of Cardiology, Children's Hospital of Philadelphia, United States
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228
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Driesen BW, Voskuil M, Grotenhuis HB. Current Treatment Options for the Failing Fontan Circulation. Curr Cardiol Rev 2022; 18:e060122200067. [PMID: 34994331 PMCID: PMC9893132 DOI: 10.2174/1573403x18666220106114518] [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: 12/21/2020] [Revised: 10/22/2021] [Accepted: 11/16/2021] [Indexed: 11/22/2022] Open
Abstract
The Fontan operation was introduced in 1968. For congenital malformations, where biventricular repair is unsuitable, the Fontan procedure has provided a long-term palliation strategy with improved outcomes compared to the initially developed procedures. Despite these improvements, several complications merely due to a failing Fontan circulation, including myocardial dysfunction, arrhythmias, increased pulmonary vascular resistance, protein-losing enteropathy, hepatic dysfunction, plastic bronchitis, and thrombo-embolism, may occur, thereby limiting the life-expectancy in this patient cohort. This review provides an overview of the most common complications of Fontan circulation and the currently available treatment options.
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Affiliation(s)
- Bart W. Driesen
- Department of Pediatric Cardiology, Wilhelmina Children’s Hospital, University Medical Center, Utrecht, Utrecht, The Netherlands
- Department of Cardiology, University Medical Center Utrecht, Utrecht, The Netherlands
- Department of Cardiology, Laurentius Ziekenhuis, Roermond, The Netherlands
| | - Michiel Voskuil
- Department of Cardiology, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Heynric B. Grotenhuis
- Department of Pediatric Cardiology, Wilhelmina Children’s Hospital, University Medical Center, Utrecht, Utrecht, The Netherlands
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229
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Calderon J, Newburger JW, Rollins CK. Neurodevelopmental and Mental Health Outcomes in Patients With Fontan Circulation: A State-of-the-Art Review. Front Pediatr 2022; 10:826349. [PMID: 35356444 PMCID: PMC8959547 DOI: 10.3389/fped.2022.826349] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/30/2021] [Accepted: 02/14/2022] [Indexed: 11/13/2022] Open
Abstract
Children, adolescents and adults living with Fontan circulation face numerous neurological and developmental challenges. As the population with complex CHD increases thanks to outstanding improvement in medical and surgical care, the long-term developmental and mental health sequelae have become a public health priority in pediatric and congenital cardiology. Many patients with a Fontan circulation experience difficulty in areas of cognition related to attention and executive functioning, visual spatial reasoning and psychosocial development. They are also at high risk for mental health morbidities, particularly anxiety disorders and depression. Several hemodynamic risk factors, beginning during the fetal period, may influence outcomes and yield to abnormal brain growth and development. Brain injury such as white matter lesions, stroke or hemorrhage can occur before, during, or after surgery. Other sociodemographic and surgical risk factors such as multiple catheterizations and surgeries and prolonged hospital stay play a detrimental role in patients' neurodevelopmental prognosis. Prevention and intervention to optimize long-term outcomes are critical in the care of this vulnerable population with complex CHD.
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Affiliation(s)
- Johanna Calderon
- PhyMedExp, Université de Montpellier, National Institute of Health and Medical Research (INSERM), CNRS, Montpellier, France.,Department of Psychiatry, Harvard Medical School, Boston, MA, United States
| | - Jane W Newburger
- Department of Cardiology, Boston Children's Hospital, Boston, MA, United States.,Department of Pediatrics, Harvard Medical School, Boston, MA, United States
| | - Caitlin K Rollins
- Department of Neurology, Boston Children's Hospital, Boston, MA, United States.,Department of Neurology, Harvard Medical School, Boston, MA, United States
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230
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Affiliation(s)
- Jack Rychik
- Corresponding author. Cardiac Center, the Children’s Hospital of Philadelphia, 3401 Civic Center Boulevard, Philadelphia, PA 19104, USA. Tel: +1 215 5902192, Fax: +1 267 426 5082,
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231
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Management of patients with single ventricle physiology across the lifespan: contributions from magnetic resonance and computed tomography imaging. Can J Cardiol 2022; 38:946-962. [DOI: 10.1016/j.cjca.2022.01.011] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2021] [Revised: 12/27/2021] [Accepted: 01/02/2022] [Indexed: 12/12/2022] Open
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232
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Nagata H, Yamamura K, Matsuoka R, Kato K, Ohga S. Transition in cardiology 2: Maternal and fetal congenital heart disease. Pediatr Int 2022; 64:e15098. [PMID: 35507001 DOI: 10.1111/ped.15098] [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: 04/28/2021] [Revised: 10/20/2021] [Accepted: 11/11/2021] [Indexed: 11/29/2022]
Abstract
The number of women with congenital heart disease (CHD) reaching reproductive age has been increasing. Many women with CHDs are desirous of pregnancy, but they face issues regarding preconception, antepartum, and postpartum management. On the other hand, the fetal diagnosis of CHD has improved with advances in the technique and equipment for fetal echocardiography. Recently, experiences with fetal intervention have been reported in patients with severe CHD, such as critical aortic stenosis. Nevertheless, some types of CHD are challenge to diagnose prenatally, resulting in adverse outcomes. Medical care is part of the transitional care for women and fetuses with CHD during the perinatal period. Pre-conceptional and prenatal counseling play an important role in transitional care. Sex and reproductive education need to be performed as early as possible. We herein review the current status, important issues to be resolved, and the future of maternal and fetal CHD to relevant caregivers.
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Affiliation(s)
- Hazumu Nagata
- Department of Pediatrics, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Kenichiro Yamamura
- Department of Pediatrics, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Ryohei Matsuoka
- Department of Pediatrics, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Kiyoko Kato
- Department of Obstetrics and Gynecology, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Shouichi Ohga
- Department of Pediatrics, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
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233
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Alcohol use is prevalent among adults with the fontan circulation but does not correlate with liver disease. INTERNATIONAL JOURNAL OF CARDIOLOGY CONGENITAL HEART DISEASE 2022. [DOI: 10.1016/j.ijcchd.2022.100339] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
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234
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Martino D, Rizzardi C, Vigezzi S, Guariento C, Sturniolo G, Tesser F, Salvo GD. Long-term management of Fontan patients: The importance of a multidisciplinary approach. Front Pediatr 2022; 10:886208. [PMID: 36090574 PMCID: PMC9452819 DOI: 10.3389/fped.2022.886208] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/28/2022] [Accepted: 07/11/2022] [Indexed: 11/16/2022] Open
Abstract
The Fontan operation is a palliative procedure that leads to increased survival of patients with a functional single ventricle (SV). Starting from 1967 when the first operation was performed by Francis Fontan, more and more patients have reached adulthood. Furthermore, it is expected that in the next 20 years, the population with Fontan circulation will reach 150,000 subjects. The absence of right ventricular propulsion and the inability to improve cardiac output because of the low cardiac reserve are the main issues with the Fontan circulation; however, potential complications may also involve multiple organ systems, such as the liver, lungs, brain, bones, and the lymphatic system. As these patients were initially managed mainly by pediatric cardiologists, it was important to assure the appropriate transition to adult care with the involvement of a multidisciplinary team, including adult congenital cardiologists and multiple subspecialists, many of whom are neither yet familiar with the pathophysiology nor the end-organ consequences of the Fontan circulation. Therefore, the aim of our work was to collect all the best available evidence on Fontan's complications management to provide "simple and immediate" information sources for practitioners looking for state of the art evidence to guide their decision-making and work practices. Moreover, we suggest a model of follow-up of patients with Fontan based on a patient-centered multidisciplinary approach.
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Affiliation(s)
- Diletta Martino
- Pediatric Unit, Department for Women's and Children's Health, University Hospital of Padova, Padua, Italy
| | - Caterina Rizzardi
- Pediatric Unit, Department for Women's and Children's Health, University Hospital of Padova, Padua, Italy
| | - Serena Vigezzi
- Pediatric Unit, Department for Women's and Children's Health, University Hospital of Padova, Padua, Italy
| | - Chiara Guariento
- Pediatric Unit, Department for Women's and Children's Health, University Hospital of Padova, Padua, Italy
| | - Giulia Sturniolo
- Pediatric Unit, Department for Women's and Children's Health, University Hospital of Padova, Padua, Italy
| | - Francesca Tesser
- Pediatric Unit, Department for Women's and Children's Health, University Hospital of Padova, Padua, Italy
| | - Giovanni di Salvo
- Pediatric and Congenital Cardiology Unit, Department for Women's and Children's Health, University Hospital of Padova, Padua, Italy
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235
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Niaz T, Stephens EH, Gleich SJ, Dearani JA, Johnson JN, Sas DJ, Bly S, Driscoll DJ, Cetta F. Acute Kidney Injury and Renal Replacement Therapy After Fontan Operation. Am J Cardiol 2021; 161:84-94. [PMID: 34794622 DOI: 10.1016/j.amjcard.2021.08.056] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/16/2021] [Revised: 08/27/2021] [Accepted: 08/31/2021] [Indexed: 11/15/2022]
Abstract
Fontan circulation leads to chronic elevation of central venous pressure. We sought to identify the incidence, risk factors, and survival among patients who developed acute kidney injury (AKI) after the Fontan operation. We retrospectively reviewed 1,166 patients who had Fontan operation/revision at Mayo Clinic Rochester from 1973 to 2017 and identified patients who had AKI (defined by AKI Network criteria) within 7 days of surgery. A total of 132 patients (11%) developed AKI after the Fontan operation with no significant era effect. Of those who developed AKI, severe (grade 3) kidney injury was present in 101 patients (76.5%). Multivariable risk factors for AKI were asplenia (odds ratio [OR] 4.2, p <0.0001), elevated preoperative pulmonary artery pressure (per 1 mm Hg increase, OR 1.04, p = 0.0002), intraoperative arrhythmias (OR 1.9, p = 0.02), and elevated post-bypass Fontan pressure (per 1 mm Hg increase, OR 1.12, p = 0.0007). Renal replacement therapy (RRT) was used in 72 patients (54%), predominantly through peritoneal dialysis (n = 56, 78%). Multivariable risk factors for RRT were age ≤3 years (OR 9.7, p = 0.0004), female gender (OR 2.6, p = 0.02), and aortic cross-clamp time >60 minutes (OR 3.1, p = 0.01). Patients with AKI had more postoperative complications, including bleeding, stroke, pericardial tamponade, low cardiac output state and cardiac arrest, than those without AKI. This resulted in longer intensive care unit stay (39 vs 17 days, p = 0.0001). In-hospital mortality was exceedingly higher among patients with AKI versus no AKI (58%, 76 of 132 vs 10%, 99 of 1,034, p <0.0001); however, there was no significant difference based on the need for RRT. Recovery from AKI was observed in 56 patients (42%). Over 20-year follow-up, patients with AKI had a distinctly higher all-cause-mortality (82%) than those without AKI (35%). It is prudent to identity patients at a higher risk of developing postoperative AKI after Fontan operation to ensure renal protective strategies in the perioperative period. Postoperative AKI leads to substantial short and long-term morbidity and mortality, but the need for RRT does not affect the outcomes.
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Affiliation(s)
| | | | - Stephen J Gleich
- Department of Anesthesiology; Division of Pediatric Critical Care Medicine
| | | | | | - David J Sas
- Division of Pediatric Nephrology and Hypertension
| | - Stephen Bly
- Wanek Family Program for Hypoplastic Left Heart Syndrome, Mayo Clinic, Rochester, Minnesota
| | | | - Frank Cetta
- Division of Pediatric Cardiology; Department of Cardiovascular Medicine; Wanek Family Program for Hypoplastic Left Heart Syndrome, Mayo Clinic, Rochester, Minnesota.
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236
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Zartner PA, Mini N, Momcilovic D, Schneider MB, Dittrich S. Telemonitoring with Electronic Devices in Patients with a Single Ventricle Anatomy. Thorac Cardiovasc Surg 2021; 69:e53-e60. [PMID: 34891178 PMCID: PMC8672881 DOI: 10.1055/s-0041-1735479] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Background A growing number of patients with a single ventricle anatomy, who had a
Fontan palliation as a child, are now reaching adulthood. Many need an epimyocardial
pacemaker system with an optional telemonitoring (TM) unit, which evaluates the collected
data and sends it via Internet to the patient's physician. There are no data on the
reliability and clinical relevance of these systems in this patient group. Methods We analyzed data in 48 consecutive patients (mean age 18 years, standard
deviation 9 years) with a Fontan or Fontan-like palliation who received a cardiac
implantable electronic device with a TM unit from Biotronik (Home Monitoring) or Medtronic
(CareLink) between 2005 and 2020 with regard to the reliability and clinical relevance of
the downloaded data. Results The observation period was from 4 months to 14 years (mean 7 years,
standard deviation 3.9 years). A total of 2.9 event messages (EMs)/patient/month and 1.3
intracardiac electrogram recordings/patient/month were received. Two patients died during
follow-up. The combination of regularly arriving statistical data and 313 clinically
relevant EMs led to the modification of antiarrhythmic or diuretic medication,
hospitalization with cardioversion or ablation, and cortisone therapy to avoid exit block
in 21 (44%) patients. Conclusion TM is an instrument to receive functional and physiologic parameters of
our Fontan patients. It provides the ability to respond early for signs of system failure,
or arrhythmia, even if the patient is not experiencing any problems. It is a useful tool
to manage this difficult patient population without frequent hospital visits.
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Affiliation(s)
- Peter A Zartner
- Department of Cardiology, German Paediatric Heart Centre, University of Bonn, Bonn, Germany
| | - Nathalie Mini
- Department of Cardiology, German Paediatric Heart Centre, University of Bonn, Bonn, Germany
| | - Diana Momcilovic
- Department of Cardiology and Pulmonology, University of Bonn, Bonn, Germany
| | - Martin B Schneider
- Department of Cardiology, German Paediatric Heart Centre, University of Bonn, Bonn, Germany
| | - Sven Dittrich
- Department of Paediatric Cardiology, University of Erlangen-Nuremberg, Erlangen, Germany
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237
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Inai K, Inuzuka R, Ono H, Nii M, Ohtsuki S, Kurita Y, Takeda A, Hirono K, Takei K, Yasukouchi S, Yoshikawa T, Furutani Y, Shimada E, Shinohara T, Shinozaki T, Matsuyama Y, Senzaki H, Nakanishi T. Predictors of long-term mortality among perioperative survivors of Fontan operation. Eur Heart J 2021; 43:2373-2384. [PMID: 34888643 DOI: 10.1093/eurheartj/ehab826] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/16/2021] [Revised: 09/12/2021] [Accepted: 11/17/2021] [Indexed: 01/02/2023] Open
Abstract
AIMS The criteria for 'good' Fontan haemodynamics have been poorly defined in relation to long-term outcomes. The aim of this study was to identify the risk factors for mortality among haemodynamic parameters obtained early after the Fontan operation. METHODS AND RESULTS Clinical data of all perioperative survivors of the Fontan operation performed before 2011, from nine institutions, were collected through a retrospective chart review. In total, 1260 patients were included. The median age at the time of Fontan operation was 3.6 years. Post-operative cardiac catheterization was conducted in 1117 patients at a median period of 1.0 years after the operation. During the median follow-up period of 10.2 years, 107 patients died. The mortality rates at 10, 20, and 25 years after the operation were 5%, 12%, and 22%, respectively. On multivariable analysis, older age at the time of the operation {≥15 years, hazard ratio (HR) [95% confidence interval (CI)]: 3.2 (1.7-5.9)} and haemodynamic parameters obtained at post-operative catheterization, such as low ejection fraction [<30%, HR (95% CI): 7.5 (3.2-18)], low systemic oxygen saturation [<80%, HR (95% CI): 3.8 (1.6-9.1)], high central venous pressure [≥16 mmHg, HR (95% CI): 2.3 (1.3-3.9)], and low mean systemic arterial pressure [<60 mmHg, HR (95% CI): 3.0 (1.4-6.2)] were identified as independent predictors of mortality. The predictive model based on these parameters had a c-index of 0.75 at 10 years. CONCLUSIONS Haemodynamic parameters obtained at a median period of 1.0 years, post-operatively, can accurately identify patients with a high mortality risk, who may need intensive management to improve long-term outcomes. KEY QUESTION What defines 'worse' Fontan haemodynamics? KEY FINDING Older age at Fontan (≥15 years), low ejection fraction (<30%), low oxygen saturation (<80%), high central venous pressure (≥16 mmHg), and low mean systemic arterial pressure (<60 mmHg) were identified as independent predictors of mortality. TAKE HOME MESSAGE Haemodynamic parameters obtained at a median period of 1.0 years, post-operatively, can accurately identify patients with a high mortality risk, who may need intensive management to improve long-term outcomes.
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Affiliation(s)
- Kei Inai
- Department of Pediatric Cardiology and Adult Congenital Cardiology, Tokyo Women's Medical University, 8-1, Kawada-cho, Shinjuku, Tokyo 162-8666, Japan
| | - Ryo Inuzuka
- Department of Pediatrics, University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo 113-8654, Japan
| | - Hiroshi Ono
- Department of Cardiology, National Center for Child Health and Development, 2-10-1 Ookura, Setagaya-ku, Tokyo 153-0074, Japan
| | - Masaki Nii
- Department of Pediatric Cardiology, Shizuoka Children's Hospital, 860 Urushiyama, Shizuoka City 420-8660, Japan
| | - Shinichi Ohtsuki
- Department of Pediatric Cardiology, Okayama University, 2-5-1 Kita-ku, Okayama City 700-0914, Japan
| | - Yoshihiko Kurita
- Department of Pediatric Cardiology, Okayama University, 2-5-1 Kita-ku, Okayama City 700-0914, Japan
| | - Atsuhito Takeda
- Department of Pediatrics, Hokkaido University, Kita 14, Nishi 5, Kita-ku, Sapporo 060-8648, Japan
| | - Keiichi Hirono
- Department of Pediatrics, University of Toyama, 2630 Sugitani, Toyama City 930-0194, Japan
| | - Kohta Takei
- Department of Pediatric Cardiology, Nagano Children's Hospital, 3100 Toyoshina, Azumino, Nagano 399-8205, Japan
| | - Satoshi Yasukouchi
- Department of Pediatric Cardiology, Nagano Children's Hospital, 3100 Toyoshina, Azumino, Nagano 399-8205, Japan
| | - Tadahiro Yoshikawa
- Department of Pediatric Cardiology, Sakakibara Heart Institute, 3-16-1 Asahi-machi, Fuchu-shi, Tokyo 183-0003, Japan
| | - Yoshiyuki Furutani
- Department of Pediatric Cardiology and Adult Congenital Cardiology, Tokyo Women's Medical University, 8-1, Kawada-cho, Shinjuku, Tokyo 162-8666, Japan
| | - Eriko Shimada
- Department of Pediatric Cardiology and Adult Congenital Cardiology, Tokyo Women's Medical University, 8-1, Kawada-cho, Shinjuku, Tokyo 162-8666, Japan
| | - Tokuko Shinohara
- Department of Pediatric Cardiology and Adult Congenital Cardiology, Tokyo Women's Medical University, 8-1, Kawada-cho, Shinjuku, Tokyo 162-8666, Japan
| | - Tomohiro Shinozaki
- Faculty of Engineering, Department of Information and Computer Technology, Tokyo University of Science, 7-3-1 Hongo, Bunkyo-ku, Tokyo 113-8654, Japan
| | - Yutaka Matsuyama
- Department of Biostatistics, School of Public Health, University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo 113-8654, Japan
| | - Hideaki Senzaki
- Department of Pediatrics, International University of Health and Welfare Mita Hospital, 1-4-3 Mita, Minato-ku, Tokyo 108-8329, Japan
| | - Toshio Nakanishi
- Department of Pediatric Cardiology and Adult Congenital Cardiology, Tokyo Women's Medical University, 8-1, Kawada-cho, Shinjuku, Tokyo 162-8666, Japan.,Sakakibara Heart Institute Clinics, Tokyo, Japan
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Sadat-Hossieny S, Karamlou T, Marino BS, Gossett JG, Schumacher K, Patel A, Worley S, Alsaied T, Amdani S. Contemporary Provider Management Practices and Attitudes Toward Referral for Advanced Heart Failure Therapies in Fontan Patients Across North America. J Card Fail 2021; 28:576-587. [PMID: 34991953 DOI: 10.1016/j.cardfail.2021.10.016] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2021] [Revised: 10/27/2021] [Accepted: 10/27/2021] [Indexed: 11/17/2022]
Abstract
BACKGROUND To date, no reports have described clinicians' management practices for patients with Fontan circulatory failure or their understanding of risk factors for mortality and transplant outcomes in these patients. METHODS AND RESULTS A cross-sectional survey of caregivers across North America was conducted from February to September 2020. Responses were compared by primary specialty (heart failure/transplant vs non-heart failure/transplant), years of experience (early, mid, and late career), and Fontan center volume (low, medium, and high). Of 400 responses, the majority were from general cardiologists (111, 28%) followed by heart failure/transplant specialists (93, 23%). Although most agreed that patients with Fontan physiology will have signs/symptoms of heart failure (369 [93%]) and eventuate in heart transplant (286 [72%]), many disagreed (180 [45%]) that routine evaluation by a transplant cardiologist is needed without symptoms. Transplant providers were more likely than non-transplant providers to suggest referral for manifestations of Fontan circulatory failure such as protein-losing enteropathy, plastic bronchitis, liver fibrosis/cirrhosis, and worsening valve regurgitation. Non-transplant providers were more likely to suggest that protein-losing enteropathy, plastic bronchitis, and Fontan-associated liver disease lead to inferior outcomes after transplantation. Early career and transplant providers more favorably viewed ventricular assist device use for Fontan patients failing traditional heart failure therapy (P < .05 for all). CONCLUSIONS There is significant variation in the management of Fontan patients, including heterogeneous timing of referral of such patients to the heart failure/transplant team, which may have implications for future outcomes.
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Affiliation(s)
- Sara Sadat-Hossieny
- Department of Pediatric Cardiology, Cleveland Clinic Children's, Cleveland, Ohio
| | - Tara Karamlou
- Heart, Vascular, and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio
| | - Bradley S Marino
- Department of Pediatric Cardiology, Cleveland Clinic Children's, Cleveland, Ohio
| | - Jeffrey G Gossett
- Cohen Children's Medical Center, Northwell Health, New Hyde Park, New York
| | - Kurt Schumacher
- Congenital Heart Center, C.S. Mott Children's Hospital, University of Michigan, Ann Arbor, Michigan
| | - Angira Patel
- Division of Cardiology, Ann & Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Sarah Worley
- Department of Quantitative Health Sciences, Cleveland Clinic, Cleveland, Ohio
| | - Tarek Alsaied
- University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Shahnawaz Amdani
- Department of Pediatric Cardiology, Cleveland Clinic Children's, Cleveland, Ohio.
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239
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Herrmann JL. Commentary: Systemic ventricular assist devices for the Fontan circulation: We can, but for whom and when? J Thorac Cardiovasc Surg 2021; 164:365-366. [PMID: 34922761 DOI: 10.1016/j.jtcvs.2021.11.067] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/26/2021] [Revised: 11/26/2021] [Accepted: 11/30/2021] [Indexed: 10/19/2022]
Affiliation(s)
- Jeremy L Herrmann
- Division of Thoracic and Cardiovascular Surgery, Indiana University School of Medicine, Indianapolis, Ind; Riley Children's Health at Indiana University Health, Indianapolis, Ind.
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240
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Fusco F, Scognamiglio G, Merola A, Roma AS, Nicastro C, Spatarella M, D'Abbraccio M, Di Mauro G, Atripaldi U, Atripaldi L, Correra A, Palma M, Barracano R, Borrelli N, Capuano A, Sarubbi B. COVID-19 vaccination in adults with congenital heart disease: Real-world data from an Italian tertiary centre. INTERNATIONAL JOURNAL OF CARDIOLOGY CONGENITAL HEART DISEASE 2021; 6:100266. [PMID: 35360668 PMCID: PMC8552781 DOI: 10.1016/j.ijcchd.2021.100266] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2021] [Accepted: 10/25/2021] [Indexed: 11/01/2022] Open
Abstract
Background real-world data on COVID-19 vaccine safety, immunogenicity and acceptance in adults with congenital heart disease (ACHD) are lacking. Methods ACHD patients who were offered COVID-19 vaccination from January to June 2021 were included. Data on adverse events, on patients' attitude towards vaccination and antispike IgG titre were retrospectively collected. A group of healthy individuals with similar age and sex undergoing vaccination was included for comparison. Results 208 patients followed in a single ACHD tertiary centre (33.3 [26-45] years, 54% male) received COVID-19 vaccine, 65% vaccinated at our institution: 199 (96%) received Pfizer-BioNTech BNT162b2 vaccine, 4 (2%) Moderna-1273 and 5 (2%) AstraZeneca-ChAdOx1. Median follow-up after vaccination was 79 [57-96] days. No major adverse event was reported and the incidence of minor events was not different between ACHD patients and the control group. One patient was diagnosed with acute pericarditis. There were two deaths unrelated to the vaccine during follow-up. Three (1.5%) vaccinated patients tested positive for COVID-19. Antispike IgG titre, available in 159 (76%) patients, was 1334 [600-3401] BAU/ml, not significantly different from the control group (p=0.2). One patient with Fontan failure was seronegative. Advanced physiological stage was associated with lower antibody response, independently from previous viral exposure (p<0.0001). Fourteen percent refused COVID-19 vaccination at our institution. However, 50% of vaccinated patients declared to have been influenced by the discussion with the ACHD cardiologist and 66% of those vaccinated in situ reported that undergoing COVID-19 vaccination at the ACHD centre made them feel safer. Conclusion COVID-19 vaccines appear safe in ACHD with satisfactory immunogenicity. However, the most vulnerable patients showed lower antibody response. ACHD team may play a key role in vaccine acceptance.
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Affiliation(s)
- Flavia Fusco
- Adult Congenital Heart Disease Unit, AO dei Colli - Monaldi Hospital, Naples, Italy
| | | | - Assunta Merola
- Adult Congenital Heart Disease Unit, AO dei Colli - Monaldi Hospital, Naples, Italy
| | - Anna Selvaggia Roma
- Adult Congenital Heart Disease Unit, AO dei Colli - Monaldi Hospital, Naples, Italy
| | - Carmine Nicastro
- Department for Laboratory Medicine, AO dei Colli - Monaldi Hospital, Naples, Italy
| | | | - Maurizio D'Abbraccio
- Vaccination Unit for Vulnerable Patients, AORN dei Colli - Cotugno Hospital, Naples, Italy
| | - Gabriella Di Mauro
- Section of Pharmacology "L. Donatelli", Department of Experimental Medicine, University of Campania "Luigi Vanvitelli", Naples, Italy
| | - Umberto Atripaldi
- Department for Laboratory Medicine, AO dei Colli - Monaldi Hospital, Naples, Italy
| | - Lidia Atripaldi
- Department for Laboratory Medicine, AO dei Colli - Monaldi Hospital, Naples, Italy
| | - Anna Correra
- Adult Congenital Heart Disease Unit, AO dei Colli - Monaldi Hospital, Naples, Italy
| | - Michela Palma
- Adult Congenital Heart Disease Unit, AO dei Colli - Monaldi Hospital, Naples, Italy
| | - Rosaria Barracano
- Adult Congenital Heart Disease Unit, AO dei Colli - Monaldi Hospital, Naples, Italy
| | - Nunzia Borrelli
- Adult Congenital Heart Disease Unit, AO dei Colli - Monaldi Hospital, Naples, Italy
| | - Annalisa Capuano
- Section of Pharmacology "L. Donatelli", Department of Experimental Medicine, University of Campania "Luigi Vanvitelli", Naples, Italy
| | - Berardo Sarubbi
- Section of Pharmacology "L. Donatelli", Department of Experimental Medicine, University of Campania "Luigi Vanvitelli", Naples, Italy
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241
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McConville P. Toward a phenomenology of congenital illness: a case of single-ventricle heart disease. MEDICINE, HEALTH CARE, AND PHILOSOPHY 2021; 24:587-595. [PMID: 34024020 DOI: 10.1007/s11019-021-10026-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 05/13/2021] [Indexed: 06/12/2023]
Abstract
Phenomenology has contributed to healthcare by providing resources for understanding the lived experience of the patient and their situation. But within a burgeoning literature on the characteristic features of illness, there has not yet been an account appropriate to describe congenital illnesses: conditions which are present from birth and cause suffering or medical threat to their bearers. Congenital illness sits uncomfortably with standard accounts in phenomenology of illness, in which concepts such as loss, doubt, alienation and unhomelikeness presuppose prior health. These accounts reflect, in different ways, Maurice Merleau-Ponty's assumption that the ways of living of the ill contain allusions to fundamental, healthy functions. The originality of congenital illness complicates this assumption and demands its own original phenomenology. In this paper, I sketch my personal experience living with a single-ventricle heart condition. While some of this story may reflect my own idiosyncratic experience, I hope that much of it will resonate with the congenital illness experience. I argue that the phenomenological literature on illness, grounded in the notion of loss, does not describe the congenital illness experience. I show how a number of other patient-centred theories of health and illness which have been influential on phenomenology can and cannot elucidate congenital illness. In particular, I consider Georges Canguilhem's account of the normal and the pathological; debates in disability; and the notion of illness as biographical disruption. I show that congenital illness results in the preadmission of its patients to a paradoxical logic of medical palliation, one product of which is existential maturity.
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Affiliation(s)
- Pat McConville
- Monash Bioethics Centre, Monash University, 20 Chancellors Walk, Wellington Road, Clayton, VIC, 3800, Australia.
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242
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Prominent atrial fibrosis and its correlation with dilated atrium atrial tachyarrhythmia and long after classic Fontan surgery. J Cardiol 2021; 79:671-677. [DOI: 10.1016/j.jjcc.2021.12.005] [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: 07/13/2021] [Revised: 11/24/2021] [Accepted: 12/01/2021] [Indexed: 11/20/2022]
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243
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Katz DA, Lubert AM, Gao Z, Powell AW, Szugye C, Woodly S, Goldstein SL, Alsaied T, Opotowsky AR. Comparison of creatinine and cystatin C estimation of glomerular filtration rate in the Fontan circulation. INTERNATIONAL JOURNAL OF CARDIOLOGY CONGENITAL HEART DISEASE 2021. [DOI: 10.1016/j.ijcchd.2021.100286] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022] Open
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244
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McGovern E, Alsaied T, Szugye N, Pradhan S, Batlivala SP, Lubert A, Hirsch R. The Fontan Pathway: Change in Dimension and Catheter-Based Intervention over Time. Pediatr Cardiol 2021; 42:1740-1748. [PMID: 34136951 DOI: 10.1007/s00246-021-02658-2] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/14/2021] [Accepted: 06/07/2021] [Indexed: 11/29/2022]
Abstract
An unobstructed Fontan pathway is essential for optimal hemodynamics. We hypothesize that more extracardiac conduit (ECC) Fontan pathways develop obstruction compared to lateral tunnel (LT) Fontans and that the dilation typically observed in LTs results in similar mid-term clinical outcomes. A single-center, retrospective study was done including all Fontan cardiac catheterizations from 2006 to 2019. Angiography and medical records were reviewed to define Fontan pathway dimensions, interventions, and clinical outcomes. 232 patients underwent cardiac catheterization, where 60% were ECCs and 30% LTs. The minimum cross-sectional area (CSA) of ECCs was significantly smaller than LTs and LTs dilated over time. 13% of patients had Fontan pathway stenting at a median age of 16.2 years. The minimum CSA for patients who underwent intervention was significantly smaller than patients who did not. Lower weight at Fontan surgery was associated with intervention on the Fontan pathway, with a threshold weight of 15 kg for patients with an ECC. The median follow-up was 3.3 years. Patients who had Fontan pathway intervention were not more likely to experience the composite adverse clinical outcome. LTs were more likely than ECCs to have worse clinical outcome, when liver fibrosis was included. This is the first study to describe angiographic dimensions of the Fontan pathway in a large number of patients over time. ECCs tend to become stenotic. Lower weight at Fontan surgery is a potential risk for Fontan pathway intervention. LTs may experience worse clinical outcomes in follow-up. This information can help inform the optimal timing and method of post-Fontan surveillance.
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Affiliation(s)
- E McGovern
- Division of Pediatric Cardiology, Department of Pediatrics, University of Kentucky, Lexington, KY, USA.
| | - T Alsaied
- The Heart Institute, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - N Szugye
- The Heart Institute, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - S Pradhan
- The Heart Institute, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - S P Batlivala
- The Heart Institute, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - A Lubert
- The Heart Institute, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - R Hirsch
- The Heart Institute, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
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245
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Ybarra AM, Khanna G, Turmelle YP, Stoll J, Castleberry CD, Scheel J, Ballweg JA, Ameduri R, Kimberling M, Makil E, Birnbaum BF, Exil V, Canter CE, Simpson KE. Heterogeneous outcomes of liver disease after heart transplantation for a failed Fontan procedure. Pediatr Transplant 2021; 25:e14094. [PMID: 34296503 DOI: 10.1111/petr.14094] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/12/2021] [Revised: 05/29/2021] [Accepted: 07/02/2021] [Indexed: 01/03/2023]
Abstract
BACKGROUND Fontan-associated liver disease (FALD) uniformly affects patients with long-term Fontan physiology. The effect of isolated heart transplant (HT) on the course of FALD post-HT is not well understood. METHODS We evaluated serial liver imaging pre- and post-HT to assess liver changes over time in a single-center retrospective analysis of Fontan HT recipients who had pre- and ≥1-year post-HT liver imaging. Available patient demographic and clinical data were reviewed, including available liver biopsy results. RESULTS Serial liver imaging was available in 19 patients with a median age at HT of 12 years (range 3-23), the median age from Fontan to HT of 5.7 years (range 0.8-16), and the median time from imaging to follow up of 27 months (range 12-136 months). Pre-HT liver imaging was classified as follows: normal (n=1), congested (n=9), fibrotic (n=7), and cirrhotic (n=2). The majority of transplanted patients (15/19) had improvement in their post-HT liver imaging, including 13 patients with initially abnormal imaging pre-HT having normal liver imaging at follow-up. One patient had persistent cirrhosis at 26-month follow-up, one patient had unchanged fibrosis at 18-month follow-up, and one patient progressed from fibrosis pre-HT to cirrhosis post-HT at 136 months. No patients had overt isolated liver failure during pre- or post-HT follow-up. Liver biopsy did not consistently correlate with imaging findings. CONCLUSIONS Post-HT liver imaging evaluation in Fontan patients reveals heterogeneous liver outcomes. These results not only provide evidence for the improvement of FALD post-HT but also show the need for serial liver imaging follow-up post-HT.
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Affiliation(s)
- Aecha M Ybarra
- Department of Pediatrics, Washington University School of Medicine, St. Louis, MO, USA
| | - Geetika Khanna
- Department of Radiology, Washington University School of Medicine, St. Louis, MO, USA
| | - Yumirle P Turmelle
- Department of Radiology, Washington University School of Medicine, St. Louis, MO, USA
| | - Janis Stoll
- Department of Pediatrics, Washington University School of Medicine, St. Louis, MO, USA
| | - Chesney D Castleberry
- Department of Pediatrics, Washington University School of Medicine, St. Louis, MO, USA
| | - Janet Scheel
- Department of Pediatrics, Washington University School of Medicine, St. Louis, MO, USA
| | - Jean A Ballweg
- Department of Pediatrics, University of Nebraska, Omaha, NE, USA
| | - Rebecca Ameduri
- Department of Pediatrics, University of Minnesota Masonic Children's Hospital, Minneapolis, MN, USA
| | | | - Elizabeth Makil
- Department of Pediatrics, University of Oklahoma Health Sciences Center, Oklahoma City, OK, USA
| | - Brian F Birnbaum
- Department of Pediatrics, University of Missouri-Kansas City, Kansas City, MO, USA
| | - Vernat Exil
- Department of Pediatrics, University of Iowa Hospitals and Clinics, Iowa City, IA, USA
| | - Charles E Canter
- Department of Pediatrics, Washington University School of Medicine, St. Louis, MO, USA
| | - Kathleen E Simpson
- Department of Pediatrics, Washington University School of Medicine, St. Louis, MO, USA
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246
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Raimondi F, Martins D, Coenen R, Panaioli E, Khraiche D, Boddaert N, Bonnet D, Atkins M, El-Said H, Alshawabkeh L, Hsiao A. Prevalence of Venovenous Shunting and High-Output State Quantified with 4D Flow MRI in Patients with Fontan Circulation. Radiol Cardiothorac Imaging 2021; 3:e210161. [PMID: 34934948 PMCID: PMC8686005 DOI: 10.1148/ryct.210161] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2021] [Revised: 11/04/2021] [Accepted: 11/12/2021] [Indexed: 11/11/2022]
Abstract
PURPOSE To assess the ability of four-dimensional (4D) flow MRI to quantify flow volume of the Fontan circuit, including the frequency and hemodynamic contribution of systemic-to-pulmonary venovenous collateral vessels. MATERIALS AND METHODS In this retrospective study, patients with Fontan circulation were included from three institutions (2017-2021). Flow measurements were performed at several locations along the circuit by two readers, and collateral shunt volumes were quantified. The frequency of venovenous collaterals and structural defects were tabulated from concurrent MR angiography, contemporaneous CT, or catheter angiography and related to Fontan clinical status. Statistical analysis included Pearson and Spearman correlation and Bland-Altman analysis. RESULTS Seventy-five patients (mean age, 20 years; range, 5-58 years; 46 female and 29 male patients) were included. Interobserver agreement was high for aortic output, pulmonary arteries, pulmonary veins, superior vena cava (Glenn shunt), and inferior vena cava (Fontan conduit) (range, ρ = 0.913-0.975). Calculated shunt volume also showed strong agreement, on the basis of the difference between aortic and pulmonary flow (ρ = 0.935). A total of 37 of 75 (49%) of the patients exhibited shunts exceeding 1.00 L/min, 81% (30 of 37) of whom had pulmonary venous or atrial flow volume step-ups and corresponding venovenous collaterals. A total of 12% of patients (nine of 75) exhibited a high-output state (>4 L/min/m2), most of whom had venovenous shunts exceeding 30% of cardiac output. CONCLUSION Fontan flow and venovenous shunting can be reliably quantified at 4D flow MRI; high-output states were found in a higher proportion of patients than expected, among whom venovenous collaterals were common and constituted a substantial proportion of cardiac output.Keywords: Pediatrics, MR Angiography, Cardiac, Technology Assessment, Hemodynamics/Flow Dynamics, Congenital Supplemental material is available for this article. © RSNA, 2021.
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Affiliation(s)
- Francesca Raimondi
- From the Unité Médico-Chirurgicale de Cardiologie
Congénitale et Pédiatrique, Centre de Référence des
Maladies Cardiaques Congénitales Complexes-M3C, Hôpital
Universitaire Necker-Enfants Malades, Université de Paris, Paris, France
(F.R., D.K., D.B.); Pediatric Radiology Unit, Hôpital Universitaire
Necker-Enfants Malades, Université de Paris, Paris, France (F.R., E.P.,
N.B.); Decision and Bayesian Computation, Computation Biology Department, CNRS,
URS 3756, Neuroscience Department, CNRS UMR 3571, Institut Pasteur, Paris,
France (F.R.); School of Biomedical Engineering & Imaging Sciences,
King’s College London, Lambeth Wing, St Thomas’ Hospital, London,
England (F.R.); Department of Pediatric Cardiology, Hospital de Santa Cruz,
Centro Hospitalar Lisboa Ocidental, Lisbon, Portugal (D.M.); Radiology and
Cardiology Unit, Erasmus MC, Rotterdam, the Netherlands (R.C.); Fairfax
Radiological Consultants, Fairfax, Va (M.A.); and Departments of Pediatric
Cardiology (H.E.S.), Cardiovascular Medicine (L.A.), and Radiology (A.H.),
University of California, San Diego, 9300 Campus Point Dr, Room 7756, La Jolla,
CA 92037-7756
| | - Duarte Martins
- From the Unité Médico-Chirurgicale de Cardiologie
Congénitale et Pédiatrique, Centre de Référence des
Maladies Cardiaques Congénitales Complexes-M3C, Hôpital
Universitaire Necker-Enfants Malades, Université de Paris, Paris, France
(F.R., D.K., D.B.); Pediatric Radiology Unit, Hôpital Universitaire
Necker-Enfants Malades, Université de Paris, Paris, France (F.R., E.P.,
N.B.); Decision and Bayesian Computation, Computation Biology Department, CNRS,
URS 3756, Neuroscience Department, CNRS UMR 3571, Institut Pasteur, Paris,
France (F.R.); School of Biomedical Engineering & Imaging Sciences,
King’s College London, Lambeth Wing, St Thomas’ Hospital, London,
England (F.R.); Department of Pediatric Cardiology, Hospital de Santa Cruz,
Centro Hospitalar Lisboa Ocidental, Lisbon, Portugal (D.M.); Radiology and
Cardiology Unit, Erasmus MC, Rotterdam, the Netherlands (R.C.); Fairfax
Radiological Consultants, Fairfax, Va (M.A.); and Departments of Pediatric
Cardiology (H.E.S.), Cardiovascular Medicine (L.A.), and Radiology (A.H.),
University of California, San Diego, 9300 Campus Point Dr, Room 7756, La Jolla,
CA 92037-7756
| | - Raluca Coenen
- From the Unité Médico-Chirurgicale de Cardiologie
Congénitale et Pédiatrique, Centre de Référence des
Maladies Cardiaques Congénitales Complexes-M3C, Hôpital
Universitaire Necker-Enfants Malades, Université de Paris, Paris, France
(F.R., D.K., D.B.); Pediatric Radiology Unit, Hôpital Universitaire
Necker-Enfants Malades, Université de Paris, Paris, France (F.R., E.P.,
N.B.); Decision and Bayesian Computation, Computation Biology Department, CNRS,
URS 3756, Neuroscience Department, CNRS UMR 3571, Institut Pasteur, Paris,
France (F.R.); School of Biomedical Engineering & Imaging Sciences,
King’s College London, Lambeth Wing, St Thomas’ Hospital, London,
England (F.R.); Department of Pediatric Cardiology, Hospital de Santa Cruz,
Centro Hospitalar Lisboa Ocidental, Lisbon, Portugal (D.M.); Radiology and
Cardiology Unit, Erasmus MC, Rotterdam, the Netherlands (R.C.); Fairfax
Radiological Consultants, Fairfax, Va (M.A.); and Departments of Pediatric
Cardiology (H.E.S.), Cardiovascular Medicine (L.A.), and Radiology (A.H.),
University of California, San Diego, 9300 Campus Point Dr, Room 7756, La Jolla,
CA 92037-7756
| | - Elena Panaioli
- From the Unité Médico-Chirurgicale de Cardiologie
Congénitale et Pédiatrique, Centre de Référence des
Maladies Cardiaques Congénitales Complexes-M3C, Hôpital
Universitaire Necker-Enfants Malades, Université de Paris, Paris, France
(F.R., D.K., D.B.); Pediatric Radiology Unit, Hôpital Universitaire
Necker-Enfants Malades, Université de Paris, Paris, France (F.R., E.P.,
N.B.); Decision and Bayesian Computation, Computation Biology Department, CNRS,
URS 3756, Neuroscience Department, CNRS UMR 3571, Institut Pasteur, Paris,
France (F.R.); School of Biomedical Engineering & Imaging Sciences,
King’s College London, Lambeth Wing, St Thomas’ Hospital, London,
England (F.R.); Department of Pediatric Cardiology, Hospital de Santa Cruz,
Centro Hospitalar Lisboa Ocidental, Lisbon, Portugal (D.M.); Radiology and
Cardiology Unit, Erasmus MC, Rotterdam, the Netherlands (R.C.); Fairfax
Radiological Consultants, Fairfax, Va (M.A.); and Departments of Pediatric
Cardiology (H.E.S.), Cardiovascular Medicine (L.A.), and Radiology (A.H.),
University of California, San Diego, 9300 Campus Point Dr, Room 7756, La Jolla,
CA 92037-7756
| | - Diala Khraiche
- From the Unité Médico-Chirurgicale de Cardiologie
Congénitale et Pédiatrique, Centre de Référence des
Maladies Cardiaques Congénitales Complexes-M3C, Hôpital
Universitaire Necker-Enfants Malades, Université de Paris, Paris, France
(F.R., D.K., D.B.); Pediatric Radiology Unit, Hôpital Universitaire
Necker-Enfants Malades, Université de Paris, Paris, France (F.R., E.P.,
N.B.); Decision and Bayesian Computation, Computation Biology Department, CNRS,
URS 3756, Neuroscience Department, CNRS UMR 3571, Institut Pasteur, Paris,
France (F.R.); School of Biomedical Engineering & Imaging Sciences,
King’s College London, Lambeth Wing, St Thomas’ Hospital, London,
England (F.R.); Department of Pediatric Cardiology, Hospital de Santa Cruz,
Centro Hospitalar Lisboa Ocidental, Lisbon, Portugal (D.M.); Radiology and
Cardiology Unit, Erasmus MC, Rotterdam, the Netherlands (R.C.); Fairfax
Radiological Consultants, Fairfax, Va (M.A.); and Departments of Pediatric
Cardiology (H.E.S.), Cardiovascular Medicine (L.A.), and Radiology (A.H.),
University of California, San Diego, 9300 Campus Point Dr, Room 7756, La Jolla,
CA 92037-7756
| | - Nathalie Boddaert
- From the Unité Médico-Chirurgicale de Cardiologie
Congénitale et Pédiatrique, Centre de Référence des
Maladies Cardiaques Congénitales Complexes-M3C, Hôpital
Universitaire Necker-Enfants Malades, Université de Paris, Paris, France
(F.R., D.K., D.B.); Pediatric Radiology Unit, Hôpital Universitaire
Necker-Enfants Malades, Université de Paris, Paris, France (F.R., E.P.,
N.B.); Decision and Bayesian Computation, Computation Biology Department, CNRS,
URS 3756, Neuroscience Department, CNRS UMR 3571, Institut Pasteur, Paris,
France (F.R.); School of Biomedical Engineering & Imaging Sciences,
King’s College London, Lambeth Wing, St Thomas’ Hospital, London,
England (F.R.); Department of Pediatric Cardiology, Hospital de Santa Cruz,
Centro Hospitalar Lisboa Ocidental, Lisbon, Portugal (D.M.); Radiology and
Cardiology Unit, Erasmus MC, Rotterdam, the Netherlands (R.C.); Fairfax
Radiological Consultants, Fairfax, Va (M.A.); and Departments of Pediatric
Cardiology (H.E.S.), Cardiovascular Medicine (L.A.), and Radiology (A.H.),
University of California, San Diego, 9300 Campus Point Dr, Room 7756, La Jolla,
CA 92037-7756
| | - Damien Bonnet
- From the Unité Médico-Chirurgicale de Cardiologie
Congénitale et Pédiatrique, Centre de Référence des
Maladies Cardiaques Congénitales Complexes-M3C, Hôpital
Universitaire Necker-Enfants Malades, Université de Paris, Paris, France
(F.R., D.K., D.B.); Pediatric Radiology Unit, Hôpital Universitaire
Necker-Enfants Malades, Université de Paris, Paris, France (F.R., E.P.,
N.B.); Decision and Bayesian Computation, Computation Biology Department, CNRS,
URS 3756, Neuroscience Department, CNRS UMR 3571, Institut Pasteur, Paris,
France (F.R.); School of Biomedical Engineering & Imaging Sciences,
King’s College London, Lambeth Wing, St Thomas’ Hospital, London,
England (F.R.); Department of Pediatric Cardiology, Hospital de Santa Cruz,
Centro Hospitalar Lisboa Ocidental, Lisbon, Portugal (D.M.); Radiology and
Cardiology Unit, Erasmus MC, Rotterdam, the Netherlands (R.C.); Fairfax
Radiological Consultants, Fairfax, Va (M.A.); and Departments of Pediatric
Cardiology (H.E.S.), Cardiovascular Medicine (L.A.), and Radiology (A.H.),
University of California, San Diego, 9300 Campus Point Dr, Room 7756, La Jolla,
CA 92037-7756
| | - Melany Atkins
- From the Unité Médico-Chirurgicale de Cardiologie
Congénitale et Pédiatrique, Centre de Référence des
Maladies Cardiaques Congénitales Complexes-M3C, Hôpital
Universitaire Necker-Enfants Malades, Université de Paris, Paris, France
(F.R., D.K., D.B.); Pediatric Radiology Unit, Hôpital Universitaire
Necker-Enfants Malades, Université de Paris, Paris, France (F.R., E.P.,
N.B.); Decision and Bayesian Computation, Computation Biology Department, CNRS,
URS 3756, Neuroscience Department, CNRS UMR 3571, Institut Pasteur, Paris,
France (F.R.); School of Biomedical Engineering & Imaging Sciences,
King’s College London, Lambeth Wing, St Thomas’ Hospital, London,
England (F.R.); Department of Pediatric Cardiology, Hospital de Santa Cruz,
Centro Hospitalar Lisboa Ocidental, Lisbon, Portugal (D.M.); Radiology and
Cardiology Unit, Erasmus MC, Rotterdam, the Netherlands (R.C.); Fairfax
Radiological Consultants, Fairfax, Va (M.A.); and Departments of Pediatric
Cardiology (H.E.S.), Cardiovascular Medicine (L.A.), and Radiology (A.H.),
University of California, San Diego, 9300 Campus Point Dr, Room 7756, La Jolla,
CA 92037-7756
| | - Howaida El-Said
- From the Unité Médico-Chirurgicale de Cardiologie
Congénitale et Pédiatrique, Centre de Référence des
Maladies Cardiaques Congénitales Complexes-M3C, Hôpital
Universitaire Necker-Enfants Malades, Université de Paris, Paris, France
(F.R., D.K., D.B.); Pediatric Radiology Unit, Hôpital Universitaire
Necker-Enfants Malades, Université de Paris, Paris, France (F.R., E.P.,
N.B.); Decision and Bayesian Computation, Computation Biology Department, CNRS,
URS 3756, Neuroscience Department, CNRS UMR 3571, Institut Pasteur, Paris,
France (F.R.); School of Biomedical Engineering & Imaging Sciences,
King’s College London, Lambeth Wing, St Thomas’ Hospital, London,
England (F.R.); Department of Pediatric Cardiology, Hospital de Santa Cruz,
Centro Hospitalar Lisboa Ocidental, Lisbon, Portugal (D.M.); Radiology and
Cardiology Unit, Erasmus MC, Rotterdam, the Netherlands (R.C.); Fairfax
Radiological Consultants, Fairfax, Va (M.A.); and Departments of Pediatric
Cardiology (H.E.S.), Cardiovascular Medicine (L.A.), and Radiology (A.H.),
University of California, San Diego, 9300 Campus Point Dr, Room 7756, La Jolla,
CA 92037-7756
| | - Laith Alshawabkeh
- From the Unité Médico-Chirurgicale de Cardiologie
Congénitale et Pédiatrique, Centre de Référence des
Maladies Cardiaques Congénitales Complexes-M3C, Hôpital
Universitaire Necker-Enfants Malades, Université de Paris, Paris, France
(F.R., D.K., D.B.); Pediatric Radiology Unit, Hôpital Universitaire
Necker-Enfants Malades, Université de Paris, Paris, France (F.R., E.P.,
N.B.); Decision and Bayesian Computation, Computation Biology Department, CNRS,
URS 3756, Neuroscience Department, CNRS UMR 3571, Institut Pasteur, Paris,
France (F.R.); School of Biomedical Engineering & Imaging Sciences,
King’s College London, Lambeth Wing, St Thomas’ Hospital, London,
England (F.R.); Department of Pediatric Cardiology, Hospital de Santa Cruz,
Centro Hospitalar Lisboa Ocidental, Lisbon, Portugal (D.M.); Radiology and
Cardiology Unit, Erasmus MC, Rotterdam, the Netherlands (R.C.); Fairfax
Radiological Consultants, Fairfax, Va (M.A.); and Departments of Pediatric
Cardiology (H.E.S.), Cardiovascular Medicine (L.A.), and Radiology (A.H.),
University of California, San Diego, 9300 Campus Point Dr, Room 7756, La Jolla,
CA 92037-7756
| | - Albert Hsiao
- From the Unité Médico-Chirurgicale de Cardiologie
Congénitale et Pédiatrique, Centre de Référence des
Maladies Cardiaques Congénitales Complexes-M3C, Hôpital
Universitaire Necker-Enfants Malades, Université de Paris, Paris, France
(F.R., D.K., D.B.); Pediatric Radiology Unit, Hôpital Universitaire
Necker-Enfants Malades, Université de Paris, Paris, France (F.R., E.P.,
N.B.); Decision and Bayesian Computation, Computation Biology Department, CNRS,
URS 3756, Neuroscience Department, CNRS UMR 3571, Institut Pasteur, Paris,
France (F.R.); School of Biomedical Engineering & Imaging Sciences,
King’s College London, Lambeth Wing, St Thomas’ Hospital, London,
England (F.R.); Department of Pediatric Cardiology, Hospital de Santa Cruz,
Centro Hospitalar Lisboa Ocidental, Lisbon, Portugal (D.M.); Radiology and
Cardiology Unit, Erasmus MC, Rotterdam, the Netherlands (R.C.); Fairfax
Radiological Consultants, Fairfax, Va (M.A.); and Departments of Pediatric
Cardiology (H.E.S.), Cardiovascular Medicine (L.A.), and Radiology (A.H.),
University of California, San Diego, 9300 Campus Point Dr, Room 7756, La Jolla,
CA 92037-7756
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247
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Rijnberg FM, van der Woude SFS, Hazekamp MG, van den Boogaard PJ, Lamb HJ, Terol Espinosa de Los Monteros C, Kroft LJM, Kenjeres S, Karim T, Jongbloed MRM, Westenberg JJM, Wentzel JJ, Roest AAW. Extracardiac conduit adequacy along the respiratory cycle in adolescent Fontan patients. Eur J Cardiothorac Surg 2021; 62:6423130. [PMID: 34747442 PMCID: PMC9257669 DOI: 10.1093/ejcts/ezab478] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/05/2021] [Revised: 09/12/2021] [Accepted: 09/26/2021] [Indexed: 11/30/2022] Open
Affiliation(s)
- Friso M Rijnberg
- Department of Cardiothoracic Surgery, Leiden University Medical Center, Leiden, Netherlands
| | | | - Mark G Hazekamp
- Department of Cardiothoracic Surgery, Leiden University Medical Center, Leiden, Netherlands
| | | | - Hildo J Lamb
- Department of Radiology, Leiden University Medical Center, Leiden, Netherlands
| | | | - Lucia J M Kroft
- Department of Radiology, Leiden University Medical Center, Leiden, Netherlands
| | - Sasa Kenjeres
- Department of Chemical Engineering, Faculty of Applied Sciences, Delft University of Technology and J.M. Burgers Centrum Research School for Fluid Mechanics, Delft, Netherlands
| | - Tawab Karim
- Department of Cardiology, Biomechanical Engineering, Erasmus MC, Rotterdam, Netherlands
| | - Monique R M Jongbloed
- Department of Cardiology and Anatomy and Embryology, Leiden University Medical Center, Leiden, Netherlands
| | - Jos J M Westenberg
- Department of Radiology, Leiden University Medical Center, Leiden, Netherlands
| | - Jolanda J Wentzel
- Department of Cardiology, Biomechanical Engineering, Erasmus MC, Rotterdam, Netherlands
| | - Arno A W Roest
- Department of Pediatric Cardiology, Leiden University Medical Center, Leiden, Netherlands
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248
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Knobbe K, Partha M, Seckeler MD, Klewer S, Hsu CH, Edgin J, Morgan WJ, Provencio-Dean N, Lopez S, Parthasarathy S, Combs D. Association Between Sleep Disturbances With Neurodevelopmental Problems and Decreased Health-Related Quality of Life in Children With Fontan Circulation. J Am Heart Assoc 2021; 10:e021749. [PMID: 34668394 PMCID: PMC8751823 DOI: 10.1161/jaha.121.021749] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/23/2023]
Abstract
Background Children with Fontan circulation are known to be at increased risk for neurodevelopmental problems and decreased health-related quality of life (HRQOL), but many factors that may contribute to this risk are unknown. Sleep disturbances may be one previously unidentified factor that contributes to this risk. Methods and Results We analyzed data from the Pediatric Heart Network Fontan cross-sectional study to evaluate associations between a parent or child report of sleep disturbance with reported neurodevelopmental concerns and HRQOL in 558 children with Fontan circulation. Parent-reported sleep disturbance was present in 11% of participants and child-reported sleep disturbance was present in 15%. Parent-reported sleep disturbance was associated with a significantly higher risk of attention problems, anxiety, depression, behavioral problems, and developmental delay (P<0.001 for all). Similarly, parent-reported disturbance was associated with decreased HRQOL on both parent and child-reported HRQOL (P<0.001 for most domains). Child-reported sleep disturbances were associated with increased odds of anxiety, depression, and attention problems as well as worse HRQOL. These associations were present even after adjustment for cardiac, demographic, and socioeconomic factors that may affect HRQOL and neurodevelopmental status. Conclusions Sleep disturbances in children with Fontan circulation are associated with an increased risk of neurodevelopmental problems as well as reduced HRQOL compared with those without sleep disturbance. Better understanding of sleep disturbances is needed in children with Fontan circulation, as sleep disturbances may represent a reversible cause of neurodevelopmental problems and decreased HRQOL in this population.
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Affiliation(s)
- Kirstin Knobbe
- UAHS Center for Sleep & Circadian Sciences University of Arizona Tucson AZ
| | - Meghana Partha
- UAHS Center for Sleep & Circadian Sciences University of Arizona Tucson AZ
| | | | - Scott Klewer
- Department of Pediatrics University of Arizona Tucson AZ
| | - Chiu-Hsieh Hsu
- Mel and Enid Zuckerman College of Public Health University of Arizona Tucson AZ
| | - Jamie Edgin
- Department of Psychology University of Arizona Tucson AZ.,Sonoran University Center for Excellence in Developmental DisabilitiesUniversity of Arizona Tucson AZ
| | - Wayne J Morgan
- Department of Pediatrics University of Arizona Tucson AZ
| | | | - Silvia Lopez
- UAHS Center for Sleep & Circadian Sciences University of Arizona Tucson AZ
| | | | - Daniel Combs
- UAHS Center for Sleep & Circadian Sciences University of Arizona Tucson AZ.,Department of Pediatrics University of Arizona Tucson AZ
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249
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Vaikunth SS, Leonard MB, Whitehead KK, Goldberg DJ, Rychik J, Zemel BS, Avitabile CM. Deficits in the Functional Muscle-Bone Unit in Youths with Fontan Physiology. J Pediatr 2021; 238:202-207. [PMID: 34214589 PMCID: PMC8634795 DOI: 10.1016/j.jpeds.2021.06.068] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/12/2021] [Revised: 06/22/2021] [Accepted: 06/24/2021] [Indexed: 12/16/2022]
Abstract
OBJECTIVE To determine whether dual energy X-ray absorptiometry (DXA), a clinically available tool, mirrors the magnitude of deficits in trabecular and cortical bone mineral density (BMD) demonstrated on peripheral quantitative computed tomography in youth with Fontan physiology. STUDY DESIGN We aimed to describe DXA-derived BMD at multiple sites and to investigate the relationship between BMD and leg lean mass, a surrogate for skeletal muscle loading. Subjects with Fontan (n = 46; aged 5-20 years) underwent DXA in a cross-sectional study of growth and bone and muscle health as described previously. Data from the Bone Mineral Density in Childhood Study were used to calculate age-, sex-, and race-specific BMD z-scores of the whole body, lumbar spine, hip, femoral neck, distal one-third radius, ultradistal radius, and leg lean mass z-score (LLMZ). RESULTS Fontan BMD z-scores were significantly lower than reference at all sites-whole body, -0.34 ± 0.85 (P = .01); spine, -0.41 ± 0.96 (P = .008); hip, -0.75 ± 1.1 (P < .001); femoral neck, -0.73 ± 1.0 (P < .001); distal one-third radius, -0.87 ± 1.1 (P < .001); and ultradistal radius. -0.92 ± 1.03 (P < .001)-as was LLMZ (-0.93 ± 1.1; P < .001). Lower LLMZ was associated with lower BMD of the whole body (R2 = 0.40; P < .001), lumbar spine (R2 = 0.16; P = .005), total hip (R2 = 0.32; P < .001), femoral neck (R2 = 0.47; P < .001), and ultradistal radius (R2 = 0.35; P < .001). CONCLUSIONS Patients with Fontan have marked deficits in both cortical (hip, distal one-third radius) and trabecular (lumbar spine, femoral neck, ultradistal radius) BMD. Lower LLMZ is associated with lower BMD and may reflect inadequate skeletal muscle loading. Interventions to increase muscle mass may improve bone accrual.
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Affiliation(s)
- Sumeet S. Vaikunth
- Division of Cardiovascular Medicine, Stanford University School of Medicine, Palo Alto, CA, USA
| | - Mary B. Leonard
- Departments of Medicine and Pediatrics, Stanford University School of Medicine, Palo Alto, CA, USA
| | - Kevin K. Whitehead
- Division of Cardiology, The Children’s Hospital of Philadelphia, Philadelphia, PA, USA,Department of Pediatrics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - David J. Goldberg
- Division of Cardiology, The Children’s Hospital of Philadelphia, Philadelphia, PA, USA,Department of Pediatrics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Jack Rychik
- Division of Cardiology, The Children’s Hospital of Philadelphia, Philadelphia, PA, USA,Department of Pediatrics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Babette S. Zemel
- Department of Pediatrics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA.,Division of Gastroenterology, Hepatology and Nutrition, The Children’s Hospital of Philadelphia, Philadelphia, PA, USA
| | - Catherine M. Avitabile
- Division of Cardiology, The Children’s Hospital of Philadelphia, Philadelphia, PA, USA,Department of Pediatrics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
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250
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Hanser A, Martirosian P, Hornung A, Hofbeck M, Grosse U, Esser M, Schick F, Schäfer J, Nikolaou K, Sieverding L. T2-Weighted High-Resolution Isotropic Magnetic Resonance Lymphangiography of the Thoracic and Abdominal Lymphatic Vessels with and without Previous High-Fat Meal. Acad Radiol 2021; 28 Suppl 1:S218-S224. [PMID: 33183951 DOI: 10.1016/j.acra.2020.10.008] [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: 08/12/2020] [Revised: 09/29/2020] [Accepted: 10/01/2020] [Indexed: 10/23/2022]
Abstract
RATIONALE AND OBJECTIVES The aim of this study was to assess the potential benefit of a high-fat meal for preparation of patients before lymphangiography of the thoracic and abdominal lymphatic vessels by a heavily T2-weighted 3D magnetic resonance sequence at 3T. MATERIALS AND METHODS A heavily T2-weighted 3D Fast-Spin-Echo sequence was applied twice for lymphangiography in 15 healthy volunteers. One examination was performed following overnight fasting and the second examination was conducted 3 hours after a drinking of 200 ml of cream and a solid meal. The effect of a high-fat meal on the visualization of different segments of the thoracic and abdominal lymphatic vessels was analyzed by scoring of the image quality. RESULTS Evaluation of the summarized score of all four segments of the thoracic duct showed significantly improved general visualization of the lymphatic system in the postprandial examination when compared to the results obtained after overnight fasting (mean ± SD: 4.5 ± 1.7 vs. 5.9 ± 1.8, p = 0.007*). Regarding different segments of the lymphatic system significant differences between pre and post cream lymphangiographies were found in the cervical segment (p = 0.012*), the inferior thoracic segment (p = 0.003*) and the abdominal segment (p = 0.035*). In contrast, the visualization of the superior thoracic segment was not significantly improved by high fat meal preparation of the subjects (p = 0.388). CONCLUSION A high-fat meal 3 hours prior to T2-weighted MR-lymphangiography improves the visualization of the main lymphatic thoracic and abdominal vessels, particularly the abdominal and cervical part as well as the inferior segment of the thoracic duct.
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