Pseudotumor cerebri associated with modified Fontan anatomy

Special Considerations in Critical Care of the Congenital Heart Disease Patient

Outcomes of congenital heart disease have improved markedly over the past 20 years, with survival to adulthood now close to 90%. The mean age of admission to an intensive care unit (ICU) is 40 years. The incidence of hospital and critical care admissions have increased significantly as a consequence of this improved survival. Intensivists are now confronted with the management not only of complex adult congenital heart disease (ACHD) lesions from a cardiac perspective, but also of extracardiac organ consequences of years of abnormal circulation after surgical or palliative correction. Kidney and liver dysfunction and respiratory and hematologic abnormalities are very common in this population. ACHD patients can present to the ICU for a vast number of reasons, classified in this review as medical noncardiac, medical cardiac, and surgical. Community/hospital-acquired infections, cerebrovascular accidents, and respiratory failure, alongside arrhythmias and heart failure, are responsible for medical admissions. Surgical admissions include postoperative management after correction or palliation, but also medical optimisation and work-up for advanced therapies. ICU management of this large heterogeneous group requires a thorough understanding of the pathophysiology in order to apply conventional adult critical care modalities; left ventricular or right ventricular dysfunction, pulmonary hypertension, intracardiac, extracardiac, and palliative surgical shunts can be present and require additional consideration. This review focuses on the pathophysiology, long-term sequelae, and different treatment modalities to supply a framework for the ICU physician caring for these patients. Successful outcome, especially in complex lesions, depends on early involvement of specialised ACHD centres.

Fontan Circulation Associated Organ Abnormalities Beyond the Heart, Lungs, Liver, and Gut: A Systematic Review

Introduction

Patients with a Fontan circulation are at risk for sequelae of Fontan physiology during follow-up. Fontan physiology affects all organ systems and an overview of end-organ damage is needed.

Methods

We performed a systematic review of abnormalities in multiple organ systems for patients with a longstanding Fontan circulation. We searched online databases for articles describing abnormalities in multiple organ systems. Cardio-pulmonary abnormalities, protein losing enteropathy, and Fontan associated liver disease have already extensively been described and were excluded from this systematic review.

Results

Our search returned 5,704 unique articles. After screening, we found 111 articles relating to multiple organ systems. We found abnormalities in, among others, the nervous system, pituitary, kidneys, and musculoskeletal system. Pituitary edema—relating to the unique pituitary vasculature- may affect the thyroid axis. Renal dysfunction is common. Creatinine based renal function estimates may be inappropriate due to myopenia. Both lean muscle mass and bone mineral density are decreased. These abnormalities in multiple organ systems may be related to Fontan physiology, cyanosis, iatrogenic factors, or lifestyle.

Conclusions

Health care providers should be vigilant for hypothyroidism, visual or hearing deficits, and sleep disordered breathing in Fontan patients. We recommend including cystatin C for assessment of renal function. This review may aid health care providers and guide future research.

Systematic Review Registration:https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42021232461, PROSPERO, identifier: CRD42021232461.

Multiple echocardiography abnormalities associated with endoscopic third ventriculostomy failure

OBJECTIVE Although endoscopic third ventriculostomy (ETV) with choroid plexus cauterization (CPC) has gained increasing prominence in the management of hydrocephalus caused by intraventricular hemorrhage of prematurity, the rates of long-term shunt independence remain low. Furthermore, limited evidence is available to identify infants who might benefit from the procedure. The authors tested the hypothesis that elevated venous pressure that results from comorbid cardiac disease might predispose patients to ETV/CPC failure and shunt dependence. METHODS A retrospective analysis was performed on a consecutive series of 48 infants with hydrocephalus who underwent ETV/CPC and also underwent preoperative echocardiography between 2007 and 2014. Comorbid cardiac abnormalities that are known to result in elevated right heart pressure were reviewed. Associations between ETV/CPC success and the presence of pulmonary hypertension, right ventricular hypertrophy, left-to-right shunting, ventricular septal defect, or patent ductus arteriosus were determined using multivariate logistic regression analysis. RESULTS Of the 48 children who met the inclusion criteria, ETV/CPC failed in 31 (65%). In univariate analysis, no single echocardiogram abnormality was associated with shunt failure, but the presence of 2 or more concurrent echocardiogram abnormalities was associated with ETV/CPC failure (17 [85%] of 20 vs 14 [50%] of 28, respectively; p = 0.018). In multivariate logistic regression analysis, when the authors adjusted for the child's ETV success score, the presence of 2 abnormalities remained independently associated with poor outcome (2 or more echocardiogram abnormalities, OR 0.13, 95% CI 0.01-0.7, p = 0.032; ETV success score, OR 1.1, 95% CI 1-1.2, p = 0.05). CONCLUSIONS In this study, cardiac abnormalities were inversely associated with the success of ETV/CPC in infants with hydrocephalus of prematurity. ETV/CPC might not be as efficacious in patients with significant cardiac anomalies. These results provide a basis for future efforts to stratify surgical candidacy for ETV/CPC on the basis of comorbid abnormalities. Proper cardiac physiological pressure monitoring might help elucidate the relationship between cardiac abnormalities and hydrocephalus.