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Abdulkarim A, Shaji S, Elfituri M, Gunsaulus M, Zafar MA, Zaidi AN, Pass RH, Feingold B, Kurland G, Kreutzer J, Ghassemzadeh R, Goldstein B, West S, Alsaied T. Pulmonary Complications in Patients With Fontan Circulation: JACC Review Topic of the Week. J Am Coll Cardiol 2023; 81:2434-2444. [PMID: 37344046 DOI: 10.1016/j.jacc.2023.04.036] [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: 02/07/2023] [Revised: 04/03/2023] [Accepted: 04/10/2023] [Indexed: 06/23/2023]
Abstract
The Fontan operation has resulted in significant improvement in survival of patients with single ventricle physiology. As a result, there is a growing population of individuals with Fontan physiology reaching adolescence and adulthood. Despite the improved survival, there are long-term morbidities associated with the Fontan operation. Pulmonary complications are common and may contribute to both circulatory and pulmonary insufficiency, leading ultimately to Fontan failure. These complications include restrictive lung disease, sleep abnormalities, plastic bronchitis, and cyanosis. Cyanosis post-Fontan procedure can be attributed to multiple causes including systemic to pulmonary venous collateral channels and pulmonary arteriovenous malformations. This review presents the unique cardiopulmonary interactions in the Fontan circulation. Understanding the cardiopulmonary interactions along with improved recognition and treatment of pulmonary abnormalities may improve the long-term outcomes in this growing patient population. Interventions focused on improving pulmonary function including inspiratory muscle training and endurance training have shown a promising effect post-Fontan procedure.
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Affiliation(s)
- Ali Abdulkarim
- Department of Pediatrics, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Shawn Shaji
- Heart Institute, University of Pittsburgh Medical Center, Children's Hospital of Pittsburgh, Pittsburgh, Pennsylvania, USA; Division of Pediatric Cardiology, Department of Pediatrics, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Mahmud Elfituri
- Department of Pediatrics, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Megan Gunsaulus
- Heart Institute, University of Pittsburgh Medical Center, Children's Hospital of Pittsburgh, Pittsburgh, Pennsylvania, USA; Division of Pediatric Cardiology, Department of Pediatrics, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Muhammad A Zafar
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
| | - Ali N Zaidi
- Mount Sinai Heart, Mount Sinai Kravis Children's Heart Center, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Robert H Pass
- Department of Pediatrics, Icahn School of Medicine at Mount Sinai, Division of Pediatric Cardiology and Mount Sinai Kravis Children's Heart Center, New York, New York, USA
| | - Brian Feingold
- Heart Institute, University of Pittsburgh Medical Center, Children's Hospital of Pittsburgh, Pittsburgh, Pennsylvania, USA; Division of Pediatric Cardiology, Department of Pediatrics, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Geoffrey Kurland
- University of Pittsburgh Medical Center, Children's Hospital of Pittsburgh, Pittsburgh, Pennsylvania, USA; Division of Pediatric Pulmonology, Department of Pediatrics, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Jacqueline Kreutzer
- Heart Institute, University of Pittsburgh Medical Center, Children's Hospital of Pittsburgh, Pittsburgh, Pennsylvania, USA; Division of Pediatric Cardiology, Department of Pediatrics, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Rod Ghassemzadeh
- University of Pittsburgh Medical Center, Children's Hospital of Pittsburgh, Department of Critical Care, Pittsburgh, Pennsylvania, USA
| | - Bryan Goldstein
- Heart Institute, University of Pittsburgh Medical Center, Children's Hospital of Pittsburgh, Pittsburgh, Pennsylvania, USA; Division of Pediatric Cardiology, Department of Pediatrics, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Shawn West
- Heart Institute, University of Pittsburgh Medical Center, Children's Hospital of Pittsburgh, Pittsburgh, Pennsylvania, USA; Division of Pediatric Cardiology, Department of Pediatrics, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Tarek Alsaied
- Heart Institute, University of Pittsburgh Medical Center, Children's Hospital of Pittsburgh, Pittsburgh, Pennsylvania, USA; Division of Pediatric Cardiology, Department of Pediatrics, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA.
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Saxena P, Maddali MM, Kaur C, Zacharias S. Fontan-Associated Plastic Bronchitis. J Cardiothorac Vasc Anesth 2023; 37:1063-1064. [PMID: 36918341 DOI: 10.1053/j.jvca.2023.02.021] [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: 01/28/2023] [Revised: 02/09/2023] [Accepted: 02/13/2023] [Indexed: 02/21/2023]
Affiliation(s)
- Pravin Saxena
- Department of Cardiac Anesthesia, National Heart Center, Royal Hospital, Muscat, Oman
| | - Madan Mohan Maddali
- Department of Cardiac Anesthesia, National Heart Center, Royal Hospital, Muscat, Oman.
| | - Charanjit Kaur
- Department of Cardiac Anesthesia, National Heart Center, Royal Hospital, Muscat, Oman
| | - Sunny Zacharias
- Department of Cardiothoracic Surgery, National Heart Center, Royal Hospital, Muscat, Oman
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3
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Kim WC, Gonzalez Barlatay FM, Taliotis DM. Successful Fenestration of an Extracardiac Conduit in a Fontan Patient With the Baylis NRG RF Transeptal Needle and Creation of Fontan Fenestration with a 20-mm 535 Formula Stent. STRUCTURAL HEART : THE JOURNAL OF THE HEART TEAM 2022; 6:100064. [PMID: 37288337 PMCID: PMC10242561 DOI: 10.1016/j.shj.2022.100064] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/28/2022] [Revised: 05/04/2022] [Accepted: 06/03/2022] [Indexed: 06/09/2023]
Affiliation(s)
- Wan Cheol Kim
- Address correspondence to: Wan Cheol Kim, MD, Bristol Royal Hospital for Children & Bristol Heart Institute, University Hospitals Bristol NHS Foundation Trust, Bristol BS2 8HW, UK.
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Mackie AS, Veldtman GR, Thorup L, Hjortdal VE, Dori Y. Plastic Bronchitis and Protein-Losing Enteropathy in the Fontan Patient: Evolving Understanding and Emerging Therapies. Can J Cardiol 2022; 38:988-1001. [DOI: 10.1016/j.cjca.2022.03.011] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2021] [Revised: 03/08/2022] [Accepted: 03/12/2022] [Indexed: 12/17/2022] Open
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Liptzin DR, McGraw MD, Houin PR, Veress LA. Fibrin airway cast obstruction: Experience, classification, and treatment guideline from Denver. Pediatr Pulmonol 2022; 57:529-537. [PMID: 34713989 DOI: 10.1002/ppul.25746] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/13/2020] [Revised: 10/14/2021] [Accepted: 10/15/2021] [Indexed: 12/24/2022]
Abstract
BACKGROUND AND OBJECTIVES Plastic bronchitis (PB) is a condition characterized by the formation of thick airway casts leading to acute and often life-threatening airway obstruction. PB occurs mainly in pediatric patients with congenital heart disease (CHO) who have undergone staged surgical palliation (Glenn, Fontan), but can also occur after chemical inhalation, H1N1, severe COVID-19, sickle cell disease, severe asthma, and other diseases. Mortality risk from PB can be up to 40%-60%, and no treatment guideline exist. The objectives herein are to develop a standardized evaluation, classification, and treatment guideline for PB patients presenting with tracheobronchial casts, based on our experience with PB at the Children's Hospital of Colorado in Denver. METHODS We describe 11 patients with CHO-associated PB (post-Fontan [n = 9], pre-Fontan [n = 2]) who presented with their initial episodes. We utilized histopathological analysis of tracheobronchial casts to guide treatment in these patients, utilizing our hospital-wide guideline document and classification system. RESULTS We found that 100% of post-Fontan PB patients had fibrinous airway casts, while pre-Fontan PB casts were fibrinous only in one of two patients (50%). Utilizing histopathology as a guide to therapy, PB patients with fibrin airway casts were treated with airway-delivered fibrinolytics and anticoagulants, as well as aggressive airway clearance and other supportive care measures. These therapies resulted in successful cast resolution and improved survival in post-Fontan PB patients. CONCLUSION We have shown an improved outcome in PB patients whose treatment plan was based on Denver's PB classification schema and standardized treatment guideline based on tracheobronchial cast histopathology.
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Affiliation(s)
- Deborah R Liptzin
- Department of Pediatrics, Section of Pulmonary and Sleep Medicine, University of Colorado Denver (Primary Research Site), Aurora, Colorado, USA
| | - Matthew D McGraw
- Department of Pediatrics, Section of Pulmonary and Sleep Medicine, University of Colorado Denver (Primary Research Site), Aurora, Colorado, USA
- Division of Pediatric Pulmonology, Department of Pediatrics, University of Rochester, Rochester, New York, USA
| | - Paul R Houin
- Department of Pediatrics, Section of Pulmonary and Sleep Medicine, University of Colorado Denver (Primary Research Site), Aurora, Colorado, USA
| | - Livia A Veress
- Department of Pediatrics, Section of Pulmonary and Sleep Medicine, University of Colorado Denver (Primary Research Site), Aurora, Colorado, USA
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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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Transcatheter creation of a pulmonary artery to left atrial fenestration in a failing Fontan circulation using the Atrial Flow Regulator (AFR). Cardiol Young 2021; 31:1376-1379. [PMID: 33766177 DOI: 10.1017/s1047951121000731] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Transcatheter creation of an interatrial communication using the Occlutech Atrial Flow Regulator Device for pulmonary hypertension or heart failure is well described. We report a case of an 8-year-old boy with a failing Fontan circulation, in whom the Atrial Flow Regulator was used to successfully create a fenestration between the pulmonary artery and left atrium, improving his clinical condition.
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8
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Lymphatic Disorders and Management in Patients with Congenital Heart Disease. Ann Thorac Surg 2020; 113:1101-1111. [PMID: 33373590 DOI: 10.1016/j.athoracsur.2020.10.058] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/07/2020] [Revised: 09/11/2020] [Accepted: 10/05/2020] [Indexed: 11/20/2022]
Abstract
Congenital heart disease can lead to significant lymphatic complications such as chylothorax, plastic bronchitis, protein losing enteropathy and ascites. Recent improvements in lymphatic imaging and the development of new lymphatic procedures can help alleviate symptoms and improve outcomes.
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9
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Chavhan GB, Lam CZ, Greer MLC, Temple M, Amaral J, Grosse-Wortmann L. Magnetic Resonance Lymphangiography. Radiol Clin North Am 2020; 58:693-706. [PMID: 32471538 DOI: 10.1016/j.rcl.2020.02.002] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Dynamic contrast-enhanced magnetic resonance lymphangiography is a novel technique to image central conducting lymphatics. It is performed by injecting contrast into groin lymph nodes and following passage of contrast through lymphatic system using T1-weighted MR images. Currently, it has been successfully applied to image and plan treatment of thoracic duct pathologies, lymphatic leaks, and other lymphatic abnormalities such as plastic bronchitis. It is useful in the assessment of chylothorax and chyloperitoneum. Its role in other areas such as intestinal lymphangiectasia and a variety of lymphatic anomalies is likely to increase.
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Affiliation(s)
- Govind B Chavhan
- Department of Diagnostic Imaging, The Hospital for Sick Children and Medical Imaging, University of Toronto, 555 University Avenue, Toronto, Ontario M5G 1X8, Canada.
| | - Christopher Z Lam
- Department of Diagnostic Imaging, The Hospital for Sick Children and Medical Imaging, University of Toronto, 555 University Avenue, Toronto, Ontario M5G 1X8, Canada
| | - Mary-Louise C Greer
- Department of Diagnostic Imaging, The Hospital for Sick Children and Medical Imaging, University of Toronto, 555 University Avenue, Toronto, Ontario M5G 1X8, Canada
| | - Michael Temple
- Department of Diagnostic Imaging, The Hospital for Sick Children and Medical Imaging, University of Toronto, 555 University Avenue, Toronto, Ontario M5G 1X8, Canada; Division of Image Guided Therapy (IGT), Department of Diagnostic Imaging, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Joao Amaral
- Department of Diagnostic Imaging, The Hospital for Sick Children and Medical Imaging, University of Toronto, 555 University Avenue, Toronto, Ontario M5G 1X8, Canada; Division of Image Guided Therapy (IGT), Department of Diagnostic Imaging, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Lars Grosse-Wortmann
- Department of Diagnostic Imaging, The Hospital for Sick Children and Medical Imaging, University of Toronto, 555 University Avenue, Toronto, Ontario M5G 1X8, Canada; Division of Cardiology, Department of Paediatrics, The Hospital for Sick Children, University of Toronto, 555 University Avenue, Toronto, Ontario M5G 1X8, Canada
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10
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Harteveld LM, Blom NA, Hazekamp MG, Ten Harkel ADJ. Treatment and outcome of plastic bronchitis in single ventricle patients: a systematic review. Interact Cardiovasc Thorac Surg 2020; 30:846-853. [DOI: 10.1093/icvts/ivaa032] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2019] [Revised: 01/14/2020] [Accepted: 01/30/2020] [Indexed: 12/23/2022] Open
Abstract
Abstract
Plastic bronchitis (PB) is a life-threatening complication in single ventricle (SV) patients of which the exact pathophysiology, outcome and optimal treatment are still unclear. This study aims to systematically review the literature to give insight into the characteristics, outcome and management options of SV patients with PB. A systematic review was conducted, using the electronic database PubMed to find records published up to August 2018, describing SV patients and PB in which characteristics, treatment and/or outcome were adequately described per case. A total of 577 records were screened of which 73 had sufficient data describing 133 SV cases with PB. Most cases had completed a Fontan palliation (n = 126) with a median interval between Fontan completion and diagnosis of PB of 18.4 months (Q1–Q3 5.0–36.3). Overall mortality was 15.2% and was associated with the diagnosis of PB within 12 months after Fontan palliation (5-year survival of 56.1% ≤12 months vs 94.8% >12 months, P = 0.002) and a higher age at Fontan completion (47.4 months for non-survivors vs 36.0 months for survivors, P = 0.015). Most patients received a combination therapy from 3 different treatment strategies, i.e. therapy for relief of airway obstruction, anti-inflammatory treatment and treatment to improve haemodynamics of the Fontan physiology (55.1%). In conclusion, SV patients who are diagnosed with PB within 12 months after Fontan palliation have a higher risk of mortality. Moreover, most cases received a combination therapy consisting of all 3 treatment strategies.
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Affiliation(s)
- Lisette M Harteveld
- The Centre for Congenital Heart Disease Amsterdam–Leiden, Leiden, Netherlands
- Department of Paediatric Cardiology, Leiden University Medical Centre, Leiden, Netherlands
| | - Nico A Blom
- The Centre for Congenital Heart Disease Amsterdam–Leiden, Leiden, Netherlands
- Department of Paediatric Cardiology, Leiden University Medical Centre, Leiden, Netherlands
- Department of Paediatric Cardiology, Amsterdam University Medical Centre, Academic Medical Centre, Amsterdam, Netherlands
| | - Mark G Hazekamp
- The Centre for Congenital Heart Disease Amsterdam–Leiden, Leiden, Netherlands
- Department of Cardiothoracic Surgery, Leiden University Medical Centre, Leiden, Netherlands
| | - Arend D J Ten Harkel
- The Centre for Congenital Heart Disease Amsterdam–Leiden, Leiden, Netherlands
- Department of Paediatric Cardiology, Leiden University Medical Centre, Leiden, Netherlands
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Nakamoto H, Kayama S, Harada M, Honjo T, Kubota K, Sawamura S. Airway emergency during general anesthesia in a child with plastic bronchitis following Fontan surgery: a case report. JA Clin Rep 2020; 6:6. [PMID: 32025939 PMCID: PMC6974346 DOI: 10.1186/s40981-020-0311-5] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2019] [Accepted: 01/14/2020] [Indexed: 11/28/2022] Open
Abstract
Background Plastic bronchitis (PB) is a complication of Fontan surgery, results in the formation of mucus plug in the tracheobronchial tree, causing potentially fatal airway obstruction. We report critical airway emergency during general anesthesia in a child with plastic bronchitis. Case presentation A 5-year-old boy was scheduled for intrapulmonary lymphatic embolization through percutaneous catheterization under general anesthesia. He underwent Fontan surgery at the age of 2 and frequently developed respiratory failure due to plastic bronchitis. After induction of general anesthesia and tracheal intubation, mechanical ventilation became difficult even with an inspiratory pressure ≥ 50 mmHg due to airway obstruction. He expectorated a large mucus plug through the tracheal tube after administration of sugammadex, naloxone, and flumazenil, and respiratory condition was stabilized thereafter. Conclusion General anesthesia for a patient with plastic bronchitis should be planned with extracorporeal membrane oxygenation or cardiopulmonary bypass stand by.
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Affiliation(s)
- Hirofumi Nakamoto
- Department of Anesthesiology, Teikyo University School of Medicine, 2-11-1 Kaga, Itabashi-ku, Tokyo, 173-8605, Japan.
| | - Satoru Kayama
- Department of Anesthesiology, Teikyo University School of Medicine, 2-11-1 Kaga, Itabashi-ku, Tokyo, 173-8605, Japan
| | - Mae Harada
- Department of Anesthesiology, Teikyo University School of Medicine, 2-11-1 Kaga, Itabashi-ku, Tokyo, 173-8605, Japan
| | - Takahiro Honjo
- Department of Anesthesiology, Teikyo University School of Medicine, 2-11-1 Kaga, Itabashi-ku, Tokyo, 173-8605, Japan
| | - Kinuko Kubota
- Department of Anesthesiology, Teikyo University School of Medicine, 2-11-1 Kaga, Itabashi-ku, Tokyo, 173-8605, Japan
| | - Shigehito Sawamura
- Department of Anesthesiology, Teikyo University School of Medicine, 2-11-1 Kaga, Itabashi-ku, Tokyo, 173-8605, Japan
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Geanacopoulos AT, Savla JJ, Pogoriler J, Piccione J, Phinizy P, DeWitt AG, Blinder JJ, Pinto E, Itkin M, Dori Y, Goldfarb SB. Bronchoscopic and histologic findings during lymphatic intervention for plastic bronchitis. Pediatr Pulmonol 2018; 53:1574-1581. [PMID: 30207430 PMCID: PMC6309194 DOI: 10.1002/ppul.24161] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/04/2018] [Accepted: 08/13/2018] [Indexed: 01/11/2023]
Abstract
BACKGROUND Percutaneous lymphatic intervention (PCL) is a promising new therapy for plastic bronchitis (PB). We characterized bronchoalveolar lavage (BAL) and cast morphology in surgically repaired congenital heart disease (CHD) patients with PB during PCL. We quantified respiratory and bronchoscopic characteristics and correlated them with post-intervention respiratory outcomes. METHODS We retrospectively reviewed patients with PB and surgically repaired CHD undergoing PCL and bronchoscopy at our institution. Pre-intervention characteristics, bronchoscopy notes, BAL cell counts, virology, and cultures were collected. A pathologist blinded to clinical data reviewed cast specimens. Respiratory outcomes were evaluated through standardized telephone questionnaire. RESULTS Sixty-two patients were included with a median follow-up of 20 months. No patients experienced airway bleeding, obstruction, or prolonged intubation related to bronchoscopy. Of BAL infectious studies, the positive results were 4 (8%) fungal, 6 (11%) bacterial, and 6 (14%) viral. Median BAL count per 100 cells for neutrophils, lymphocytes, and eosinophils were 13, 10, and 0, respectively. Of 23 bronchial casts analyzed, all contained lymphocytes, and 19 (83%) were proteinaceous, with 14 containing neutrophils and/or eosinophils. Median BAL neutrophil count was greater in patients with proteinaceous neutrophilic or eosinophilic casts compared to casts without neutrophils or lymphocytes (P = 0.030). Post-intervention, there was a significant reduction in respiratory medications and support and casting frequency. CONCLUSIONS The predominance of neutrophilic proteinaceous casts and high percentage of positive BAL infectious studies support short-term fibrinolytic and anti-infective therapies in PB in select patients. Flexible bronchoscopy enables safe assessment of cast burden. PCL effectively treats PB and reduces respiratory therapies.
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Affiliation(s)
| | - Jill J Savla
- Division of Cardiology, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Jennifer Pogoriler
- Division of Anatomic Pathology, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Joseph Piccione
- Division of Pulmonary Medicine, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Pelton Phinizy
- Division of Pulmonary Medicine, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Aaron G DeWitt
- Division of Cardiac Critical Care Medicine, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Joshua J Blinder
- Division of Cardiac Critical Care Medicine, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Erin Pinto
- Division of Cardiology, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Maxim Itkin
- Division of Interventional Radiology, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Yoav Dori
- Division of Cardiology, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Samuel B Goldfarb
- Division of Pulmonary Medicine, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
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13
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Abstract
PURPOSE OF REVIEW The essential role of the lymphatic system in fluid homeostasis, nutrient transport, and immune trafficking is well recognized; however, there is limited understanding of the mechanisms that regulate lymphatic function, particularly in the setting of critical illness. The lymphatics likely affect disease severity and progression in every condition, from severe systemic inflammatory states to respiratory failure. Here, we review structural and functional disorders of the lymphatic system, both congenital and acquired, as they relate to care of the pediatric patient in the intensive care setting, including novel areas of research into medical and procedural therapeutic interventions. RECENT FINDINGS The mainstay of current therapies for congenital and acquired lymphatic abnormalities has involved nonspecific medical management or surgical procedures to obstruct or divert lymphatic flow. With the development of dynamic contrast-enhanced magnetic resonance lymphangiography, image-directed percutaneous intervention may largely replace surgery. Because of new insights into the mechanisms that regulate lymphatic biology, pharmacologic inhibitors of mTOR and leukotriene B4 signaling are each in Phase II clinical trials to treat abnormal lymphatic structure and function, respectively. SUMMARY As our understanding of normal lymphatic biology continues to advance, we will be able to develop novel strategies to support and augment lymphatic function during critical illness and through convalescence.
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The Long-Term Management of Children and Adults with a Fontan Circulation: A Systematic Review and Survey of Current Practice in Australia and New Zealand. Pediatr Cardiol 2017; 38:56-69. [PMID: 27787594 DOI: 10.1007/s00246-016-1484-6] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/03/2016] [Accepted: 10/15/2016] [Indexed: 01/28/2023]
Abstract
Although long-term survival is now the norm, Fontan patients face significant morbidity and premature mortality. Wide variation exists in long-term Fontan management. With an aim of improving their long-term management, we conducted a systematic review to identify best available evidence and gaps in knowledge for future research focus. We also surveyed cardiologists in Australia and New Zealand managing Fontan patients, to determine the alignment of current local practice with best available evidence. A systematic review was conducted using strict search criteria (PRISMA guidelines), pertaining to long-term Fontan management. All adult congenital and paediatric cardiologists registered with The Australia and New Zealand Fontan Registry were invited to respond to an online survey. Reasonable quality evidence exists for non-inferiority of aspirin over warfarin for thromboprophylaxis in standard-risk Fontan patients. No strong evidence is currently available for the routine use of ACE inhibitors, beta blockers or pulmonary vasodilators. Little evidence exists regarding optimal arrhythmia treatment, exercise restriction/prescription, routine fenestration closure, elective Fontan conversion and screening/management of liver abnormalities. Although pregnancy is generally well tolerated, there are high rates of miscarriage and premature delivery. Thirty-nine out of 78 (50 %) cardiologists responded to the survey. Heterogeneity in response was demonstrated with regard to long-term anti-coagulation, other medication use, fenestration closure and pregnancy and contraception counselling. Substantial gaps in our knowledge remain with regard to the long-term management of Fontan patients. This is reflected in the survey of cardiologists managing these patients. We have identified a number of key areas for future research.
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Charlagorla P, Breinholt JP. Creating a Fontan fenestration in a child with dextrocardia and interrupted inferior vena cava. Ann Pediatr Cardiol 2016; 9:179-82. [PMID: 27212858 PMCID: PMC4867808 DOI: 10.4103/0974-2069.173547] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Plastic bronchitis is a rare life-threatening complication of the Fontan operation. Transcatheter Fontan fenestration can ameliorate symptoms by decompressing elevated venous pressures. Transcatheter creation of a fenestration can be technically challenging in cases with complex venous anatomy. We report a case of a 5-year-old boy with heterotaxy, dextrocardia with unbalanced atrioventricular canal (AVC), atrial and visceral situs inversus, left-sided superior vena cava (SVC), and left-sided interrupted inferior vena cava (IVC) with azygos continuation. With few modifications to the equipment, a successful Fontan fenestration with stent implantation was performed via transjugular approach. At 2-year follow-up, his symptoms of plastic bronchitis improved significantly.
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Affiliation(s)
- Pradeepkumar Charlagorla
- Department of Pediatrics, Division of Cardiology, Riley Hospital for Children, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - John P Breinholt
- Department of Pediatrics, Division of Cardiology, Riley Hospital for Children, Indiana University School of Medicine, Indianapolis, Indiana, USA
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16
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Dori Y, Keller MS, Rome JJ, Gillespie MJ, Glatz AC, Dodds K, Goldberg DJ, Goldfarb S, Rychik J, Itkin M. Percutaneous Lymphatic Embolization of Abnormal Pulmonary Lymphatic Flow as Treatment of Plastic Bronchitis in Patients With Congenital Heart Disease. Circulation 2016; 133:1160-70. [PMID: 26864093 DOI: 10.1161/circulationaha.115.019710] [Citation(s) in RCA: 188] [Impact Index Per Article: 23.5] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/29/2015] [Accepted: 02/01/2016] [Indexed: 11/16/2022]
Abstract
BACKGROUND Plastic bronchitis is a potentially fatal disorder occurring in children with single-ventricle physiology, and other diseases, as well, such as asthma. In this study, we report findings of abnormal pulmonary lymphatic flow, demonstrated by MRI lymphatic imaging, in patients with plastic bronchitis and percutaneous lymphatic intervention as a treatment for these patients. METHODS AND RESULTS This is a retrospective case series of 18 patients with surgically corrected congenital heart disease and plastic bronchitis who presented for lymphatic imaging and intervention. Lymphatic imaging included heavy T2-weighted MRI and dynamic contrast-enhanced magnetic resonance lymphangiogram. All patients underwent bilateral intranodal lymphangiogram, and most patients underwent percutaneous lymphatic intervention. In 16 of 18 patients, MRI or lymphangiogram or both demonstrated retrograde lymphatic flow from the thoracic duct toward lung parenchyma. Intranodal lymphangiogram and thoracic duct catheterization was successful in all patients. Seventeen of 18 patients underwent either lymphatic embolization procedures or thoracic duct stenting with covered stents to exclude retrograde flow into the lungs. One of the 2 patients who did not have retrograde lymphatic flow did not undergo a lymphatic interventional procedure. A total of 15 of 17(88%) patients who underwent an intervention had significant symptomatic improvement at a median follow-up of 315 days (range, 45-770 days). The most common complication observed was nonspecific transient abdominal pain and transient hypotension. CONCLUSIONS In this study, we demonstrated abnormal pulmonary lymphatic perfusion in most patients with plastic bronchitis. Interruption of the lymphatic flow resulted in significant improvement of symptoms in these patients and, in some cases, at least temporary resolution of cast formation.
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Affiliation(s)
- Yoav Dori
- From Division of Cardiology, Division of Pulmonary Medicine, and Department of Radiology, The Children's Hospital of Philadelphia, PA (Y.D., M.S.K., J.J.R., M.J.G., A.C.G., K.D., D.J.G., S.G., J.R.); and Division of Interventional Radiology, Hospital of the University of Pennsylvania, Philadelphia (M.I.).
| | - Marc S Keller
- From Division of Cardiology, Division of Pulmonary Medicine, and Department of Radiology, The Children's Hospital of Philadelphia, PA (Y.D., M.S.K., J.J.R., M.J.G., A.C.G., K.D., D.J.G., S.G., J.R.); and Division of Interventional Radiology, Hospital of the University of Pennsylvania, Philadelphia (M.I.)
| | - Jonathan J Rome
- From Division of Cardiology, Division of Pulmonary Medicine, and Department of Radiology, The Children's Hospital of Philadelphia, PA (Y.D., M.S.K., J.J.R., M.J.G., A.C.G., K.D., D.J.G., S.G., J.R.); and Division of Interventional Radiology, Hospital of the University of Pennsylvania, Philadelphia (M.I.)
| | - Matthew J Gillespie
- From Division of Cardiology, Division of Pulmonary Medicine, and Department of Radiology, The Children's Hospital of Philadelphia, PA (Y.D., M.S.K., J.J.R., M.J.G., A.C.G., K.D., D.J.G., S.G., J.R.); and Division of Interventional Radiology, Hospital of the University of Pennsylvania, Philadelphia (M.I.)
| | - Andrew C Glatz
- From Division of Cardiology, Division of Pulmonary Medicine, and Department of Radiology, The Children's Hospital of Philadelphia, PA (Y.D., M.S.K., J.J.R., M.J.G., A.C.G., K.D., D.J.G., S.G., J.R.); and Division of Interventional Radiology, Hospital of the University of Pennsylvania, Philadelphia (M.I.)
| | - Kathryn Dodds
- From Division of Cardiology, Division of Pulmonary Medicine, and Department of Radiology, The Children's Hospital of Philadelphia, PA (Y.D., M.S.K., J.J.R., M.J.G., A.C.G., K.D., D.J.G., S.G., J.R.); and Division of Interventional Radiology, Hospital of the University of Pennsylvania, Philadelphia (M.I.)
| | - David J Goldberg
- From Division of Cardiology, Division of Pulmonary Medicine, and Department of Radiology, The Children's Hospital of Philadelphia, PA (Y.D., M.S.K., J.J.R., M.J.G., A.C.G., K.D., D.J.G., S.G., J.R.); and Division of Interventional Radiology, Hospital of the University of Pennsylvania, Philadelphia (M.I.)
| | - Samuel Goldfarb
- From Division of Cardiology, Division of Pulmonary Medicine, and Department of Radiology, The Children's Hospital of Philadelphia, PA (Y.D., M.S.K., J.J.R., M.J.G., A.C.G., K.D., D.J.G., S.G., J.R.); and Division of Interventional Radiology, Hospital of the University of Pennsylvania, Philadelphia (M.I.)
| | - Jack Rychik
- From Division of Cardiology, Division of Pulmonary Medicine, and Department of Radiology, The Children's Hospital of Philadelphia, PA (Y.D., M.S.K., J.J.R., M.J.G., A.C.G., K.D., D.J.G., S.G., J.R.); and Division of Interventional Radiology, Hospital of the University of Pennsylvania, Philadelphia (M.I.)
| | - Maxim Itkin
- From Division of Cardiology, Division of Pulmonary Medicine, and Department of Radiology, The Children's Hospital of Philadelphia, PA (Y.D., M.S.K., J.J.R., M.J.G., A.C.G., K.D., D.J.G., S.G., J.R.); and Division of Interventional Radiology, Hospital of the University of Pennsylvania, Philadelphia (M.I.)
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Nogan SJ, Cass ND, Wiet GJ, Ruda JM. Plastic bronchitis arising from solitary influenza B infection: A report of two cases in children. Int J Pediatr Otorhinolaryngol 2015; 79:1140-4. [PMID: 25957780 DOI: 10.1016/j.ijporl.2015.03.028] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/28/2015] [Revised: 03/22/2015] [Accepted: 03/28/2015] [Indexed: 11/25/2022]
Abstract
Plastic bronchitis (PB) is characterized by thick, inspissated, tracheobronchial casts. It is classified as either inflammatory or acellular based on the content of the endobronchial casts. PB has never been reported in a healthy child with solitary influenza B infection. This study is a retrospective case series of two children who presented to our institution in acute respiratory distress. Emergency rigid bronchoscopy was performed with extraction of casts from the L mainstem bronchus in both patients. Influenza B was the only isolate identified. In otherwise healthy children with respiratory distress, influenza B-mediated inflammatory PB must be considered in the differential diagnosis.
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Affiliation(s)
- Stephen J Nogan
- Department of Otolaryngology-Head & Neck Surgery, Ohio State University-Wexner Medical Center, Columbus, OH 43212, USA.
| | - Nathan D Cass
- Department of Otolaryngology, University of Colorado Anschutz Medical Campus, Aurora, CO 80045, USA.
| | - Gregory J Wiet
- Department of Otolaryngology-Head & Neck Surgery, Ohio State University-Wexner Medical Center, Columbus, OH 43212, USA; Department of Pediatric Otolaryngology, Nationwide Children's Hospital, Columbus, OH 43205, USA.
| | - James M Ruda
- Department of Otolaryngology-Head & Neck Surgery, Ohio State University-Wexner Medical Center, Columbus, OH 43212, USA; Department of Pediatric Otolaryngology, Nationwide Children's Hospital, Columbus, OH 43205, USA.
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Casadonte JR, Wax DF, Gossett JG. Extracardiac Fontan fenestration using the SafeSept transseptal guidewire and snare-controlled diabolo-shaped covered-stent placement. Catheter Cardiovasc Interv 2015; 87:426-31. [DOI: 10.1002/ccd.26081] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/12/2015] [Accepted: 05/23/2015] [Indexed: 11/09/2022]
Affiliation(s)
- Joseph R. Casadonte
- Division of Pediatric Cardiology; Ann & Robert H. Lurie Children's Hospital of Chicago; Northwestern University's Feinberg School of Medicine; Chicago Illinois
| | - David F. Wax
- Division of Pediatric Cardiology; Ann & Robert H. Lurie Children's Hospital of Chicago; Northwestern University's Feinberg School of Medicine; Chicago Illinois
| | - Jeffrey G. Gossett
- Division of Pediatric Cardiology; Ann & Robert H. Lurie Children's Hospital of Chicago; Northwestern University's Feinberg School of Medicine; Chicago Illinois
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Zhang J, Kang X. Plastic bronchitis associated with influenza virus infection in children: a report on 14 cases. Int J Pediatr Otorhinolaryngol 2015; 79:481-6. [PMID: 25639552 DOI: 10.1016/j.ijporl.2015.01.002] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/30/2014] [Revised: 12/29/2014] [Accepted: 01/08/2015] [Indexed: 10/24/2022]
Abstract
BACKGROUND Plastic bronchitis (PB) is a rare disease characterized by formation of bronchial casts. It is usually associated with congenital heart disease, sickle cell disease, lymphoma, and lung diseases such as asthma and pneumonia. OBJECTIVES To report 14 cases of PB with influenza A or influenza B infection. METHODS We analyzed the clinical manifestations, bronchoscopic and histologic findings, clinical courses, and outcomes. RESULTS These cases indicate that PB is a life-threatening complication of severe influenza. Plastic bronchitis should be considered in the diagnosis of children with acute respiratory distress such as lung atelectasis accompanied by influenza. CONCLUSIONS Diagnosis should be made by bronchial endoscopy and histopathology, and bronchial casts removed as early as possible.
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Affiliation(s)
- Jianhui Zhang
- Department of Pediatric Intensive Care Unit, Guangzhou Women and Children's Medical Center, 9 Jinsui Road, Guangzhou, China.
| | - Xiaolei Kang
- Department of Pediatric Intensive Care Unit, Guangzhou Women and Children's Medical Center, 9 Jinsui Road, Guangzhou, China
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20
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Houin PR, Veress LA, Rancourt RC, Hendry-Hofer TB, Loader JE, Rioux JS, Garlick RB, White CW. Intratracheal heparin improves plastic bronchitis due to sulfur mustard analog. Pediatr Pulmonol 2015; 50:118-26. [PMID: 24692161 PMCID: PMC4182164 DOI: 10.1002/ppul.23043] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/12/2013] [Revised: 02/04/2014] [Accepted: 03/04/2014] [Indexed: 11/11/2022]
Abstract
BACKGROUND Inhalation of sulfur mustard (SM) and SM analog, 2-chloroethyl ethyl sulfide (CEES), cause fibrinous cast formation that occludes the conducting airways, similar to children with Fontan physiology-induced plastic bronchitis. These airway casts cause significant mortality and morbidity, including hypoxemia and respiratory distress. Our hypothesis was that intratracheal heparin, a highly cost effective and easily preserved rescue therapy, could reverse morbidity and mortality induced by bronchial cast formation. METHODS Sprague-Dawley rats were exposed to 7.5% CEES via nose-only aerosol inhalation to produce extensive cast formation and mortality. The rats were distributed into three groups: non-treated, phosphate-buffered saline (PBS)-treated, and heparin-treated groups. Morbidity was assessed with oxygen saturations and clinical distress. Blood and bronchoalveolar lavage fluid (BALF) were obtained for analysis, and lungs were fixed for airway microdissection to quantify the extent of airway cast formation. RESULTS Heparin, given intratracheally, improved survival (100%) when compared to non-treated (75%) and PBS-treated (90%) controls. Heparin-treated rats also had improved oxygen saturations, clinical distress and airway cast scores. Heparin-treated rats had increased thrombin clotting times, factor Xa inhibition and activated partial thromboplastin times, indicating systemic absorption of heparin. There were also increased red blood cells (RBCs) in the BALF in 2/6 heparin-treated rats compared to PBS-treated control rats. CONCLUSIONS Intratracheal heparin 1 hr after CEES inhalation improved survival, oxygenation, airway obstruction, and clinical distress. There was systemic absorption of heparin in rats treated intratracheally. Some rats had increased RBCs in BALF, suggesting a potential for intrapulmonary bleeding if used chronically after SM inhalation.
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Affiliation(s)
- Paul R Houin
- Department of Pediatrics, University of Colorado Health Sciences Center, Aurora, Colorado
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Avitabile CM, Goldberg DJ, Dodds K, Dori Y, Ravishankar C, Rychik J. A multifaceted approach to the management of plastic bronchitis after cavopulmonary palliation. Ann Thorac Surg 2014; 98:634-40. [PMID: 24841545 DOI: 10.1016/j.athoracsur.2014.04.015] [Citation(s) in RCA: 48] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/06/2014] [Revised: 03/23/2014] [Accepted: 04/01/2014] [Indexed: 11/26/2022]
Abstract
BACKGROUND Plastic bronchitis is a rare, potentially life-threatening complication after Fontan operation. Hemodynamic alterations (elevated central venous pressure and low cardiac output) likely contribute to the formation of tracheobronchial casts composed of inflammatory debris, mucin, and fibrin. Pathologic studies of cast composition support medical treatment with fibrinolytics such as inhaled tissue plasminogen activator (t-PA). METHODS This was a retrospective case series of medical, surgical, and catheter-based treatment of patients with plastic bronchitis after cavopulmonary palliation. RESULTS Included were 14 patients (86% male, 93% white). Median age at Fontan operation was 2.7 years (range, 1.2 to 4.1 years), with median interval to plastic bronchitis presentation of 1.5 years (range, 9 days to 15.4 years). Cast composition was available for 11 patients (79%) and included fibrin deposits in 7. All patients were treated with pulmonary vasodilators, and 13 (93%) were treated with inhaled t-PA. Hemodynamically significant lesions in the Fontan pathway were addressed by catheter-based (n=9) and surgical (n=3) interventions. Three patients (21%) underwent heart transplantation. Median follow-up was 2.7 years (range, 0.6 to 8.7 years). Symptoms improved, such that 6 of 13 patients (46%) were weaned off t-PA. Rare or episodic casts are successfully managed with outpatient t-PA in most of the other patients. Of the 3 patients who underwent heart transplant, 2 are asymptomatic and 1 has recurrent casts in the setting of elevated filling pressures and rejection. CONCLUSIONS A systematic step-wise algorithm that includes optimization of hemodynamics, aggressive pulmonary vasodilation, and inhaled t-PA is an effective treatment strategy for patients with plastic bronchitis after cavopulmonary connection.
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Affiliation(s)
- Catherine M Avitabile
- Division of Cardiology, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania.
| | - David J Goldberg
- Division of Cardiology, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania; Department of Pediatrics, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania
| | - Kathryn Dodds
- Division of Cardiology, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Yoav Dori
- Division of Cardiology, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania; Department of Pediatrics, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania
| | - Chitra Ravishankar
- Division of Cardiology, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania; Department of Pediatrics, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania
| | - Jack Rychik
- Division of Cardiology, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania; Department of Pediatrics, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania
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Schumacher KR, Singh TP, Kuebler J, Aprile K, O'Brien M, Blume ED. Risk factors and outcome of Fontan-associated plastic bronchitis: a case-control study. J Am Heart Assoc 2014; 3:e000865. [PMID: 24755155 PMCID: PMC4187467 DOI: 10.1161/jaha.114.000865] [Citation(s) in RCA: 45] [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] [Indexed: 01/01/2023]
Abstract
Background The onset of plastic bronchitis (PB) can be debilitating in survivors of Fontan surgery. The rarity of this complication makes designing studies to understand risk factors for PB challenging. This 2‐center case‐control study aimed to describe patient outcomes and to assess the association of antecedent patient factors with PB development. Methods and Results Using center registries, PB patients (n=25) were matched 1:2 to non‐PB Fontans (n=43) by date of Fontan surgery and center. The groups were compared for baseline characteristics. Association of patient characteristics with PB was assessed using logistic regression and of potential risk factors with onset of PB using time‐to‐event analyses. The median time from Fontan to PB diagnosis was 2.5 years. Overall, 12/25 PB patients died or underwent heart transplant; the median transplant‐free survival was 8.3 years after diagnosis. Factors associated with developing PB included post‐surgical chylothorax (44% PB versus 10% control; odds ratio [OR] 7.3; P=0.003), chest tube (CT) duration at stage 2 (P=0.04) and Fontan (P=0.004), and postoperative ascites (36% PB versus 12% control; OR 4.2; P=0.003). CT drainage >13 days at Fontan was associated with earlier PB onset (P=0.04). Early‐onset PB was associated with an increased risk of death (OR 5.0; P=0.002). Conclusions PB is a life‐threatening disorder. A longer duration of CT drainage after surgery, chylothorax, and development of ascites are all associated with developing PB. Understanding the pathophysiology of peri‐operative complications in individual patients and using targeted interventions may delay the onset of the PB phenotype.
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End-organ consequences of the Fontan operation: liver fibrosis, protein-losing enteropathy and plastic bronchitis. Cardiol Young 2013; 23:831-40. [PMID: 24401255 DOI: 10.1017/s1047951113001650] [Citation(s) in RCA: 73] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
Abstract
The Fontan operation, although part of a life-saving surgical strategy, manifests a variety of end-organ complications and unique morbidities that are being recognised with increasing frequency as patients survive into their second and third decades of life and beyond. Liver fibrosis, protein-losing enteropathy and plastic bronchitis are consequences of a complex physiology involving circulatory insufficiency, inflammation and lymphatic derangement. These conditions are manifest in a chronic, indolent state. Management strategies are emerging, which shed some light on the origins of these complications. A better characterisation of the end-organ consequences of the Fontan circulation is necessary, which can then allow for development of specific methods for treatment. Ideally, the goal is to establish systematic strategies that might reduce or eliminate the development of these potentially life-threatening challenges.
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Mondésert B, Marcotte F, Mongeon FP, Dore A, Mercier LA, Ibrahim R, Asgar A, Miro J, Poirier N, Khairy P. Fontan Circulation: Success or Failure? Can J Cardiol 2013; 29:811-20. [DOI: 10.1016/j.cjca.2012.12.009] [Citation(s) in RCA: 56] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2012] [Revised: 12/10/2012] [Accepted: 12/10/2012] [Indexed: 12/29/2022] Open
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Veress LA, Hendry-Hofer TB, Loader JE, Rioux JS, Garlick RB, White CW. Tissue plasminogen activator prevents mortality from sulfur mustard analog-induced airway obstruction. Am J Respir Cell Mol Biol 2013; 48:439-47. [PMID: 23258228 DOI: 10.1165/rcmb.2012-0177oc] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
Sulfur mustard (SM) inhalation causes the rare but life-threatening disorder of plastic bronchitis, characterized by bronchial cast formation, resulting in severe airway obstruction that can lead to respiratory failure and death. Mortality in those requiring intubation is greater than 80%. To date, no antidote exists for SM toxicity. In addition, therapies for plastic bronchitis are solely anecdotal, due to lack of systematic research available to assess drug efficacy in improving mortality and/or morbidity. Adult rats exposed to SM analog were treated with intratracheal tissue plasminogen activator (tPA) (0.15-0.7 mg/kg, 5.5 and 6.5 h), compared with controls (no treatment, isoflurane, and placebo). Respiratory distress and pulse oximetry were assessed (for 12 or 48 h), and arterial blood gases were obtained at study termination (12 h). Microdissection of fixed lungs was done to assess airway obstruction by casts. Optimal intratracheal tPA treatment (0.7 mg/kg) completely eliminated mortality (0% at 48 h), and greatly improved morbidity in this nearly uniformly fatal disease model (90-100% mortality at 48 h). tPA normalized plastic bronchitis-associated hypoxemia, hypercarbia, and lactic acidosis, and improved respiratory distress (i.e., clinical scores) while decreasing airway fibrin casts. Intratracheal tPA diminished airway-obstructive fibrin-containing casts while improving clinical respiratory distress, pulmonary gas exchange, tissue oxygenation, and oxygen utilization in our model of severe chemically induced plastic bronchitis. Most importantly, mortality, which was associated with hypoxemia and clinical respiratory distress, was eliminated.
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Affiliation(s)
- Livia A Veress
- Department of Pediatrics, University of Colorado Health Sciences Center, Denver, CO, USA.
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Ezmigna DR, Morgan WJ, Witte MH, Brown MA. Lymphoscintigraphy in plastic bronchitis, a pediatric case report. Pediatr Pulmonol 2013; 48:515-8. [PMID: 22949350 DOI: 10.1002/ppul.22673] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/01/2012] [Accepted: 06/18/2012] [Indexed: 11/07/2022]
Abstract
Plastic bronchitis (PB) is an uncommon, potentially fatal disease, marked by endobronchial cast formation causing variable degrees of respiratory distress. Primary and secondary pulmonary lymphatic abnormalities have been identified among the underlying mechanisms of cast formation. We present a case of PB where lymphoscintigraphy demonstrated the underlying lymphatic defect. A 6-year-old Hispanic male with congenital heart disease (CHD; post-Fontan) presented with recurrent pneumonia, respiratory distress. Bronchoscopy showed inflamed hypervascular mucosa and thick mucus plugs; no casts were seen. Later, PB was diagnosed after the patient expectorated a bronchial cast. Cast analysis showed lymphocytic aggregates with mucin and fibrin. Lymphoscintigraphy revealed abnormal lymphatic collaterals and retrograde trace reflux into the superior mediastinum, a picture consistent with thoracic duct lymph leakage into the tracheobronchial tree. The pathogenesis of PB is not fully understood, especially in patients with CHD. Chyle in bronchial casts suggests abnormal lymphatic flow. Reports of lymph flow abnormalities, especially endobronchial lymph leakage in CHD are limited. Lymphoscintigraphy in our case demonstrated clear evidence of retrograde lymph reflux and leakage into the bronchial tree. The case presented suggests that in some patients following Fontan surgery, high intrathoracic lymphatic pressure and retrograde lymph flow may contribute to recurrent cast formation. Finding the underlying lymphatic abnormality helps in specific case management. Lymphoscintigraphy is a safer and easier method than lymphangiography. Surgical lymphatic-venous shunting may be possible in select cases.
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Affiliation(s)
- Dima R Ezmigna
- Department of Pediatrics, University of Arizona, Tucson, Arizona 85724, USA.
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Michielon G, Carotti A, Pongiglione G, Cogo P, Parisi F. Orthotopic heart transplantation in patients with univentricular physiology. Curr Cardiol Rev 2013; 7:85-91. [PMID: 22548031 PMCID: PMC3197093 DOI: 10.2174/157340311797484259] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/01/2011] [Revised: 04/28/2011] [Accepted: 06/24/2011] [Indexed: 11/23/2022] Open
Abstract
Parallel advancements in surgical technique, preoperative and postoperative care, as well as a better understanding of physiology in patients with duct-dependent pulmonary or systemic circulation and a functional single ventricle, have led to superb results in staged palliation of most complex congenital heart disease (CHD) [1]. The Fontan procedure and its technical modifications have resulted in markedly improved outcomes of patients with single ventricle anatomy [2,3,4]. The improved early survival has led to an exponential increase of the proportion of Fontan patients surviving long into adolescence and young adulthood [5]. Improved early and late survival has not yet abolished late mortality secondary to myocardial failure, therefore increasing the referrals for cardiac transplantation [6]. Interstage attrition [7] is moreover expected in staged palliation towards completion of a Fontan-type circulation, while Fontan failure represents a growing indication for heart transplantation [8]. Heart transplantation has therefore become the potential “fourth stage” [9] or a possible alternative to a high-risk Fontan operation [10] in a strategy of staged palliation for single ventricle physiology. Heart transplant barely accounts for 16% of pediatric solid organ transplants [11]. The thirteenth official pediatric heart transplantation report- 2010 [11] indicates that pediatric recipients received only 12.5% of the total reported heart transplants worldwide. Congenital heart disease is not only the most common recipient diagnosis, but also the most powerful predictor of 1-year mortality after OHT. Results of orthotopic heart transplantations (OHT) for failing single ventricle physiology are mixed. Some authors advocate excellent early and mid-term survival after OHT for failing Fontan [9], while others suggest that rescue-OHT after failing Fontan seems unwarranted [10]. Moreover, OHT outcome appears to be different according to the surgical staging towards the Fontan operation and surgical technique of Fontan completion [12]. The focus of this report is a complete review of the recent literature on OHT for failing single ventricles, outlining the clinical issues affecting Fontan failure, OHT listing and OHT outcome. These data are endorsed reporting our experience with OHT for failing single ventricle physiology in recent years.
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Affiliation(s)
- Guido Michielon
- Dipartimento Medico-Chirurgico di Cardiologia Pediatrica Ospedale Pediatrico Bambino Gesù Roma, Italy
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Plastic Bronchitis After Extracardiac Fontan Operation. Ann Thorac Surg 2012; 94:860-4. [DOI: 10.1016/j.athoracsur.2012.04.043] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/14/2012] [Revised: 04/10/2012] [Accepted: 04/12/2012] [Indexed: 11/17/2022]
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Kobayashi D, Turner DR, Forbes TJ. Transhepatic approach to create stent fenestration in the extracardiac fontan conduit in a child with dextrocardia and interrupted inferior vena cava with azygos continuation. Catheter Cardiovasc Interv 2012; 81:843-8. [DOI: 10.1002/ccd.24551] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/15/2011] [Accepted: 06/30/2012] [Indexed: 11/06/2022]
Affiliation(s)
- Daisuke Kobayashi
- Division of Pediatric Cardiology; Children's Hospital of Michigan; Carman and Ann Adams Department of Pediatrics; Wayne State University School of Medicine; Detroit; Michigan
| | - Daniel R. Turner
- Division of Pediatric Cardiology; Children's Hospital of Michigan; Carman and Ann Adams Department of Pediatrics; Wayne State University School of Medicine; Detroit; Michigan
| | - Thomas J. Forbes
- Division of Pediatric Cardiology; Children's Hospital of Michigan; Carman and Ann Adams Department of Pediatrics; Wayne State University School of Medicine; Detroit; Michigan
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LaRue M, Gossett JG, Stewart RD, Backer CL, Mavroudis C, Jacobs ML. Plastic Bronchitis in Patients With Fontan Physiology: Review of the Literature and Preliminary Experience With Fontan Conversion and Cardiac Transplantation. World J Pediatr Congenit Heart Surg 2012; 3:364-72. [DOI: 10.1177/2150135112438107] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Affiliation(s)
- Madeleine LaRue
- Case Western Reserve University School of Medicine, Cleveland, OH, USA
| | - Jeffrey G. Gossett
- Division of Pediatric Cardiology, Children’s Memorial Hospital, Chicago, IL, USA
| | - Robert D. Stewart
- Department of Congenital Heart Surgery, Cleveland Clinic Children’s Hospital, Center for Pediatric and Adult Congenital Heart Disease, Cleveland, OH, USA
| | - Carl L. Backer
- Department of Surgery, Division of Cardiovascular-Thoracic Surgery, Children’s Memorial Hospital, Chicago, IL, USA
| | - Constantine Mavroudis
- Congenital Heart Institute, Walt Disney Pavilion, Florida Hospital for Children, Orlando, FL, USA
| | - Marshall L. Jacobs
- Department of Congenital Heart Surgery, Cleveland Clinic Children’s Hospital, Center for Pediatric and Adult Congenital Heart Disease, Cleveland, OH, USA
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Schmitz LM, Rihawi M. Plastic bronchitis: a complication of myocardial revascularization. Am J Respir Crit Care Med 2012; 185:896-7. [PMID: 22505758 DOI: 10.1164/ajrccm.185.8.896a] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
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Do P, Randhawa I, Chin T, Parsapour K, Nussbaum E. Successful management of plastic bronchitis in a child post Fontan: case report and literature review. Lung 2012; 190:463-8. [PMID: 22430124 DOI: 10.1007/s00408-012-9384-x] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2011] [Accepted: 03/02/2012] [Indexed: 11/27/2022]
Abstract
PURPOSE Plastic bronchitis is the occlusion of the major bronchial airways by a firm, gelatinous mucoid cast. It is a rare condition, which while classically described in asthma and sickle cell disease has greater mortality in patients with congenital heart disease. The management of this disease is obscure given the lack of clinical data regarding treatment therapies. METHODS We describe a case of an 11-year-old female status after Fontan surgery who presented with respiratory distress secondary to atelectasis of the right lung. RESULTS A bronchoscopy was performed demonstrating an obstructing bronchial cast with successful extraction. The plastic bronchitis continued to recur and she was placed on multiple inhaled mucolytics as well as inhaled tissue plasminogen activator with temporary resolution. Further evaluation of the etiology of her casts revealed that she had elevated pulmonary arterial pressures. Repeated bronchoscopic removal of the casts was utilized as well as continuation of the aggressive airway clearance. Ultimately fenestration of her Fontan was performed along with treatment of pulmonary vasodilators sildenafil and bosentan. Although there was improvement of the cast formation, her airway clearance could only be weaned to four times a day therapy with which she was discharged home after a 3-month hospitalization. She continues to remain on this therapy and has not required hospitalization since the initial incident over 1 year ago. CONCLUSIONS Plastic bronchitis in a patient with Fontan physiology presents a treatment dilemma that may require comprehensive therapy in severe cases such as described.
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Affiliation(s)
- Paul Do
- Miller Children's Hospital, 2801 Atlantic Ave. Ground Floor, Long Beach, CA, USA.
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Feinstein JA, Benson DW, Dubin AM, Cohen MS, Maxey DM, Mahle WT, Pahl E, Villafañe J, Bhatt AB, Peng LF, Johnson BA, Marsden AL, Daniels CJ, Rudd NA, Caldarone CA, Mussatto KA, Morales DL, Ivy DD, Gaynor JW, Tweddell JS, Deal BJ, Furck AK, Rosenthal GL, Ohye RG, Ghanayem NS, Cheatham JP, Tworetzky W, Martin GR. Hypoplastic left heart syndrome: current considerations and expectations. J Am Coll Cardiol 2012; 59:S1-42. [PMID: 22192720 PMCID: PMC6110391 DOI: 10.1016/j.jacc.2011.09.022] [Citation(s) in RCA: 349] [Impact Index Per Article: 29.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/19/2011] [Revised: 09/06/2011] [Accepted: 09/20/2011] [Indexed: 01/25/2023]
Abstract
In the recent era, no congenital heart defect has undergone a more dramatic change in diagnostic approach, management, and outcomes than hypoplastic left heart syndrome (HLHS). During this time, survival to the age of 5 years (including Fontan) has ranged from 50% to 69%, but current expectations are that 70% of newborns born today with HLHS may reach adulthood. Although the 3-stage treatment approach to HLHS is now well founded, there is significant variation among centers. In this white paper, we present the current state of the art in our understanding and treatment of HLHS during the stages of care: 1) pre-Stage I: fetal and neonatal assessment and management; 2) Stage I: perioperative care, interstage monitoring, and management strategies; 3) Stage II: surgeries; 4) Stage III: Fontan surgery; and 5) long-term follow-up. Issues surrounding the genetics of HLHS, developmental outcomes, and quality of life are addressed in addition to the many other considerations for caring for this group of complex patients.
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Affiliation(s)
- Jeffrey A Feinstein
- Department of Pediatrics, Stanford University School of Medicine, Lucile Salter Packard Children's Hospital, Palo Alto, California 94304, USA.
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Davies RR, Chen JM, Mosca RS. The Fontan procedure: evolution in technique; attendant imperfections and transplantation for "failure". Semin Thorac Cardiovasc Surg Pediatr Card Surg Annu 2011; 14:55-66. [PMID: 21444050 DOI: 10.1053/j.pcsu.2011.01.014] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/30/2023]
Abstract
Application of the Fontan procedure has allowed the survival of many patients with univentricular cardiac lesions into mid adulthood. Despite its ingenious design, implementation, and thoughtful modifications, its attendant hemodynamic perturbations persist; central venous hypertension and reduced cardiac output. These aberrations in physiology have led to pernicious changes in organ function. A more thorough understanding of these derangements and attempts at Fontan revision have temporized, yet the morbidity and patient attrition persists. Mechanical assistance to normalize the circulation is being investigated and holds some promise. At present, cardiac transplantation remains the last stage of palliation for many.
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Affiliation(s)
- Ryan R Davies
- Department of Cardiothoracic Surgery, Stanford University/Lucille Packard Children's Hospital, Palo Alto, CA, USA
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Abstract
The Fontan operation, originally described for the surgical management of tricuspid atresia, is now the final surgery in the strategy of staged palliation for a number of different forms of congenital cardiac disease with a functionally univentricular heart. Despite the improved technical outcomes of the Fontan operation, staged palliation does not recreate a normal physiology. Without a pumping chamber delivering blood to the lungs, the cardiovascular system is less efficient; cardiac output is generally diminished, and the systemic venous pressure is increased. As a result, patients with "Fontan physiology" may face a number of rare but potentially life-threatening complications including hepatic dysfunction, abnormalities of coagulation, protein-losing enteropathy, and plastic bronchitis. Despite the staged palliation resulting in remarkable survival, the possible complications for this group of patients are complex, involve multiple organ systems, and can be life threatening. Identifying the mechanisms associated with each of the rare complications, and developing strategies to treat them, requires the work of many people at many institutions. Continued collaboration between sub-specialists and between institutions will be required to optimise the care for this group of survivors with functionally univentricular hearts.
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Chin AJ, Whitehead KK, Watrous RL. Insights After 40 Years of the Fontan Operation. World J Pediatr Congenit Heart Surg 2010; 1:328-43. [DOI: 10.1177/2150135110379623] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
Fontan’s visionary operation and its modifications over the ensuing decades have re-established nonturbulent flow and substantially reduced cyanosis for patients with severe hypoplasia of one ventricle. However, a long list of largely unexpected sequelae has emerged over the last 40 years. Although it is not difficult to understand how care providers could become discouraged, a number of myths have arisen, which we will attempt to dispel with real-world counterexamples as well as with lessons learned from other disciplines: evolutionary, developmental, and computational biology. We argue that distinctive biochemical abnormalities pointing to dysfunction in multiple organs, including the largest organ system in the body, the endothelium, occur long before grossly observable changes in cardiac imaging can be recognized. With a rational redesign of both our surveillance scheme and our wellness strategies, we hope that Fontan survivors and their families, as well as physicians, nurses, and therapists, will see why Fontan’s principle remains just as vibrant today as it was in 1971.
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Affiliation(s)
- Alvin J. Chin
- Department of Pediatrics, University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania
- Division of Cardiology, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Kevin K. Whitehead
- Department of Pediatrics, University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania
- Division of Cardiology, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Raymond L. Watrous
- Department of Electrical and Systems Engineering, University of Pennsylvania School of Engineering and Applied Science, Philadelphia, Pennsylvania
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Preciado D, Verghese S, Choi S. Aggressive bronchoscopic management of plastic bronchitis. Int J Pediatr Otorhinolaryngol 2010; 74:820-2. [PMID: 20546943 DOI: 10.1016/j.ijporl.2010.02.005] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/14/2009] [Revised: 02/02/2010] [Accepted: 02/03/2010] [Indexed: 11/18/2022]
Abstract
Plastic bronchitis or "Bronchitis Plastica" is a rare disease characterized by the formation of thick, tenacious, arborizing mucofibrinous tracheobronchial casts that result in life-threatening airway obstruction and pulmonary failure. We review three children who developed recurrent plastic bronchitis after undergoing a Fontan procedure for single ventricle physiology. Case series of three patients with plastic bronchitis at a tertiary referral children's hospital. All patients required repeated bronchoscopies, one requiring four separate ones over a week's period, for removal of the rigid casts. Extra-corporal membrane oxygenation (ECMO) was needed in two children because of severe respiratory failure. All were also managed with adjunctive intensive medical support. Pulmonary function returned to normal in all children, but recurred 2 months later in one who subsequently expired due to pulmonary failure. Plastic bronchitis is an unusual condition of unknown cause that occurs in multiple clinical settings, but especially in those children who have undergone a Fontan operation. Management of this distressing situation is difficult and early diagnosis and aggressive measures to remove rigid casts combined with intensive medical care are necessary. The intrinsic cardiopulmonary physiology of children with Fontan procedures, including the risk of arrhythmias, hypo-oxygenation, and pulmonary hypertension make this condition even more complex.
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Affiliation(s)
- Diego Preciado
- Division of Pediatric Otolaryngology-Head and Neck Surgery, Children's National Medical Center, George Washington University, Washington, DC 20010, USA.
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The use of high-frequency jet ventilation for removal of obstructing casts in patients with plastic bronchitis. Pediatr Crit Care Med 2009; 10:e34-6. [PMID: 19433939 DOI: 10.1097/pcc.0b013e3181a334ba] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
OBJECTIVE To describe improved cast removal with short periods of high-frequency jet ventilation (HFJV) in patients with single ventricle physiology. DESIGN Case report. SETTING Pediatric cardiac intensive care unit. PATIENTS Two patients with plastic bronchitis during prolonged stay in a intensive care unit after a Fontan-type operation. INTERVENTIONS Short periods of HFJV. MAIN RESULTS Plastic bronchitis with lower airway obstruction developed in two intubated patients during intensive care stay after the Fontan operation. Mucolytics and suctioning were not effective in controlling symptoms. Urgent bronchoscopy was considered a high-risk procedure for the first patient and was not available for the second. Cast removal was achieved with short periods of HFJV and subsequent suctioning. CONCLUSIONS The use of short-term HFJV resulted in resolution of the airway obstruction in intubated patients with plastic bronchitis.
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Do TB, Chu JM, Berdjis F, Anas NG. Fontan patient with plastic bronchitis treated successfully using aerosolized tissue plasminogen activator: a case report and review of the literature. Pediatr Cardiol 2009; 30:352-5. [PMID: 19005718 DOI: 10.1007/s00246-008-9312-2] [Citation(s) in RCA: 45] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/04/2008] [Accepted: 09/12/2008] [Indexed: 11/27/2022]
Abstract
Plastic bronchitis is an uncommon condition characterized by the production of large pale bronchial casts that obstruct the tracheobronchial tree. The cellular content, cohesiveness, and often rubber-like consistency distinguish bronchial casts from the usual mucus plugs found with such disease states as asthma. Plastic bronchitis can be found secondary to many conditions, and a simplified classification scheme organizes it into two groups: an inflammatory type consisting of casts with an eosinophilic inflammatory infiltrate and an acellular type with a predominance of fibrin distinguished by its relative lack of cellular infiltrate, its mucin predominance, and its appearance only in children with congenital cyanotic heart disease. This report describes a 5-year-old girl who experienced plastic bronchitis 3 months after a Fontan procedure for hypoplastic left heart syndrome that was treated successfully with aerosolized tissue plasminogen activator.
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Affiliation(s)
- Thomas B Do
- Children's Hospital of Orange County, Orange, CA 92868, USA.
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Chin AJ, Stephens P, Goldmuntz E, Leonard MB. Serum alkaline phosphatase reflects post-Fontan hemodynamics in children. Pediatr Cardiol 2009; 30:138-45. [PMID: 18685798 DOI: 10.1007/s00246-008-9292-2] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/30/2008] [Revised: 07/11/2008] [Accepted: 07/11/2008] [Indexed: 11/30/2022]
Abstract
Although survivors of Fontan palliation for a single ventricle are known to have lower cardiac index than patients with two-ventricle surgical reconstructions, it is unclear whether two frequently observed sequelae, short stature and protein-losing enteropathy (PLE), have hemodynamic origins. A serum marker that reflects hemodynamic status would be a tremendous asset in the long-term management of children with these sequelae. The authors recently noted severely reduced total alkaline phosphatase (TALP) levels in two children with early-onset PLE after Fontan operations, both of whom had low cardiac output at cardiac catheterization. Catheter-based or surgical interventions that rapidly increased cardiac output in these two patients resulted not only in relief of PLE but also in a prompt TALP rise. To examine whether the apparent correlation of low TALP with impaired cardiac output also is seen in Fontan patients without PLE, this study retrospectively examined the TALP data from two other Fontan patients who underwent cardiac catheterization specifically to assess the potential benefit of vasodilator therapy. The TALP levels were abnormally low in both cases but increased after up-titration of angiotensin-converting enzyme inhibition. Serum TALP activity, an indicator of osteoblastic function particularly in pre-adolescence, may be a marker of low cardiac output after a Fontan operation.
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Affiliation(s)
- Alvin J Chin
- Division of Cardiology, Abramson Research Center, The Children's Hospital of Philadelphia, and Department of Pediatrics, University of Pennsylvania, School of Medicine, Philadelphia, PA 19104, USA.
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Peters B, Ewert P, Berger F. The role of stents in the treatment of congenital heart disease: Current status and future perspectives. Ann Pediatr Cardiol 2009; 2:3-23. [PMID: 20300265 PMCID: PMC2840765 DOI: 10.4103/0974-2069.52802] [Citation(s) in RCA: 61] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
Intravascular or intracardiac stenoses occur in many forms of congenital heart disease (CHD). Therefore, the implantation of stents has become an accepted interventional procedure for stenotic lesions in pediatric cardiology. Furthermore, stents are know to be used to exclude vessel aneurysm or to ensure patency of existing or newly created intracardiac communications. With the further refinement of the first generation of devices, a variety of "modern" stents with different design characteristics have evolved. Despite the tremendous technical improvement over the last 20 years, the "ideal stent" has not yet been developed. Therefore, the pediatric interventionalist has to decide which stent is suitable for each lesion. On this basis, currently available stents are discussed in regard to their advantages and disadvantages for common application in CHD. New concepts and designs developed to overcome some of the existing problems, like the failure of adaptation to somatic growth, are presented. Thus, in the future, biodegradable or growth stents might replace the currently used generation of stents. This might truly lead to widening indications for the use of stents in the treatment of CHD.
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Affiliation(s)
- Bjoern Peters
- Department of Congenital Heart Disease/Pediatric Cardiology, Deutsches Herzzentrum Berlin, Germany
| | - Peter Ewert
- Department of Congenital Heart Disease/Pediatric Cardiology, Deutsches Herzzentrum Berlin, Germany
| | - Felix Berger
- Department of Congenital Heart Disease/Pediatric Cardiology, Deutsches Herzzentrum Berlin, Germany
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Plastic Bronchitis in a Child with Fontan’s Physiology Presenting for Urgent Rigid Bronchoscopy. Anesth Analg 2008; 107:1446-7. [DOI: 10.1213/ane.0b013e3181833e8c] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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45
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Mehta C, Jones T, De Giovanni J. Percutaneous transcatheter communication between the pulmonary artery and atrium following an extra-cardiac Fontan. Catheter Cardiovasc Interv 2008; 71:936-9. [DOI: 10.1002/ccd.21453] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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46
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Nayar S, Parmar R, Kulkarni S, Cherian KM. Treatment of Plastic Bronchitis. Ann Thorac Surg 2007; 83:1884-6. [PMID: 17462426 DOI: 10.1016/j.athoracsur.2006.12.027] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/25/2006] [Revised: 12/05/2006] [Accepted: 12/13/2006] [Indexed: 11/20/2022]
Abstract
Plastic bronchitis may be seen after palliative surgery for cyanotic heart disease. Although type II (acellular) casts are seen more commonly, we describe a type I cast after palliative surgery for cyanotic heart disease in which ligation of thoracic duct did not result in complete resolution.
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Affiliation(s)
- Sushma Nayar
- Department of Pathology, Frontier Lifeline, and Dr KM Cherian Heart Foundation, Chennai, India.
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