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Zentner D, Celermajer DS, Gentles T, d’Udekem Y, Ayer J, Blue GM, Bridgman C, Burchill L, Cheung M, Cordina R, Culnane E, Davis A, du Plessis K, Eagleson K, Finucane K, Frank B, Greenway S, Grigg L, Hardikar W, Hornung T, Hynson J, Iyengar AJ, James P, Justo R, Kalman J, Kasparian N, Le B, Marshall K, Mathew J, McGiffin D, McGuire M, Monagle P, Moore B, Neilsen J, O’Connor B, O’Donnell C, Pflaumer A, Rice K, Sholler G, Skinner JR, Sood S, Ward J, Weintraub R, Wilson T, Wilson W, Winlaw D, Wood A. Management of People With a Fontan Circulation: a Cardiac Society of Australia and New Zealand Position statement. Heart Lung Circ 2020; 29:5-39. [DOI: 10.1016/j.hlc.2019.09.010] [Citation(s) in RCA: 24] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2019] [Accepted: 09/16/2019] [Indexed: 02/07/2023]
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Attard C, Huang J, Monagle P, Ignjatovic V. Pathophysiology of thrombosis and anticoagulation post Fontan surgery. Thromb Res 2018; 172:204-213. [PMID: 29685556 DOI: 10.1016/j.thromres.2018.04.011] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2017] [Revised: 04/05/2018] [Accepted: 04/11/2018] [Indexed: 01/19/2023]
Abstract
The Fontan procedure has transformed the lives of children born with single-ventricle physiology, previously deemed inoperable. Worldwide, there are an increasing number of children with Fontan circulation, with the potential for survival into adulthood. Due to the abnormal circulation, Fontan patients have an increased risk of thromboembolic (TE) events, with up to 25% of events leading to death. Despite the importance of preventing TE events in this patient population, there is currently no clinical consensus on the optimal monitoring, thromboprophylaxis therapies, and treatment of these events. This paper reviews the available literature regarding anticoagulation in the pediatric and adult Fontan population, including the mechanisms for thrombosis and current antithrombotic therapies.
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Affiliation(s)
- Chantal Attard
- Murdoch Children's Research Institute, Haematology Research Group, Parkville, Victoria, Australia; Royal Children's Hospital, Department of Clinical Haematology, Parkville, Victoria, Australia; The University of Melbourne, Department of Paediatrics, Parkville, Victoria, Australia.
| | - Joanna Huang
- Murdoch Children's Research Institute, Haematology Research Group, Parkville, Victoria, Australia; Royal Children's Hospital, Department of Clinical Haematology, Parkville, Victoria, Australia; Monash University, School of Clinical Sciences, Clayton, Victoria, Australia
| | - Paul Monagle
- Murdoch Children's Research Institute, Haematology Research Group, Parkville, Victoria, Australia; Royal Children's Hospital, Department of Clinical Haematology, Parkville, Victoria, Australia; The University of Melbourne, Department of Paediatrics, Parkville, Victoria, Australia
| | - Vera Ignjatovic
- Murdoch Children's Research Institute, Haematology Research Group, Parkville, Victoria, Australia; Royal Children's Hospital, Department of Clinical Haematology, Parkville, Victoria, Australia
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Bendaly EA, DiMeglio LA, Fadel WF, Hurwitz RA. Bone density in children with single ventricle physiology. Pediatr Cardiol 2015; 36:779-85. [PMID: 25511666 PMCID: PMC4858165 DOI: 10.1007/s00246-014-1083-3] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/19/2014] [Accepted: 12/05/2014] [Indexed: 11/27/2022]
Abstract
Children with chronic diseases are at risk for low bone mineral density (BMD). There are no studies of BMD in children with congenital heart disease and particularly single ventricle (SV). Children with this defect are often treated with warfarin, suspected to negatively impact BMD in adults. We assessed BMD in patients with SV physiology and compared the BMD of subjects taking warfarin to those who were not. Subjects 5-12 years with SV were included. BMD z scores by dual-energy X-ray absorptiometry of the spine and total body less head (TBLH) were obtained. Calcium intake, activity level, height, and Tanner stage were assessed. Linear regression models and t tests were used to investigate differences between participants and normative data as well as between subjects' subgroups. Twenty-six subjects were included and 16 took warfarin. Mean BMD z score at the spine was significantly lower than expected at -1.0 ± 0.2 (p < 0.0001), as was the BMD z score for TBLH at -0.8 ± 0.2 (p < 0.0001). Those results remained significant after adjusting for height. Subjects who were on warfarin tended to have lower BMD at both the spine and TBLH than those who were not, with a z score difference of 0.6 ± 0.46 at the spine (p = 0.106) and a difference of 0.4 ± 0.34 at TBLH (p = 0.132). BMD is significantly reduced in children with SV. Warfarin appears to lower BMD but the effect is less conclusive. Continued evaluation is recommended for these patients at risk for reduced bone density. Evaluation of other cardiac patients on warfarin therapy should also be considered.
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Affiliation(s)
- Edgard A Bendaly
- Section of Pediatric Cardiology, Department of Pediatrics, Sanford Children's Hospital, University of South Dakota, 1600 W 22nd Street, PO Box 5039, Sioux Falls, SD, 57117, USA,
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Sandler K, Markham L, Mah M, Byrum E, Williams J. Optimizing CT angiography in patients with Fontan physiology: single-center experience of dual-site power injection. Clin Radiol 2014; 69:e562-7. [DOI: 10.1016/j.crad.2014.09.011] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2014] [Revised: 09/10/2014] [Accepted: 09/15/2014] [Indexed: 11/30/2022]
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Cotts T, Khairy P, Opotowsky AR, John AS, Valente AM, Zaidi AN, Cook SC, Aboulhosn J, Ting JG, Gurvitz M, Landzberg MJ, Verstappen A, Kay J, Earing M, Franklin W, Kogon B, Broberg CS. Clinical research priorities in adult congenital heart disease. Int J Cardiol 2013; 171:351-60. [PMID: 24411207 DOI: 10.1016/j.ijcard.2013.12.034] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/15/2013] [Accepted: 12/14/2013] [Indexed: 12/31/2022]
Abstract
BACKGROUND Adult congenital heart disease (ACHD) clinicians are hampered by the paucity of data to inform clinical decision-making. The objective of this study was to identify priorities for clinical research in ACHD. METHODS A list of 45 research questions was developed by the Alliance for Adult Research in Congenital Cardiology (AARCC), compiled into a survey, and administered to ACHD providers. Patient input was sought via the Adult Congenital Heart Association at community meetings and online forums. The 25 top questions were sent to ACHD providers worldwide via an online survey. Each question was ranked based on perceived priority and weighted based on time spent in ACHD care. The top 10 topics identified are presented and discussed. RESULTS The final online survey yielded 139 responses. Top priority questions related to tetralogy of Fallot (timing of pulmonary valve replacement and criteria for primary prevention ICDs), patients with systemic right ventricles (determining the optimal echocardiographic techniques for measuring right ventricular function, and indications for tricuspid valve replacement and primary prevention ICDs), and single ventricle/Fontan patients (role of pulmonary vasodilators, optimal anticoagulation, medical therapy for preservation of ventricular function, treatment for protein losing enteropathy). In addition, establishing criteria to refer ACHD patients for cardiac transplantation was deemed a priority. CONCLUSIONS The ACHD field is in need of prospective research to address fundamental clinical questions. It is hoped that this methodical consultation process will inform researchers and funding organizations about clinical research topics deemed to be of high priority.
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Affiliation(s)
- Timothy Cotts
- Department of Internal Medicine, University of Michigan Medical School, Ann Arbor, MI, United States; Department of Pediatrics, University of Michigan Medical School, Ann Arbor, MI, United States.
| | - Paul Khairy
- Montreal Heart Institute, Université de Montréal, Montreal, Canada
| | - Alexander R Opotowsky
- Boston Children's Hospital, Department of Cardiology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, United States; Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, United States
| | - Anitha S John
- Division of Cardiology, Children's National Medical Center, Washington, D.C., United States
| | - Anne Marie Valente
- Boston Children's Hospital, Department of Cardiology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, United States; Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, United States
| | - Ali N Zaidi
- Columbus Ohio Adult Congenital Heart Disease Program, The Heart Center, Nationwide Children's Hospital, The Ohio State University, Columbus, OH, United States; Department of Pediatrics, The Ohio State University, Columbus, OH, United States; Department of Internal Medicine, The Ohio State University, Columbus, OH, United States
| | - Stephen C Cook
- Department of Pediatrics, Heart Institute, Children's Hospital of Pittsburgh of UPMC, Pittsburgh, PA, United States
| | - Jamil Aboulhosn
- Department of Internal Medicine, University of California, Los Angeles, CA, United States
| | - Jennifer Grando Ting
- Heart & Vascular Institute, Hershey Medical Center, Pennsylvania State University, Hershey, PA, United States
| | - Michelle Gurvitz
- Boston Children's Hospital, Department of Cardiology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, United States; Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, United States
| | - Michael J Landzberg
- Boston Children's Hospital, Department of Cardiology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, United States; Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, United States
| | - Amy Verstappen
- Adult Congenital Heart Association, Philadelphia, PA, United States
| | - Joseph Kay
- Department of Internal Medicine, University of Colorado, Denver, United States; Department of Pediatrics, University of Colorado, Denver, United States
| | - Michael Earing
- Department of Internal Medicine, Medical College of Wisconsin, Milwaukee, WI, United States; Department of Pediatrics, Medical College of Wisconsin, Milwaukee, WI, United States
| | - Wayne Franklin
- Department of Medicine, Baylor College of Medicine, Texas Children's Hospital, Houston, TX, United States; Department of Pediatrics, Baylor College of Medicine, Texas Children's Hospital, Houston, TX, United States
| | - Brian Kogon
- Division of Cardiothoracic Surgery, Emory University, Atlanta, GA, United States
| | - Craig S Broberg
- Knight Cardiovascular Institute, Oregon Health & Science University, Portland, OR, United States
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Grewal J, Al Hussein M, Feldstein J, Kiess M, Ellis J, Human D, Leipsic J. Evaluation of Silent Thrombus after the Fontan Operation. CONGENIT HEART DIS 2012; 8:40-7. [DOI: 10.1111/j.1747-0803.2012.00699.x] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/09/2012] [Indexed: 01/05/2023]
Affiliation(s)
- Jasmine Grewal
- Division of Cardiology, St. Paul's Hospital; University of British Columbia; Vancouver; BC; Canada
| | - Mosaad Al Hussein
- Division of Cardiology, St. Paul's Hospital; University of British Columbia; Vancouver; BC; Canada
| | - Jaimee Feldstein
- Division of Cardiology, St. Paul's Hospital; University of British Columbia; Vancouver; BC; Canada
| | - Marla Kiess
- Division of Cardiology, St. Paul's Hospital; University of British Columbia; Vancouver; BC; Canada
| | - Jennifer Ellis
- Department of Radiology, St. Paul's Hospital; University of British Columbia; Vancouver; BC; Canada
| | - Derek Human
- Division of Cardiology, St. Paul's Hospital; University of British Columbia; Vancouver; BC; Canada
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Eagle SS, Daves SM. The Adult With Fontan Physiology: Systematic Approach to Perioperative Management for Noncardiac Surgery. J Cardiothorac Vasc Anesth 2011; 25:320-34. [DOI: 10.1053/j.jvca.2010.12.003] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/01/2010] [Indexed: 01/19/2023]
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Prabhu SP, Mahmood S, Sena L, Lee EY. MDCT evaluation of pulmonary embolism in children and young adults following a lateral tunnel Fontan procedure: optimizing contrast-enhancement techniques. Pediatr Radiol 2009; 39:938-44. [PMID: 19471914 DOI: 10.1007/s00247-009-1304-8] [Citation(s) in RCA: 43] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/03/2009] [Revised: 04/11/2009] [Accepted: 04/30/2009] [Indexed: 11/29/2022]
Abstract
BACKGROUND Pulmonary embolism (PE) is a life-threatening thromboembolic complication in patients who have undergone a Fontan procedure for augmenting pulmonary blood flow in the setting of single-ventricle physiology. In patients following a Fontan procedure, lack of proper contrast agent mixing in the right atrium and sluggish, low-velocity blood flow within the Fontan circulation often results in suboptimal contrast enhancement within the pulmonary artery for evaluating PE. Unfortunately, there is a paucity of information describing the optimal contrast-enhancement technique with multidetector CT (MDCT) for evaluating PE in children and young adults following a Fontan procedure. OBJECTIVE We illustrate the MDCT imaging findings of suboptimal contrast enhancement within the pulmonary artery, which can be mistaken for PE, in patients following a lateral Fontan procedure, and we discuss MDCT techniques to optimize contrast enhancement within the pulmonary artery in these patients for evaluating PE. MATERIALS AND METHODS The MDCT imaging findings in pediatric and young adult patients following a lateral Fontan procedure and with clinically suspected PE are illustrated. We describe intravenous contrast agent injection techniques that can be used to optimize the contrast enhancement in the pulmonary artery in patients following a lateral Fontan procedure. RESULTS The use of a suboptimal contrast-enhancement technique led to initial misdiagnosis and incomplete evaluation of PE in the three patients following a lateral Fontan procedure. Imaging in two patients showed that optimal evaluation of thrombosis in the Fontan pathway and PE in the pulmonary arteries can be successfully achieved with simultaneous upper- and lower-limb injections of contrast agent. CONCLUSION This series demonstrates that suboptimal contrast enhancement can result in misdiagnosis or incomplete evaluation of PE in children and young adults following a lateral Fontan procedure. Careful attention to optimizing contrast enhancement during MDCT examination for evaluation of PE in these patients is essential to prevent misdiagnosis and incomplete evaluation.
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Affiliation(s)
- Sanjay P Prabhu
- Department of Radiology, Children's Hospital Boston and Harvard Medical School, Boston, MA 02115, USA
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Abstract
Among factors contributing to morbidity and failure of the Fontan circulation is the group of events referred to as thromboembolic complications. These events have been variously attributed to low flow states, stasis in the venous pathways, right-to-left shunts, blind cul-de-sacs, prosthetic material, atrial arrhythmias, and hypercoagulable states. Numerous investigations, most retrospective, have been undertaken to characterize thromboembolic events; describe the frequency and circumstances of these occurrences; and relate the risk of these events to patient, surgical, hemodynamic, and hematologic factors. Practices vary widely with respect to strategies of prophylactic anticoagulation in the hopes of minimizing the occurrence and morbidity of thromboembolism after Fontan operations. Review of the literature suggests that the factors associated with thromboembolic events after Fontan operations likely represent a complex field of biologic factors with multiple interactions. It is unlikely that a single agent will represent the solution to this complex problem.
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Affiliation(s)
- M L Jacobs
- Section of Cardiothoracic Surgery, St. Christopher's Hospital for Children, Erie Avenue at Front Street, Philadelphia, PA 19134, USA.
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Gossett JG, Rocchini AP, Armstrong AK. Superior vena cava thrombectomy with the X-SIZER® catheter system in a child with Fontan palliation. Catheter Cardiovasc Interv 2006; 69:28-32. [PMID: 17139678 DOI: 10.1002/ccd.20927] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
A 4-year-old female with hypoplastic left heart syndrome and Fontan palliation presented with severe neurologic impairment from thrombosis of the superior vena cava (SVC). She underwent successful SVC thrombectomy with the X-SIZER Thrombectomy Catheter System, followed by balloon angioplasty. She demonstrated rapid improvement in her neurologic deficits after the procedure. This represents the first published use of the X-SIZER in a child and its first published use for SVC thrombectomy.
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Affiliation(s)
- Jeffrey G Gossett
- Division of Pediatric Cardiology, Department of Pediatrics and Communicable Diseases, University of Michigan Health System, Ann Arbor, Michigan 48109-0204, USA
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Abstract
We tested the hypothesis that Chinese patients have a coagulation profile that is less prothrombotic than that of Caucasian counterparts after the Fontan procedure by determining the type and prevalence of anticoagulant and procoagulant deficiencies in Chinese patients and comparing the findings to those previously reported in Caucasian series. The liver function and coagulation factors were assessed in 21 ethnic Chinese patients, aged 17.0 +/- 5.6 years, at 10.7 +/- 4.0 years after the Fontan procedure. The results were compared to those of 21 age-matched Chinese controls with minor congenital heart disease. The prevalence of coagulation factor deficiencies in our patients was further compared to that reported in Caucasian patients. When compared with controls, patients had significantly lower protein C (p = 0.014), factors II (p = 0.024), V (p < 0.001), VII (p < 0.001), IX (p = 0.036), and X (p < 0.001), and higher bilirubin (p = 0.001) levels. The prevalence of protein C deficiency was 9.5%, whereas those of factor II, V, VII, IX, and X deficiencies were 0, 66.7, 9.5, 0, and 57.1%, respectively. When compared with Caucasian data, our data showed a significantly lower prevalence of protein C, total protein S, antithorombin III, factor II, and factor VII deficiencies. Furthermore, the previously reported increase in factor VIII levels was not found. In contrast, the prevalence of factor X deficiency was higher in our patients. This study provides the first evidence of ethnic differences in coagulation factor abnormalities after the Fontan procedure. The imbalance between procoagulant and anticoagulant pathways in Chinese patients favors a bleeding, rather than a thrombotic, tendency.
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Affiliation(s)
- Y-F Cheung
- Division of Paediatric Cardiology, Department of Paediatrics and Adolescent Medicine, Grantham Hospital,The University of Hong Kong, 125, Wong Chuk Hang Road, Aberdeen, Hong Kong, People's Republic of China.
| | - G W Chay
- Division of Paediatric Cardiology, Department of Paediatrics and Adolescent Medicine, Grantham Hospital,The University of Hong Kong, 125, Wong Chuk Hang Road, Aberdeen, Hong Kong, People's Republic of China
| | - E S K Ma
- Division of Haematology, Department of Pathology, Queen Mary Hospital, The University of Hong Kong, Pokjulam Road, Hong Kong, People's Republic of China
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Cheung EWY, Chay GW, Ma ESK, Cheung YF. Systemic oxygen saturation and coagulation factor abnormalities before and after the fontan procedure. Am J Cardiol 2005; 96:1571-5. [PMID: 16310443 DOI: 10.1016/j.amjcard.2005.07.074] [Citation(s) in RCA: 18] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/13/2005] [Revised: 07/06/2005] [Accepted: 07/06/2005] [Indexed: 01/19/2023]
Abstract
Coagulation factor abnormalities are believed to predispose to increased risk for thromboembolism after the Fontan procedure. Recent data, however, suggest that coagulation abnormalities may precede the operation. This study determined coagulation factor abnormalities in patients with single-ventricle congenital heart defects before the Fontan procedure and compared the findings with age-matched post-Fontan patients and control subjects. Liver function, coagulation factor levels, and pulse oximetry readings were determined in 11 pre-Fontan patients aged 9.3+/-5.6 years. The results were compared with those of 11 age-matched post-Fontan patients, at 9.1+/-2.4 years after the Fontan procedure, and 11 age-matched controls by simple analysis of variance and post hoc Tukey's test. Liver function was normal in patients before and after surgery apart from mildly elevated bilirubin levels in post-Fontan patients (p=0.027). When compared with controls, pre-Fontan patients had significantly lower levels of protein C; protein S; antithrombin III; and factors II, V, VII, and X and longer prothrombin times (all with p<0.05). When compared with post-Fontan patients, pre-Fontan patients had similarly lower levels of free protein S (p<0.001), protein C (p=0.06), and antithrombin III (p=0.001). Systemic oxygen saturation correlated positively with the levels of anticoagulants (protein C, protein S, antithrombin III) and procoagulants (factors II, V, VII, and X) (all with p<0.05, r=0.33 to 0.61). In conclusion, the findings suggest that coagulation factor abnormalities precede the Fontan procedure and tend to normalize after the operation, relating perhaps to improved systemic oxygenation.
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Affiliation(s)
- Eddie W Y Cheung
- Division of Paediatric Cardiology, Department of Paediatrics and Adolescent Medicine, Grantham Hospital, Hong Kong, China
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Barker PCA, Nowak C, King K, Mosca RS, Bove EL, Goldberg CS. Risk factors for cerebrovascular events following fontan palliation in patients with a functional single ventricle. Am J Cardiol 2005; 96:587-91. [PMID: 16098317 DOI: 10.1016/j.amjcard.2005.04.025] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/03/2004] [Revised: 04/08/2005] [Accepted: 04/08/2005] [Indexed: 10/25/2022]
Abstract
The risk for cerebrovascular events (CVEs) is increased in children with functional single ventricles (FSVs). However, there are limited data indicating the prevalence of CVEs or the role of preventative therapy. To measure the prevalence of clinically evident CVEs in patients with FSVs, identify risk factors, and analyze the effect of aspirin on the risk for CVEs, a retrospective chart review was performed on all patients who underwent Fontan palliation at the University of Michigan from January 1, 1975, to June 30, 1998 (n = 402). Data collected included original anatomy, Fontan type, date of CVE, medications at the time of CVE, intraoperative placement of fenestration, and date of last follow-up. The overall mortality rate was 12%. There were 38 CVEs (9%), of which only 11 (3%, or 0.0036/patient-year) could not be attributed to a defined event (catheterization, extracorporeal membrane oxygenation, or cardiac arrest). Anticoagulation with aspirin was associated with a statistically significantly decreased risk for CVEs. Fontan type was not associated with the risk for CVEs. Thus, patients with FSVs are at increased risk for CVEs, although the de novo risk was low. Aspirin use is associated with a decreased risk for CVEs.
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Affiliation(s)
- Piers C A Barker
- Division of Pediatric Cardiology, Department of Pediatrics, University of Michigan, Ann Arbor, Michigan, USA
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Cheung YF, Chay GW, Chiu CSW, Cheng LC. Long-term anticoagulation therapy and thromboembolic complications after the Fontan procedure. Int J Cardiol 2005; 102:509-13. [PMID: 16004898 DOI: 10.1016/j.ijcard.2004.05.051] [Citation(s) in RCA: 41] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/04/2004] [Revised: 04/27/2004] [Accepted: 05/27/2004] [Indexed: 11/27/2022]
Abstract
BACKGROUND The necessity for chronic anticoagulation of Fontan patients remains controversial. We determined the prevalence of thromboembolic complications after the Fontan procedure in relation to different long-term anticoagulation strategies. METHODS The clinical outcomes, postoperative anticoagulation strategies and occurrence of thromboembolic complications in 102 ethnic Chinese patients who had undergone Fontan procedure between 1980 and 2002 were reviewed. RESULTS The early and late surgical mortalities, all unrelated to thromboembolism, were 10.8% (11/102) and 5.8% (6/104), respectively. Of the 85 survivors, 46 (54%) were maintained on long-term warfarin therapy, 8 (9%) on aspirin prophylaxis while 31 (37%) were not on chronic anticoagulation. Four (4.5%) patients, two with and two without warfarin prophylaxis, developed thromboembolic complications at 0.14 to 7.7 years after the Fontan procedure (0.74%/patient-year). Three had a grossly dilated right atrium after atriopulmonary connection, two of whom had atrial fenestrations. The other had atrial tachycardia. Freedom from development of thromboembolic complications (mean+/-S.E.) at 1, 5 and 10 years after surgery was 97+/-19%, 96+/-2.5% and 92+/-4.2%, respectively. When compared with those on long-term warfarin therapy, patients without chronic anticoagulation were followed-up longer (p=0.001), more likely to have undergone atriopulmonary connection (p<0.001), less likely to have fenestrations (p=0.02) and cardiac arrhythmias (p=0.02) but not predisposed to increased risk of thromboembolism (p=1.00). CONCLUSION The study supports the contention that chronic anticoagulation may not be required for majority of ethnic Chinese Fontan patients. Nonetheless, it may perhaps be considered in those with grossly dilated right atrium, cardiac arrhythmias and residual right-to-left shunts.
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Affiliation(s)
- Y F Cheung
- Department of Paediatrics and Adolescent Medicine, Division of Paediatric Cardiology, Grantham Hospital, The University of Hong Kong, Aberdeen, Hong Kong, People's Republic of China.
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Walker F, Siu SC, Woods S, Cameron DA, Webb GD, Harris L. Long-Term outcomes of cardiac pacing in adults with congenital heart disease. J Am Coll Cardiol 2004; 43:1894-901. [PMID: 15145118 DOI: 10.1016/j.jacc.2003.12.044] [Citation(s) in RCA: 51] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/15/2003] [Revised: 12/17/2003] [Accepted: 12/23/2003] [Indexed: 10/26/2022]
Abstract
OBJECTIVES The purpose of this retrospective study was to define long-term outcomes after pacemaker therapy in adults with congenital heart disease (CHD). BACKGROUND Adults with CHD represent a unique and expanding population. Many will require pacemaker or implantable defibrillator therapy, with a lifelong need for re-intervention and follow-up. They pose technical and management challenges not encountered in other groups receiving pacing, and the complication and re-intervention rates specific to this population are not well-defined. METHODS We reviewed outcomes of 168 adults with CHD, 89 females, mean age 40 years, in whom a pacemaker or anti-tachycardia device was implanted. RESULTS Mean age at implant was 28 years with mean pacing duration 11 years at follow-up (range, 0.5 to 38.0). Seventy-two (42%) received initial dual-chamber devices and remained in this mode, while 23 (14%) went from ventricular to dual-chamber pacing in follow-up. Initial mode of pacing did not have a significant effect on subsequent atrial arrhythmia. Patients receiving an initial epicardial system were younger than those paced endocardially (17 +/- 12 years vs. 35 +/- 16 years, p < 0.001) and more likely to undergo re-intervention (p = 0.019). Difficulty with vascular access was encountered in 25 patients (15%), while 45 (27%) experienced lead-related complications. No significant predictors of lead complications were identified. CONCLUSIONS Lead complications were not significantly different for epicardial versus endocardial, nor physiologic versus ventricular pacing, but a trend toward improved lead survival in patients receiving endocardial leads at first implant was observed. Adults with CHD remain at risk for atrial arrhythmias regardless of pacing mode.
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Affiliation(s)
- Fiona Walker
- Toronto Congenital Cardiac Centre for Adults, Toronto General Hospital, Toronto, Ontario, Canada
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van den Bosch AE, Roos-Hesselink JW, Van Domburg R, Bogers AJJC, Simoons ML, Meijboom FJ. Long-term outcome and quality of life in adult patients after the Fontan operation. Am J Cardiol 2004; 93:1141-5. [PMID: 15110207 DOI: 10.1016/j.amjcard.2004.01.041] [Citation(s) in RCA: 115] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/16/2003] [Revised: 01/12/2004] [Accepted: 01/12/2004] [Indexed: 11/17/2022]
Abstract
The first successful Fontan operation was performed in 1971, and this first cohort of Fontan patients is reaching adulthood with unclear outcome of this palliative procedure. We studied the mortality, morbidity, and quality of life in our adult Fontan patients. We examined all patients (n = 36) who underwent a Fontan procedure and were being seen in an adult outpatient clinic by using electrocardiography, exercise testing, and echocardiography. Quality of life was assessed by the Short Form 36 questionnaire. The mean follow-up period was 15 years (range 0 to 23). Of the initial 36 patients, 10 died (28%) at a mean of 10 years (range 0 to 21) after the Fontan operation and 1 patient underwent cardiac transplantation. Reoperations were performed in 21 patients (58%), and the most common reason was revision of the Fontan connection. Sustained supraventricular tachycardia was observed in 20 patients (56%) with an increased incidence of arrhythmias with longer follow-up. Thromboembolic events were detected in 9 patients (25%), 5 of whom had adequate anticoagulant levels at the time of event. The thromboembolic event was fatal for 3 patients. A total of 195 hospital admissions (mean 3.8 +/- 2.7, range 1 to 13) was recorded. Quality-of-life assessment showed physical functioning, mental health, and general health perception to be significantly lower for Fontan patients than for the normal Dutch population. Thus, we found high mortality and very high morbidity in adult patients after the Fontan operation. In particular, reoperations, arrhythmias, and thromboembolic events compromised quality of life.
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Monagle P, Karl TR. Thromboembolic problems after the Fontan operation. Semin Thorac Cardiovasc Surg Pediatr Card Surg Annu 2004; 5:36-47. [PMID: 11994863 DOI: 10.1053/pcsu.2002.29716] [Citation(s) in RCA: 91] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
One of the major causes of morbidity and mortality after the Fontan operation is thromboembolic events (TE). To assess the current knowledge of TE after Fontan surgery, a comprehensive MEDLINE search of the English literature from 1971 to 2000 was conducted using the key words Fontan, univentricular heart, children, thrombosis, congenital heart disease, cavopulmonary, and palliation. Other relevant publications were identified from bibliographies of the literature retrieved. Fifty-one studies were identified and analyzed for incidence, potential morbidity and mortality, risk factors, prophylactic options, and risk/benefit ratio of prophylactic anticoagulation as relates to TE after Fontan surgery. There were 23 case reports, 13 retrospective cohort studies that included some details about TE among other reported outcomes after Fontan procedures, eight retrospective cohort studies in which TE was the primary outcome measure, and seven articles reporting cross-sectional point surveys, only three of which directly surveyed TE as an outcome. Based on an analysis of the current literature, there is insufficient evidence to make clear recommendations about optimal anticoagulant prophylaxis at this time. Multicenter randomized controlled trials comparing prophylactic antiplatelet with anticoagulation therapies are needed to provide rational scientific guidelines for future management of Fontan patients.
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Affiliation(s)
- Paul Monagle
- Division of Laboratory Services, Royal Children's Hospital, Parkville, Victoria, Australia
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Varma C, Warr MR, Hendler AL, Paul NS, Webb GD, Therrien J. Prevalence of "silent" pulmonary emboli in adults after the Fontan operation. J Am Coll Cardiol 2003; 41:2252-8. [PMID: 12821256 DOI: 10.1016/s0735-1097(03)00490-x] [Citation(s) in RCA: 103] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
OBJECTIVES The study was done to determine the prevalence of pulmonary emboli (PE) in asymptomatic adult Fontan patients and to identify the risk factors associated with PE. BACKGROUND Right atrial thrombi and systemic thromboembolic complications have been reported after the Fontan procedure. However, the frequency of silent PE in this patient population is not known. METHODS All consecutive adult Fontan patients attending the adult congenital clinic over a six-month period underwent ventilation-perfusion (VQ) scanning and blood testing for thrombophilia tendency. If the VQ scan showed an intermediate or high probability for PE, a computerized tomography (CT) pulmonary angiogram was performed to confirm the presence of PE. RESULTS Thirty patients (mean age 26 +/- 7 years, 57% men) were included in this study. Five (17%) adult Fontan patients had an intermediate or high probability for PE on VQ scan, all of which were confirmed on CT pulmonary angiography. No patient had a thrombophilia tendency. Pulmonary emboli were not present in any patients (30%) taking warfarin. Late age at time of Fontan operation (19 +/- 6 years vs. 11 +/- 6 years, p = 0.012) and type of Fontan anatomy (p = 0.001) were associated with increased risk of silent PE. CONCLUSIONS Seventeen percent of adult patients with Fontan procedure have clinically silent PE. The long-term hemodynamic implications of this with respect to Fontan attrition over time are unknown. Large randomized prospective studies looking at anticoagulation therapy in all Fontan patients are urgently needed.
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Affiliation(s)
- Chetan Varma
- Toronto General Hospital, University of Toronto, ON, Canada
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Narkewicz MR, Sondheimer HM, Ziegler JW, Otanni Y, Lorts A, Shaffer EM, Horgan JG, Sokol RJ. Hepatic dysfunction following the Fontan procedure. J Pediatr Gastroenterol Nutr 2003; 36:352-7. [PMID: 12604973 DOI: 10.1097/00005176-200303000-00009] [Citation(s) in RCA: 54] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
OBJECTIVES The Fontan procedure offers a palliation for the hemodynamic derangements associated with congenital heart lesions characterized by a single functional ventricle, but it causes a chronically elevated systemic venous pressure that may result in hepatic congestion. The objective of this study was to characterize hepatic function and its relationship to cardiac function in children who had undergone the Fontan procedure. METHODS In a cross-sectional study of 11 children aged 38 months to 216 months (mean, 149 months), the authors evaluated indices of cardiac and hepatic function, including galactose clearance, Doppler hepatic ultrasonography, synthetic function, and markers of liver injury, at 9 months to 176 months (mean, 100 months) after children had undergone the Fontan procedure. RESULTS The most common biochemical abnormality of hepatic function was a prolongation of the prothrombin time and a low factor V level. There was a trend toward progressive abnormality in prothrombin time with increasing interval since the Fontan procedure. Galactose elimination half-life and galactose elimination capacity were inversely correlated with the time after Fontan (R2= 0.65, P = 0.004). There was no relationship between cardiac functional measurements and liver function. CONCLUSIONS Prothrombin time and galactose elimination half-life are abnormal in children who have undergone the Fontan procedure and may be useful markers of hepatic function in the longitudinal assessment of these patients.
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Affiliation(s)
- Michael R Narkewicz
- Department of Pediatrics, University of Colorado School of Medicine and The Children's Hospital, Denver, 80218, USA.
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Seipelt RG, Franke A, Vazquez-Jimenez JF, Hanrath P, von Bernuth G, Messmer BJ, Mühler EG. Thromboembolic complications after Fontan procedures: comparison of different therapeutic approaches. Ann Thorac Surg 2002; 74:556-62. [PMID: 12173844 DOI: 10.1016/s0003-4975(02)03677-9] [Citation(s) in RCA: 95] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
BACKGROUND Although patients after Fontan procedure have a high incidence of thromboembolic complications, anticoagulant therapy is not handled uniformly. We analyzed the frequency and clinical relevance of thromboembolism after Fontan procedure and compared different therapeutic approaches. METHODS From 1986 to 1998, 101 patients (mean age, 7.3 +/- 8.1 years) underwent Fontan type procedure (modified Fontan, n = 40; total cavopulmonary connection, n = 61). In 85 of 87 survivors, transthoracic echocardiography was performed; and in 31 transesophageal echocardiography and/or angiography was performed. Mean follow-up was 5.7 +/- 3.5 years. Three groups with different anticoagulant regimen were compared: group I without medication (n = 45), group II with acetylsalicylic acid therapy (n = 14) and group III with Coumadin (n = 26). RESULTS Thromboembolic events occurred in 13 of 85 patients (15.3%; 3.3 events/100 patient-years). Type of operation as well as other known risk factors had no influence on the rate of thromboembolism. Within the first postoperative year, seven of 13 events occurred. A second peak developed beyond 10 years of follow-up. Patients benefit significantly from Coumadin compared with those who did not receive any medication, with similar results in the entire population and the subgroup of patients with total cavopulmonary connection (log-rank, p = 0.031 and p = 0.033, respectively). With 4.2 events/100 patient-years, the cumulative event rate was substantially higher in group I than with 1.6 in group II and with 1.1 in group III. No relevant bleeding complications occurred. CONCLUSIONS Thromboembolism is frequent after Fontan procedure with a peak during the first postoperative year and another peak beyond 10 years of follow-up. Coumadin is the most effective prophylactic therapy in preventing thromboembolism. Therefore, we suggest initial oral anticoagulation therapy in patients with Fontan type operation.
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Affiliation(s)
- Ralf G Seipelt
- Department of Thoracic and Cardiovascular Surgery, Medical Clinic I, Aachen, Germany.
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22
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Freedom RM, Hamilton R, Yoo SJ, Mikailian H, Benson L, McCrindle B, Justino H, Williams WG. The Fontan procedure: analysis of cohorts and late complications. Cardiol Young 2000; 10:307-31. [PMID: 10950328 DOI: 10.1017/s1047951100009616] [Citation(s) in RCA: 56] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Affiliation(s)
- R M Freedom
- Department of Pathology and Laboratory Medicine, the Hospital for Sick Children, Toronto, Canada.
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23
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Monagle P, Cochrane A, McCrindle B, Benson L, Williams W, Andrew M. Thromboembolic complications after fontan procedures--the role of prophylactic anticoagulation. J Thorac Cardiovasc Surg 1998; 115:493-8. [PMID: 9535434 DOI: 10.1016/s0022-5223(98)70310-1] [Citation(s) in RCA: 125] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
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Oski JA, Canter CE, Spray TL, Kan JS, Cameron DE, Murphy AM. Embolic stroke after ligation of the pulmonary artery in patients with functional single ventricle. Am Heart J 1996; 132:836-40. [PMID: 8831374 DOI: 10.1016/s0002-8703(96)90319-1] [Citation(s) in RCA: 21] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
In the setting of functional single ventricle with pulmonary overcirculation, pulmonary artery banding is frequently used to alleviate symptoms and to prepare for staged repair. At subsequent cavopulmonary anastomosis or Fontan procedure, the pulmonary artery may be ligated at the site of the pulmonary band. This article describes the association of embolic stroke and thrombus in a ligated or divided pulmonary artery stump in three patients with functional single ventricle. These events occurred from 1990 through 1992 among the 1700 inpatient pediatric cardiology admissions at two institutions. The patients, ranging in age from 15 months to 9 years, had cerebral infarctions documented by computed axial tomography scan or magnetic resonance imaging associated with the echocardiographic finding of thrombus in the proximal pulmonary artery stump after the embolic strokes. The strokes occurred 5 days to 5 years after surgery. Two patients had a second infarction within 2 to 5 weeks of the initial stroke. It is concluded that the presence of the ligated pulmonary artery stump may place patients at risk for embolic stroke. Surgical approaches to reduce the risk of thrombus formation should be considered prospectively in this patient group.
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Affiliation(s)
- J A Oski
- Division of Pediatric Cardiology, Johns Hopkins University School of Medicine, Baltimore, MD, USA
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Fishberger SB, Wernovsky G, Gentles TL, Gamble WJ, Gauvreau K, Burnett J, Mayer JE, Walsh EP. Long-term outcome in patients with pacemakers following the Fontan operation. Am J Cardiol 1996; 77:887-9. [PMID: 8623749 DOI: 10.1016/s0002-9149(97)89191-6] [Citation(s) in RCA: 44] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
Patients with pacemakers after Fontan surgery compared favorably with nonpaced patients with respect to survival. In patients with atrioventricular block, dual chamber pacing was superior to VVI pacing.
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Affiliation(s)
- S B Fishberger
- Department of Cardiology, Children's Hospital, Boston, Massachusetts 02115, USA
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