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Sahni A, Marshall L, Cetatoiu MA, Davee J, Schulz N, Eickhoff ER, St Clair N, Ghelani S, Prakash A, Hammer PE, Hoganson DM, Del Nido PJ, Rathod RH, Govindarajan V. Biomechanical Analysis of Age-Dependent Changes in Fontan Power Loss. Ann Biomed Eng 2024; 52:2440-2456. [PMID: 38753109 DOI: 10.1007/s10439-024-03534-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2023] [Accepted: 05/02/2024] [Indexed: 08/17/2024]
Abstract
The hemodynamics in Fontan patients with single ventricles rely on favorable flow and energetics, especially in the absence of a subpulmonary ventricle. Age-related changes in energetics for extracardiac and lateral tunnel Fontan procedures are not well understood. Vorticity (VOR) and viscous dissipation rate (VDR) are two descriptors that can provide insights into flow dynamics and dissipative areas in Fontan pathways, potentially contributing to power loss. This study examined power loss and its correlation with spatio-temporal flow descriptors (vorticity and VDR). Data from 414 Fontan patients were used to establish a relationship between the superior vena cava (SVC) to inferior vena cava (IVC) flow ratio and age. Computational flow modeling was conducted for both extracardiac conduits (ECC, n = 16) and lateral tunnels (LT, n = 25) at different caval inflow ratios of 2, 1, and 0.5 that corresponded with ages 3, 8, and 15+. In both cohorts, vorticity and VDR correlated well with PL, but ECC cohort exhibited a slightly stronger correlation for PL-VOR (>0.83) and PL-VDR (>0.89) than that for LT cohort (>0.76 and > 0.77, respectively) at all ages. Our data also suggested that absolute and indexed PL increase (p < 0.02) non-linearly as caval inflow changes with age and are highly patient-specific. Comparison of indexed power loss between our ECC and LT cohort showed that while ECC had a slightly higher median PL for all 3 caval inflow ratio examined (3.3, 8.3, 15.3) as opposed to (2.7, 7.6, 14.8), these differences were statistically non-significant. Lastly, there was a consistent rise in pressure gradient across the TCPC with age-related increase in IVC flows for both ECC and LT Fontan patient cohort. Our study provided hemodynamic insights into Fontan energetics and how they are impacted by age-dependent change in caval inflow. This workflow may help assess the long-term sustainability of the Fontan circulation and inform the design of more efficient Fontan conduits.
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Affiliation(s)
- A Sahni
- Department of Cardiac Surgery, Boston Children's Hospital, 300 Longwood Avenue, Boston, MA, 02115, USA
| | - L Marshall
- Department of Cardiac Surgery, Boston Children's Hospital, 300 Longwood Avenue, Boston, MA, 02115, USA
| | - M A Cetatoiu
- Department of Cardiac Surgery, Boston Children's Hospital, 300 Longwood Avenue, Boston, MA, 02115, USA
| | - J Davee
- Department of Cardiac Surgery, Boston Children's Hospital, 300 Longwood Avenue, Boston, MA, 02115, USA
| | - N Schulz
- Department of Cardiac Surgery, Boston Children's Hospital, 300 Longwood Avenue, Boston, MA, 02115, USA
| | - E R Eickhoff
- Department of Cardiac Surgery, Boston Children's Hospital, 300 Longwood Avenue, Boston, MA, 02115, USA
| | - N St Clair
- Department of Cardiac Surgery, Boston Children's Hospital, 300 Longwood Avenue, Boston, MA, 02115, USA
| | - S Ghelani
- Department of Cardiology, Boston Children's Hospital, Boston, MA, USA
- Department of Pediatrics, Harvard Medical School, Boston, MA, USA
| | - A Prakash
- Department of Cardiology, Boston Children's Hospital, Boston, MA, USA
- Department of Pediatrics, Harvard Medical School, Boston, MA, USA
| | - P E Hammer
- Department of Cardiac Surgery, Boston Children's Hospital, 300 Longwood Avenue, Boston, MA, 02115, USA
- Department of Surgery, Harvard Medical School, Boston, MA, USA
| | - D M Hoganson
- Department of Cardiac Surgery, Boston Children's Hospital, 300 Longwood Avenue, Boston, MA, 02115, USA
- Department of Surgery, Harvard Medical School, Boston, MA, USA
| | - P J Del Nido
- Department of Cardiac Surgery, Boston Children's Hospital, 300 Longwood Avenue, Boston, MA, 02115, USA
- Department of Surgery, Harvard Medical School, Boston, MA, USA
| | - R H Rathod
- Department of Cardiology, Boston Children's Hospital, Boston, MA, USA
- Department of Pediatrics, Harvard Medical School, Boston, MA, USA
| | - Vijay Govindarajan
- Department of Cardiac Surgery, Boston Children's Hospital, 300 Longwood Avenue, Boston, MA, 02115, USA.
- Department of Surgery, Harvard Medical School, Boston, MA, USA.
- Department of Internal Medicine (Cardiology), The University of Texas Health Science Center at Houston, Houston, TX, USA.
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2
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Curtis SF, Cicioni M, Mullikin A, Williams J, Campbell JM, Barker PCA, McCrary AW. Detection of occult thrombosis in individuals with Fontan circulation by cardiac MRI. Cardiol Young 2024; 34:1544-1549. [PMID: 38506050 DOI: 10.1017/s1047951124000489] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/21/2024]
Abstract
OBJECTIVE Identifying thrombus formation in Fontan circulation has been highly variable, with reports between 17 and 33%. Initially, thrombus detection was mainly done through echocardiograms. Delayed-enhancement cardiac MRI is emerging as a more effective imaging technique for thrombus identification. This study aims to determine the prevalence of occult cardiac thrombosis in patients undergoing clinically indicated cardiac MRI. METHODS A retrospective chart review of children and adults in the Duke University Hospital Fontan registry who underwent delayed-enhancement cardiac MRI. Individuals were excluded if they never received a delayed-enhancement cardiac MRI or had insufficient data. Demographic characteristics, native heart anatomy, cardiac MRI measurements, and thromboembolic events were collected for all patients. RESULTS In total, 119 unique individuals met inclusion criteria with a total of 171 scans. The median age at Fontan procedure was 3 (interquartile range 1, 4) years. The majority of patients had dominant systemic right ventricle. Cardiac function was relatively unchanged from the first cardiac MRI to the third cardiac MRI. While 36.4% had a thrombotic event by history, only 0.5% (1 patient) had an intracardiac thrombus detected by delayed-enhancement cardiac MRI. CONCLUSIONS Despite previous echocardiographic reports of high prevalence of occult thrombosis in patients with Fontan circulation, we found very low prevalence using delayed-enhancement cardiac MRI. As more individuals are reaching adulthood after requiring early Fontan procedures in childhood, further work is needed to develop thrombus-screening protocols as a part of anticoagulation management.
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Affiliation(s)
- Samantha F Curtis
- Department of Internal Medicine-Pediatrics, Duke University Medical Center, Durham, NC, USA
| | - Mariah Cicioni
- Department of Pediatric, Duke University Medical Center, Durham, NC, USA
| | | | - Jason Williams
- Division of Pediatric Cardiology, Department of Pediatrics, Duke University Medical Center, Durham, NC, USA
| | - J Michael Campbell
- Division of Pediatric Cardiology, Department of Pediatrics, Duke University Medical Center, Durham, NC, USA
| | - Piers C A Barker
- Division of Pediatric Cardiology, Department of Pediatrics, Duke University Medical Center, Durham, NC, USA
| | - Andrew W McCrary
- Division of Pediatric Cardiology, Department of Pediatrics, Duke University Medical Center, Durham, NC, USA
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3
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Téllez L, Payancé A, Tjwa E, Del Cerro MJ, Idorn L, Ovroutski S, De Bruyne R, Verkade HJ, De Rita F, de Lange C, Angelini A, Paradis V, Rautou PE, García-Pagán JC. EASL-ERN position paper on liver involvement in patients with Fontan-type circulation. J Hepatol 2023; 79:1270-1301. [PMID: 37863545 DOI: 10.1016/j.jhep.2023.07.013] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/06/2023] [Accepted: 07/06/2023] [Indexed: 10/22/2023]
Abstract
Fontan-type surgery is the final step in the sequential palliative surgical treatment of infants born with a univentricular heart. The resulting long-term haemodynamic changes promote liver damage, leading to Fontan-associated liver disease (FALD), in virtually all patients with Fontan circulation. Owing to the lack of a uniform definition of FALD and the competitive risk of other complications developed by Fontan patients, the impact of FALD on the prognosis of these patients is currently debatable. However, based on the increasing number of adult Fontan patients and recent research interest, the European Association for The Study of the Liver and the European Reference Network on Rare Liver Diseases thought a position paper timely. The aims of the current paper are: (1) to provide a clear definition and description of FALD, including clinical, analytical, radiological, haemodynamic, and histological features; (2) to facilitate guidance for staging the liver disease; and (3) to provide evidence- and experience-based recommendations for the management of different clinical scenarios.
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Affiliation(s)
- Luis Téllez
- Gastroenterology and Hepatology Department, Hospital Universitario Ramón y Cajal, Madrid, Spain; Instituto Ramón y Cajal de Investigación Sanitaria (IRYCIS), CIBEREHD (Centro de Investigación Biomédica en Red Enfermedades Hepáticas y Digestivas), University of Alcalá, Madrid, Spain
| | - Audrey Payancé
- DHU Unity, Pôle des Maladies de l'Appareil Digestif, Service d'Hépatologie, Hôpital Beaujon, AP-HP, Clichy, France; Université Denis Diderot-Paris 7, Sorbonne Paris Cité, Paris, France
| | - Eric Tjwa
- Department of Gastroenterology and Hepatology, Radboud University Medical Center, Nijmegen, The Netherlands
| | - María Jesús Del Cerro
- Pediatric Cardiology Department, Hospital Universitario Ramón y Cajal, Madrid, Spain; Instituto Ramón y Cajal de Investigación Sanitaria (IRYCIS), University of Alcalá, Madrid, Spain
| | - Lars Idorn
- Department of Pediatrics, Section of Pediatric Cardiology, Rigshospitalet, Copenhagen, Denmark
| | - Stanislav Ovroutski
- Department of Congenital Heart Disease/Pediatric Cardiology, Deutsches Herzzentrum Berlin, Berlin, Germany
| | - Ruth De Bruyne
- Department of Pediatric Gastroenterology, Hepatology and Nutrition, Ghent University Hospital, Belgium
| | - Henkjan J Verkade
- Department of Pediatrics, Beatrix Children's Hospital/University Medical Center Groningen, The Netherlands
| | - Fabrizio De Rita
- Adult Congenital and Paediatric Heart Unit, Freeman Hospital, Newcastle Upon Tyne Hospitals NHS Foundation Trust, Newcastle Upon Tyne, UK
| | - Charlotte de Lange
- Department of Pediatric Radiology, Queen Silvia Childrens' Hospital, Sahlgrenska University Hospital, Behandlingsvagen 7, 41650 Göteborg, Sweden
| | - Annalisa Angelini
- Pathology of Cardiac Transplantation and Regenerative Medicine Unit, Department of Cardiac, Thoracic and Vascular Sciences and Public Health, University of Padua, Padua, Italy
| | - Valérie Paradis
- Centre de recherche sur l'inflammation, INSERM1149, Université Paris Cité, Paris, France; Pathology Department, Beaujon Hospital, APHP.Nord, Clichy, France
| | - Pierre Emmanuel Rautou
- AP-HP, Service d'Hépatologie, Hôpital Beaujon, DMU DIGEST, Centre de Référence des Maladies Vasculaires du Foie, FILFOIE, Clichy, France; Université Paris-Cité, Inserm, Centre de recherche sur l'inflammation, UMR 1149, Paris, France
| | - Juan Carlos García-Pagán
- Barcelona Hepatic Hemodynamic Laboratory, Liver Unit, Hospital Clínic, Institut de Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Departament de Medicina i Ciències de la Salut, University of Barcelona, Barcelona, Spain; CIBEREHD (Centro de Investigación Biomédica en Red Enfermedades Hepáticas y Digestivas), Health Care Provider of the European Reference Network on Rare Liver Disorders (ERN-Liver), Spain.
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4
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Kazerouninia A, Georgekutty J, Kendsersky P, Byrne RD, Seto B, Chu PY, Wang Y, Rodriguez FH, Smith C, Saraf A, Lloyd MS, Frischhertz BP, Parekh DR, Ermis PR, Franklin WJ, Lam WW. A Multisite Retrospective Review of Direct Oral Anticoagulants Compared to Warfarin in Adult Fontan Patients. Cardiovasc Drugs Ther 2023; 37:519-527. [PMID: 35022950 PMCID: PMC11040449 DOI: 10.1007/s10557-021-07298-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 11/29/2021] [Indexed: 11/25/2022]
Abstract
PURPOSE Direct oral anticoagulants (DOACs) are not recommended in adult Fontan patients (Level of Evidence C). We hypothesized that DOACs are comparable to warfarin and do not increase thrombotic and embolic complications (TEs) or clinically significant bleeds. METHODS We reviewed the medical records of adult Fontan patients on DOACs or warfarin at three major medical centers. We identified 130 patients: 48 on DOACs and 107 on warfarin. In total, they were treated for 810 months on DOACs and 5637 months on warfarin. RESULTS The incidence of TEs in patients on DOACs compared to those on warfarin was not increased in a statistically significant way (hazard ratio [HR] 1.7 and p value 0.431). Similarly, the incidence of nonmajor and major bleeds in patients on DOACs compared to those on warfarin was also not increased in a statistically significant way (HR for nonmajor bleeds in DOAC patients was 2.8 with a p value of 0.167 and the HR for major bleeds was 2.0 with a p value 0.267). In multivariate analysis, congestive heart failure (CHF) was a risk factor for TEs across both groups (odds ratio [OR] = 4.8, 95% confidence interval [CI] = 1.3-17.6) and bleed history was a risk factor for clinically significant bleeds (OR = 6.8, 95% CI = 2.7-17.2). CONCLUSION In this small, retrospective multicenter study, the use of DOACs did not increase the risk of TEs or clinically significant bleeds compared to warfarin in a statistically significant way.
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Affiliation(s)
- Amir Kazerouninia
- Departments of Internal Medicine and Pediatrics, Baylor College of Medicine, Houston, TX, USA.
| | - Justin Georgekutty
- Division of Pediatric Cardiology, Cohen Children's Medical Center/Northwell Health, New Hyde Park, NY, USA
| | - Payton Kendsersky
- Department of Medicine, Duke University School of Medicine, Durham, NC, USA
| | - Ryan D Byrne
- Departments of Internal Medicine and Pediatrics, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Brendan Seto
- University of Hawaii, John A. Burns School of Medicine, Honolulu, HI, USA
| | - Patricia Y Chu
- Departments of Internal Medicine and Pediatrics, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Yunfei Wang
- Division of Pediatric Cardiology, Texas Children's Hospital/Baylor College of Medicine, Houston, TX, USA
| | - Fred H Rodriguez
- Departments of Pediatrics and Internal Medicine, Division of Cardiology, Emory University, Atlanta, GA, USA
- Sibley Heart Center Cardiology, Atlanta, GA, USA
| | - Clayton Smith
- Departments of Pediatrics and Internal Medicine, Division of Cardiology, Emory University, Atlanta, GA, USA
- Sibley Heart Center Cardiology, Atlanta, GA, USA
| | - Anita Saraf
- Departments of Pediatrics and Internal Medicine, Division of Cardiology, Emory University, Atlanta, GA, USA
- Sibley Heart Center Cardiology, Atlanta, GA, USA
| | - Michael S Lloyd
- Department of Internal Medicine, Division of Cardiology, Emory University, Atlanta, GA, USA
| | - Benjamin P Frischhertz
- Vanderbilt Heart and Vascular Institute, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Dhaval R Parekh
- Division of Adult Congenital Cardiology, Texas Children's Hospital/Baylor College of Medicine, Houston, TX, USA
| | - Peter R Ermis
- Division of Adult Congenital Cardiology, Texas Children's Hospital/Baylor College of Medicine, Houston, TX, USA
| | - Wayne J Franklin
- Division of Adult Congenital Cardiology, Texas Children's Hospital/Baylor College of Medicine, Houston, TX, USA
| | - Wilson W Lam
- Division of Adult Congenital Cardiology, Texas Children's Hospital/Baylor College of Medicine, Houston, TX, USA
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5
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Skubera M, Gołąb A, Sternalski T, Trojnarska O, Plicner D, Smaś-Suska M, Mazurek-Kula A, Bartczak-Rutkowska A, Pająk J, Podolec P, Tomkiewicz-Pająk L. Thromboembolic Complications in Adult Patients Following Fontan Procedure-A Multicenter Study. J Clin Med 2023; 12:jcm12103465. [PMID: 37240571 DOI: 10.3390/jcm12103465] [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: 02/20/2023] [Revised: 04/20/2023] [Accepted: 05/12/2023] [Indexed: 05/28/2023] Open
Abstract
BACKGROUND Morbidity and mortality following Fontan (FO) surgery are primarily thromboembolic in nature. However, follow-up data regarding thromboembolic complications (TECs) in adult patients after FO procedure are inconsistent. In this multicenter study, we investigated the incidence of TECs in FO patients. METHODS We studied 91 patients who underwent FO procedure. Clinical data, laboratory, and imaging investigations were collected prospectively during the scheduled medical appointments in 3 Adult Congenital Heart Disease Departments in Poland. TECs were recorded during a median follow-up of 31 months. RESULTS Four patients (4.4%) were lost to follow-up. The mean age of patients was 25.3 (±6.0) years at enrollment, and the mean time between FO operation and investigation was 22.1 (±5.1) years. A total of 21 out of 91 patients (23.1%) had a history of 24 TECs since an FO procedure, mainly pulmonary embolism (PE; n = 12, 13.2%), including 4 (33.3%) silent PE. The mean time since FO operation to the first TEC was 17.8 (±5.1) years. During follow-up, we documented 9 TECs in 7 (8.0%) patients, mainly PE (n = 5, 5.5%). Most patients with TEC had a left type of systemic ventricle (57.1%). Three patients (42.9%) were treated with aspirin, 3 (3.4%) with Vitamin K antagonists or novel oral anticoagulants, and 1 patient had no antithrombotic treatment at the time of TEC occurrence. Supraventricular tachyarrhythmias were present in 3 patients (42.9%). CONCLUSIONS This prospective study shows that TECs are common in FO patients, and a significant number of these events occur during adolescence and young adulthood. We also indicated how much TECs are underestimated in the growing adult FO population. The complexity of the problem requires more studies, especially to standardize the prevention of TECs in the whole FO population.
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Affiliation(s)
- Maciej Skubera
- Department of Cardiac and Vascular Diseases, John Paul II Hospital, 31-202 Krakow, Poland
| | - Aleksandra Gołąb
- Faculty of Medicine and Dentistry, Pomeranian Medical University in Szczecin, 70-204 Szczecin, Poland
- Center for Research and Innovative Technology, John Paul II Hospital, 31-202 Krakow, Poland
| | - Tomasz Sternalski
- Faculty of Medicine, Collegium Medicum Jagiellonian University, 31-008 Krakow, Poland
| | - Olga Trojnarska
- 1st Department of Cardiology, Poznan University of Medical Sciences, 61-701 Poznan, Poland
| | - Dariusz Plicner
- Department of Cardiovascular Surgery and Transplantation, John Paul II Hospital, 31-202 Krakow, Poland
- Unit of Experimental Cardiology and Cardiac Surgery, Faculty of Medicine and Health Sciences, Andrzej Frycz Modrzewski Krakow University, 30-705 Krakow, Poland
| | - Monika Smaś-Suska
- Department of Liver Diseases, John Paul II Hospital, 31-202 Krakow, Poland
| | - Anna Mazurek-Kula
- Department of Cardiology, Polish Mother's Memorial Hospital, Research Institute, 93-338 Lodz, Poland
| | | | - Jacek Pająk
- Institute of Medical Sciences, Department of Surgery, Medical College of Rzeszow University, 35-025 Rzeszow, Poland
| | - Piotr Podolec
- Department of Cardiac and Vascular Diseases, John Paul II Hospital, 31-202 Krakow, Poland
- Institute of Cardiology, Jagiellonian University Medical College, 31-008 Krakow, Poland
| | - Lidia Tomkiewicz-Pająk
- Department of Cardiac and Vascular Diseases, John Paul II Hospital, 31-202 Krakow, Poland
- Department of Liver Diseases, John Paul II Hospital, 31-202 Krakow, Poland
- Institute of Cardiology, Jagiellonian University Medical College, 31-008 Krakow, Poland
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6
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Ciliberti P, Ciancarella P, Bruno P, Curione D, Bordonaro V, Lisignoli V, Panebianco M, Chinali M, Secinaro A, Galletti L, Guccione P. Cardiac Imaging in Patients After Fontan Palliation: Which Test and When? Front Pediatr 2022; 10:876742. [PMID: 35652057 PMCID: PMC9149285 DOI: 10.3389/fped.2022.876742] [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: 02/15/2022] [Accepted: 04/13/2022] [Indexed: 11/13/2022] Open
Abstract
The Fontan operation represents the final stage of a series of palliative surgical procedures for children born with complex congenital heart disease, where a "usual" biventricular physiology cannot be restored. The palliation results in the direct connection of the systemic venous returns to the pulmonary arterial circulation without an interposed ventricle. In this unique physiology, systemic venous hypertension and intrathoracic pressures changes due to respiratory mechanics play the main role for propelling blood through the pulmonary vasculature. Although the Fontan operation has dramatically improved survival in patients with a single ventricle congenital heart disease, significant morbidity is still a concern. Patients with Fontan physiology are in fact suffering from a multitude of complications mainly due to the increased systemic venous pressure. Consequently, these patients need close clinical and imaging monitoring, where cardiac exams play a key role. In this article, we review the main cardiac imaging modalities available, summarizing their main strengths and limitations in this peculiar setting. The main purpose is to provide a practical approach for all clinicians involved in the care of these patients, even for those less experienced in cardiac imaging.
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Affiliation(s)
- Paolo Ciliberti
- Department of Cardiac Surgery, Cardiology, Heart and Lung Transplantation Bambino Gesu' Children's Hospital, IRCCS, Rome, Italy
| | - Paolo Ciancarella
- Advanced Cardiothoracic Imaging Unit, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
| | - Pasqualina Bruno
- Department of Cardiac Surgery, Cardiology, Heart and Lung Transplantation Bambino Gesu' Children's Hospital, IRCCS, Rome, Italy
| | - Davide Curione
- Advanced Cardiothoracic Imaging Unit, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
| | - Veronica Bordonaro
- Advanced Cardiothoracic Imaging Unit, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
| | - Veronica Lisignoli
- Department of Cardiac Surgery, Cardiology, Heart and Lung Transplantation Bambino Gesu' Children's Hospital, IRCCS, Rome, Italy
| | - Mario Panebianco
- Department of Cardiac Surgery, Cardiology, Heart and Lung Transplantation Bambino Gesu' Children's Hospital, IRCCS, Rome, Italy
| | - Marcello Chinali
- Department of Cardiac Surgery, Cardiology, Heart and Lung Transplantation Bambino Gesu' Children's Hospital, IRCCS, Rome, Italy
| | - Aurelio Secinaro
- Advanced Cardiothoracic Imaging Unit, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
| | - Lorenzo Galletti
- Department of Cardiac Surgery, Cardiology, Heart and Lung Transplantation Bambino Gesu' Children's Hospital, IRCCS, Rome, Italy
| | - Paolo Guccione
- Department of Cardiac Surgery, Cardiology, Heart and Lung Transplantation Bambino Gesu' Children's Hospital, IRCCS, Rome, Italy
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7
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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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8
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Skubera M, Gołąb A, Plicner D, Natorska J, Ząbczyk M, Trojnarska O, Mazurek-Kula A, Smaś-Suska M, Bartczak-Rutkowska A, Podolec P, Tomkiewicz-Pająk L. Properties of Plasma Clots in Adult Patients Following Fontan Procedure: Relation to Clot Permeability and Lysis Time-Multicenter Study. J Clin Med 2021; 10:jcm10245976. [PMID: 34945271 PMCID: PMC8709107 DOI: 10.3390/jcm10245976] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2021] [Revised: 12/13/2021] [Accepted: 12/16/2021] [Indexed: 11/16/2022] Open
Abstract
Objectives: thromboembolic complications are a major cause of morbidity and mortality following Fontan (FO) surgery. It is also well established that altered FO circulation results in systemic complications, including liver and endothelium damage. We sought to evaluate whether dysfunctions of these sources of hemostatic factors may result in changes of fibrin clot properties. Methods: a permeation coefficient (Ks) and clot lysis time (CLT) were assessed in 66 FO patients, aged 23.0 years [IQR 19.3–27.0], and 59 controls, aged 24.0 years [IQR 19.0–29.0]. Ks was determined using a pressure-driven system. CLT value was measured according to assay described by Pieters et al. Endothelium and liver-derived hemostatic factors along with liver function parameters were evaluated. The median time between FO operation and investigation was 20.5 years [IQR 16.3–22.0]. Results: FO patients had lower Ks (p = 0.005) and prolonged CLT (p < 0.001) compared to that of controls. Ks correlated with CLT (r = −0.28), FVIII (r = −0.30), FIX (r = −0.38), fibrinogen (r = −0.41), ALT (r = −0.25), AST (r = −0.26), GGTP (r = −0.27) and vWF antigen (r = −0.30), (all p < 0.05). CLT correlated with the time between FO operation and investigation (r = 0.29) and FIX (r = 0.25), (all p < 0.05). After adjustment for potential cofounders, TAFI antigen and GGTP were independent predictors of reduced Ks (OR 1.041 per 1% increase, 95% CI 1.009–1.081, p = 0.011 and OR 1.025 per 1 U/L increase, 95% CI 1.005–1.053, p = 0.033, respectively). Protein C and LDL cholesterol predicted prolonged CLT (OR 1.078 per 1% increase, 95% CI 1.027–1.153, p = 0.001 and OR 6.360 per 1 μmol/L increase, 95% CI 1.492–39.894, p = 0.011, respectively). Whereas elevated tPA was associated with lower risk of prolonged CLT (OR 0.550 per 1 ng/mL, 95% CI 0.314–0.854, p = 0.004). GGTP correlated positively with time between FO surgery and investigation (r = 0.25, p = 0.045) and patients with abnormal elevated GGTP activity (n = 28, 42.4%) had decreased Ks, compared to that of the others (5.9 × 10−9 cm2 vs. 6.8 × 10−9 cm2, p = 0.042). Conclusion: our study shows that cellular liver damage and endothelial injury were associated with prothrombotic clot phenotype reflected by Ks and CLT.
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Affiliation(s)
- Maciej Skubera
- Department of Cardiac and Vascular Diseases, John Paul II Hospital, 31-202 Krakow, Poland; (M.S.); (M.S.-S.); (P.P.); (L.T.-P.)
- Institute of Cardiology, Jagiellonian University Medical College, 31-008 Krakow, Poland; (J.N.); (M.Z.)
| | - Aleksandra Gołąb
- Faculty of Medicine and Dentistry, Pomeranian Medical University, 70-204 Szczecin, Poland;
| | - Dariusz Plicner
- Department of Cardiovascular Surgery and Transplantation, John Paul II Hospital, 31-202 Krakow, Poland
- Unit of Experimental Cardiology and Cardiac Surgery, Faculty of Medicine and Health Sciences, Andrzej Frycz Modrzewski Krakow University, 30-705 Krakow, Poland
- Correspondence: ; Tel.: +48-(12)-252-4503
| | - Joanna Natorska
- Institute of Cardiology, Jagiellonian University Medical College, 31-008 Krakow, Poland; (J.N.); (M.Z.)
- Center for Research and Innovative Technology, John Paul II Hospital, 31-202 Krakow, Poland
| | - Michał Ząbczyk
- Institute of Cardiology, Jagiellonian University Medical College, 31-008 Krakow, Poland; (J.N.); (M.Z.)
- Center for Research and Innovative Technology, John Paul II Hospital, 31-202 Krakow, Poland
| | - Olga Trojnarska
- 1st Department of Cardiology, Poznan University of Medical Sciences, 61-701 Poznan, Poland; (O.T.); (A.B.-R.)
| | - Anna Mazurek-Kula
- Department of Cardiology, Polish Mother’s Memorial Hospital, Research Institute, 93-338 Lodz, Poland;
| | - Monika Smaś-Suska
- Department of Cardiac and Vascular Diseases, John Paul II Hospital, 31-202 Krakow, Poland; (M.S.); (M.S.-S.); (P.P.); (L.T.-P.)
| | | | - Piotr Podolec
- Department of Cardiac and Vascular Diseases, John Paul II Hospital, 31-202 Krakow, Poland; (M.S.); (M.S.-S.); (P.P.); (L.T.-P.)
- Institute of Cardiology, Jagiellonian University Medical College, 31-008 Krakow, Poland; (J.N.); (M.Z.)
| | - Lidia Tomkiewicz-Pająk
- Department of Cardiac and Vascular Diseases, John Paul II Hospital, 31-202 Krakow, Poland; (M.S.); (M.S.-S.); (P.P.); (L.T.-P.)
- Institute of Cardiology, Jagiellonian University Medical College, 31-008 Krakow, Poland; (J.N.); (M.Z.)
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9
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Girnius A, Zentner D, Valente AM, Pieper PG, Economy KE, Ladouceur M, Roos-Hesselink JW, Warshak C, Partington SL, Gao Z, Ollberding N, Faust M, Girnius S, Kaemmerer H, Nagdyman N, Cohen S, Canobbio M, Akagi T, Grewal J, Bradley E, Buber Y, Palumbo J, Walker N, Aboulhosn J, Oechslin E, Baumgartner H, Kurdi W, Book WM, Mulder BJM, Veldtman GR. Bleeding and thrombotic risk in pregnant women with Fontan physiology. Heart 2021; 107:1390-1397. [PMID: 33234672 PMCID: PMC10367127 DOI: 10.1136/heartjnl-2020-317397] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/27/2020] [Revised: 10/16/2020] [Accepted: 10/21/2020] [Indexed: 02/03/2023] Open
Abstract
BACKGROUND/OBJECTIVES Pregnancy may potentiate the inherent hypercoagulability of the Fontan circulation, thereby amplifying adverse events. This study sought to evaluate thrombosis and bleeding risk in pregnant women with a Fontan. METHODS We performed a retrospective observational cohort study across 13 international centres and recorded data on thrombotic and bleeding events, antithrombotic therapies and pre-pregnancy thrombotic risk factors. RESULTS We analysed 84 women with Fontan physiology undergoing 108 pregnancies, average gestation 33±5 weeks. The most common antithrombotic therapy in pregnancy was aspirin (ASA, 47 pregnancies (43.5%)). Heparin (unfractionated (UFH) or low molecular weight (LMWH)) was prescribed in 32 pregnancies (30%) and vitamin K antagonist (VKA) in 10 pregnancies (9%). Three pregnancies were complicated by thrombotic events (2.8%). Thirty-eight pregnancies (35%) were complicated by bleeding, of which 5 (13%) were severe. Most bleeds were obstetric, occurring antepartum (45%) and postpartum (42%). The use of therapeutic heparin (OR 15.6, 95% CI 1.88 to 129, p=0.006), VKA (OR 11.7, 95% CI 1.06 to 130, p=0.032) or any combination of anticoagulation medication (OR 13.0, 95% CI 1.13 to 150, p=0.032) were significantly associated with bleeding events, while ASA (OR 5.41, 95% CI 0.73 to 40.4, p=0.067) and prophylactic heparin were not (OR 4.68, 95% CI 0.488 to 44.9, p=0.096). CONCLUSIONS Current antithrombotic strategies appear effective at attenuating thrombotic risk in pregnant women with a Fontan. However, this comes with high (>30%) bleeding risk, of which 13% are life threatening. Achieving haemostatic balance is challenging in pregnant women with a Fontan, necessitating individualised risk-adjusted counselling and therapeutic approaches that are monitored during the course of pregnancy.
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Affiliation(s)
- Andrea Girnius
- Anesthesiology, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
| | - Dominica Zentner
- Department of Cardiology and Department of Genomic Medicine, Royal Melbourne Hospital, Melbourne, Victoria, Australia.,Faculty of Medicine, Dentistry and Health Sciences, University of Melbourne, Melbourne, Victoria, Australia
| | - Anne Marie Valente
- Brigham and Women's Hospital, Department of Medicine, Division of Cardiovascular Disease, Department of Cardiology Harvard Medical School, Boston, Massachusetts, USA
| | - Petronella G Pieper
- Department of Cardiology, University Medical Center Groningen, Groningen, The Netherlands
| | - Katherine E Economy
- Brigham and Women's Hospital, Department of Obstetrics and Gynecology, Division Maternal Fetal Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Magalie Ladouceur
- Cardiology, Hopital Europeen Georges Pompidou, Paris, France.,Pediatric Cardiology, Hopital Universitaire Necker-Enfants Malades, Paris, France
| | | | - Carri Warshak
- Obstetrics and Gynecology, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
| | - Sara L Partington
- Division of Cardiovascular Medicine, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA.,Division of Cardiology, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Zhiqian Gao
- Heart Institute, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
| | - Nicholas Ollberding
- Department of Pediatrics, Cincinnati Children's Hospital Medical Centre, Cincinnati, Ohio, USA.,Division of Biostatistics and Epidemiology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
| | - Michelle Faust
- Heart Institute, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
| | - Saulius Girnius
- Department of Hematology, Trihealth Cancer Institute, Cincinnati, Ohio, USA
| | | | | | - Scott Cohen
- Department of Cardiology, The Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | - Mary Canobbio
- School of Nursing, University of California Los Angeles, Los Angeles, California, USA
| | - Teiji Akagi
- Cardiovascular Medicine, Okayama University, Okayama, Japan
| | - Jasmine Grewal
- Cardiology, The University of British Columbia Faculty of Medicine, Vancouver, British Columbia, Canada
| | - Elisa Bradley
- Adult Congenital Heart Disease, The Ohio State University & Nationwide Children's Hospital, Nationwide Children's Hospital, Columbus, Ohio, USA
| | - Yonathan Buber
- Department of Medicine, Division of Cardiology, University of Washington School of Medicine, Seattle, Washington, USA
| | - Joseph Palumbo
- Haematology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
| | | | - Jamil Aboulhosn
- Ahmanson/UCLA ACHD Center, David Geffen School of Medicine at UCLA, Los Angeles, California, USA
| | - Erwin Oechslin
- Toronto Congenital Cardiac Centre for Adults, Peter Munk Cardiac Centre, University Heatlh Network and University of Toronto, Toronto, Ontario, Canada.,Bitove Family Professorship of Adult Congenital Heart Disease, Toronto General Hospital, Toronto, Ontario, Canada
| | - Helmut Baumgartner
- Department of Cardiology III: Adult Congenital and Valvular Heart Disease, University Hospital Muenster, Muenster, Albert Schweitzer Campus 1, Building A1, 48149 Muenster, Germany
| | - Wesam Kurdi
- King Faisal Specialist Hospital and Research Center, Riyadh, Saudi Arabia
| | - Wendy M Book
- Internal Medicine, Division of Cardiology, Emory University, Atlanta, Georgia, USA
| | | | - Gruschen R Veldtman
- Adult Congenital Heart Disease, King Faisal Specialist Hospital and Research Centre, Riyadh, Saudi Arabia
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10
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Abdominal Imaging of Children and Young Adults With Fontan Circulation: Pathophysiology and Surveillance. AJR Am J Roentgenol 2021; 217:207-217. [PMID: 33909464 DOI: 10.2214/ajr.20.23404] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
OBJECTIVE. The Fontan procedure has significantly improved the survival in children with a functional single ventricle, but it is associated with chronically elevated systemic venous pressure that leads to multisystemic complications. Imaging plays an important role in assessing these complications and guiding management. The pathophysiology, imaging modalities, and current surveillance recommendations are discussed and illustrated. CONCLUSION. Significant improvement in survival of patients with Fontan circulation is associated with ongoing cardiac and extracardiac comorbidities and multisystemic complications. The liver and intestines are particularly vulnerable to damage. In addition, this patient population has been shown to be at increased risk of certain malignancies such as hepatocellular carcinoma and neuroendocrine tumors. Familiarity with imaging findings of Fontan-associated liver disease and other abdominal complications of the Fontan circulation is essential for radiologists because we are likely to encounter these patients in our general practice.
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11
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Kawamatsu N, Ishizu T, Machino-Ohtsuka T, Masuda K, Horigome H, Takechi F, Tateno S, Fukuda T, Kijima Y, Shiina Y, Komiyama N, Niwa K, Hiramatsu Y, Ieda M. Direct oral anticoagulant use and outcomes in adult patients with Fontan circulation: A multicenter retrospective cohort study. Int J Cardiol 2020; 327:74-79. [PMID: 33220361 DOI: 10.1016/j.ijcard.2020.11.024] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/03/2020] [Revised: 11/07/2020] [Accepted: 11/12/2020] [Indexed: 12/25/2022]
Abstract
BACKGROUND Many adult patients with Fontan circulation are treated with antithrombotic agents, including direct oral anticoagulants (DOACs). However, few studies have investigated the efficacy, feasibility, and safety of DOACs in adult patients with Fontan circulation. METHODS AND RESULTS In this retrospective cohort study, clinical records of 139 adult patients with Fontan circulation (70 females, 50.4%) from April 2015 to March 2018 were reviewed and classified into five groups according to the therapeutic agents used: DOAC (n = 36), vitamin K antagonist (VKA; n = 41), antiplatelet drug (n = 43), combination of an antiplatelet and anticoagulant (n = 14), and no-antithrombotic prophylaxis (n = 5). In a 1114-patient-year follow-up, 28 major events occurred, including 10 thrombotic and 18 bleeding events; 11 of 18 (61%) female patients had severe menorrhagia. The incidence (% patient-years) of major events was 0.6, 1.42, 3.74, and 5.13 in the DOAC, antiplatelet, VKA, combination, and no-antithrombotic groups, respectively. The Cox proportional hazards analysis revealed that the DOAC group had a lower rate of primary endpoints than the VKA group in males. CONCLUSIONS DOAC may be a safe antithrombotic agent for use in adult patients with Fontan circulation, particularly in males. However, these findings should be confirmed in multi-institutional prospective studies.
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Affiliation(s)
- Naoto Kawamatsu
- Department of Cardiology, Faculty of Medicine, University of Tsukuba, Tsukuba, Japan
| | - Tomoko Ishizu
- Department of Cardiology, Faculty of Medicine, University of Tsukuba, Tsukuba, Japan.
| | | | - Keita Masuda
- Department of Cardiology, Faculty of Medicine, University of Tsukuba, Tsukuba, Japan
| | - Hitoshi Horigome
- Department of Child Health, University of Tsukuba, Tsukuba, Japan
| | - Fumie Takechi
- Department of Adult Congenital Heart Disease, Chiba Cerebral and Cardiovascular Center, Chiba, Japan
| | - Shigeru Tateno
- Department of Adult Congenital Heart Disease, Chiba Cerebral and Cardiovascular Center, Chiba, Japan
| | - Terunobu Fukuda
- Department of Cardiovascular Medicine, St. Luke's International Hospital, Tokyo, Japan
| | - Yasufumi Kijima
- Department of Cardiovascular Medicine, St. Luke's International Hospital, Tokyo, Japan
| | - Yumi Shiina
- Department of Cardiovascular Medicine, St. Luke's International Hospital, Tokyo, Japan
| | - Nobuyuki Komiyama
- Department of Cardiovascular Medicine, St. Luke's International Hospital, Tokyo, Japan
| | - Koichiro Niwa
- Department of Cardiovascular Medicine, St. Luke's International Hospital, Tokyo, Japan
| | - Yuji Hiramatsu
- Division of Cardiovascular Surgery, University of Tsukuba, Tsukuba, Japan
| | - Masaki Ieda
- Department of Cardiology, Faculty of Medicine, University of Tsukuba, Tsukuba, Japan
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12
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Al-Jazairi AS, Al Alshaykh HA, Di Salvo G, De Vol EB, Alhalees ZY. Assessment of Late Thromboembolic Complications Post-Fontan Procedure in Relation to Different Antithrombotic Regimens: 30-Years' Follow-up Experience. Ann Pharmacother 2019; 53:786-793. [PMID: 30788973 DOI: 10.1177/1060028019829860] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Background: The current CHEST guidelines recommend the use of antithrombotic therapy, either aspirin or warfarin, as a primary thromboembolic complications (TECs) prophylaxis in patients who undergo Fontan procedure, without specification on drug selection or duration of therapy. Objective: To investigate the incidence rate of late TECs, occurring after 1-year post-Fontan procedure and to assess the difference in rate of late TECs between warfarin and aspirin. Methods: A retrospective cohort study included patients who had Fontan procedures between 1985-2010 at our institution. Patients were stratified according to the antithrombotic regimen-warfarin, aspirin, or no therapy-at the time of TECs. Results: We screened 499 patients who underwent Fontan procedures; 431 procedures met the inclusion criteria. Over a median follow-up of 13.6 years (IQR= 8.7), freedom from late TECs at 5, 10, 15, and 20 years was 97.54%, 96.90%, 90.78%, and 88.07%, respectively. There was no difference in late TEC incidence rates per 1000 patient-years between warfarin and aspirin: 7.82 and 5.83 events, respectively; rate ratio= 1.34 (95% CI= 0.68-2.60). Warfarin was associated with a higher major bleeding incidence rate per 1000 patient-years: 3.70 versus 2.91 events with aspirin; rate ratio= 1.27 (95% CI= 0.49 to 3.29). Conclusion and Relevance: The incidence rate of late clinical TECs post-Fontan procedure in our population is low. Warfarin was not superior to aspirin for prevention of late TECs. Yet warfarin was associated with a higher rate of bleeding. This finding suggests a simpler antithrombotic regimen for prevention of TEC after 1-year post-Fontan procedure.
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Affiliation(s)
| | - Hana A Al Alshaykh
- 1 King Faisal Specialist Hospital and Research Centre, Riyadh, Saudi Arabia
| | - Giovanni Di Salvo
- 1 King Faisal Specialist Hospital and Research Centre, Riyadh, Saudi Arabia
| | - Edward B De Vol
- 1 King Faisal Specialist Hospital and Research Centre, Riyadh, Saudi Arabia
| | - Zohair Y Alhalees
- 1 King Faisal Specialist Hospital and Research Centre, Riyadh, Saudi Arabia
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13
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Establishment of prophylactic enoxaparin dosing recommendations to achieve targeted anti-factor Xa concentrations in children with CHD. Cardiol Young 2018; 28:715-718. [PMID: 29490713 DOI: 10.1017/s1047951118000173] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND Enoxaparin may be used to prevent central venous catheter-related thrombosis in patients with CHD. We aimed to determine whether current enoxaparin dosing regimens effectively achieve anti-factor Xa concentrations within prophylactic goal ranges in this patient population. METHODS We implemented a formal protocol aimed at reducing central venous catheter-related thrombosis in children with CHD in January, 2016. Standard empiric prophylactic enoxaparin dosing regimens were used - for example, 0.75 mg/kg/dose every 12 hours for patients <2 months of age and 0.5 mg/kg/dose every 12 hours for patients ⩾2 months of age - with anti-factor Xa goal range of 0.25-0.49 IU/ml. Patients <2 years of age who received enoxaparin and had at least one valid steady-state anti-factor Xa measurement between 25 January, 2016 and 31 August, 2016 were retrospectively reviewed. RESULTS During the study period, 47 patients had 186 anti-factor Xa concentrations measured, of which 20 (11%) were above and 112 (60%) were below the prophylactic goal range. Anti-factor Xa concentrations within the goal range were ultimately achieved in 31 patients. Median dose required to achieve anti-factor Xa concentrations within the prophylactic range was 0.89 mg/kg/dose (25, 75%: 0.75, 1.11) for patients <2 months (n=23 patients) and 0.79 mg/kg/dose (25, 75%: 0.62, 1.11) for patients ⩾2 months (n=8 patients). CONCLUSIONS Enoxaparin doses required to achieve prophylactic anti-factor Xa concentrations in young children with CHD were consistently higher than the currently recommended prophylactic dosing regimens. Further study is needed to determine whether dose titration to achieve prophylactic anti-factor Xa concentrations is effective in preventing central venous catheter-related thrombosis.
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14
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Georgekutty J, Kazerouninia A, Wang Y, Ermis PR, Parekh DR, Franklin WJ, Lam WW. Novel oral anticoagulant use in adult Fontan patients: A single center experience. CONGENIT HEART DIS 2018; 13:541-547. [DOI: 10.1111/chd.12603] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/30/2017] [Revised: 12/16/2017] [Accepted: 02/20/2018] [Indexed: 12/21/2022]
Affiliation(s)
- Justin Georgekutty
- Division of Pediatric Cardiology; Cohen Children's Medical Center/Northwell Health; New Hyde Park New York USA
| | - Amir Kazerouninia
- Department of Internal Medicine/Department of Pediatrics; Baylor College of Medicine; Houston Texas USA
| | - YunFei Wang
- Section of Pediatric Cardiology, Texas Children's Hospital/Baylor College of Medicine; Houston Texas USA
| | - Peter R. Ermis
- Division of Adult Congenital Cardiology, Texas Children's Hospital/Baylor College of Medicine; Houston Texas USA
| | - Dhaval R. Parekh
- Division of Adult Congenital Cardiology, Texas Children's Hospital/Baylor College of Medicine; Houston Texas USA
| | - Wayne J. Franklin
- Division of Adult Congenital Cardiology, Texas Children's Hospital/Baylor College of Medicine; Houston Texas USA
| | - Wilson W. Lam
- Division of Adult Congenital Cardiology, Texas Children's Hospital/Baylor College of Medicine; Houston Texas USA
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15
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Kverneland LS, Kramer P, Ovroutski S. Five decades of the Fontan operation: A systematic review of international reports on outcomes after univentricular palliation. CONGENIT HEART DIS 2018; 13:181-193. [DOI: 10.1111/chd.12570] [Citation(s) in RCA: 61] [Impact Index Per Article: 10.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/28/2017] [Revised: 11/08/2017] [Accepted: 12/08/2017] [Indexed: 11/28/2022]
Affiliation(s)
- Laura S. Kverneland
- Department of Internal Medicine; Herlev Hospital; Copenhagen Denmark
- Department of Congenital Heart Disease/Pediatric Cardiology; German Heart Center Berlin; Berlin Germany
| | - Peter Kramer
- Department of Congenital Heart Disease/Pediatric Cardiology; German Heart Center Berlin; Berlin Germany
| | - Stanislav Ovroutski
- Department of Congenital Heart Disease/Pediatric Cardiology; German Heart Center Berlin; Berlin Germany
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16
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Ohuchi H. Seeking a Better Quality of Life for Patients after the Fontan Operation: Lessons Learned from Serial Assessment of Fontan Pathophysiology. ACTA ACUST UNITED AC 2016. [DOI: 10.9794/jspccs.32.141] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Affiliation(s)
- Hideo Ohuchi
- Departments of Pediatric Cardiology and Adult Congenital Heart Disease,
National Cerebral and Cardiovascular Center
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17
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Raben JS, Hariharan P, Robinson R, Malinauskas R, Vlachos PP. Time-Resolved Particle Image Velocimetry Measurements with Wall Shear Stress and Uncertainty Quantification for the FDA Nozzle Model. Cardiovasc Eng Technol 2015; 7:7-22. [DOI: 10.1007/s13239-015-0251-9] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/07/2015] [Accepted: 11/23/2015] [Indexed: 10/22/2022]
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18
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Sughimoto K, Okauchi K, Zannino D, Brizard CP, Liang F, Sugawara M, Liu H, Tsubota KI. Total Cavopulmonary Connection is Superior to Atriopulmonary Connection Fontan in Preventing Thrombus Formation: Computer Simulation of Flow-Related Blood Coagulation. Pediatr Cardiol 2015; 36:1436-41. [PMID: 26024646 DOI: 10.1007/s00246-015-1180-y] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/14/2014] [Accepted: 04/29/2015] [Indexed: 01/19/2023]
Abstract
The classical Fontan route, namely the atriopulmonary connection (APC), continues to be associated with a risk of thrombus formation in the atrium. A conversion to a total cavopulmonary connection (TCPC) from the APC can ameliorate hemodynamics for the failed Fontan; however, the impact of these surgical operations on thrombus formation remains elusive. This study elucidates the underlying mechanism of thrombus formation in the Fontan route by using a two-dimensional computer hemodynamic simulation based on a simple blood coagulation rule. Hemodynamics in the Fontan route was simulated with Navier-Stokes equations. The blood coagulation and the hemodynamics were combined using a particle method. Three models were created: APC with a square atrium, APC with a round atrium, and TCPC. To examine the effects of the venous blood flow velocity, the velocity at rest and during exercise (0.5 and 1.0 W/kg) was measured. The total area of the thrombi increased over time. The APC square model showed the highest incidence for thrombus formation, followed by the APC round, whereas no thrombus was formed in the TCPC model. Slower blood flow at rest was associated with a higher incidence of thrombus formation. The TCPC was superior to the classical APC in terms of preventing thrombus formation, due to significant blood flow stagnation in the atrium of the APC. Thus, local hemodynamic behavior associated with the complex channel geometry plays a major role in thrombus formation in the Fontan route.
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Affiliation(s)
- Koichi Sughimoto
- Department of Cardiac Surgery, The Royal Children's Hospital, Melbourne, Australia
| | - Kazuki Okauchi
- Department of Mechanical Engineering, Graduate School of Engineering, Chiba University, Chiba, Japan.,Hitachi Construction Machinery, Tokyo, Japan
| | - Diana Zannino
- Murdoch Childrens Research Institute, Melbourne, Australia
| | - Christian P Brizard
- Department of Cardiac Surgery, The Royal Children's Hospital, Melbourne, Australia.,Murdoch Childrens Research Institute, Melbourne, Australia
| | - Fuyou Liang
- School of Naval Architecture, Ocean and Civil Engineering (NAOCE), Shanghai Jiao Tong University, Shanghai, China.,Shanghai Jiao Tong University and Chiba University International Cooperative Research Centre (SJTU-CU ICRC), Shanghai Jiao Tong University, Shanghai, China
| | - Michiko Sugawara
- Department of Mechanical Engineering, Graduate School of Engineering, Chiba University, Chiba, Japan
| | - Hao Liu
- Department of Mechanical Engineering, Graduate School of Engineering, Chiba University, Chiba, Japan.,Shanghai Jiao Tong University and Chiba University International Cooperative Research Centre (SJTU-CU ICRC), Shanghai Jiao Tong University, Shanghai, China
| | - Ken-Ichi Tsubota
- Department of Mechanical Engineering, Graduate School of Engineering, Chiba University, Chiba, Japan.
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19
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Torok RD, Fleming GA, Hill KD. Transcatheter pulmonary embolectomy after fontan. Catheter Cardiovasc Interv 2015; 87:939-44. [PMID: 26154441 DOI: 10.1002/ccd.26096] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/23/2014] [Revised: 03/23/2015] [Accepted: 06/14/2015] [Indexed: 11/07/2022]
Abstract
Pulmonary embolism (PE) is a significant cause of morbidity and mortality among hospitalized patients, and thrombolytics are the mainstay of treatment. However, for patients who fail or have contraindications to thrombolytic therapy, catheter-based therapies, such as the AngioVac aspiration system, have emerged as an alternative to surgical embolectomy. Here, we present the novel case of a 22 year-old woman with Fontan circulation who developed severe postpartum cardiomyopathy and a saddle PE. She failed thrombolytic therapy but underwent successful pulmonary embolectomy by AngioVac aspiration. Patients with Fontan circulation have an increased incidence of thromboembolic events, and AngioVac thrombectomy is a valuable treatment option in these complex patients.
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Affiliation(s)
- Rachel D Torok
- Division of Pediatric Cardiology, Duke University Medical Center, Durham, North Carolina.,Department of Pediatrics, Duke University Medical Center, Durham, North Carolina
| | - Gregory A Fleming
- Division of Pediatric Cardiology, Duke University Medical Center, Durham, North Carolina.,Department of Pediatrics, Duke University Medical Center, Durham, North Carolina
| | - Kevin D Hill
- Division of Pediatric Cardiology, Duke University Medical Center, Durham, North Carolina.,Department of Pediatrics, Duke University Medical Center, Durham, North Carolina
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20
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Bendaly EA, DiMeglio LA, Fadel WF, Hurwitz RA. Bone density in children with single ventricle physiology. Pediatr Cardiol 2015; 36:779-85. [PMID: 25511666 PMCID: PMC4858165 DOI: 10.1007/s00246-014-1083-3] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/19/2014] [Accepted: 12/05/2014] [Indexed: 11/27/2022]
Abstract
Children with chronic diseases are at risk for low bone mineral density (BMD). There are no studies of BMD in children with congenital heart disease and particularly single ventricle (SV). Children with this defect are often treated with warfarin, suspected to negatively impact BMD in adults. We assessed BMD in patients with SV physiology and compared the BMD of subjects taking warfarin to those who were not. Subjects 5-12 years with SV were included. BMD z scores by dual-energy X-ray absorptiometry of the spine and total body less head (TBLH) were obtained. Calcium intake, activity level, height, and Tanner stage were assessed. Linear regression models and t tests were used to investigate differences between participants and normative data as well as between subjects' subgroups. Twenty-six subjects were included and 16 took warfarin. Mean BMD z score at the spine was significantly lower than expected at -1.0 ± 0.2 (p < 0.0001), as was the BMD z score for TBLH at -0.8 ± 0.2 (p < 0.0001). Those results remained significant after adjusting for height. Subjects who were on warfarin tended to have lower BMD at both the spine and TBLH than those who were not, with a z score difference of 0.6 ± 0.46 at the spine (p = 0.106) and a difference of 0.4 ± 0.34 at TBLH (p = 0.132). BMD is significantly reduced in children with SV. Warfarin appears to lower BMD but the effect is less conclusive. Continued evaluation is recommended for these patients at risk for reduced bone density. Evaluation of other cardiac patients on warfarin therapy should also be considered.
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Affiliation(s)
- Edgard A Bendaly
- Section of Pediatric Cardiology, Department of Pediatrics, Sanford Children's Hospital, University of South Dakota, 1600 W 22nd Street, PO Box 5039, Sioux Falls, SD, 57117, USA,
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21
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Nakano T, Kado H, Tatewaki H, Hinokiyama K, Oda S, Ushinohama H, Sagawa K, Nakamura M, Fusazaki N, Ishikawa S. Results of extracardiac conduit total cavopulmonary connection in 500 patients. Eur J Cardiothorac Surg 2015; 48:825-32; discussion 832. [PMID: 25769469 DOI: 10.1093/ejcts/ezv072] [Citation(s) in RCA: 77] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/13/2014] [Accepted: 12/29/2014] [Indexed: 11/14/2022] Open
Abstract
OBJECTIVES This single-institution study aimed to evaluate the early to mid-term outcomes of extracardiac conduit total cavopulmonary connection (EC-TCPC). METHODS Between March 1994 and March 2014, 500 patients (median age, 3.4 years) underwent EC-TCPC at our hospital. One hundred and twenty-three patients (24.6%) showed heterotaxy, and fenestration was created in 6 patients (1.2%). The standard institutional treatment policy included postoperative anticoagulation and individualized cardiovascular medication. The mortality and morbidity rates, haemodynamic status, cardiopulmonary exercise capacity and liver examination results during the follow-up period (median, 6.7 years) were retrospectively reviewed. RESULTS There were 2 early and 17 late deaths. The Kaplan-Meier estimated survival rate was 96.2% at 10 years and 92.8% at 15 years. Bradyarrhythmia and tachyarrhythmia occurred in 19 and 13 patients, respectively. Other late-occurring morbidities included protein-losing enteropathy in 8, thromboembolism in 5, bleeding complications in 6 and liver cirrhosis in 1 patient. The rate of freedom from late-occurring morbidities was 82.1% at 15 years. In the multivariate analysis, heterotaxy was found to be a predictor for mortality (P = 0.02), whereas age at operation was a predictor for new-onset arrhythmias (P = 0.048). In the cardiopulmonary exercise test (n = 312), the peak VO2 was 84.9 ± 17.3% of the predicted value, which tended to decrease with age (R(2) = 0.32) and elapsed time since operation (R(2) = 0.21). Postoperative cardiac catheterization (n = 468; time from surgery, 3.6 ± 4.3 years) showed central venous pressure of 9.9 ± 2.4 mmHg, ventricular end-diastolic pressure of 5.2 ± 3.3 mmHg, cardiac index of 3.4 ± 0.8 l/min/m(2) and arterial oxygen saturation of 94.2 ± 4.8%. In 101 patients who were followed up for ≥10 years, amino-terminal type III procollagen peptide and collagen type IV levels exceeded the normal ranges in 52.9 and 75.2% of patients, respectively, and liver ultrasonography revealed hyper-echoic spots in 43.3% of patients. CONCLUSIONS The early to mid-term outcomes of post-EC-TCPC patients managed with individualized pharmacotherapy were excellent, with low mortality and morbidity rates; however, development of late-occurring morbidities specific to Fontan physiology, including exercise intolerance and liver disease, must be carefully monitored during the long-term follow-up.
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Affiliation(s)
- Toshihide Nakano
- Department of Cardiovascular Surgery, Fukuoka Children's Hospital, Fukuoka, Japan
| | - Hideaki Kado
- Department of Cardiovascular Surgery, Fukuoka Children's Hospital, Fukuoka, Japan
| | - Hideki Tatewaki
- Department of Cardiovascular Surgery, Fukuoka Children's Hospital, Fukuoka, Japan
| | - Kazuhiro Hinokiyama
- Department of Cardiovascular Surgery, Fukuoka Children's Hospital, Fukuoka, Japan
| | - Shinichiro Oda
- Department of Cardiovascular Surgery, Fukuoka Children's Hospital, Fukuoka, Japan
| | - Hiroya Ushinohama
- Department of Cardiology, Fukuoka Children's Hospital, Fukuoka, Japan
| | - Koichi Sagawa
- Department of Cardiology, Fukuoka Children's Hospital, Fukuoka, Japan
| | - Makoto Nakamura
- Department of Cardiology, Fukuoka Children's Hospital, Fukuoka, Japan
| | - Naoki Fusazaki
- Department of Neonatal Cardiology, Fukuoka Children's Hospital, Fukuoka, Japan
| | - Shiro Ishikawa
- Department of Cardiology, Fukuoka Children's Hospital, Fukuoka, Japan
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22
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Dabal RJ, Kirklin JK, Kukreja M, Brown RN, Cleveland DC, Eddins MC, Lau Y. The modern Fontan operation shows no increase in mortality out to 20 years: A new paradigm. J Thorac Cardiovasc Surg 2014; 148:2517-23.e1. [DOI: 10.1016/j.jtcvs.2014.07.075] [Citation(s) in RCA: 49] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/21/2014] [Revised: 07/16/2014] [Accepted: 07/22/2014] [Indexed: 10/24/2022]
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23
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Pal Singh S, Makhija N, Talwar S. TEE images of inferior vena cava conduit thrombosis following extracardiac total cavopulmonary anastomosis. J Cardiothorac Vasc Anesth 2014; 28:e22-3. [PMID: 24680131 DOI: 10.1053/j.jvca.2013.12.002] [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: 11/28/2013] [Indexed: 11/11/2022]
Affiliation(s)
- Sarvesh Pal Singh
- Department of Cardiac Anesthesia, All India Institute of Medical Sciences, New Delhi, India
| | - Neeti Makhija
- Department of Cardiac Anesthesia, All India Institute of Medical Sciences, New Delhi, India
| | - Sachin Talwar
- CTVS Cardio-Neuro Sciences Center, All India Institute of Medical Sciences, New Delhi, India
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24
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Firdouse M, Agarwal A, Chan AK, Mondal T. Thrombosis and Thromboembolic Complications in Fontan Patients. Clin Appl Thromb Hemost 2014; 20:484-92. [DOI: 10.1177/1076029613520464] [Citation(s) in RCA: 46] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023] Open
Abstract
Hemodynamic fluctuations and thromboembolic complications are significant areas of concern during the postoperative management of patients with univentricular hearts. The objective of this study is to review the incidence and risk factors associated with thrombosis and thromboembolic complications following total cavopulmonary anastomosis, the third stage of the palliative surgical procedure. A literature search of published evidence was conducted on OvidSP MEDLINE(R) and Embase followed by paired title, abstract, and full-text screening based on specific inclusion criteria. High risks of thromboembolic outcomes were identified across studies, with variable incidences between 3% and 20%, high mortality rates up to 38%, and an inverse relationship with prophylaxis treatment administration. Several risk factors for thrombotic complications, including chronic systemic venous hypertension, protein-losing enteropathy, passive blood flow, atrial arrhythmias, conduit stenosis, prosthetic material use, coagulation factor abnormalities, and several patient characteristics were identified. Based on these findings, a prophylactic anticoagulation algorithm has been proposed.
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Affiliation(s)
| | - Arnav Agarwal
- Faculty of Health Sciences, McMaster University, Hamilton, Canada
| | - Anthony K. Chan
- Department of Pediatrics, McMaster Children’s Hospital, McMaster University, Hamilton, Canada
| | - Tapas Mondal
- Department of Pediatrics, McMaster Children’s Hospital, McMaster University, Hamilton, Canada
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25
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Thomas CA, Taylor K, Schamberger MS, Rotta AT. Safety of Warfarin Dosing in the Intensive Care Unit Following the Fontan Procedure. CONGENIT HEART DIS 2013; 9:361-5. [DOI: 10.1111/chd.12151] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Affiliation(s)
- Christopher A. Thomas
- Department of Pharmacy; Riley Hospital for Children at Indiana University Health; Indianapolis Ind USA
| | - Kathryn Taylor
- Department of Pharmacy; Riley Hospital for Children at Indiana University Health; Indianapolis Ind USA
| | - Marcus S. Schamberger
- Section of Pediatric Cardiology; Riley Hospital for Children at Indiana University Health; Indianapolis Ind USA
- Indiana University School of Medicine; Indianapolis Ind USA
| | - Alexandre T. Rotta
- Division of Pediatric Critical Care; Rainbow Babies and Children's Hospital; Cleveland OH USA
- Department of Pediatrics; Case Western Reserve University School of Medicine; Cleveland Ohio USA
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26
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Lastinger L, Zaidi AN. The adult with a fontan: a panacea without a cure? Review of long-term complications. Circ J 2013; 77:2672-81. [PMID: 24152723 DOI: 10.1253/circj.cj-13-1105] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
The univentricular heart includes a spectrum of complex cardiac defects that are managed by staged palliative surgical procedures, ultimately resulting in a Fontan procedure. Since 1971, when it was first developed, the procedure has undergone several variations. These patients require lifelong management, including a thorough knowledge of their anatomic substrate, hemodynamic status, management of rhythm and ventricular function, together with multi-organ evaluation. As these patients enter middle age, there is increasing awareness of long-term complications and mortality. This review highlights the concept behind the staged surgical palliations, the unique single ventricle physiology and the long-term complications in this complex cohort of patients.
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Affiliation(s)
- Lauren Lastinger
- Division of Pediatrics and Internal Medicine, Nationwide Children's Hospital and the Ohio State University
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27
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Potter BJ, Leong-Sit P, Fernandes SM, Feifer A, Mayer JE, Triedman JK, Walsh EP, Landzberg MJ, Khairy P. Effect of Aspirin and warfarin therapy on thromboembolic events in patients with univentricular hearts and Fontan palliation. Int J Cardiol 2013; 168:3940-3. [DOI: 10.1016/j.ijcard.2013.06.058] [Citation(s) in RCA: 52] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/25/2013] [Accepted: 06/29/2013] [Indexed: 10/26/2022]
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28
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Heart Failure in Adults who had the Fontan Procedure: Natural History, Evaluation, and Management. CURRENT TREATMENT OPTIONS IN CARDIOVASCULAR MEDICINE 2013; 15:587-601. [DOI: 10.1007/s11936-013-0257-2] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
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29
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Atrial arrhythmia after Fontan surgery leads to giant thrombus: Opening Pandora's box. Int J Cardiol 2013; 166:e23-4. [DOI: 10.1016/j.ijcard.2013.01.178] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/24/2012] [Accepted: 01/13/2013] [Indexed: 11/19/2022]
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30
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Crone E, Saliba N, George S, Hume E, Newall F, Jones S. Commencement of warfarin therapy in children following the Fontan procedure. Thromb Res 2013; 131:304-7. [DOI: 10.1016/j.thromres.2013.01.018] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2012] [Revised: 12/18/2012] [Accepted: 01/14/2013] [Indexed: 01/21/2023]
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31
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Idorn L, Jensen AS, Juul K, Reimers JI, Johansson PI, Sørensen KE, Ostrowski SR, Søndergaard L. Thromboembolic complications in Fontan patients: population-based prevalence and exploration of the etiology. Pediatr Cardiol 2013; 34:262-72. [PMID: 22843202 DOI: 10.1007/s00246-012-0431-4] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/02/2012] [Accepted: 06/29/2012] [Indexed: 01/13/2023]
Abstract
After the Fontan procedure, patients face an increased risk for thromboembolic events (TE). The etiology for this increased thrombogenecity is incompletely understood. This study aimed to determine the prevalence of TE in Danish Fontan patients and to bring new insights into the etiology of TE. Using a population-based design, we retrospectively identified all TEs in 210 Fontan patients. Whole blood assays (thromboelastography, thromboelastography functional fibrinogen and Multiplate) reflecting global hemostasis, clot strength and platelet aggregation were analyzed prospectively in 112 patients and plasma was analyzed in 76 patients for biomarkers reflecting endothelial-, glycocalyx-, platelet-, and fibrinolysis function (histone-complexed DNA fragments, Protein C, soluble CD40 ligand, soluble thrombomodulin, syndecan-1, tissue-type plasminogen activator). The results were compared in groups stratified according to age, antithrombotic therapy, TE, and glycocalyx degradation (syndecan-1 < or ≥ median). Correlation between biomarkers and demographic-, anatomical-, clinical- and biochemical parameters was investigated. The prevalence of TE was 8.1 % after a mean follow-up of 8.4 years. None of the stratified groups demonstrated evidence of hypercoagulability in the whole blood assays and no unexpected significant differences were found between the groups. All biomarkers, except protein C, correlated with one another and after stratification of glycocalyx degradation only syndecan-1 levels ≥ median correlated with other biomarkers. The prevalence of TEs was 8.1 % after mean follow-up of 8.4 years. Overall, the hemostatic profile appeared normal, however, in a subset of patients, evidence of some endothelial activation/damage including glycocalyx degradation and fibrinolysis was found, identifying a potentially more thrombogenic group.
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Affiliation(s)
- L Idorn
- Department of Cardiology, Rigshospitalet, Blegdamsvej 9, Section 2014, 2100 Copenhagen, Denmark.
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32
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Lu JC, Dorfman AL, Attili AK, Ghadimi Mahani M, Dillman JR, Agarwal PP. Evaluation with Cardiovascular MR Imaging of Baffles and Conduits Used in Palliation or Repair of Congenital Heart Disease. Radiographics 2012; 32:E107-27. [DOI: 10.1148/rg.323115096] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
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33
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Khanna G, Bhalla S, Krishnamurthy R, Canter C. Extracardiac complications of the Fontan circuit. Pediatr Radiol 2012; 42:233-41. [PMID: 21863291 DOI: 10.1007/s00247-011-2225-x] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/20/2011] [Revised: 06/21/2011] [Accepted: 07/18/2011] [Indexed: 11/30/2022]
Abstract
The Fontan operation is the primary surgical procedure used in the palliation of patients with univentricular cardiac physiology. With improved survival of children with congenital heart disease, long-term complications of the Fontan circuit are being encountered more frequently. Radiologists are more likely to see both the cardiac and extracardiac complications of the Fontan circuit. Awareness of the common extracardiac complications in children with failing Fontan circuits will aid the radiologist in making the appropriate diagnosis and guide the cardiologist caring for these patients.
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Affiliation(s)
- Geetika Khanna
- Mallinckrodt Institute of Radiology, Washington University School of Medicine, Campus Box 8131, 510 S. Kingshighway, St. Louis, MO 63110, USA.
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34
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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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35
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Kurata A, Higaki T, Yamamoto E, Shikata F, Okamura T, Nagashima M, Kido T, Kido T, Miyagawa M, Mochizuki T. Supravalvular thrombus after pulmonary artery banding and fontan procedure evaluated by multidetector-row computed tomography. J Cardiol Cases 2011; 5:e51-e54. [PMID: 30532902 DOI: 10.1016/j.jccase.2011.09.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2011] [Revised: 08/21/2011] [Accepted: 09/06/2011] [Indexed: 11/18/2022] Open
Abstract
The mechanisms responsible for thromboembolic events in children with congenital heart disease have not yet been fully elucidated. Furthermore, establishment of long-term anticoagulation therapy in Fontan patients remains controversial. Here, we report the case of a 9-year-old boy who presented with hemiparesis due to a thromboembolic stroke; the boy had previously undergone staged pulmonary artery banding and Fontan procedure. Cardiac multidetector-row computed tomography (MDCT) clearly showed the supravalvular thrombus at the roofed (blind) pulmonary valve and circulatory stasis, which could be considered a possible source of the thrombus. Follow-up CT examination showed that the thrombus disappeared, but the circulatory stasis remained. Therefore, because the risk of thrombus formation was not eliminated, anticoagulation therapy was continued for the patient. Our case indicates the possible application of cardiac MDCT for providing insight into the hemodynamic mechanisms responsible for the thromboembolic events in children with congenital heart disease.
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Affiliation(s)
- Akira Kurata
- Department of Diagnostic and Therapeutic Radiology, Ehime University Graduate School of Medicine, Shitsukawa, Toon 791-0295, Japan
| | - Takashi Higaki
- Department of Pediatrics, Ehime University Graduate School of Medicine, Shitsukawa, Toon, Japan
| | - Eiichi Yamamoto
- Department of Pediatrics, Ehime University Graduate School of Medicine, Shitsukawa, Toon, Japan
| | - Fumiaki Shikata
- Department of Cardiac Surgery, Ehime University Graduate School of Medicine, Shitsukawa, Toon, Japan
| | - Toru Okamura
- Department of Cardiac Surgery, Ehime University Graduate School of Medicine, Shitsukawa, Toon, Japan
| | - Mitsugi Nagashima
- Department of Cardiac Surgery, Ehime University Graduate School of Medicine, Shitsukawa, Toon, Japan
| | - Tomoyuki Kido
- Department of Diagnostic and Therapeutic Radiology, Ehime University Graduate School of Medicine, Shitsukawa, Toon 791-0295, Japan
| | - Teruhito Kido
- Department of Diagnostic and Therapeutic Radiology, Ehime University Graduate School of Medicine, Shitsukawa, Toon 791-0295, Japan
| | - Masao Miyagawa
- Department of Diagnostic and Therapeutic Radiology, Ehime University Graduate School of Medicine, Shitsukawa, Toon 791-0295, Japan
| | - Teruhito Mochizuki
- Department of Diagnostic and Therapeutic Radiology, Ehime University Graduate School of Medicine, Shitsukawa, Toon 791-0295, Japan
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36
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Preventing Thrombosis After the Fontan Procedure. J Am Coll Cardiol 2011; 58:652-3. [DOI: 10.1016/j.jacc.2011.01.062] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/23/2010] [Accepted: 01/04/2011] [Indexed: 01/19/2023]
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37
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Eagle SS, Daves SM. The Adult With Fontan Physiology: Systematic Approach to Perioperative Management for Noncardiac Surgery. J Cardiothorac Vasc Anesth 2011; 25:320-34. [DOI: 10.1053/j.jvca.2010.12.003] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/01/2010] [Indexed: 01/19/2023]
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38
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Abstract
Choussat's "Ten Commandments," which describes the components of an ideal Fontan candidate, was first published in 1977. Despite the wisdom in these commandments, it is clear from a historic perspective that total compliance with all criteria does not necessarily portend excellent long-term survival. I believe the end point of the original commandments should be modified to include improvement in long-term survival. I suggest the following single commandment: "Thou Shalt Be Perfect."
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39
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Anderson PAW, Breitbart RE, McCrindle BW, Sleeper LA, Atz AM, Hsu DT, Lu M, Margossian R, Williams RV. The Fontan patient: inconsistencies in medication therapy across seven pediatric heart network centers. Pediatr Cardiol 2010; 31:1219-28. [PMID: 20938655 PMCID: PMC3050513 DOI: 10.1007/s00246-010-9807-5] [Citation(s) in RCA: 48] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/02/2010] [Accepted: 09/19/2010] [Indexed: 11/25/2022]
Abstract
Patients who have undergone the Fontan procedure are at risk for thrombosis, ventricular dysfunction, and valve regurgitation, but data to guide the medical treatment and prevention of these adverse outcomes in this population are lacking. This analysis examined medication usage among Fontan patients by putative indication and by study center. The medical history and current medications of 546 Fontan subjects, ages 6-18 years, were assessed in a Pediatric Heart Network multicenter cross-sectional study. Cardiac imaging was performed within 3 months of enrollment. The majority of the subjects (64%) were taking two or more medications. Antithrombotics were taken by 86% of those with a history of stroke, thrombosis, or both and 67% of those without such a history (P = 0.01). Conversely, 14% of those with a history of stroke, thrombosis, or both were taking no antithrombotic. Angiotensin-converting enzyme inhibitor (ACEi) therapy was independently associated with moderate or severe atrioventricular valve regurgitation (P = 0.004), right ventricular morphology (P < 0.001), and shorter time since Fontan (P = 0.004) but not with ventricular systolic dysfunction. Glycoside therapy and diuretic therapy each was associated with older age at Fontan (P = 0.001 and P = 0.023, respectively) and a history of post-Fontan arrhythmia (P < 0.001 and P = 0.003, respectively) but not with ventricular systolic dysfunction. Medication use rates varied widely among the centers, even with controls for center differences in patient characteristics. Prospective therapeutic trials are needed to guide the medical treatment of Fontan patients.
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Affiliation(s)
| | - Roger E. Breitbart
- Department of Cardiology, Children’s Hospital Boston, 300 Longwood Avenue, Boston, MA 02115, USA
| | - Brian W. McCrindle
- Department of Pediatrics, The Hospital for Sick Children, Toronto, ON, Canada
| | - Lynn A. Sleeper
- Center for Statistical Analysis and Research, New England Research Institutes, Watertown, MA, USA
| | - Andrew M. Atz
- Department of Pediatrics, Medical University of South Carolina, Charleston, SC, USA
| | - Daphne T. Hsu
- Department of Pediatrics, Children’s Hospital of New York, New York, NY, USA
| | - Minmin Lu
- Center for Statistical Analysis and Research, New England Research Institutes, Watertown, MA, USA
| | - Renee Margossian
- Department of Cardiology, Children’s Hospital Boston, 300 Longwood Avenue, Boston, MA 02115, USA
| | - Richard V. Williams
- Department of Pediatrics, Primary Children’s Medical Center, Salt Lake City, UT, USA
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40
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Reed RC, Rutledge JC. Laboratory and clinical predictors of thrombosis and hemorrhage in 29 pediatric extracorporeal membrane oxygenation nonsurvivors. Pediatr Dev Pathol 2010; 13:385-92. [PMID: 20085498 DOI: 10.2350/09-09-0704-oa.1] [Citation(s) in RCA: 60] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
Extracorporeal membrane oxygenation (ECMO) is a life-saving therapy for infants and children with cardiac and respiratory failure. However, thrombosis and hemorrhage are common complications. To determine clinical and laboratory predictors of thrombosis and hemorrhage resulting from ECMO, records and slides were reviewed from 29 consecutive autopsies from 2004 through 2008 of pediatric patients who received ECMO at our institution. Laboratory results, including prothrombin time, activated partial thromboplastin time, platelet count, fibrinogen level, and activated clotting time, were analyzed, as was heparin dosing. Thrombosis and hemorrhage were very common, with 1 or both seen in 86% of patients. Sixty-nine percent had thrombosis, and 52% had hemorrhage after ECMO initiation, including intracranial hemorrhage in 33% of the patients in whom brain examination was permitted. Hemorrhage and thrombosis coexisted in 31% of patients. Thrombosis was significantly more common in patients with congenital cardiac disease. Duration of ECMO therapy, being on ECMO at death, sepsis, and patient age and sex did not predict hemorrhage or thrombosis at autopsy. Laboratory tests were poor predictors of thrombosis and hemorrhage, with no correlation between these complications and prothrombin time, partial thromboplastin time, platelet count, fibrinogen level, activated clotting time, or heparin dose. In conclusion, thrombosis and hemorrhage continue to be frequent complications among patients who die during or after ECMO therapy. Patients with congenital cardiac disease appear especially susceptible to thrombosis on ECMO. Prothrombin time, partial thromboplastin time, platelet count, fibrinogen level, activated clotting time, and heparin dose are poor predictors of thrombosis or hemorrhage for pediatric patients who die after ECMO.
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Affiliation(s)
- Robyn C Reed
- Department of Pathology, Kosair Children's Hospital, Louisville, KY 40202, USA.
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41
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Abstract
Fifty years ago, only a quarter of infants born with congenital heart disease (CHD) survived beyond the first year of life. It has been estimated that 80% to 85% of patients can expect to reach adulthood. Today, there are close to 1 million adults living with CHD in the United States alone. Since its introduction, the Fontan operation has become established as the dominant surgical repair in patients with univentricular heart physiology. Long-term morbidity associated with this procedure is being more commonly appreciated and liver complications have become more frequently apparent. Hepatologist awareness and familiarity in managing this population alongside the CHD specialist is important for the care of these patients. This dual perspective can provide comprehensive integrated care.
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42
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Ganigara M, Prabhu A, Varghese R, Pavithran S, Valliatu J, Kumar RNS. Extracardiac Fontan Operation after Late Bidirectional Glenn Shunt. Asian Cardiovasc Thorac Ann 2010; 18:253-9. [DOI: 10.1177/0218492310367961] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
The outcomes of 33 consecutive extracardiac Fontan operations performed between 1999 and 2008 in patients who mostly had initial Glenn shunts beyond infancy were reviewed. Preoperatively, the median oxygen saturation was 76.2% and mean pulmonary artery pressure was 10.5 mm Hg. The median age was 4.1 years at Glenn shunt procedure and 10 years at Fontan operation. The duration of chest tube drainage was longer in these patients than in series where Glenn shunts were created at a younger age. All patients received warfarin for 1 year, then warfarin and/or aspirin. At follow-up (median, 14 months), there was no significant ventricular dysfunction. Median oxygen saturation at the last follow-up was 92%. All patients in sinus rhythm preoperatively continued in this status. There was no Fontan failure or mortality. All patients were in New York Heart Association class I or II, although objective cardiopulmonary exercise evaluation in 8 patients showed impaired exercise tolerance. Despite a trend towards prolonged pleural effusion, there was no adverse outcome in the short or intermediate term. Long-term follow-up is required to see whether delayed creation of a Glenn shunt is associated with late disadvantages.
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Affiliation(s)
| | - Atul Prabhu
- The Madras Medical Mission, Mogappair, Chennai, Tamil Nadu, India
| | - Roy Varghese
- The Madras Medical Mission, Mogappair, Chennai, Tamil Nadu, India
| | - Sreeja Pavithran
- The Madras Medical Mission, Mogappair, Chennai, Tamil Nadu, India
| | - John Valliatu
- The Madras Medical Mission, Mogappair, Chennai, Tamil Nadu, India
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Abstract
PURPOSE OF REVIEW Among the most frequently encountered congenital heart malformations are those with so-called single ventricle physiology, in which there is only one ventricle to pump blood to the pulmonary and systemic vascular beds, respectively. Long-term survival is possible, based on the principle of right heart bypass, whereby the ventricle pumps blood only to the systemic circuit, whereas pulmonary blood flow occurs passively. Such a circulatory system is achieved in a series of staged reconstructive operations, each of which was formerly accompanied by very high rates of major morbidity and mortality. Current approaches to single ventricle physiology as well as areas of controversy will be reviewed. RECENT FINDINGS The development of a number of inventive operations, combined with a greater understanding of the physiologic requirements for success after single ventricle reconstruction has resulted in dramatic improvements in outcomes. The identification and modification of risk factors as well as the recent development of catheter-based intervention offer the real prospect of significant continued improvement. SUMMARY Advances in the care of children with single ventricle hearts have resulted in remarkably improved prognosis, with the expectation of continued improvement in not only survival but also quality of life.
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Cavo M, Wang W, O'Brien SH. Use of low molecular weight heparin for thromboprophylaxis in a pediatric inpatient population: reasons for use and incidence of bleeding complications. Thromb Res 2009; 125:370-2. [PMID: 19368960 DOI: 10.1016/j.thromres.2009.03.004] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2008] [Revised: 03/13/2009] [Accepted: 03/17/2009] [Indexed: 11/17/2022]
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Odegard KC, Zurakowski D, DiNardo JA, Castro RA, McGowan FX, Neufeld EJ, Laussen PC. Prospective longitudinal study of coagulation profiles in children with hypoplastic left heart syndrome from stage I through Fontan completion. J Thorac Cardiovasc Surg 2009; 137:934-41. [PMID: 19327521 DOI: 10.1016/j.jtcvs.2008.09.031] [Citation(s) in RCA: 79] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/11/2008] [Revised: 07/28/2008] [Accepted: 09/11/2008] [Indexed: 01/19/2023]
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