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Stout K, Buber J. The Last Stage of the Fontan Operation? J Am Coll Cardiol 2023; 81:2172-2174. [PMID: 37257952 DOI: 10.1016/j.jacc.2023.04.023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/19/2023] [Accepted: 04/21/2023] [Indexed: 06/02/2023]
Affiliation(s)
- Karen Stout
- Division of Cardiology, Department of Medicine, University of Washington and Seattle Children's Hospital, Seattle, Washington, USA.
| | - Jonathan Buber
- Division of Cardiology, Department of Medicine, University of Washington and Seattle Children's Hospital, Seattle, Washington, USA
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Mondésert B, Moore JP, Khairy P. Cardiac Implantable Electronic Devices in the Fontan Patient. Can J Cardiol 2022; 38:1048-1058. [PMID: 35588949 DOI: 10.1016/j.cjca.2022.04.024] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2022] [Revised: 04/18/2022] [Accepted: 04/19/2022] [Indexed: 12/22/2022] Open
Abstract
As a result of remarkable progress in operative techniques and cardiology care during childhood, Fontan patients continue to age and require team-based multidisciplinary expertise to manage complications encountered in adulthood. They face particular challenges in terms of altered hemodynamic stressors, cardiac and hepatic failure, and arrhythmias. Arrhythmias in Fontan patients are highly prevalent and associated with underlying anatomy, surgical technique, and postoperative sequelae. Diagnostic tools, treatments, and device strategies for arrhythmias in Fontan patients should be adapted to the specific anatomy, type of surgical repair, and clinical status. Great strides in our understanding of arrhythmia mechanisms, options and techniques to obtain access to relevant cardiac structures, and application of both old and new technologies have contributed to improving cardiac implantable electronic device (CIED) therapies for this unique population. In this state-of-the-art review, we discuss the various arrhythmias encountered in Fontan patients, their diagnosis, and options for treatment and prevention, with a focus on CIEDs. Throughout, access challenges particular to the Fontan circulation are considered. Recently developed technologies, such as the sub-cutaneous implantable cardioverter defibrillator carry the potential to be transformative but require awareness of Fontan-specific issues. Moreover, new leadless pacing technology represents a promising strategy that may soon become applicable to Fontan patients with sinus node dysfunction. CIEDs are essential tools in managing Fontan patients but the complex clinical scenarios that arise in this patient population are among the most challenging for the congenital electrophysiologist.
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Affiliation(s)
- Blandine Mondésert
- Adult Congenital Heart Disease Center, Montreal Heart Institute, Medicine Department, Université de Montréal, Montreal, Canada.
| | - Jeremy P Moore
- Division of Cardiology, Department of Medicine, Ahmanson/UCLA Adult Congenital Heart Disease Center, Los Angeles, CA; UCLA Cardiac Arrhythmia Center, UCLA Health System, Los Angeles, CA; Division of Cardiology, Department of Pediatrics, UCLA Health System, Los Angeles, CA
| | - Paul Khairy
- Adult Congenital Heart Disease Center, Montreal Heart Institute, Medicine Department, Université de Montréal, Montreal, Canada
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Buber J, Schwaegler RG, Mazor Dray E. Echocardiographic evaluation of univentricular physiology and cavopulmonary shunts. Echocardiography 2019; 36:1381-1390. [PMID: 31246324 DOI: 10.1111/echo.14421] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2019] [Accepted: 05/26/2019] [Indexed: 12/30/2022] Open
Abstract
Since the surgical palliation of a univentricular congenital heart defect was first described in the early 1970s, thousands of lives were saved by this groundbreaking operation. Although initially described for the palliation of tricuspid valve atresia, the Fontan operation is now utilized for many other univentricular heart defects involving either hypoplastic right or left ventricles, and the number of babies who survive the surgery and the postsurgical hospitalization continues to grow. Echocardiography constitutes the mainstay follow-up imaging modality for patients with a Fontan system. In order to obtain all the needed information from the echocardiographic studies, close familiarity with the native congenital heart defects, the build of the Fontan systems, and the potential long-term complications is required. Detailed studies provide valuable information on the various components of the Fontan circulation such as the function of the single ventricle and the valves, flow in the Glenn and Fontan pathways, and possible sources of cyanosis and shunts. Three-dimensional and transesophageal echocardiogram studies can assist in delineating the Fontan anatomy and to evaluate smaller intracardiac structures.
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Affiliation(s)
- Jonathan Buber
- Division of Cardiology, Department of Medicine, University of Washington School of Medicine, Seattle, WA, USA
| | - Rebecca Gibbons Schwaegler
- Division of Cardiology, Department of Medicine, University of Washington School of Medicine, Seattle, WA, USA
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Wood J, Sawyer A, Mulrennan S, Bullock A. Respiratory exacerbation in a young adult with cystic fibrosis and tricuspid atresia. Respirol Case Rep 2018; 6:e00318. [PMID: 29619223 PMCID: PMC5879030 DOI: 10.1002/rcr2.318] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2017] [Revised: 03/12/2018] [Accepted: 03/13/2018] [Indexed: 11/23/2022] Open
Abstract
Tricuspid atresia (TAt) is a complex congenital heart defect (CHD) characterized by the absence of the tricuspid valve and right ventricular hypoplasia requiring surgery in childhood, the Fontan procedure. We present a case of a 21‐year‐old male with TAt and cystic fibrosis (CF), who underwent a Fontan procedure in childhood, presenting to an adult CF clinic with severe deterioration in his respiratory status and multi‐organ dysfunction associated with CF. This report describes problems associated with the management of a CF respiratory exacerbation and extrapulmonary manifestations of CF in the unique situation of a Fontan circulation, a circulation with absence of a subpulmonary ventricle and pulsatile pulmonary arterial blood flow where maintenance of systemic cardiac output is totally dependent on good respiratory function and low pulmonary artery pressures.
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Affiliation(s)
- Jamie Wood
- Physiotherapy Department Sir Charles Gairdner Hospital Perth Australia.,Department of Respiratory Medicine Sir Charles Gairdner Hospital Perth Australia
| | - Abbey Sawyer
- Physiotherapy Department Sir Charles Gairdner Hospital Perth Australia
| | - Siobhain Mulrennan
- Department of Respiratory Medicine Sir Charles Gairdner Hospital Perth Australia.,The Faculty of Health and Medical Sciences University of Western Australia Perth Australia
| | - Andrew Bullock
- Department of CardiologyACHD Service, Sir Charles Gairdner Hospital Perth Australia
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Yeo L, Luewan S, Markush D, Gill N, Romero R. Prenatal Diagnosis of Dextrocardia with Complex Congenital Heart Disease Using Fetal Intelligent Navigation Echocardiography (FINE) and a Literature Review. Fetal Diagn Ther 2017. [PMID: 28641300 DOI: 10.1159/000468929] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
Fetal dextrocardia is a type of cardiac malposition where the major axis from base to apex points to the right side. This condition is usually associated with a wide spectrum of complex cardiac defects. As a result, dextrocardia is conceptually difficult to understand and diagnose on prenatal ultrasound. The advantage of four-dimensional sonography with spatiotemporal image correlation (STIC) is that this modality can facilitate fetal cardiac examination. A novel method known as fetal intelligent navigation echocardiography (FINE) allows automatic generation of nine standard fetal echocardiography views in normal hearts by applying intelligent navigation technology to STIC volume datasets. In fetuses with congenital heart disease, FINE is also able to demonstrate abnormal cardiac anatomy and relationships when there is normal cardiac axis and position. However, this technology has never been applied to cases of cardiac malposition. We report herein for the first time, a case of fetal dextrocardia and situs solitus with complex congenital heart disease in which the FINE method was invaluable in diagnosing multiple abnormalities and defining complex anatomic relationships. We also review the literature on prenatal sonographic diagnosis of dextrocardia (with an emphasis on situs solitus), as well as tricuspid atresia with its associated cardiac features.
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Affiliation(s)
- Lami Yeo
- Perinatology Research Branch, Program for Perinatal Research and Obstetrics, Division of Intramural Research, Eunice Kennedy Shriver National Institute of Child Health and Human Development, NIH, Bethesda, MD, and Detroit, MI, USA
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Vernick CA, Horak J, Greshner A, Vernick WJ. The Fontan circulation and right parietal craniotomy for seizures: the challenges of adult congenital heart disease. J Clin Anesth 2010; 22:460-5. [PMID: 20868969 DOI: 10.1016/j.jclinane.2009.07.012] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2008] [Revised: 06/24/2009] [Accepted: 07/01/2009] [Indexed: 11/27/2022]
Abstract
The management of a patient who had previously undergone surgical palliation of tricuspid atresia at the age of two, and who required right parietal craniotomy for resection of seizure focus, is presented. The anesthetic considerations in patients with Fontan physiology are also presented, as well as the impact on patients undergoing neurosurgical procedures, specifically, craniotomy for seizure focus resection. The physiologic demands of modern surgical practice requires that there is a thorough understanding of the complex circulations that exist in patients with congenital heart disease.
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Affiliation(s)
- Coleen A Vernick
- Department of Anesthesia, Thomas Jefferson University Hospital, Philadelphia, PA 19107, USA
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Slack J, Johns I, Van Eps A, Reef VB. Imaging diagnosis--tricuspid atresia in an alpaca. Vet Radiol Ultrasound 2008; 49:309-12. [PMID: 18546792 DOI: 10.1111/j.1740-8261.2008.00372.x] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Affiliation(s)
- JoAnn Slack
- Department of Clinical Studies, Section of Sports Medicine and Imaging, New Bolton Center, School of Veterinary Medicine, University of Pennsylvania, 382 West Street Road, Kennett Square, PA 19348-1692, USA.
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Abstract
As early as 1699, Chemineau described a heart composed of 2 auricles but only 1 ventricle.
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The univentricular heart has since fascinated the medical community. Unique in its complexity and scope, the univentricular heart has sparked intense debates about embryology and nomenclature, challenged our understanding of cardiovascular physiology and hemodynamics, and inspired some of the most creative surgical and interventional approaches in human history. The present report provides an overview of the nomenclature and classification of the univentricular heart, epidemiology and pathological subtypes, genetic factors, physiology, clinical features, diagnostic assessment, therapy, and postoperative sequelae. Although the present report touches on issues applicable to neonates and children with univentricular hearts, the focus is on information of interest and relevance to the adult cardiologist.
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Affiliation(s)
- Paul Khairy
- Adult Congenital Heart Center, Montreal Heart Institute, 5000 Bélanger St, Montreal, Quebec, H1T 1C8, Canada.
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Ruhl KM, Koos R, Mahnken AH. Echocardiogram-gated multislice spiral CT in functionally univentricular heart following long-lasting Waterston-Cooley anastomosis. AUSTRALASIAN RADIOLOGY 2006; 50:490-4. [PMID: 16981950 DOI: 10.1111/j.1440-1673.2006.01634.x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/11/2023]
Abstract
Waterston-Cooley anastomosis may be carried out in patients with tricuspid atresia to provide pulmonary perfusion. It is associated with several complications, including preferential blood flow to the right lung, hypoplasia of the left pulmonary artery, obstruction of the anatomosis or rupture of pulmonary aneurysms. We study a patient with thrombosis in the pulmonary arteries following surgical construction of a Waterston shunt in childhood. Imaging findings and clinical symptoms are discussed with emphasis on echocardiogram-gated multislice spiral CT.
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Affiliation(s)
- K M Ruhl
- Department of Diagnostic Radiology, University of Technology, Aachen, Germany.
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Gonçalves LF, Lee W, Chaiworapongsa T, Espinoza J, Schoen ML, Falkensammer P, Treadwell M, Romero R. Four-dimensional ultrasonography of the fetal heart with spatiotemporal image correlation. Am J Obstet Gynecol 2004; 189:1792-802. [PMID: 14710117 DOI: 10.1016/s0002-9378(03)00913-x] [Citation(s) in RCA: 156] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE This study was undertaken to describe a new technique for the examination of the fetal heart using four-dimensional ultrasonography with spatiotemporal image correlation (STIC). STUDY DESIGN Volume data sets of the fetal heart were acquired with a new cardiac gating technique (STIC), which uses automated transverse and longitudinal sweeps of the anterior chest wall. These volumes were obtained from 69 fetuses: 35 normal, 16 with congenital anomalies not affecting the cardiovascular system, and 18 with cardiac abnormalities. Dynamic multiplanar slicing and surface rendering of cardiac structures were performed. To illustrate the STIC technique, two representative volumes from a normal fetus were compared with volumes obtained from fetuses with the following congenital heart anomalies: atrioventricular septal defect, tricuspid stenosis, tricuspid atresia, and interrupted inferior vena cava with abnormal venous drainage. RESULTS Volume datasets obtained with a transverse sweep were utilized to demonstrate the cardiac chambers, moderator band, interatrial and interventricular septae, atrioventricular valves, pulmonary veins, and outflow tracts. With the use of a reference dot to navigate the four-chamber view, intracardiac structures could be simultaneously studied in three orthogonal planes. The same volume dataset was used for surface rendering of the atrioventricular valves. The aortic and ductal arches were best visualized when the original plane of acquisition was sagittal. Volumes could be interactively manipulated to simultaneously visualize both outflow tracts, in addition to the aortic and ductal arches. Novel views of specific structures were generated. For example, the location and extent of a ventricular septal defect was imaged in a sagittal view of the interventricular septum. Furthermore, surface-rendered images of the atrioventricular valves were employed to distinguish between normal and pathologic conditions. Representative video clips were posted on the Journal's Web site to demonstrate the diagnostic capabilities of this new technique. CONCLUSION Dynamic multiplanar slicing and surface rendering of the fetal heart are feasible with STIC technology. One good quality volume dataset, obtained from a transverse sweep, can be used to examine the four-chamber view and the outflow tracts. This novel method may assist in the evaluation of fetal cardiac anatomy.
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Affiliation(s)
- Luís F Gonçalves
- Perinatology Research Branch, National Institute of Child Health and Human Development, National Institutes of Health/Department of Health and Human Services, Bethesda, MD, USA
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