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Yoon H, Kim J, Lim HJ, Lee MJ. Quantitative Liver Imaging in Children. Invest Radiol 2024:00004424-990000000-00238. [PMID: 39047265 DOI: 10.1097/rli.0000000000001101] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/27/2024]
Abstract
ABSTRACT In children and adults, quantitative imaging examinations determine the effectiveness of treatment for liver disease. However, pediatric liver disease differs in presentation from liver disease in adults. Children also needed to be followed for a longer period from onset and have less control of their bodies, showing more movement than adults during imaging examinations, which leads to a greater need for sedation. Thus, it is essential to appropriately tailor and accurately perform noninvasive imaging tests in these younger patients. This article is an overview of updated imaging techniques used to assess liver disease quantitatively in children. The common initial imaging study for diffuse liver disease in pediatric patients is ultrasound. In addition to preexisting echo analysis, newly developed attenuation imaging techniques have been introduced to evaluate fatty liver. Ultrasound elastography is also now actively used to evaluate liver conditions, and the broad age spectrum of the pediatric population requires caution to be taken even in the selection of probes. Magnetic resonance imaging (MRI) is another important imaging tool used to evaluate liver disease despite requiring sedation or anesthesia in young children because it allows quantitative analysis with sequences such as fat analysis and MR elastography. In addition to ultrasound and MRI, we review quantitative imaging methods specifically for fatty liver, Wilson disease, biliary atresia, hepatic fibrosis, Fontan-associated liver disease, autoimmune hepatitis, sinusoidal obstruction syndrome, and the transplanted liver. Lastly, concerns such as growth and motion that need to be addressed specifically for children are summarized.
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Affiliation(s)
- Haesung Yoon
- From the Department of Radiology, Gangnam Severance Hospital, Seoul, South Korea (H.Y.); Department of Radiology and Research Institute of Radiological Science, Yonsei University, College of Medicine, Seoul, South Korea (H.Y., J.K., H.J.L., M.-J.L.); and Department of Pediatric Radiology, Severance Children's Hospital, Seoul, South Korea (J.K., H.J.L., M.-J.L.)
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Gould M, Gunsaulus M, Feingold B, Goldstein B, Hoskoppal A, Kreutzer J, Lanford L, Trucco S, Alsaied T. Thrombocytopenia is Associated with Higher Fontan Pressure and Increased Morbidity in Patients with Fontan Circulation. Pediatr Cardiol 2024:10.1007/s00246-024-03567-w. [PMID: 38951145 DOI: 10.1007/s00246-024-03567-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/19/2024] [Accepted: 06/22/2024] [Indexed: 07/03/2024]
Abstract
After the Fontan procedure, patients require lifelong follow-up due to significant late morbidity and mortality. Thrombocytopenia is seen frequently post-Fontan, likely due to secondary hypersplenism from elevated Fontan pressure. We investigated platelet counts in patients with a Fontan circulation and assessed associations with catheterization data and clinical outcomes. This retrospective study included 92 patients (33% female) post-Fontan who had a complete blood count performed between January 2011 and July 2023. The age at evaluation was 24.0 ± 8.9 years. Outcomes measured included elevated Fontan pressure (≥ 15 mmHg), Fontan-associated liver disease (FALD), unscheduled admissions, transplant, and death. Participants with thrombocytopenia (≤ 150,000/µL) had significantly higher rates of elevated Fontan pressure (OR 8.1, 95% CI 1.3-52.7, p = 0.03), FALD (OR 4.1, 95% CI 1.6-10.6, p = 0.004), and unscheduled admissions (362 ± 577 versus 115 ± 185 admissions per 1000 patient-years, p = 0.02). Thrombocytopenia post-Fontan is associated with elevated Fontan pressure, FALD, and increased morbidity. Platelet count could serve as a non-invasive factor in identifying patients at risk of decompensation.
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Affiliation(s)
- Michael Gould
- Department of Pediatrics, UPMC Children's Hospital of Pittsburgh, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA.
| | - Megan Gunsaulus
- The Heart and Vascular Institute, UPMC Children's Hospital of Pittsburgh, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
- Division of Pediatric Cardiology, Department of Pediatrics, Nationwide Children's Hospital, Columbus, OH, USA
| | - Brian Feingold
- The Heart and Vascular Institute, UPMC Children's Hospital of Pittsburgh, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Bryan Goldstein
- The Heart and Vascular Institute, UPMC Children's Hospital of Pittsburgh, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Arvind Hoskoppal
- The Heart and Vascular Institute, UPMC Children's Hospital of Pittsburgh, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Jacqueline Kreutzer
- The Heart and Vascular Institute, UPMC Children's Hospital of Pittsburgh, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Lizabeth Lanford
- The Heart and Vascular Institute, UPMC Children's Hospital of Pittsburgh, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Sara Trucco
- The Heart and Vascular Institute, UPMC Children's Hospital of Pittsburgh, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Tarek Alsaied
- The Heart and Vascular Institute, UPMC Children's Hospital of Pittsburgh, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
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Gunsaulus M, Wang L, Haack L, Christopher A, Feingold B, Squires J, Horslen S, Hoskoppal A, Rose-Felker K, West S, Trucco S, Squires J, Olivieri L, Kreutzer J, Goldstein B, Alsaied T. Cardiac MRI-Derived Inferior Vena Cava Cross-Sectional Area Correlates with Measures of Fontan-Associated Liver Disease. Pediatr Cardiol 2024; 45:909-920. [PMID: 36454265 DOI: 10.1007/s00246-022-03054-0] [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: 09/25/2022] [Accepted: 11/15/2022] [Indexed: 12/05/2022]
Abstract
There is currently no clear consensus on screening techniques to evaluate the presence or severity of Fontan-associated liver disease (FALD). Cardiac MRI (CMR) is used routinely for post-Fontan surveillance, but CMR-derived measures that relate to the severity of FALD are not yet defined. This was a cross-sectional single-center study of post-Fontan patients who underwent a CMR. CMR exams were re-analyzed by a single pediatric cardiologist. Surrogates of FALD included Gamma-Glutamyl Transferase (GGT), Fibrosis-4 laboratory score (FIB-4), and imaging findings. Findings consistent with cirrhosis on liver ultrasound included increased liver echogenicity and/or nodularity. Statistical analyses were performed to investigate potential relationships between CMR parameters and markers of FALD. Sixty-one patients were included. A larger inferior vena cava cross-sectional area (IVC-CSA) indexed to height was significantly associated with a higher FIB-4 score (Spearman's ρ = 0.28, p = 0.04), a higher GGT level (Spearman's ρ = 0.40, p = 0.02), and findings consistent with cirrhosis on liver ultrasound (OR 1.17, 95% CI: (1.01, 1.35), p = 0.04). None of the other CMR parameters were associated with markers of FALD. A larger indexed IVC-CSA was associated with higher systemic ventricle end-diastolic pressure (EDP) on cardiac catheterization (Spearman's ρ = 0.39, p = 0.018) as well as older age (Spearman's ρ = 0.46, p = < 0.001). Indexed IVC-CSA was the only CMR parameter that was associated with markers of FALD. This measure has the potential to serve as an additional non-invasive tool to improve screening strategies for FALD.
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Affiliation(s)
- Megan Gunsaulus
- Pediatric Cardiology, UPMC Children's Hospital of Pittsburgh, 4401 Penn Avenue, 5th Floor Faculty Pavilion, Pittsburgh, PA, 15224, USA.
| | - Li Wang
- Epidemiology Data Center, University of Pittsburgh Graduate School of Public Health, Pittsburgh, PA, USA
| | - Lindsey Haack
- Pediatric Cardiology, UPMC Children's Hospital of Pittsburgh, 4401 Penn Avenue, 5th Floor Faculty Pavilion, Pittsburgh, PA, 15224, USA
| | - Adam Christopher
- Pediatric Cardiology, UPMC Children's Hospital of Pittsburgh, 4401 Penn Avenue, 5th Floor Faculty Pavilion, Pittsburgh, PA, 15224, USA
| | - Brian Feingold
- Pediatric Cardiology, UPMC Children's Hospital of Pittsburgh, 4401 Penn Avenue, 5th Floor Faculty Pavilion, Pittsburgh, PA, 15224, USA
| | - James Squires
- Pediatric Gastroenterology, UPMC Children's Hospital of Pittsburgh, Pittsburgh, PA, USA
| | - Simon Horslen
- Pediatric Gastroenterology, UPMC Children's Hospital of Pittsburgh, Pittsburgh, PA, USA
| | - Arvind Hoskoppal
- Pediatric Cardiology, UPMC Children's Hospital of Pittsburgh, 4401 Penn Avenue, 5th Floor Faculty Pavilion, Pittsburgh, PA, 15224, USA
| | - Kirsten Rose-Felker
- Pediatric Cardiology, UPMC Children's Hospital of Pittsburgh, 4401 Penn Avenue, 5th Floor Faculty Pavilion, Pittsburgh, PA, 15224, USA
| | - Shawn West
- Pediatric Cardiology, UPMC Children's Hospital of Pittsburgh, 4401 Penn Avenue, 5th Floor Faculty Pavilion, Pittsburgh, PA, 15224, USA
| | - Sara Trucco
- Pediatric Cardiology, UPMC Children's Hospital of Pittsburgh, 4401 Penn Avenue, 5th Floor Faculty Pavilion, Pittsburgh, PA, 15224, USA
| | - Judy Squires
- Pediatric Radiology, UPMC Children's Hospital of Pittsburgh, Pittsburgh, PA, USA
| | - Laura Olivieri
- Pediatric Cardiology, UPMC Children's Hospital of Pittsburgh, 4401 Penn Avenue, 5th Floor Faculty Pavilion, Pittsburgh, PA, 15224, USA
| | - Jacqueline Kreutzer
- Pediatric Cardiology, UPMC Children's Hospital of Pittsburgh, 4401 Penn Avenue, 5th Floor Faculty Pavilion, Pittsburgh, PA, 15224, USA
| | - Bryan Goldstein
- Pediatric Cardiology, UPMC Children's Hospital of Pittsburgh, 4401 Penn Avenue, 5th Floor Faculty Pavilion, Pittsburgh, PA, 15224, USA
| | - Tarek Alsaied
- Pediatric Cardiology, UPMC Children's Hospital of Pittsburgh, 4401 Penn Avenue, 5th Floor Faculty Pavilion, Pittsburgh, PA, 15224, USA
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Derinkuyu BE, Dillman JR, Lubert AM, Palermo JJ, Opotowsky AR, Trout AT. Associations of Liver Stiffness Measured by Ultrasound Shear-Wave Elastography With Portal Hypertension and Circulatory Failure in Individuals With Fontan Circulation. AJR Am J Roentgenol 2024; 222:e2329640. [PMID: 37530396 DOI: 10.2214/ajr.23.29640] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/03/2023]
Abstract
BACKGROUND. The Fontan operation palliates single-ventricle congenital heart disease but causes hepatic congestion with associated progressive hepatic fibrosis. OBJECTIVE. The purpose of this study was to evaluate associations between liver stiffness measured using ultrasound (US) shear-wave elastography (SWE) in patients with Fontan palliation and the occurrence of portal hypertension and Fontan circulatory failure during follow-up. METHODS. This retrospective study included 119 individuals 10 years old or older (median age, 19.1 years; 61 female patients, 58 male patients) with Fontan circulation who underwent liver US with 2D SWE from January 1, 2015, to January 1, 2022, and had 1 year or more of clinical follow-up (unless experiencing earlier outcome-related events). Median liver stiffness from the initial US examination was documented. Varices, ascites, splenomegaly, and thrombocytopenia (VAST) scores (range, 0-4) were determined as a marker of portal hypertension on initial US examination and 1 year or more of follow-up imaging (US, CT, or MRI). Composite clinical outcome for Fontan circulatory failure (death, mechanical circulatory support, cardiac transplant, or unexpected Fontan circulation-related hospitalization) was assessed. Analysis included the Wilcoxon rank sum test, logistic regression analysis with stepwise variable selection, and ROC analysis. RESULTS. Median initial liver stiffness was 2.22 m/s. Median initial VAST score was 0 (IQR, 0-1); median follow-up VAST score was 1 (IQR, 0-2) (p = .004). Fontan circulatory failure occurred in 37 of 119 (31%) patients (median follow-up, 3.4 years). Initial liver stiffness was higher in patients with a follow-up VAST score of 1 or greater (2.37 m/s) than in those with a follow-up VAST score of 0 (2.08 m/s) (p = .005), and initial liver stiffness was higher in patients with (2.43 m/s) than without (2.10 m/s) Fontan circulatory failure during follow-up (p < .001). Initial liver stiffness was the only significant independent predictor of Fontan circulatory failure (OR = 3.76; p < .001); age, sex, Fontan operation type, dominant ventricular morphology, and initial VAST score were not independent predictors. Initial liver stiffness had an AUC of 0.70 (sensitivity, 79%; specificity, 57%; threshold, > 2.11 m/s) for predicting a follow-up VAST score of 1 or greater and an AUC of 0.74 (sensitivity, 84%; specificity, 52%; threshold, > 2.12 m/s) for predicting Fontan circulatory failure. CONCLUSION. In patients with Fontan circulation, increased initial liver stiffness was associated with portal hypertension and circulatory failure during follow-up, although it had moderate performance in predicting these outcomes. CLINICAL IMPACT. US SWE may play a role in post-Fontan surveillance, supporting tailored medical and surgical care.
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Affiliation(s)
- Betul E Derinkuyu
- Department of Radiology, Cincinnati Children's Hospital Medical Center, 3333 Burnet Ave, Cincinnati, OH 45229
- Department of Radiology, University of Cincinnati College of Medicine, Cincinnati, OH
| | - Jonathan R Dillman
- Department of Radiology, Cincinnati Children's Hospital Medical Center, 3333 Burnet Ave, Cincinnati, OH 45229
- Department of Radiology, University of Cincinnati College of Medicine, Cincinnati, OH
| | - Adam M Lubert
- Heart Institute, Cincinnati Children's Hospital Medical Center, Cincinnati, OH
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH
| | - Joseph J Palermo
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH
- Division of Gastroenterology, Hepatology, and Nutrition, Cincinnati Children's Hospital Medical Center, Cincinnati, OH
| | - Alexander R Opotowsky
- Heart Institute, Cincinnati Children's Hospital Medical Center, Cincinnati, OH
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH
| | - Andrew T Trout
- Department of Radiology, Cincinnati Children's Hospital Medical Center, 3333 Burnet Ave, Cincinnati, OH 45229
- Department of Radiology, University of Cincinnati College of Medicine, Cincinnati, OH
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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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Fahnhorst SE, Brandewie K, Perry T, Opotowsky AR, Lubert AM, Lorts A, Morales DLS, Villa CR. Single Center Experience With Durable Continuous Flow Single Ventricle Assist Device: A Viable Option in Fontan Circulatory Failure. ASAIO J 2023; 69:956-961. [PMID: 37200481 DOI: 10.1097/mat.0000000000001986] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/20/2023] Open
Abstract
Ventricular assist devices are increasingly used for patients with single ventricle physiology. We describe the use of durable, continuous flow, single ventricular assist device (SVAD) therapy in Fontan circulatory failure patients. Retrospective, single-center review of patients with Fontan circulation implanted with a SVAD between 2017 and 2022. Patient characteristics and outcomes were obtained by chart review. Nine patients underwent SVAD implantation (median age 24 years). Most patients had a total cavopulmonary connection; one had an atriopulmonary Fontan. Five patients had a systemic right ventricle. SVAD was most often utilized as bridge to candidacy (67%). Eight patients had at least moderate systemic ventricular systolic dysfunction. SVAD support continued for a median of 65 days (longest duration, 1,105 days) and one patient remains on support at time of submission. Of five patients discharged home, median length of stay after SVAD was 24 days. Six patients were transplanted (median 96 days from SVAD). Two patients died from pretransplant multisystem organ failure before transplant. All transplanted patients remain alive (median time since transplant 593 days). Continuous flow SVAD therapy can be effective for patients with Fontan circulatory failure and systolic dysfunction. Further studies should investigate feasibility and optimal SVAD timing with more advanced Fontan associated end-organ dysfunction.
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Affiliation(s)
- Sarah E Fahnhorst
- From the Heart Institute, Cincinnati Children's Hospital Medical Center, Department of Pediatrics, University of Cincinnati, Cincinnati, Ohio
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Ibuki K, Imamura T, Nakaoka H, Takarada S, Okabe M, Ozawa S, Kinugawa K, Hirono K. Serum Angiopoetin-2 Levels in Pediatric Patients After Fontan Operation. Am J Cardiol 2023; 203:23-28. [PMID: 37481808 DOI: 10.1016/j.amjcard.2023.06.112] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/26/2023] [Revised: 06/21/2023] [Accepted: 06/29/2023] [Indexed: 07/25/2023]
Abstract
Angiopoietin-2 is associated with chronic inflammation and angiogenesis, but its activity after Fontan operation in pediatric patients remains uncertain. We compared serum angiopoietin-2 levels in pediatric patients after Fontan operation versus those with congenital heart disease as a control group. A total of 185 patients (median age 7 [3 to 12] years, 106 males) were included, consisting of 140 in the Fontan group and 45 in the control group. Serum angiopoietin-2 levels were significantly higher in the Fontan group (7,670 vs 2,351 pg/ml, p <0.001). In the Fontan group, a serum angiopoietin-2 level ≥3.9 of common logarithm was an independent risk factor for death or Fontan-related adverse events with an adjusted hazard ratio of 6.25 (95% confidence interval 1.64 to 23.9, p = 0.007). In preoperative variables, desaturation was independently associated with increased serum angiopoietin-2 levels after Fontan operation (p = 0.047). In conclusion, serum angiopoietin-2 levels were elevated in the pediatric phase after Fontan operation. In Fontan patients, a higher serum angiopoietin-2 level was an independent risk factor for death or Fontan-related adverse events. The clinical implication of measuring and monitoring serum angiopoietin-2 levels in this cohort requires further investigation.
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Affiliation(s)
| | - Teruhiko Imamura
- Second Department of Internal Medicine, University of Toyama, Toyama, Japan.
| | | | | | | | | | - Koichiro Kinugawa
- Second Department of Internal Medicine, University of Toyama, Toyama, Japan
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Acosta Izquierdo L, Rai A, Saprungruang A, Chavhan GB, Kamath BM, Dipchand AI, Seed M, Yoo SJ, Lam CZ. Assessment of liver fibrosis using a 3-dimensional high-resolution late gadolinium enhancement sequence in children and adolescents with Fontan circulation. Eur Radiol 2023; 33:5446-5454. [PMID: 36786904 DOI: 10.1007/s00330-023-09452-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2022] [Revised: 12/05/2022] [Accepted: 02/03/2023] [Indexed: 02/15/2023]
Abstract
OBJECTIVES To assess abnormal liver enhancement on 15-20 min delayed 3D high-resolution late gadolinium enhancement (3D HR LGE) sequence in patients with Fontan circulation. METHODS Retrospective study of pediatric Fontan patients (< 18 years old) with combined cardiac-liver MRI from January 2018 to August 2021. Abnormal hepatic enhancement was graded (0-3) for each lobe, summed for a total liver enhancement score (0-6), and compared to repaired tetralogy of Fallot (rTOF) patients. Correlations with other hepatic imaging biomarkers were performed. Temporal relationships of enhancement compared to traditional early portal venous and 5-7-min delayed phase liver imaging were analyzed. RESULTS The Fontan group (n = 35, 13 ± 3.4 years old, median time from Fontan 10 (9-12) years) had 23/35 (66%) with delayed 3D HR LGE total liver enhancement score > 0 (range 0-5), with greater involvement of the right lobe (1 (0-1) vs 0 (0-1), p < 0.01). The rTOF group (n = 35, 14 ± 2.6 years old) had no abnormal enhancement. In the Fontan group, total liver enhancement was 3 (2-4) in the early portal venous phase, lower at 1 (1-2) in the 5-7-min delayed phase (p < 0.01), and lowest at 1 (0-2) in the 15-20-min delayed phase (p = 0.03). 3D HR LGE enhancement correlated inversely with portal vein flow (rs = - 0.42, p = 0.01) and positively with left lobe stiffness (rs = 0.51, p < 0.01). The enhancement score decreased in 13/35 (37%) between the 5-7- and 15-20-min delayed phases. CONCLUSIONS Liver fibrosis can be assessed on 3D HR LGE sequences in patients with Fontan circulation, correlates with other imaging biomarkers of Fontan liver disease, and may add information for hepatic surveillance in this population. KEY POINTS • Abnormal liver enhancement on 3D HR LGE sequences in Fontan patients likely represents liver fibrosis and is seen in up to 66% of children and adolescents with variable distribution and severity. • The degree of 3D HR LGE liver enhancement correlates with decreased portal vein flow and increased left hepatic lobe stiffness.
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Affiliation(s)
- Laura Acosta Izquierdo
- Department of Diagnostic Imaging, Hospital for Sick Children, 555 University Avenue, Toronto, Ontario, M5G 1X8, Canada
- Department of Medical Imaging, University of Toronto, Toronto, Ontario, Canada
| | - Archana Rai
- Department of Diagnostic Imaging, Hospital for Sick Children, 555 University Avenue, Toronto, Ontario, M5G 1X8, Canada
- Department of Medical Imaging, University of Toronto, Toronto, Ontario, Canada
| | - Ankavipar Saprungruang
- Department of Diagnostic Imaging, Hospital for Sick Children, 555 University Avenue, Toronto, Ontario, M5G 1X8, Canada
- Division of Cardiology, Department of Paediatrics, Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
| | - Govind B Chavhan
- Department of Diagnostic Imaging, Hospital for Sick Children, 555 University Avenue, Toronto, Ontario, M5G 1X8, Canada
- Department of Medical Imaging, University of Toronto, Toronto, Ontario, Canada
| | - Binita M Kamath
- Division of Gastroenterology, Hepatology and Nutrition, Department of Paediatrics, Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
| | - Anne I Dipchand
- Division of Cardiology, Department of Paediatrics, Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
| | - Mike Seed
- Department of Diagnostic Imaging, Hospital for Sick Children, 555 University Avenue, Toronto, Ontario, M5G 1X8, Canada
- Department of Medical Imaging, University of Toronto, Toronto, Ontario, Canada
- Division of Cardiology, Department of Paediatrics, Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
| | - Shi-Joon Yoo
- Department of Diagnostic Imaging, Hospital for Sick Children, 555 University Avenue, Toronto, Ontario, M5G 1X8, Canada
- Department of Medical Imaging, University of Toronto, Toronto, Ontario, Canada
| | - Christopher Z Lam
- Department of Diagnostic Imaging, Hospital for Sick Children, 555 University Avenue, Toronto, Ontario, M5G 1X8, Canada.
- Department of Medical Imaging, University of Toronto, Toronto, Ontario, Canada.
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9
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Caro-Domínguez P, Secinaro A, Valverde I, Fouilloux V. Imaging and surgical management of congenital heart diseases. Pediatr Radiol 2023; 53:677-694. [PMID: 36334120 DOI: 10.1007/s00247-022-05536-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/28/2022] [Revised: 08/01/2022] [Accepted: 10/14/2022] [Indexed: 11/07/2022]
Abstract
Congenital heart disease affects approximately 1% of live births per year. In recent years, there has been a decrease in the morbidity and mortality of these cases due to advances in medical and surgical care. Imaging plays a key role in the management of these children, with chest radiography, echocardiography and chest ultrasound the first diagnostic tools, and cardiac computed tomography, catheterization and magnetic resonance imaging reserved to assess better the anatomy and physiology of the most complex cases. This article is a beginner's guide to the anatomy of the most frequent congenital heart diseases (atrial and ventricular septal defects, abnormal pulmonary venous connections, univentricular heart, tetralogy of Fallot, transposition of the great arteries and coarctation of the aorta), their surgical management, the most common postsurgical complications, deciding which imaging modality is needed, and when and how to image gently.
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Affiliation(s)
- Pablo Caro-Domínguez
- Pediatric Radiology Unit, Department of Radiology, Hospital Universitario Virgen del Rocío, Avenida Manuel Siurot s/n, Seville, Spain.
| | - Aurelio Secinaro
- Advanced Cardiothoracic Imaging Unit, Department of Imaging, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
| | - Israel Valverde
- Pediatric Cardiology Unit and Cardiovascular Pathology Unit, Hospital Universitario Virgen del Rocio and Institute of Biomedicine of Seville, Seville, Spain
- School of Biomedical Engineering and Imaging Sciences, King's College London, London, UK
| | - Virginie Fouilloux
- Department of Congenital and Pediatric Cardiac Surgery, Timone Children Hospital, Marseille, France
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10
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de Lange C, Möller T, Hebelka H. Fontan-associated liver disease: Diagnosis, surveillance, and management. Front Pediatr 2023; 11:1100514. [PMID: 36937979 PMCID: PMC10020358 DOI: 10.3389/fped.2023.1100514] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/16/2022] [Accepted: 02/09/2023] [Indexed: 03/06/2023] Open
Abstract
The Fontan operation is a lifesaving procedure for patients with functional single-ventricle congenital heart disease, where hypoplastic left heart syndrome is the most frequent anomaly. Hemodynamic changes following Fontan circulation creation are now increasingly recognized to cause multiorgan affection, where the development of a chronic liver disease, Fontan-associated liver disease (FALD), is one of the most important morbidities. Virtually, all patients with a Fontan circulation develop liver congestion, resulting in fibrosis and cirrhosis, and most patients experience childhood onset. FALD is a distinctive type of congestive hepatopathy, and its pathogenesis is thought to be a multifactorial process driven by increased nonpulsatile central venous pressure and decreased cardiac output, both of which are inherent in the Fontan circulation. In the advanced stage of liver injury, complications of portal hypertension often occur, and there is a risk of developing secondary liver cancer, reported at young age. However, FALD develops with few clinical symptoms, a surprisingly variable degree of severity in liver disease, and with little relation to poor cardiac function. The disease mechanisms and modifying factors of its development are still not fully understood. As one of the more important noncardiac complications of the Fontan circulation, FALD needs to be diagnosed in a timely manner with a structured monitoring scheme of disease development, early detection of malignancy, and determination of the optimal time point for transplantation. There is also a clear need for consensus on the best surveillance strategy for FALD. In this regard, imaging plays an important role together with clinical scoring systems, biochemical workups, and histology. Patients operated on with a Fontan circulation are generally followed up in cardiology units. Ultimately, the resulting multiorgan affection requires a multidisciplinary team of healthcare personnel to address the different organ complications. This article discusses the current concepts, diagnosis, and management of FALD, with special emphasis on the role of different imaging techniques in the diagnosis and monitoring of disease progression, as well as current recommendations for liver disease surveillance.
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Affiliation(s)
- Charlotte de Lange
- Department of Pediatric Radiology, Queen Silvia Children's Hospital, Sahlgrenska University Hospital, Gothenburg, Sweden
- Institution of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Thomas Möller
- Department of Pediatric Cardiology, Oslo University Hospital, Oslo, Norway
| | - Hanna Hebelka
- Department of Pediatric Radiology, Queen Silvia Children's Hospital, Sahlgrenska University Hospital, Gothenburg, Sweden
- Institution of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
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11
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Nolan PE, Catania R, Vendrami CL, Borhani AA, Miller FH. Large Regenerative Nodules and Focal Nodular Hyperplasia-Like Lesions. Radiol Clin North Am 2022; 60:795-808. [DOI: 10.1016/j.rcl.2022.05.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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12
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Navallas M, Yoo SJ, Chavhan GB, Amirabadi A, Ling SC, Seed M, Lam CZ. Semiquantitative characterization of dynamic magnetic resonance perfusion of the liver in pediatric Fontan patients. Pediatr Radiol 2022; 52:483-492. [PMID: 34854967 DOI: 10.1007/s00247-021-05221-6] [Citation(s) in RCA: 2] [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: 06/01/2021] [Revised: 09/13/2021] [Accepted: 10/05/2021] [Indexed: 11/27/2022]
Abstract
BACKGROUND Dynamic contrast-enhanced magnetic resonance imaging (MRI) of the liver in pediatric Fontan patients often shows peripheral reticular areas of hypoenhancement, which has not been studied in detail. OBJECTIVE To semiquantitatively score the hepatic MR perfusion abnormality seen in pediatric Fontan patients, and to correlate the perfusion abnormality with functional clinical and hemodynamic parameters. MATERIALS AND METHODS All children (< 18 years old) after Fontan palliation with combined clinical cardiac and liver MRI performed between May 2017 and April 2019 were considered for inclusion. A semiquantitative perfusion score was used to assess the severity of the hepatic reticular pattern seen on dynamic contrast-enhanced liver imaging. The liver was divided into four sections: right posterior, right anterior, left medial and left lateral. Each liver section was assigned a score from 0 to 4 depending on the amount of abnormal reticular hypoenhancement. Scoring was assigned for each section of the liver across eight successive dynamic contrast-enhanced modified spoiled gradient echo runs. Scores were correlated with clinical and hemodynamic parameters. RESULTS All Fontan children showed hepatic reticular hypoenhancement by MRI, most severe in the early portal venous phase with a median maximum total perfusion abnormality score of 12 (range: 9-14). All perfusion abnormalities progressively resolved during the hepatic venous phase. Perfusion abnormality scores were greatest in the right compared to left hepatic lobes (7 range: [6-8] vs. 5 [range: 3-6], P < 0.01). The maximum left hepatic lobe perfusion abnormality scores were greatest in children with versus without imaging signs of portal hypertension (8 [range: 7-8] vs. 4 [range: 3-5], P < 0.01). High unconjugated bilirubin and low platelets correlated with greater perfusion abnormality (R = 0.450, P = 0.024, and R = - 0.458, P < 0.01, respectively). Age at MRI, time from Fontan, focal liver lesions and cardiac MRI hemodynamic parameters did not show significant correlations with the severity of the liver perfusion abnormality. CONCLUSION All Fontan children have hepatic reticular hypoenhancement abnormalities seen with MRI that are most severe in the right hepatic lobe and universally show gradual resolution through the hepatic venous phase. Perfusion abnormality in the left hepatic lobe is worse in children with portal hypertension.
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Affiliation(s)
- María Navallas
- Department of Diagnostic Imaging, Hospital for Sick Children, 555 University Ave., Toronto, Ontario, M5G 1X8, Canada.
- Division of Pediatric Imaging, Department of Medical Imaging, University of Toronto, Toronto, Ontario, Canada.
| | - Shi-Joon Yoo
- Department of Diagnostic Imaging, Hospital for Sick Children, 555 University Ave., Toronto, Ontario, M5G 1X8, Canada
- Division of Pediatric Imaging, Department of Medical Imaging, University of Toronto, Toronto, Ontario, Canada
- Division of Cardiology, Department of Paediatrics, Hospital for Sick Children, Toronto, Ontario, Canada
| | - Govind B Chavhan
- Department of Diagnostic Imaging, Hospital for Sick Children, 555 University Ave., Toronto, Ontario, M5G 1X8, Canada
- Division of Pediatric Imaging, Department of Medical Imaging, University of Toronto, Toronto, Ontario, Canada
| | - Afsaneh Amirabadi
- Department of Diagnostic Imaging, Hospital for Sick Children, 555 University Ave., Toronto, Ontario, M5G 1X8, Canada
- Division of Pediatric Imaging, Department of Medical Imaging, University of Toronto, Toronto, Ontario, Canada
| | - Simon C Ling
- Division of Gastroenterology, Hepatology & Nutrition, Department of Paediatrics, Hospital for Sick Children, Toronto, Ontario, Canada
| | - Michael Seed
- Division of Cardiology, Department of Paediatrics, Hospital for Sick Children, Toronto, Ontario, Canada
| | - Christopher Z Lam
- Department of Diagnostic Imaging, Hospital for Sick Children, 555 University Ave., Toronto, Ontario, M5G 1X8, Canada
- Division of Pediatric Imaging, Department of Medical Imaging, University of Toronto, Toronto, Ontario, Canada
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13
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Developing an adolescent and adult Fontan Management Programme. Cardiol Young 2022; 32:230-235. [PMID: 33966676 DOI: 10.1017/s104795112100175x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
Patients with single-ventricle CHD undergo a series of palliative surgeries that culminate in the Fontan procedure. While the Fontan procedure allows most patients to survive to adulthood, the Fontan circulation can eventually lead to multiple cardiac complications and multi-organ dysfunction. Care for adolescents and adults with a Fontan circulation has begun to transition from a primarily cardiac-focused model to care models, which are designed to monitor multiple organ systems, and using clues from this screening, identify patients who are at risk for adverse outcomes. The complexity of care required for these patients led our centre to develop a multidisciplinary Fontan Management Programme with the primary goals of earlier detection and treatment of complications through the development of a cohesive network of diverse medical subspecialists with Fontan expertise.
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14
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Rychik J, Goldberg DJ, Rand E, Mancilla EE, Heimall J, Seivert N, Campbell D, O'Malley S, Dodds KM. A Path FORWARD: Development of a Comprehensive Multidisciplinary Clinic to Create Health and Wellness for the Child and Adolescent with a Fontan Circulation. Pediatr Cardiol 2022; 43:1175-1192. [PMID: 35604474 PMCID: PMC9125546 DOI: 10.1007/s00246-022-02930-z] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/22/2022] [Accepted: 04/28/2022] [Indexed: 12/19/2022]
Abstract
Today, it is anticipated most individuals diagnosed with single-ventricle malformation will survive surgical reconstruction through a successful Fontan operation. As greater numbers of patients survive, so has the recognition that individuals with Fontan circulation face a variety of challenges. The goal of a normal quality and duration of life will not be reached by all. The hurdles fall into a variety of domains. From a cardiovascular perspective, the Fontan circulation is fundamentally flawed by its inherent nature of creating a state of chronically elevated venous pressure and congestion, accompanied by a relatively low cardiac output. Ventricular dysfunction, atrioventricular valve regurgitation, and arrhythmia may directly impact cardiac performance and can progress with time. Problems are not limited to the cardiovascular system. Fontan circulatory physiology impacts a multitude of biological processes and health parameters outside the heart. The lymphatic circulation is under strain manifesting as variable degrees of protein-rich lymph loss and immune system dysregulation. Organ system dysfunction develops through altered perfusion profiles. Liver fibrosis is ubiquitous, and a process of systemic fibrogenesis in response to circulatory stressors may affect other organs as well. Somatic growth and development can be delayed. Behavioral and mental health problems are common, presenting as clinically important levels of anxiety and depression. Most striking is the high variability in prevalence and magnitude of these complications within the population, indicating the likelihood of additional factors enhancing or mitigating their emergence. We propose that optimal care for the individual with single ventricle and a Fontan circulation is ideally offered in a comprehensive multidisciplinary manner, with attention to elements that are beyond cardiac management alone. In this report, we share the concepts, our experiences, and perspectives on development of a clinic model-the "Fontan rehabilitation, wellness and resilience development" or FORWARD program. We provide insights into the mechanics of our multidisciplinary model of care and the benefits offered serving our growing population of individuals with a Fontan circulation and their families.
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Affiliation(s)
- Jack Rychik
- Division of Cardiology, Children's Hospital of Philadelphia, Philadelphia, USA.
- Department of Pediatrics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, USA.
- Fontan FORWARD Program, Cardiac Center at the Children's Hospital of Philadelphia, 3401 Civic Center Boulevard, Philadelphia, PA, 19104, USA.
| | - David J Goldberg
- Division of Cardiology, Children's Hospital of Philadelphia, Philadelphia, USA
- Department of Pediatrics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, USA
| | - Elizabeth Rand
- Division of Gastroenterology, Hepatology and Nutrition, Children's Hospital of Philadelphia, Philadelphia, USA
- Department of Pediatrics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, USA
| | - Edna E Mancilla
- Division of Endocrinology and Diabetes, Children's Hospital of Philadelphia, Philadelphia, USA
- Department of Pediatrics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, USA
| | - Jennifer Heimall
- Division of Allergy and Immunology, Children's Hospital of Philadelphia, Philadelphia, USA
- Department of Pediatrics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, USA
| | - Nicholas Seivert
- Department of Child and Adolescent Psychiatry, and Behavioral Sciences, Children's Hospital of Philadelphia, Philadelphia, USA
- Department of Psychiatry, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, USA
| | - Danielle Campbell
- Clinical Nutrition, Children's Hospital of Philadelphia, Philadelphia, USA
| | - Shannon O'Malley
- Division of Cardiology, Children's Hospital of Philadelphia, Philadelphia, USA
| | - Kathryn M Dodds
- Division of Cardiology, Children's Hospital of Philadelphia, Philadelphia, USA
- Department of Nursing at the University of Pennsylvania, Philadelphia, USA
- Fontan FORWARD Program, Cardiac Center at the Children's Hospital of Philadelphia, 3401 Civic Center Boulevard, Philadelphia, PA, 19104, USA
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15
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Management of patients with single ventricle physiology across the lifespan: contributions from magnetic resonance and computed tomography imaging. Can J Cardiol 2022; 38:946-962. [DOI: 10.1016/j.cjca.2022.01.011] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2021] [Revised: 12/27/2021] [Accepted: 01/02/2022] [Indexed: 12/12/2022] Open
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16
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Brayer SW, Zafar F, Lubert AM, Trout AT, Palermo JJ, Opotowsky AR, Anwar N, Dillman JR, Alsaied T. Relation of Magnetic Resonance Elastography to Fontan Circulatory Failure in a Cohort of Pediatric and Adult Patients. Pediatr Cardiol 2021; 42:1871-1878. [PMID: 34448042 DOI: 10.1007/s00246-021-02707-w] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/28/2021] [Accepted: 08/04/2021] [Indexed: 01/03/2023]
Abstract
Elevated magnetic resonance elastography (MRE)-derived liver stiffness may be associated with worse outcomes in people with Fontan circulation. We sought to evaluate the association between liver stiffness and Fontan failure or portal hypertension. Single center cross-sectional retrospective study of people with Fontan circulation who underwent MRE between 2011 and 2020. The cohort was divided into adult (age ≥ 21 years) and pediatric (< 21 years) groups. Fontan circulatory failure (FF) was defined as any of the following: death, transplantation, ventricular assist device, heart failure symptoms requiring escalation of diuretics. Radiologic portal hypertension was defined as the presence of one or more of the following: splenomegaly, ascites, or gastrointestinal varices. 128 patients were included (average age = 22.6 ± 8.7 years) and 58 (45%) were children. Median liver stiffness was 4.3 kPa (interquartile range (IQR) 3.8-5.8) for the entire cohort. Thirty patients (23%) developed FF (16 adults, 14 children). Liver stiffness was higher in adults with FF compared to those without FF (4.9 (IQR 4.0-6.0) vs. 4.2 (IQR 3.8-4.7) kPa, p = 0.04). There was no difference in liver stiffness between pediatric patients with and without FF (4.4 (IQR 4.1-5.4) vs. 4.4 (IQR 3.8-5.0), p = 0.5). Adults with radiologic portal hypertension and adults with moderate or severe atrioventricular valve regurgitation had higher liver stiffness than adults without. MRE-derived liver stiffness is associated with atrioventricular valve regurgitation, portal hypertension, and poor clinical outcomes in adults with Fontan circulation. There was no association between liver stiffness and FF in pediatric patients. This difference may be due to the progressive nature of Fontan-associated liver disease.
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Affiliation(s)
- Samuel W Brayer
- Pediatric Residency Training Program, Cincinnati Children's Hospital Medical Center, 3333 Burnet Avenue, Cincinnati, OH, USA.
| | - Faizeen Zafar
- Pediatric Residency Training Program, Cincinnati Children's Hospital Medical Center, 3333 Burnet Avenue, Cincinnati, OH, USA
| | - Adam M Lubert
- Department of Pediatrics, Cincinnati Children's Hospital Heart Institute, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Andrew T Trout
- Department of Radiology, Cincinnati Children's Hospital Medical Center, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Joseph J Palermo
- Division of Gastroenterology, Department of Pediatrics, Cincinnati Children's Hospital Medical Center, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Alexander R Opotowsky
- Department of Pediatrics, Cincinnati Children's Hospital Heart Institute, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Nadeem Anwar
- Division of Gastroenterology, Department of Medicine, University of Cincinnati Medical Center, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Jonathan R Dillman
- Department of Radiology, Cincinnati Children's Hospital Medical Center, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Tarek Alsaied
- UPMC Children's Hospital of Pittsburgh Heart and Vascular Institute, Pittsburgh, PA, USA
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17
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Langguth P, Salehi Ravesh M, Moritz JD, Rinne K, Harneit PL, Khodami JK, Graessner J, Uebing A, Jansen O, Both M, Hansen JH. Non-contrast enhanced magnetic resonance imaging for characterization of Fontan associated liver disease. Int J Cardiol 2021; 349:48-54. [PMID: 34808211 DOI: 10.1016/j.ijcard.2021.11.048] [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: 05/24/2021] [Accepted: 11/16/2021] [Indexed: 11/05/2022]
Abstract
OBJECTIVES To evaluate the ability of non-contrast enhanced magnetic resonance imaging (MRI) techniques to characterize Fontan associated liver disease (FALD) in adolescent and adult Fontan patients. METHODS Fontan patients (n = 29) and healthy controls (n = 13) underwent an MRI protocol with T1, T2 and Apparent Diffusion Coefficient (ADC) mapping. Routine FALD screening included abdominal ultrasound and laboratory testing. RESULTS Median follow-up after Fontan operation was 15.1 (IQR 12.0-16.8) years. Distinct differences in tissue characteristics were visualized. T1 and T2 relaxation times were prolonged in Fontan patients, particularly of the right lobe (T1: 745 (IQR 715-784) ms vs. 586 (IQR 555-602) ms, p < 0.001; T2: 63 (IQR 59-64) ms vs. 58 (IQR 56-60) ms, p = 0.002). Left lobe ADC was lower in Fontan patients (1.10 (IQR 1.06-1.18) x 10-3 mm2/s vs. 1.23 (IQR 1.19-1.29) x 10-3 mm2/s, p < 0.001). T2 mapping was able to differentiate between controls and Fontan patients with different FALD severity. Right lobe T2 was higher in patients with moderate or severe in comparison to those with no or mild changes and healthy controls (64 (IQR 61-67) ms vs. 60 (IQR 59-63) ms vs. 58 (IQR 56-60) ms, p = 0.001). CONCLUSIONS Non-contrast enhanced MRI methods are able to visualize regional differences in liver tissue characteristics. T1 and T2 relaxation times were prolonged in Fontan patients suggestive of fibrosis or congestive hepatopathy, while reduced ADC might reflect impaired microperfusion. These methods have promising clinical potential for detection of liver abnormalities in Fontan patients. The usefulness of T2 mapping to grade FALD severity merits further investigation.
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Affiliation(s)
- Patrick Langguth
- Department of Radiology and Neuroradiology, University Hospital Schleswig-Holstein, Campus Kiel, Germany
| | - Mona Salehi Ravesh
- Department of Radiology and Neuroradiology, University Hospital Schleswig-Holstein, Campus Kiel, Germany
| | - Jörg Detlev Moritz
- Department of Radiology and Neuroradiology, University Hospital Schleswig-Holstein, Campus Kiel, Germany
| | - Katy Rinne
- Department of Congenital Heart Disease and Pediatric Cardiology, University Hospital Schleswig-Holstein, Campus Kiel, Germany
| | - Paul Lennard Harneit
- Department of Congenital Heart Disease and Pediatric Cardiology, University Hospital Schleswig-Holstein, Campus Kiel, Germany
| | - Joshua Kian Khodami
- Department of Congenital Heart Disease and Pediatric Cardiology, University Hospital Schleswig-Holstein, Campus Kiel, Germany
| | | | - Anselm Uebing
- Department of Congenital Heart Disease and Pediatric Cardiology, University Hospital Schleswig-Holstein, Campus Kiel, Germany; DZHK (German Center for Cardiovascular Research), Partner Site Hamburg/Kiel/Lübeck, Germany
| | - Olav Jansen
- Department of Radiology and Neuroradiology, University Hospital Schleswig-Holstein, Campus Kiel, Germany
| | - Marcus Both
- Department of Radiology and Neuroradiology, University Hospital Schleswig-Holstein, Campus Kiel, Germany
| | - Jan Hinnerk Hansen
- Department of Congenital Heart Disease and Pediatric Cardiology, University Hospital Schleswig-Holstein, Campus Kiel, Germany; DZHK (German Center for Cardiovascular Research), Partner Site Hamburg/Kiel/Lübeck, Germany.
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18
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Spectrum of Fontan-associated liver disease assessed by MRI and US in young adolescents. Abdom Radiol (NY) 2021; 46:3205-3216. [PMID: 33688987 PMCID: PMC8215034 DOI: 10.1007/s00261-021-02994-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2020] [Revised: 02/09/2021] [Accepted: 02/11/2021] [Indexed: 12/11/2022]
Abstract
Purpose Patients with Fontan circulation are at risk of developing hepatic fibrosis/cirrhosis. The mechanisms and disease development are unclear and early secondary liver cancer is a concern. This study will describe hepatic imaging findings in a national cohort of adolescents with Fontan circulation. Methods The patients prospectively underwent abdominal contrast enhanced magnetic resonance imaging (MRI) including diffusion-weighted imaging. Images were assessed for criteria of fibrosis/cirrhosis including characterization of hepatic nodules. These nodules were in addition, assessed by ultrasonography (US). Nodules ≥ 1 cm were investigated and monitored to evaluate malignant transformation. Clinical and hepatic serological data were recorded. Results Forty-six patients, median age of 16.5 years (15.4–17.9 years) were enrolled. All patients underwent US examination and MRI was performed in 35/46 patients. On MRI, 60% had hepatomegaly and 37% had signs of fibrosis/cirrhosis. Seven patients had together 13 nodules ≥ 1 cm in diameter. Only 4/13 (17%) where seen on US. Nodules had variable MRI signal characteristics including hepatobiliary contrast enhancement and two nodules revealed portal venous phase ‘wash-out’ on the first examination. No further imaging signs of malignancy were revealed during the follow-up period of median 24.4 (7–42) months. Conclusion The majority of adolescents with Fontan circulation had imaging findings of fibrosis/cirrhosis of varying severity. US had low detection rate of hepatic nodules compared to MRI. The imaging work-up before transition to adult cardiology care did not reveal findings suggestive of malignancy. However, the high prevalence of Fontan-associated liver disease calls for surveillance strategies even in childhood. Supplementary Information The online version of this article (10.1007/s00261-021-02994-0) contains supplementary material, which is available to authorized users.
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19
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Perucca G, de Lange C, Franchi-Abella S, Napolitano M, Riccabona M, Ključevšek D, Toso S, Herrmann J, Stafrace S, Darge K, Damasio MB, Bruno C, Woźniak MM, Lobo L, Ibe D, Smets AM, Petit P, Ording Müller LS. Surveillance of Fontan-associated liver disease: current standards and a proposal from the European Society of Paediatric Radiology Abdominal Task Force. Pediatr Radiol 2021; 51:2598-2606. [PMID: 34654967 PMCID: PMC8599216 DOI: 10.1007/s00247-021-05173-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/08/2021] [Revised: 06/08/2021] [Accepted: 07/31/2021] [Indexed: 12/16/2022]
Abstract
Since Francis Fontan first introduced the eponymous technique, the Fontan procedure, this type of surgical palliation has allowed thousands of children affected by specific heart malformations to reach adulthood. Nevertheless, abdominal, thoracic, lymphatic and neurologic complications are the price that is paid by these patients. Our review focuses on Fontan-associated liver disease; the purpose is to summarize the current understanding of its physiopathology, the aim of follow-up and the specific radiologic follow-up performed in Europe. Finally, we as members of the Abdominal Task Force of the European Society of Paediatric Radiology propose a consensus-based imaging follow-up algorithm.
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Affiliation(s)
- Giulia Perucca
- Department of Pediatric Radiology, Regina Margherita Children’s Hospital, Turin, Italy
| | - Charlotte de Lange
- Department of Radiology and Clinical Physiology, Queen Silvia Children’s Hospital, Sahlgrenska University Hospital, Göteborg, Sweden
| | - Stéphanie Franchi-Abella
- Pediatric Radiology Department, Hôpital Bicêtre, Hôpitaux Universitaire Paris-Sud, Assistance Publique Hôpitaux de Paris, Le Kremlin-Bicêtre, France
| | - Marcello Napolitano
- Department of Paediatric Radiology and Neuroradiology, V. Buzzi Children’s Hospital, Milan, Italy
| | - Michael Riccabona
- Department of Radiology, Division of Pediatric Radiology, Medical University Graz and University Hospital LKH, Graz, Austria
| | - Damjana Ključevšek
- Department of Radiology, University Children’s Hospital Ljubljana, Ljubljana, Slovenia
| | - Seema Toso
- Department of Pediatric Radiology, University Hospital of Geneva, Geneva, Switzerland
| | - Jochen Herrmann
- Department of Pediatric Radiology, University Hospital Hamburg Eppendorf, Hamburg, Germany
| | - Samuel Stafrace
- Department of Diagnostic Imaging, Sidra Medicine, Doha, Qatar ,Weill Cornell Medicine, Doha, Qatar
| | - Kassa Darge
- Department of Radiology, The Children’s Hospital of Philadelphia, University of Pennsylvania, Philadelphia, PA USA
| | | | - Costanza Bruno
- Department of Radiology, Azienda Ospedaliera Universitaria Integrata Verona (AOUI), Verona, Italy
| | | | - Luisa Lobo
- Serviço de Imagiologia Geral, Hospital de Santa Maria–Centro Hospitalar Universitário Lisboa, Norte (CHULN), Lisbon, Portugal
| | - Donald Ibe
- Department of Radiology, Silhouette Diagnostic Consultants, Abuja, Nigeria
| | - Anne M. Smets
- Department of Radiology and Nuclear Medicine, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands
| | - Philippe Petit
- Aix Marseille Université, AP-HM, Equipe d’Accueil 3279 - IFR 125, Hôpital Timone Enfants, Service d’Imagerie Pédiatrique et Prénatale, Marseille, France
| | - Lil-Sofie Ording Müller
- Unit for Paediatric Radiology, Department of Radiology, Oslo University Hospital, Rikshospitalet, PB 4950 Nydalen, 0424 Oslo, Norway.
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20
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Perucca G, de Lange C, Franchi-Abella S, Napolitano M, Riccabona M, Ključevšek D, Toso S, Herrmann J, Stafrace S, Darge K, Damasio MB, Bruno C, Woźniak MM, Lobo L, Ibe D, Smets AM, Petit P, Müller LSO. Radiologic follow-up in Fontan-associated liver disease in Europe: European Society of Paediatric Radiology survey demonstrates the need for a consensus protocol. Pediatr Radiol 2021; 51:2607-2610. [PMID: 34654969 PMCID: PMC8599243 DOI: 10.1007/s00247-021-05172-y] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/08/2021] [Revised: 06/08/2021] [Accepted: 07/31/2021] [Indexed: 12/17/2022]
Abstract
Fontan surgery is a life-saving procedure for newborns with complex cardiac malformations, but it originates complications in different organs. The liver is also affected, with development of fibrosis and sometimes cirrhosis and hepatocellular carcinoma. There is no general agreement on how to follow-up these children for the development of liver disease. To understand the current practice on liver follow-up, we invited members of the European Society of Paediatric Radiology (ESPR) to fill out an online questionnaire. The survey comprised seven questions about when and how liver follow-up is performed on Fontan patients. While we found some agreement on the use of US as screening tool, and of MRI for nodule characterization, the discrepancies on timing and the lack of a shared protocol make it currently impossible to compare data among centers.
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Affiliation(s)
- Giulia Perucca
- Department of Pediatric Radiology, Regina Margherita Children’s Hospital, Turin, Italy
| | - Charlotte de Lange
- Department of Radiology and Clinical Physiology, Queen Silvia Children’s Hospital, Sahlgrenska University Hospital, Göteborg, Sweden
| | - Stéphanie Franchi-Abella
- Pediatric Radiology Department, Hôpital Bicêtre, Hôpitaux Universitaire Paris-Sud, Assistance Publique Hôpitaux de Paris, Le Kremlin-Bicêtre, France
| | - Marcello Napolitano
- Department of Paediatric Radiology and Neuroradiology, V. Buzzi Children’s Hospital, Milan, Italy
| | - Michael Riccabona
- Department of Radiology, Division of Pediatric Radiology, Medical University Graz and University Hospital LKH, Graz, Austria
| | - Damjana Ključevšek
- Department of Radiology, University Children’s Hospital Ljubljana, Ljubljana, Slovenia
| | - Seema Toso
- Department of Pediatric Radiology, University Hospital of Geneva, Geneva, Switzerland
| | - Jochen Herrmann
- Department of Pediatric Radiology, University Hospital Hamburg Eppendorf, Hamburg, Germany
| | - Samuel Stafrace
- Department of Diagnostic Imaging, Sidra Medicine, Doha, Qatar ,Weill Cornell Medicine, Doha, Qatar
| | - Kassa Darge
- Department of Radiology, The Children’s Hospital of Philadelphia, University of Pennsylvania, Philadelphia, PA USA
| | | | - Costanza Bruno
- Department of Radiology, Azienda Ospedaliera Universitaria Integrata Verona (AOUI), Verona, Italy
| | | | - Luisa Lobo
- Serviço de Imagiologia Geral, Hospital de Santa Maria–Centro Hospitalar Universitário Lisboa, Norte (CHULN), Lisbon, Portugal
| | - Donald Ibe
- Department of Radiology, Silhouette Diagnostic Consultants, Abuja, Nigeria
| | - Anne M. Smets
- Department of Radiology and Nuclear Medicine, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands
| | - Philippe Petit
- Aix Marseille Université, AP-HM, Equipe d’Accueil 3279 - IFR 125, Hôpital Timone Enfants, Service d’Imagerie Pédiatrique et Prénatale, Marseille, France
| | - Lil-Sofie Ording Müller
- Unit for Paediatric Radiology, Department of Radiology, Oslo University Hospital, Rikshospitalet, PB 4950 Nydalen, 0424, Oslo, Norway.
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