1
|
Lee JTC, Sarode D, Emamaullee JA. Review of pediatric combined heart-liver transplantation: A roadmap to success. Pediatr Transplant 2023; 27:e14633. [PMID: 37899638 PMCID: PMC10842164 DOI: 10.1111/petr.14633] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/06/2023] [Revised: 10/06/2023] [Accepted: 10/18/2023] [Indexed: 10/31/2023]
Abstract
BACKGROUND Combined heart-liver transplantation (CHLT) is a promising technique to address end stage organ failure in patients with concomitant heart failure and chronic liver disease. While most experience with CHLT has involved adult patients, the expanding population of children born with univentricular congenital heart disease who underwent the Fontan procedure and develop Fontan-associated liver disease (FALD) has emerged as a growing indication for pediatric CHLT. METHODS Currently, CHLT is performed at a select subset of experienced transplant centers, especially in the pediatric population. RESULTS While technically demanding, CHLT may offer survival benefit when compared to heart transplant alone with decreased rejection of both synchronous allografts and equivalent outcomes with respect to waitlist time and post-operative complications. Limitations in the technique can be attributed to need for an appropriate multidisciplinary care center, challenges with donor organ availability and allocation, and the complexity associated with patient selection and peri-operative management. CONCLUSION In this review, we summarize the history of CHLT, discuss patient selection, and highlight key facets of peri-operative care in the pediatric population.
Collapse
Affiliation(s)
- Jason T C Lee
- Division of Abdominal Organ Transplantation and Hepatobiliary Surgery, Department of Surgery, Keck School of Medicine, University of Southern California, Los Angeles, California, USA
| | - Deepika Sarode
- Division of Abdominal Organ Transplantation and Hepatobiliary Surgery, Department of Surgery, Keck School of Medicine, University of Southern California, Los Angeles, California, USA
| | - Juliet A Emamaullee
- Division of Abdominal Organ Transplantation and Hepatobiliary Surgery, Department of Surgery, Keck School of Medicine, University of Southern California, Los Angeles, California, USA
| |
Collapse
|
2
|
Haeffele C, McElhinney DB. Fontan Associated Liver Disease: Canary in the Coal Mine or Silent Killer? J Am Heart Assoc 2023; 12:e031597. [PMID: 37776191 PMCID: PMC10727260 DOI: 10.1161/jaha.123.031597] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/02/2023]
Affiliation(s)
- Christiane Haeffele
- Departments of Medicine, Cardiothoracic Surgery, and PediatricsStanford University School of MedicinePalo AltoCAUSA
| | - Doff B. McElhinney
- Departments of Medicine, Cardiothoracic Surgery, and PediatricsStanford University School of MedicinePalo AltoCAUSA
| |
Collapse
|
3
|
Ponder R, Chez L, Rosenthal CJ, Bravo K, Lluri G, Reardon L, Lin J, Levi DS, Aboulhosn JA. Clinical and invasively-measured predictors of high exercise capacity in Fontan patients. Int J Cardiol 2023; 388:131166. [PMID: 37433405 DOI: 10.1016/j.ijcard.2023.131166] [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: 05/14/2023] [Revised: 07/04/2023] [Accepted: 07/06/2023] [Indexed: 07/13/2023]
Abstract
INTRODUCTION Fontan patients have variable exercise capacity. Contemporary understanding as to which factors predict high tolerance is limited. METHODS Records from the Ahmanson/University of California, Los Angeles Adult Congenital Heart Disease Center were reviewed for adult Fontan patients who underwent CPET. Patients were considered "high performers" if their maximum oxygen uptake (VO2 max/kg)-predicted was greater than 80%. Cross-sectional clinical, hemodynamic, and liver biopsy data was gathered. High-performers were compared to control patients across these parameters via associations and regression. RESULTS A total of 195 adult patients were included; 27 patients were considered "high performers". They had lower body mass indices (BMI, p < 0.001), mean Fontan pressures (p = 0.026), and cardiac outputs (p = 0.013). High performers also had higher activity levels (p < 0.001), serum albumin levels (p = 0.003), non-invasive and invasive systemic arterial oxygen saturations (p < 0.001 and p = 0.004), lower New York Heart Association (NYHA) heart failure class (p = 0.002), and were younger at Fontan completion (p = 0.011). High performers had less severe liver fibrosis (p = 0.015). Simple regression found Fontan pressure, non-invasive O2 saturation, albumin level, activity level, age at Fontan surgery, NYHA class, and BMI to predict significant changes in VO2 max/kg %-predicted. These associations persisted in multiple regression for non-invasive O2 saturation, NYHA class II, activity level, and BMI. CONCLUSIONS Thin Fontan patients who exercise more had better exercise capacity, Fontan hemodynamic profiles, and less liver fibrosis.
Collapse
Affiliation(s)
- Reid Ponder
- Department of Medicine, Tufts University School of Medicine, Boston, MA, United States of America; Division of Cardiology, Ahmanson/UCLA Adult Congenital Heart Disease Center, David Geffen School of Medicine at UCLA, Los Angeles, CA, United States of America.
| | - Luke Chez
- Division of Pediatric Cardiology, David Geffen School of Medicine at UCLA, Los Angeles, CA, United States of America
| | - Carl J Rosenthal
- University of California-Los Angeles, Los Angeles, CA, United States of America
| | - Katia Bravo
- Department of Cardiovascular Medicine, Mayo Clinic, Jacksonville, FL, United States of America
| | - Gentian Lluri
- Division of Cardiology, Ahmanson/UCLA Adult Congenital Heart Disease Center, David Geffen School of Medicine at UCLA, Los Angeles, CA, United States of America
| | - Leigh Reardon
- Division of Pediatric Cardiology, David Geffen School of Medicine at UCLA, Los Angeles, CA, United States of America; Division of Cardiology, Ahmanson/UCLA Adult Congenital Heart Disease Center, David Geffen School of Medicine at UCLA, Los Angeles, CA, United States of America
| | - Jeannette Lin
- Division of Cardiology, Ahmanson/UCLA Adult Congenital Heart Disease Center, David Geffen School of Medicine at UCLA, Los Angeles, CA, United States of America
| | - Daniel S Levi
- Division of Pediatric Cardiology, David Geffen School of Medicine at UCLA, Los Angeles, CA, United States of America
| | - Jamil A Aboulhosn
- Division of Cardiology, Ahmanson/UCLA Adult Congenital Heart Disease Center, David Geffen School of Medicine at UCLA, Los Angeles, CA, United States of America
| |
Collapse
|
4
|
Matsukuma K, Yeh MM. Practical Guide, Challenges, and Pitfalls in Liver Fibrosis Staging. Surg Pathol Clin 2023; 16:457-472. [PMID: 37536882 DOI: 10.1016/j.path.2023.04.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/05/2023]
Abstract
Liver fibrosis staging has many challenges, including the large number of proposed staging systems, the heterogeneity of the histopathologic changes of many primary liver diseases, and the potential for slight differences in histologic interpretation to significantly affect clinical management. This review focuses first on fibrosis regression. Following this, each of the major categories of liver disease is discussed in regard to (1) appropriate fibrosis staging systems, (2) emerging concepts, (3) current clinical indications for liver biopsy, (4) clinical decisions determined by fibrosis stage, and (5) histologic challenges and pitfalls related to staging.
Collapse
Affiliation(s)
- Karen Matsukuma
- University of California Davis, Pathology and Laboratory Medicine, 4400 V Street, Sacramento, CA 95817, USA.
| | - Matthew M Yeh
- University of Washington Medical Center - Montlake, Box 356100, 1959 NE Pacific Street, Seattle, WA 98195, USA
| |
Collapse
|
5
|
Meyer Z, Haas N, Mühlberg R, Braun A, Fischer M, Mandilaras G. Transient liver elastography in the follow-up of Fontan patients: results of a nation wide survey in Germany. Front Pediatr 2023; 11:1194641. [PMID: 37711600 PMCID: PMC10499538 DOI: 10.3389/fped.2023.1194641] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/27/2023] [Accepted: 07/24/2023] [Indexed: 09/16/2023] Open
Abstract
Introduction Fontan-palliated patients are at risk for the development of Fontan-associated liver disease (FALD). Currently, there is no consensus on how to stage FALD. Transient elastography (TE) is a rapid, non-invasive method to assess FALD and liver fibrosis. Method To assess the availability and conditions of using TE to monitor liver disease in Fontan patients in german centers for pediatric cardiology and to propose the introduction of a standardized national protocol for the monitoring of liver disease, we developed a questionnaire. Results In total, 95 valid questionnaires were collected. Only 20% of the centers offer the TE investigation directly. Most of the centers transfer the patients to another department or center (40%) or didńt offer TE (40%). In only 2.6% of the centers TE is performed directly by the cardiologist. Most of the centers transfer the patients to a other department. In 29.2% TE is performed only at a certain age of the patients and in 27.7% it is performed if the patients present symptoms of failing Fontan. In only 13.9% of the centers TE is proposed in all the Fontan patients on a routine basis. Most often TE is performed only from the beginning of the adolescence. In the majority of answers it was not known if the patients are fasting for the examination (68%) or not and if the TE examination had to be performed in a specific breathing phase during TE (Inspiration/Expiration, 90%). In the majority, TE is not offered routinely (46.9%). Discussion To date in Germany, TE is only used in a few numbers of centers specialized in Fontan follow-up. A standardized protocol to use TE is currently not existing. With regard to the feasibility of the examination, it is evident that TE is a quick, cheap and easy method to distinguish between cases with and without progressive FALD. This makes TE a useful and prognostic tool for screening of liver disease and to failing Fontan circulation. Conclusion We propose a systematic TE evaluation of possible liver congestion and fibrosis, as a part of the routine follow-up of Fontan patients.
Collapse
Affiliation(s)
- Zora Meyer
- Ludwig Maximilian University of Munich, Munich, Germany
| | | | | | | | | | | |
Collapse
|
6
|
Evans WN, Acherman RJ, Galindo A, Rothman A, Ciccolo ML, Lehoux J, Restrepo H. Hepatic Fibrosis Risk Factors in Extracardiac-Fontan Patients: Observations From a Single Center. World J Pediatr Congenit Heart Surg 2023; 14:345-349. [PMID: 36883214 DOI: 10.1177/21501351231154216] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/09/2023]
Abstract
Objective: We reviewed our experience with transvenous liver biopsy-derived hepatic fibrosis scores and possible associated risk factors in those postextracardiac Fontan patients. Methods: We identified extracardiac-Fontan patients with postoperative durations <20 years who underwent cardiac catheterizations with transvenous hepatic biopsies between April 2012 and July 2022. If a patient underwent two liver biopsies, we averaged the two total fibrosis scores and concurrent time, pressure, and oxygen saturation data. We grouped patients by the following factors: (1) sex, (2) venovenous collaterals, and (3) type of functionally univentricular heart. We identified potential hepatic fibrosis risk factors as the following: female, presence of venovenous collaterals, and a functional univentricle of right-ventricular type. For statistical analysis, we used Kruskal-Wallis nonparametric testing. Results: We identified 127 patients who underwent 165 transvenous biopsies, with 38 patients undergoing 2 biopsies. We found that females with two additional risk factors had the highest median total fibrosis scores, 4 (1-8); males with <2 risk factors had the lowest median total fibrosis scores, 2 (0-5); and females with <2 additional risk factors and males with two risk factors were in the middle, median total fibrosis score 3 (0-6), P =.002; and there were no statistical differences for the other demographic or hemodynamic variables. Conclusions: For extracardiac-Fontan patients with similar demographic and hemodynamic variables, identifiable risk factors are associated with the degree of hepatic fibrosis.
Collapse
Affiliation(s)
- William N Evans
- Congenital 20567Heart Center Nevada, Las Vegas, NV, USA.,Division of Pediatric Cardiology, Department of Pediatrics, 212548Kirk Kerkorian School of Medicine, Las Vegas, NV, USA
| | - Ruben J Acherman
- Congenital 20567Heart Center Nevada, Las Vegas, NV, USA.,Division of Pediatric Cardiology, Department of Pediatrics, 212548Kirk Kerkorian School of Medicine, Las Vegas, NV, USA
| | - Alvaro Galindo
- Congenital 20567Heart Center Nevada, Las Vegas, NV, USA.,Division of Pediatric Cardiology, Department of Pediatrics, 212548Kirk Kerkorian School of Medicine, Las Vegas, NV, USA
| | - Abraham Rothman
- Congenital 20567Heart Center Nevada, Las Vegas, NV, USA.,Division of Pediatric Cardiology, Department of Pediatrics, 212548Kirk Kerkorian School of Medicine, Las Vegas, NV, USA
| | - Michael L Ciccolo
- Congenital 20567Heart Center Nevada, Las Vegas, NV, USA.,Department of Surgery, 212548Kirk Kerkorian School of Medicine at UNLV, Las Vegas, NV, USA
| | - Juan Lehoux
- Congenital 20567Heart Center Nevada, Las Vegas, NV, USA
| | - Humberto Restrepo
- Congenital 20567Heart Center Nevada, Las Vegas, NV, USA.,Division of Pediatric Cardiology, Department of Pediatrics, 212548Kirk Kerkorian School of Medicine, Las Vegas, NV, USA
| |
Collapse
|
7
|
Moscatelli S, Borrelli N, Sabatino J, Leo I, Avesani M, Montanaro C, Di Salvo G. Role of Cardiovascular Imaging in the Follow-Up of Patients with Fontan Circulation. CHILDREN (BASEL, SWITZERLAND) 2022; 9:children9121875. [PMID: 36553321 PMCID: PMC9777137 DOI: 10.3390/children9121875] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 11/04/2022] [Revised: 11/27/2022] [Accepted: 11/28/2022] [Indexed: 12/02/2022]
Abstract
Since its first description in 1971, the Fontan procedure and its modifications have led to a substantial improvement in the survival rates of patients with a variety of types of complex Congenital Heart Disease (CHD) characterised by the presence of a single, dominant ventricle. However, despite the significant improvement of the prognosis over the years, Fontan patients are still exposed to several cardiovascular and systemic complications. It is, therefore, important to fully understand the pitfalls hidden behind a Fontan anatomy and the potential predictors of ventricular failure. Cardiovascular imaging plays a key role in this context, allowing for the early identification of complications with important prognostic implications. Echocardiography remains the first-line imaging modality for serial evaluation of Fontan patients. However, there is a growing role of cardiovascular magnetic resonance and cardiac computed tomography from pre-operative assessment to longitudinal follow-up. The aim of this paper will be to provide a comprehensive overview of the role, strengths, and weaknesses of each imaging modality in the assessment of congenital cardiac conditions palliated with the Fontan procedure.
Collapse
Affiliation(s)
- Sara Moscatelli
- Paediatric Cardiology Department, Royal Brompton Hospital Harefield NHS Foundation Trust, London SW3 5NP, UK
| | - Nunzia Borrelli
- Adult Congenital Heart Disease Unit, A.O. dei Colli, Monaldi Hospital, 80131 Naples, Italy
| | - Jolanda Sabatino
- Division of Paediatric Cardiology, Department of Women and Children’s Health, University Hospital Padua, 35128 Padua, Italy
- Paediatric Research Institute (IRP), Città Della Speranza, 35127 Padua, Italy
| | - Isabella Leo
- Department of Medical and Surgical Sciences, Magna Grecia University, 88100 Catanzaro, Italy
- Cardiac Magnetic Resonance Department, Royal Brompton Hospital Harefield NHS Foundation Trust, London SW3 5NP, UK
| | - Martina Avesani
- Division of Paediatric Cardiology, Department of Women and Children’s Health, University Hospital Padua, 35128 Padua, Italy
| | - Claudia Montanaro
- Adult Congenital Department, Royal Brompton Hospital & Harefield NHS Foundation Trust, London SW3 5NP, UK
| | - Giovanni Di Salvo
- Division of Paediatric Cardiology, Department of Women and Children’s Health, University Hospital Padua, 35128 Padua, Italy
- Paediatric Research Institute (IRP), Città Della Speranza, 35127 Padua, Italy
- Correspondence:
| |
Collapse
|
8
|
Selective Use of Pulmonary Vasodilators in Patients with Fontan Physiology. J Interv Cardiol 2022; 2022:7602793. [DOI: 10.1155/2022/7602793] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2022] [Revised: 10/27/2022] [Accepted: 11/04/2022] [Indexed: 11/11/2022] Open
Abstract
Background. Fontan-associated liver disease is a well-known sequela following the Fontan procedure for patients living with single-ventricle heart disease. Pulmonary vasodilators, such as phosphodiesterase type 5 inhibitors, have emerged as a potential therapeutic option for lowering central venous pressures by reducing pulmonary vascular resistance. Method. We performed a single-center retrospective review of Fontan patients who were placed on pulmonary vasodilator therapy with prehemodynamic and posthemodynamic, MR elastography, and histologic assessments. Results. A total of 125 patients with Fontan circulation underwent surveillance with cardiac catheterization during the review period. Fifty-three (42%) patients who did not have increased end-diastolic pressures at the time of cardiac catheterization were started on phosphodiesterase type 5 inhibitor therapy. Nine patients (17%) underwent posttherapy follow-up catheterization. The mean Fontan pressure decreased from 15.4 ± 3.3 mmHg to 13.3 ± 2.5 mmHg (
), after initiation of pulmonary vasodilatory therapy. There was no change in end-diastolic pressure, transpulmonary gradient, wedge pressure, pulmonary vascular resistance, cardiac index, or saturation. Eleven patients (21%) underwent pretherapy MR elastography testing with posttherapy follow-up MR elastography. We found no improvement in liver stiffness score following the application of pulmonary vasodilators. Three patients underwent pretherapy and posttherapy liver biopsies, with variable histological changes observed within the hepatic parenchyma. Conclusions. These data demonstrate indeterminate results for the selective use of pulmonary vasodilators but highlight the need for large prospective randomized control trials of pulmonary vasodilator therapies to fully assess the benefit of such therapies in Fontan-associated liver disease.
Collapse
|
9
|
Evans WN, Acherman RJ, Restrepo H. Hepatic fibrosis gender differences in extracardiac Fontan patients. J Card Surg 2022; 37:3520-3524. [PMID: 36057990 DOI: 10.1111/jocs.16880] [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: 07/23/2022] [Accepted: 08/11/2022] [Indexed: 11/30/2022]
Abstract
OBJECTIVE We investigated possible gender differences for hepatic fibrosis in extracardiac-Fontan patients. METHODS We identified extracardiac Fontan, performed between 2000 and 2016, who underwent cardiac catheterizations with transvenous hepatic biopsies between April 2012 and June 2022. We divided the patients by gender for analysis. RESULTS We identified 116 patients who underwent 145 transvenous biopsies, with 29 patients undergoing 2 biopsies at an average interval of 5 ± 1 years. We divided the 145 biopsies into two groups: 1) 98/145 (68%) males and 2) 47/145 (32%) females. For the 47 female liver biopsy specimens, the median total fibrosis score was 3 (0-8), and for the 98 male liver biopsy specimens, the median total fibrosis score was 2 (0-6), p = .007. The average age at surgery for females was 3 ± 1 years and for males 3 ± 1 years, p = .99. Average Fontan duration at biopsy for females was 11 ± 5 years and for males, 10 ± 4 years, p = .23. No other demographic, anatomic, echocardiographic, laboratory, or hemodynamic findings demonstrated statistically significant gender differences. CONCLUSIONS Females had statistically significantly higher median total fibrosis scores than males for the similar average age at extracardiac Fontan and average Fontan duration.
Collapse
Affiliation(s)
- William N Evans
- Congenital Heart Center Nevada, Las Vegas, Nevada, USA.,Division of Pediatric Cardiology, Department of Pediatrics, Kirk Kerkorian School of Medicine at UNLV, Las Vegas, Nevada, USA
| | - Ruben J Acherman
- Congenital Heart Center Nevada, Las Vegas, Nevada, USA.,Division of Pediatric Cardiology, Department of Pediatrics, Kirk Kerkorian School of Medicine at UNLV, Las Vegas, Nevada, USA
| | - Humberto Restrepo
- Congenital Heart Center Nevada, Las Vegas, Nevada, USA.,Division of Pediatric Cardiology, Department of Pediatrics, Kirk Kerkorian School of Medicine at UNLV, Las Vegas, Nevada, USA
| |
Collapse
|
10
|
Evans WN, Acherman RJ, Mayman GA, Galindo A, Rothman A, Samson R, Ciccolo ML, Lehoux J, Restrepo H. Low discontinuity of care rate for adults with complex congenital heart disease: A single center's experience. PROGRESS IN PEDIATRIC CARDIOLOGY 2022. [DOI: 10.1016/j.ppedcard.2021.101461] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
|
11
|
Invasive Hemodynamic Evaluation of the Fontan Circulation: Current Day Practice and Limitations. Curr Cardiol Rep 2022; 24:587-596. [PMID: 35230616 DOI: 10.1007/s11886-022-01679-4] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 02/03/2022] [Indexed: 12/29/2022]
Abstract
PURPOSE OF REVIEW Establishing the Fontan circulation has led to improved survival in patients born with complex congenital heart diseases. Despite early success, the long-term course of Fontan patients is complicated by multi-organ dysfunction, mainly due to a combination of low resting and blunted exercise-augmented cardiac output as well as elevated central venous (Fontan) pressure. Similarly, despite absolute hemodynamic differences compared to the normal population with biventricular circulation, the "normal" ranges of hemodynamic parameters specific to age-appropriate Fontan circulation have not been well defined. With the ever-increasing population of patients requiring Fontan correction, it is of utmost importance that an acceptable range of hemodynamics in this highly complex patient cohort is better defined. RECENT FINDINGS Multiple publications have described hemodynamic limitations and potential management options in patients with Fontan circulation; however, an acceptable range of hemodynamic parameters in this patient population has not been well defined. Identification of "normal" hemodynamic parameters among patients with Fontan circulation will allow physicians to more objectively define indications for intervention, which is a necessary first step to eliminate institutional and regional heterogeneity in Fontan management and potentially improve long-term clinical outcomes.
Collapse
|
12
|
Non-invasive biomarkers of Fontan-associated liver disease. JHEP Rep 2021; 3:100362. [PMID: 34693238 PMCID: PMC8517550 DOI: 10.1016/j.jhepr.2021.100362] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/30/2021] [Revised: 08/12/2021] [Accepted: 09/05/2021] [Indexed: 02/07/2023] Open
Abstract
Background & Aims Fontan-associated liver disease (FALD) has emerged as an important morbidity following surgical palliation of single ventricle congenital heart disease. In this study, non-invasive biomarkers that may be associated with severity of FALD were explored. Methods A retrospective cohort of paediatric patients post-Fontan who underwent liver biopsy at a high volume at a paediatric congenital heart disease centre was reviewed. Results Among 106 patients, 66% were male and 69% were Hispanic. The mean age was 14.4 ± 3.5 years, and biopsy was performed 10.8 ± 3.6 years post-Fontan. The mean BMI was 20.8 ± 5 kg/m2, with 27.4% meeting obesity criteria. Bridging fibrosis was observed in 35% of patients, and 10.4% of all patients had superimposed steatosis. Bridging fibrosis was associated with lower platelet counts (168.3 ± 58.4 vs. 203.9 ± 65.8 K/μl for congestive hepatic fibrosis score [CHFS] 0–2b, p = 0.009), higher bilirubin (1.7 ± 2.2 vs. 0.9 ± 0.7 mg/dl, p = 0.0090), higher aspartate aminotransferase-to-platelet ratio index [APRI] and fibrosis-4 [FIB-4] scores (APRI: 0.5 ± 0.3 vs. 0.4 ± 0.1, p <0.01 [AUC: 0.69] and FIB-4: 0.6 ± 0.4 vs. 0.4 ± 0.2, p <0.01 [AUC: 0.69]), and worse overall survival (median 2 years follow-up post-biopsy, p = 0.027). Regression modelling of temporal changes in platelet counts before and after biopsy correlated with fibrosis severity (p = 0.005). Conclusions In this large, relatively homogeneous adolescent population in terms of age, ethnicity, and Fontan duration, bridging fibrosis was observed in 35% of patients within the first decade post-Fontan. Bridging fibrosis was associated with worse survival. Changes in platelet counts, even years before biopsy, and APRI/FIB-4 scores had modest discriminatory power in identifying patients with advanced fibrosis. Steatosis may represent an additional risk factor for disease progression in obese patients. Further prospective studies are necessary to develop strategies to screen for FALD in the adolescent population. Lay summary In this study, the prevalence of Fontan-associated liver disease (FALD) in the young adult population and clinical variables that may be predictive of fibrosis severity or adverse outcomes were explored. Several lab-based, non-invasive markers of bridging fibrosis in FALD were identified, suggesting that these values may be followed as a prognostic biomarker for FALD progression in the adolescent population. FALD is universal within 10 years post-Fontan, with 35% of patients having bridging fibrosis. Of our adolescent patient population, 10% had concomitant hepatic steatosis, which was associated with obesity. Regression modelling demonstrates that temporal changes in platelet counts correlate with severity of fibrosis in FALD. AST-to-platelet ratio index and FIB-4 scores correlate with bridging fibrosis with a high specificity. Bridging fibrosis in FALD is associated with worse survival.
Collapse
Key Words
- ALP, alkaline phosphatase
- ALT, alanine aminotransferase
- APRI, AST-to-platelet ratio index
- AST, aspartate aminotransferase
- BMI, body mass index
- BNP, brain natriuretic peptide
- BUN, blood urea nitrogen
- CBC, complete blood count
- CHFS, congestive hepatic fibrosis score
- CHLT, combined heart–liver transplantation
- CVP, central venous pressure
- Congenital heart disease
- Congestive hepatopathy
- ECMO, extracorporeal membrane oxygenation
- FALD, Fontan-associated liver disease
- FIB-4, fibrosis-4
- GFR, glomerular filtration rate
- GGT, gamma-glutamyl transferase
- INR, international normalised ratio
- IQR, interquartile range
- LVAD, left ventricular assist device
- MELD, model of end-stage liver disease
- MELD-Na, MELD-sodium
- MELD-XI, MELD without INR
- NAFLD, non-alcoholic fatty liver disease
- PELD, paediatric end-stage liver disease
- PT, prothrombin time
- PTT, partial thromboplastin time
- TTE, transthoracic echocardiograms
- Univentricular heart disease
Collapse
|
13
|
Menteer J, Goldbeck C, Herrington C, Yanni G, Emamaullee JA. Immunologic and Survival Benefits of Combined Heart-liver Transplantation in Children. Transplantation 2021; 105:e107-e108. [PMID: 34416752 PMCID: PMC8932196 DOI: 10.1097/tp.0000000000003810] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Affiliation(s)
- Jondavid Menteer
- Heart Institute, Children’s Hospital Los Angeles, Los Angeles, CA
- Keck School of Medicine, University of Southern California, Los Angeles, CA
| | - Cameron Goldbeck
- Keck School of Medicine, University of Southern California, Los Angeles, CA
- Division of Hepatobiliary and Abdominal Organ Transplant Surgery, University of Southern California, Los Angeles, CA
| | - Cynthia Herrington
- Heart Institute, Children’s Hospital Los Angeles, Los Angeles, CA
- Keck School of Medicine, University of Southern California, Los Angeles, CA
| | - George Yanni
- Keck School of Medicine, University of Southern California, Los Angeles, CA
- Division of Gastroenterology and Hepatology, Department of Pediatrics, Children’s Hospital Los Angeles, Los Angeles, CA
| | - Juliet A. Emamaullee
- Keck School of Medicine, University of Southern California, Los Angeles, CA
- Division of Hepatobiliary and Abdominal Organ Transplant Surgery, University of Southern California, Los Angeles, CA
| |
Collapse
|
14
|
Progression in Fontan conduit stenosis and hemodynamic impact during childhood and adolescence. J Thorac Cardiovasc Surg 2021; 162:372-380.e2. [DOI: 10.1016/j.jtcvs.2020.09.140] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/04/2020] [Revised: 09/29/2020] [Accepted: 09/30/2020] [Indexed: 01/09/2023]
|
15
|
Dos L, Rueda Soriano J, Ávila P, Escribano P, Garrido-Lestache Rodríguez-Monte ME, González AE, Martínez Bendayan I, Montserrat S, Gallego P, Alonso R, Martínez Momblán MA, García Orta R, Oliver Ruiz JM, Peinado Peinado R, Cano Pérez Ó, Gutiérrez Larraya F, González A, Méndez I, Lázaro Salvador M, Avanzas P, Berga Congost G, Boraita A, Bueno H, Calvo D, Campuzano R, Delgado V, Dos L, Ferreira-González I, Gómez Doblas JJ, Pascual Figal D, Sambola Ayala A, Viana Tejedor A, Ferreiro JL, Alfonso F. Comments on the 2020 ESC guidelines for the management of adult congenital heart disease. REVISTA ESPANOLA DE CARDIOLOGIA (ENGLISH ED.) 2021; 74:371-377. [PMID: 33771487 DOI: 10.1016/j.rec.2020.11.025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/03/2020] [Accepted: 11/23/2020] [Indexed: 06/12/2023]
|
16
|
Comentarios a la guía ESC 2020 sobre el tratamiento de las cardiopatías congénitas en el adulto. Rev Esp Cardiol (Engl Ed) 2021. [DOI: 10.1016/j.recesp.2020.11.022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
|
17
|
de Lange C. Imaging of complications following Fontan circulation in children - diagnosis and surveillance. Pediatr Radiol 2020; 50:1333-1348. [PMID: 32468285 PMCID: PMC7445207 DOI: 10.1007/s00247-020-04682-5] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/02/2020] [Revised: 03/08/2020] [Accepted: 04/16/2020] [Indexed: 12/27/2022]
Abstract
The Fontan operation is performed for various cardiac lesions with single-ventricle physiology. The survival rate of Fontan patients is increasing for adolescents and young adults, with an expected 30-year survival of >80%. Medical health care providers including specialists in organ systems and pediatric radiologists need to improve their knowledge about the Fontan circulation and the various organ complications to monitor care. In this review the author explains the basic anatomical and functional features of Fontan palliation and gives an overview of the multiple long-term organ complications that might present in the pediatric population. These include decreased physical capacity, ventricular dysfunction, atrioventricular valve regurgitation and arrhythmia, as well as protein-losing enteropathy, plastic bronchitis, growth/bone composition disturbances, renal dysfunction, and the recently recognized and important liver fibrosis (Fontan-associated liver disease). Neuropsychological and behavioral deficits occur frequently. This review focuses on the key role of radiology in making the diagnosis of these complications, monitoring therapy and predicting outcomes in the pediatric age group. The author discusses how and when radiology is important in Fontan patients, as well as how new techniques enabling quantitative measures in imaging with US, MRI and CT are adapted for pediatric use, and how they contribute to urgently needed surveillance strategies.
Collapse
Affiliation(s)
- Charlotte de Lange
- Department of Radiology and Clinical Physiology, Queen Silvia Children's Hospital, Rondv.10, S-41516, Gothenburg, Sweden. .,Department of Radiology and Nuclear Medicine, Oslo University Hospital, Oslo, Norway.
| |
Collapse
|