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McGetrick ME, Riviello JJ. Neurological injury in pediatric heart disease: A review of developmental and acquired risk factors and management considerations. Semin Pediatr Neurol 2024; 49:101115. [PMID: 38677794 DOI: 10.1016/j.spen.2024.101115] [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: 10/16/2023] [Revised: 01/10/2024] [Accepted: 01/18/2024] [Indexed: 04/29/2024]
Abstract
Medical and surgical advancements have improved survival in children with acquired and congenital heart disease (CHD), but the burden of neurological morbidity is high. Brain disorders associated with CHD include white matter injury, stroke, seizure, and neurodevelopmental delays. While genetics and disease-specific factors play a substantial role in early brain injury, therapeutic management of the heart disease intensifies the risk. There is a growing interest in understanding how to reduce brain injury and improve neurodevelopmental outcomes in cardiac diseases. Pediatric neurologists serve a vital role in care teams managing these complex patients, providing interpretation of neuromonitoring and imaging, managing neurologic emergencies, assisting with neuro prognostication, and identifying future research aims.
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Affiliation(s)
- Molly E McGetrick
- Division of Cardiology and Critical Care, Department of Pediatrics, the University of Texas Southwestern, Children's Medical Center, Dallas, Texas, USA.
| | - James J Riviello
- Division of Neurology and Developmental Neuroscience, Department of Pediatrics, Baylor College of Medicine, Texas Children's Hospital, Houston, Texas, USA
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2
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Polat AB, Ertürk M, Uzunhan O, Karademir N, Öztarhan K. 27 years of experience with the Fontan procedure: characteristics and clinical outcomes of children in a tertiary referral hospital. J Cardiothorac Surg 2023; 18:38. [PMID: 36653817 PMCID: PMC9850550 DOI: 10.1186/s13019-023-02148-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2022] [Accepted: 01/10/2023] [Indexed: 01/19/2023] Open
Abstract
BACKGROUND The Fontan operation has improved the survival of children born with congenital heart disease with single ventricle physiology. The most widely adopted variations of the Fontan procedure are the extracardiac conduit, the lateral tunnel ve the intra/extracardiac conduit with fenestration. Despite advances in the treatment and prevention of early and late complications that may develop after Fontan surgery, morbidity still remains an important problem. METHODS 304 patients who underwent Fontan surgery in our center between 1995 and 2022 were included in our study. The complications that developed in patients who underwent primary Fontan or lateral tunnel surgery and extracardiac conduit Fontan application were compared. RESULTS Classic Fontan surgery and lateral tunnel surgery were performed in 26 of the patients, and extracardiac Fontan surgery was performed in 278 patients. 218 of 304 cases were patients with single ventricular pathology. 86 cases were patients with two ventricular morphologies but complex cardiac pathology. Fenestration was performed in only 6 patients, other patients did not require fenestration. The mean follow-up period of our patients was 12 years (3 months-27 years). When the complications between Fontan procedures were compared in our study, it was found that the length of hospital stay and mortality were statistically significantly reduced in patients who underwent extracardiac Fontan surgery. There was no significant difference in terms of complications that can be seen after Fontan surgery and the length of stay in the intensive care unit. CONCLUSION Fontan complex is a palliative surgery for children with complex heart disease. Palliative surgical operations aimed at the preparation of the Fontan circulation lead to the preparation of the pulmonary vascular bed and the preservation of ventricular function. The techniques applied in Fontan surgery affect the early and long-term complications and the survival of the patients. In our study, when we examined the patients who extracardiac conduit Fontan procedure for the non-cardiac route, we found that mortality and morbidity were minimal.
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Affiliation(s)
- Ahmet Bülent Polat
- grid.414934.f0000 0004 0644 9503Department of Cardiovascular Surgery, Florence Nightingale Hospital, T.C. Demiroglu Bilim University, İzzetpaşa Mah, Abide-I Hürriyet Cad, No:166, Sisli, 34394 Istanbul, Turkey
| | - Murat Ertürk
- grid.414934.f0000 0004 0644 9503Department of Cardiovascular Surgery, Florence Nightingale Hospital, T.C. Demiroglu Bilim University, İzzetpaşa Mah, Abide-I Hürriyet Cad, No:166, Sisli, 34394 Istanbul, Turkey
| | - Ozan Uzunhan
- grid.414934.f0000 0004 0644 9503Department of Newborn, Florence Nightingale Hospital, T.C. Demiroglu Bilim University, İzzetpaşa Mah, Abide-I Hürriyet Cad, No:166, Sisli, 34394 Istanbul, Turkey
| | - Nur Karademir
- grid.414934.f0000 0004 0644 9503Florence Nightingale Hospital, T.C. Demiroglu Bilim University, İzzetpaşa Mah, Abide-I Hürriyet Cad, No:166, Sisli, 34394 Istanbul, Turkey
| | - Kazım Öztarhan
- grid.414934.f0000 0004 0644 9503Department of Pediatric Cardiology, Florence Nightingale Hospital, T.C. Demiroglu Bilim University, İzzetpaşa Mah, Abide-I Hürriyet Cad, No:166, Sisli, 34394 Istanbul, Turkey
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3
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Van Den Helm S, Sparks CN, Ignjatovic V, Monagle P, Attard C. Increased Risk for Thromboembolism After Fontan Surgery: Considerations for Thromboprophylaxis. Front Pediatr 2022; 10:803408. [PMID: 35419321 PMCID: PMC8996130 DOI: 10.3389/fped.2022.803408] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/27/2021] [Accepted: 02/28/2022] [Indexed: 11/13/2022] Open
Abstract
The Fontan circulation introduces an increased risk of thromboembolism which is associated with substantial mortality and morbidity. Adverse outcomes of thromboembolic complications post-Fontan surgery vary in both nature and severity, ranging from local tissue infarction and pulmonary embolism to Fontan failure and ischemic stroke. Furthermore, recent studies have identified that subclinical stroke is common yet underdiagnosed in Fontan patients. Fontan patients are commonly treated with antiplatelet agents and/or anticoagulants as primary thromboprophylaxis. Optimal thromboprophylaxis management in the Fontan population is still unclear, and clinical consensus remains elusive despite the growing literature on the subject. This perspective will describe the nature of thromboembolism post-Fontan surgery and provide evidence for the use of both current and emerging thromboprophylaxis options for children and adults living with Fontan circulation.
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Affiliation(s)
- Suelyn Van Den Helm
- Haematology Research, Murdoch Children's Research Institute, Melbourne, VIC, Australia.,Department of Paediatrics, The University of Melbourne, Melbourne, VIC, Australia
| | - Christopher Noel Sparks
- Haematology Research, Murdoch Children's Research Institute, Melbourne, VIC, Australia.,Department of Anatomy and Physiology, The University of Melbourne, Melbourne, VIC, Australia
| | - Vera Ignjatovic
- Haematology Research, Murdoch Children's Research Institute, Melbourne, VIC, Australia.,Department of Paediatrics, The University of Melbourne, Melbourne, VIC, Australia
| | - Paul Monagle
- Haematology Research, Murdoch Children's Research Institute, Melbourne, VIC, Australia.,Department of Paediatrics, The University of Melbourne, Melbourne, VIC, Australia.,Kids Cancer Centre, Sydney Children's Hospital, Randwick, NSW, Australia.,Department of Haematology, Royal Children's Hospital, Melbourne, VIC, Australia
| | - Chantal Attard
- Haematology Research, Murdoch Children's Research Institute, Melbourne, VIC, Australia.,Department of Anatomy and Physiology, The University of Melbourne, Melbourne, VIC, Australia
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Calderon J, Newburger JW, Rollins CK. Neurodevelopmental and Mental Health Outcomes in Patients With Fontan Circulation: A State-of-the-Art Review. Front Pediatr 2022; 10:826349. [PMID: 35356444 PMCID: PMC8959547 DOI: 10.3389/fped.2022.826349] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/30/2021] [Accepted: 02/14/2022] [Indexed: 11/13/2022] Open
Abstract
Children, adolescents and adults living with Fontan circulation face numerous neurological and developmental challenges. As the population with complex CHD increases thanks to outstanding improvement in medical and surgical care, the long-term developmental and mental health sequelae have become a public health priority in pediatric and congenital cardiology. Many patients with a Fontan circulation experience difficulty in areas of cognition related to attention and executive functioning, visual spatial reasoning and psychosocial development. They are also at high risk for mental health morbidities, particularly anxiety disorders and depression. Several hemodynamic risk factors, beginning during the fetal period, may influence outcomes and yield to abnormal brain growth and development. Brain injury such as white matter lesions, stroke or hemorrhage can occur before, during, or after surgery. Other sociodemographic and surgical risk factors such as multiple catheterizations and surgeries and prolonged hospital stay play a detrimental role in patients' neurodevelopmental prognosis. Prevention and intervention to optimize long-term outcomes are critical in the care of this vulnerable population with complex CHD.
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Affiliation(s)
- Johanna Calderon
- PhyMedExp, Université de Montpellier, National Institute of Health and Medical Research (INSERM), CNRS, Montpellier, France.,Department of Psychiatry, Harvard Medical School, Boston, MA, United States
| | - Jane W Newburger
- Department of Cardiology, Boston Children's Hospital, Boston, MA, United States.,Department of Pediatrics, Harvard Medical School, Boston, MA, United States
| | - Caitlin K Rollins
- Department of Neurology, Boston Children's Hospital, Boston, MA, United States.,Department of Neurology, Harvard Medical School, Boston, MA, United States
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5
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Lang SS, Valeri A, Storm PB, Heuer GG, Tucker AM, Kennedy BC, Kozyak BW, Sinha A, Kilbaugh TJ, Huh JW. Acute neurological injury in pediatric patients with single-ventricle congenital heart disease. J Neurosurg Pediatr 2021; 28:335-343. [PMID: 34243155 DOI: 10.3171/2021.2.peds2142] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/20/2021] [Accepted: 02/22/2021] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Single-ventricle congenital heart disease (CHD) in pediatric patients with Glenn and Fontan physiology represents a unique physiology requiring the surgical diversion of the systemic venous return from the superior vena cava (Glenn) and then the inferior vena cava (Fontan) directly to the pulmonary arteries. Because many of these patients are on chronic anticoagulation therapy and may have right-to-left shunts, arrhythmias, or lymphatic disorders that predispose them to bleeding and/or clotting, they are at risk of experiencing neurological injury requiring intubation and positive pressure ventilation, which can significantly hamper pulmonary blood flow and cardiac output. The aim of this study was to describe the complex neurological and cardiopulmonary interactions of these pediatric patients after acute central nervous system (CNS) injury. METHODS The authors retrospectively analyzed the records of pediatric patients who had been admitted to a quaternary children's hospital with CHD palliated to bidirectional Glenn (BDG) or Fontan circulation and acute CNS injury and who had undergone intubation and mechanical ventilation. Patients who had been admitted from 2005 to 2019 were included in the study. Clinical characteristics, surgical outcomes, cardiovascular and pulmonary data, and intracranial pressure data were collected and analyzed. RESULTS Nine pediatric single-ventricle patients met the study inclusion criteria. All had undergone the BDG procedure, and the majority (78%) were status post Fontan palliation. The mean age was 7.4 years (range 1.3-17.3 years). At the time of acute CNS injury, which included traumatic brain injury, intracranial hemorrhage, and cerebral infarct, the median time interval from the most recent cardiac surgical procedure was 3 years (range 2 weeks-11 years). Maintaining normocarbia to mild hypercarbia for most patients during intubation periods did not cause neurological deterioration, and hemodynamic profiles were more favorable as compared to periods of hypocarbia. Hypocarbia was associated with unfavorable hemodynamics but was necessary to decrease intracranial hypertension. Most patients were managed using low mean airway pressure (MAWP) in order to minimize the impact on preload and cardiac output. CONCLUSIONS The authors highlight the complex neurological and cardiopulmonary interactions with respect to partial pressure of arterial CO2 (PaCO2) and MAWP when pediatric CHD patients with single-ventricle physiology require mechanical ventilation. The study data demonstrated that tight control of PaCO2 and minimizing MAWP with the goal of early extubation may be beneficial in this population. A multidisciplinary team of pediatric critical care intensivists, cardiac intensivists and anesthesiologists, and pediatric neurosurgeons and neurologists are recommended to ensure the best possible outcomes.
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Affiliation(s)
- Shih-Shan Lang
- 1Division of Neurosurgery, Children's Hospital of Philadelphia, Department of Neurosurgery, University of Pennsylvania, Perelman School of Medicine, Philadelphia
- 2Center for Data Driven Discovery in Biomedicine, Children's Hospital of Philadelphia, Philadelphia
| | - Amber Valeri
- 3Department of Neurosurgery, Philadelphia College of Osteopathic Medicine, Philadelphia
| | - Phillip B Storm
- 1Division of Neurosurgery, Children's Hospital of Philadelphia, Department of Neurosurgery, University of Pennsylvania, Perelman School of Medicine, Philadelphia
- 2Center for Data Driven Discovery in Biomedicine, Children's Hospital of Philadelphia, Philadelphia
| | - Gregory G Heuer
- 1Division of Neurosurgery, Children's Hospital of Philadelphia, Department of Neurosurgery, University of Pennsylvania, Perelman School of Medicine, Philadelphia
- 2Center for Data Driven Discovery in Biomedicine, Children's Hospital of Philadelphia, Philadelphia
| | - Alexander M Tucker
- 1Division of Neurosurgery, Children's Hospital of Philadelphia, Department of Neurosurgery, University of Pennsylvania, Perelman School of Medicine, Philadelphia
- 2Center for Data Driven Discovery in Biomedicine, Children's Hospital of Philadelphia, Philadelphia
| | - Benjamin C Kennedy
- 1Division of Neurosurgery, Children's Hospital of Philadelphia, Department of Neurosurgery, University of Pennsylvania, Perelman School of Medicine, Philadelphia
- 2Center for Data Driven Discovery in Biomedicine, Children's Hospital of Philadelphia, Philadelphia
| | - Benjamin W Kozyak
- 4Department of Anesthesiology and Critical Care Medicine, Children's Hospital of Philadelphia, University of Pennsylvania, Perelman School of Medicine, Philadelphia
- 5Division of Cardiac Critical Care Medicine, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania; and
| | - Anjuli Sinha
- 4Department of Anesthesiology and Critical Care Medicine, Children's Hospital of Philadelphia, University of Pennsylvania, Perelman School of Medicine, Philadelphia
- 6Division of Pediatric Cardiology, Lucile Packard Stanford Children's Hospital, Palo Alto, California
| | - Todd J Kilbaugh
- 4Department of Anesthesiology and Critical Care Medicine, Children's Hospital of Philadelphia, University of Pennsylvania, Perelman School of Medicine, Philadelphia
| | - Jimmy W Huh
- 4Department of Anesthesiology and Critical Care Medicine, Children's Hospital of Philadelphia, University of Pennsylvania, Perelman School of Medicine, Philadelphia
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Attard C, Monagle PT, d'Udekem Y, Mackay MT, Briody J, Cordina R, Hassan EB, Simm P, Rice K, Ignjatovic V. Long-term outcomes of warfarin versus aspirin after Fontan surgery. J Thorac Cardiovasc Surg 2021; 162:1218-1228.e3. [PMID: 33563422 DOI: 10.1016/j.jtcvs.2020.12.102] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/08/2020] [Revised: 11/27/2020] [Accepted: 12/21/2020] [Indexed: 12/17/2022]
Abstract
OBJECTIVES Because of the nature of the Fontan physiology, patients are at an increased risk of thromboembolic complications. As such, warfarin or aspirin is generally prescribed lifelong for thromboprophylaxis. This study aimed to compare long-term rates of cerebrovascular injury, thrombosis, bleeding, bone mineral density, and quality of life in people living with Fontan circulation receiving warfarin compared with aspirin. METHODS This was a multicenter study of a selected cohort from the Australia and New Zealand Fontan population. Participants underwent cerebral magnetic resonance imaging to detect the presence of cerebrovascular injury (n = 84) and dual-energy X-ray absorptiometry to assess bone mineral density (n = 120). Bleeding (n = 100) and quality of life (n = 90) were assessed using validated questionnaires: Warfarin and Aspirin Bleeding assessment tool and Pediatric Quality of Life Inventory, respectively. RESULTS Stroke was detected in 33 participants (39%), with only 7 (6%) being clinically symptomatic. There was no association between stroke and Fontan type or thromboprophylaxis type. Microhemorrhage and white matter injury were detected in most participants (96% and 86%, respectively), regardless of thromboprophylaxis type. Bleeding rates were high in both groups; however, bleeding was more frequent in the warfarin group. Bone mineral density was reduced in our cohort compared with the general population; however, this was further attenuated in the warfarin group. Quality of life was similar between the warfarin and aspirin groups. Home international normalized ratio monitoring was associated with better quality of life scores in the warfarin group. CONCLUSIONS Cerebrovascular injury is a frequent occurrence in the Australia and New Zealand Fontan population regardless of thromboprophylaxis type. No benefit of long-term warfarin prophylaxis could be demonstrated over aspirin; however, consideration must be given to important clinical features such as cardiac function and lung function. Furthermore, the association of reduced bone health in children receiving warfarin warrants further mechanistic studies.
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Affiliation(s)
- Chantal Attard
- Murdoch Children's Research Institute, Parkville, Australia; The University of Melbourne, Parkville, Australia.
| | - Paul T Monagle
- Murdoch Children's Research Institute, Parkville, Australia; The University of Melbourne, Parkville, Australia; The Royal Children's Hospital, Parkville, Australia
| | - Yves d'Udekem
- Murdoch Children's Research Institute, Parkville, Australia; The University of Melbourne, Parkville, Australia; The Royal Children's Hospital, Parkville, Australia
| | - Mark T Mackay
- Murdoch Children's Research Institute, Parkville, Australia; The University of Melbourne, Parkville, Australia; The Royal Children's Hospital, Parkville, Australia
| | - Julie Briody
- Nuclear Medicine, The Children's Hospital at Westmead, Westmead, Australia; The University of Sydney Children's Hospital, Westmead Clinical School, Westmead, Australia
| | - Rachael Cordina
- Department of Cardiology, Royal Prince Alfred Hospital, Sydney, Australia; Faculty of Medicine and Health Sciences, University of Sydney, Sydney, Australia
| | - Ebrahim Bani Hassan
- Australian Institute for Musculoskeletal Science, The University of Melbourne and Western Health, Melbourne, Australia; Department of Medicine-Western Health, The University of Melbourne, Melbourne, Australia
| | - Peter Simm
- Murdoch Children's Research Institute, Parkville, Australia; The Royal Children's Hospital, Parkville, Australia; Department of Paediatric Endocrinology and Diabetes, Monash Children's Hospital, Clayton, Australia
| | - Kathryn Rice
- Paediatric and Congenital Cardiac Service, Starship Children's Hospital, Auckland, New Zealand
| | - Vera Ignjatovic
- Murdoch Children's Research Institute, Parkville, Australia; The University of Melbourne, Parkville, Australia
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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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Rychik J, Atz AM, Celermajer DS, Deal BJ, Gatzoulis MA, Gewillig MH, Hsia TY, Hsu DT, Kovacs AH, McCrindle BW, Newburger JW, Pike NA, Rodefeld M, Rosenthal DN, Schumacher KR, Marino BS, Stout K, Veldtman G, Younoszai AK, d'Udekem Y. Evaluation and Management of the Child and Adult With Fontan Circulation: A Scientific Statement From the American Heart Association. Circulation 2019; 140:e234-e284. [PMID: 31256636 DOI: 10.1161/cir.0000000000000696] [Citation(s) in RCA: 407] [Impact Index Per Article: 81.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
It has been 50 years since Francis Fontan pioneered the operation that today bears his name. Initially designed for patients with tricuspid atresia, this procedure is now offered for a vast array of congenital cardiac lesions when a circulation with 2 ventricles cannot be achieved. As a result of technical advances and improvements in patient selection and perioperative management, survival has steadily increased, and it is estimated that patients operated on today may hope for a 30-year survival of >80%. Up to 70 000 patients may be alive worldwide today with Fontan circulation, and this population is expected to double in the next 20 years. In the absence of a subpulmonary ventricle, Fontan circulation is characterized by chronically elevated systemic venous pressures and decreased cardiac output. The addition of this acquired abnormal circulation to innate abnormalities associated with single-ventricle congenital heart disease exposes these patients to a variety of complications. Circulatory failure, ventricular dysfunction, atrioventricular valve regurgitation, arrhythmia, protein-losing enteropathy, and plastic bronchitis are potential complications of the Fontan circulation. Abnormalities in body composition, bone structure, and growth have been detected. Liver fibrosis and renal dysfunction are common and may progress over time. Cognitive, neuropsychological, and behavioral deficits are highly prevalent. As a testimony to the success of the current strategy of care, the proportion of adults with Fontan circulation is increasing. Healthcare providers are ill-prepared to tackle these challenges, as well as specific needs such as contraception and pregnancy in female patients. The role of therapies such as cardiovascular drugs to prevent and treat complications, heart transplantation, and mechanical circulatory support remains undetermined. There is a clear need for consensus on how best to follow up patients with Fontan circulation and to treat their complications. This American Heart Association statement summarizes the current state of knowledge on the Fontan circulation and its consequences. A proposed surveillance testing toolkit provides recommendations for a range of acceptable approaches to follow-up care for the patient with Fontan circulation. Gaps in knowledge and areas for future focus of investigation are highlighted, with the objective of laying the groundwork for creating a normal quality and duration of life for these unique individuals.
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Michel M, Zlamy M, Entenmann A, Pichler K, Scholl-Bürgi S, Karall D, Geiger R, Salvador C, Niederwanger C, Ohuchi H. Impact of the Fontan Operation on Organ Systems. Cardiovasc Hematol Disord Drug Targets 2019; 19:205-214. [PMID: 30747084 DOI: 10.2174/1871529x19666190211165124] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2018] [Revised: 01/09/2019] [Accepted: 01/29/2019] [Indexed: 02/06/2023]
Abstract
In patients having undergone the Fontan operation, besides the well discussed changes in the cardiac, pulmonary and gastrointestinal system, alterations of further organ systems including the hematologic, immunologic, endocrinological and metabolic are reported. As a medical adjunct to Fontan surgery, the systematic study of the central role of the liver as a metabolizing and synthesizing organ should allow for a better understanding of the pathomechanism underlying the typical problems in Fontan patients, and in this context, the profiling of endocrinological and metabolic patterns might offer a tool for the optimization of Fontan follow-up, targeted monitoring and specific adjunct treatment.
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Affiliation(s)
- Miriam Michel
- Department of Pediatrics III, Division of Cardiology, Pulmology, Allergology, and Cystic Fibrosis, Innsbruck Medical University, Anichstraße 35, 6020 Innsbruck, Austria
| | - Manuela Zlamy
- Department of Pediatrics I, Innsbruck Medical University, Anichstraße 35, 6020 Innsbruck, Austria
| | - Andreas Entenmann
- Department of Pediatrics I, Innsbruck Medical University, Anichstraße 35, 6020 Innsbruck, Austria
| | - Karin Pichler
- Department of Pediatrics, Vienna Medical University, Währinger Gürtel 16, 1090 Vienna, Austria
| | - Sabine Scholl-Bürgi
- Department of Pediatrics I, Innsbruck Medical University, Anichstraße 35, 6020 Innsbruck, Austria
| | - Daniela Karall
- Department of Pediatrics I, Innsbruck Medical University, Anichstraße 35, 6020 Innsbruck, Austria
| | - Ralf Geiger
- Department of Pediatrics III, Division of Cardiology, Pulmology, Allergology, and Cystic Fibrosis, Innsbruck Medical University, Anichstraße 35, 6020 Innsbruck, Austria
| | - Christina Salvador
- Department of Pediatrics I, Innsbruck Medical University, Anichstraße 35, 6020 Innsbruck, Austria
| | - Christian Niederwanger
- Department of Pediatrics I, Innsbruck Medical University, Anichstraße 35, 6020 Innsbruck, Austria
| | - Hideo Ohuchi
- Department for Pediatric Cardiology, National Cerebral and Cardiovascular Center, 5-7-1 Fujishiro-dai, Suita, Osaka 565-8565, Japan
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10
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Abstract
Functional abilities are needed for activities of daily living. In general, these skills expand with age. We hypothesised that, in contrast to what is normally expected, children surviving the Fontan may have deterioration of functional abilities, and that peri-Fontan stroke is associated with this deterioration. All children registered in the Western Canadian Complex Pediatric Therapies Follow-up Program who survived a Fontan operation in the period 1999-2016 were eligible for inclusion. At the age of 2 years (pre-Fontan) and 4.5 years (post-Fontan), the Adaptive Behavior Assessment System-II general adaptive composite score was determined (population mean: 100, standard deviation: 15). Deterioration of functional abilities was defined as ⩾1 standard deviation decrease in pre- to post-Fontan scores. Perioperative strokes were identified through chart review. Multivariable logistic regression analysis determined predictors of deterioration of functional abilities. Of 133 children, with a mean age at Fontan of 3.3 years (standard deviation 0.8) and 65% male, the mean (standard deviation) general adaptive composite score was 90.6 (17.5) at 2 years and 88.3 (19.1) at 4.5 years. After Fontan, deterioration of functional abilities occurred in 34 (26%) children, with a mean decline of 21.8 (7.1) points. Evidence of peri-Fontan stroke was found in 10 (29%) children who had deterioration of functional abilities. Peri-Fontan stroke (odds ratio 5.00 (95% CI 1.74, 14.36)) and older age at Fontan (odds ratio 1.67 (95% CI 1.02, 2.73)) predicted functional deterioration. The trajectory of functional abilities should be assessed in this population, as more than 25% experience deterioration. Efforts to prevent peri-Fontan stroke, and to complete the Fontan operation at an earlier age, may lead to reduction of this deterioration.
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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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12
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Reduced cortical volume and thickness and their relationship to medical and operative features in post-Fontan children and adolescents. Pediatr Res 2017; 81:881-890. [PMID: 28157834 DOI: 10.1038/pr.2017.30] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/21/2016] [Accepted: 01/15/2017] [Indexed: 01/07/2023]
Abstract
BACKGROUND We compared brain cortical and subcortical gray matter volumes and cortical thickness between post-Fontan patients and healthy controls, and examined brain anatomical associations with operative and medical history characteristics. METHODS Post-Fontan (n = 128 volumes; n = 115 thickness) and control subjects (n = 48 volumes; n = 45 thickness) underwent brain MRI at ages 10-19 y. Subcortical and cortical volumes and cortical thicknesses were measured for intergroup comparison. Associations between brain measures and clinical measures were assessed in the Fontan group. RESULTS Widespread, significant reduction in brain volumes and thicknesses existed in the Fontan group compared to controls, spanning all brain lobes and subcortical gray matter. Fontan subjects treated with vs. without the Norwood procedure had smaller volumes in several terminal clusters, but did not differ in cortical thickness. Older age at first operation and increasing numbers of cardiac catheterizations, operative complications, and catheterization complications were associated with lower regional volumes and thicknesses. Increasing numbers of operative complications and cardiac catheterizations were associated with smaller regional volumes in the Norwood group. CONCLUSION The post-Fontan adolescent brain differs from the normal control brain. Some of these differences are associated with potentially modifiable clinical variables, suggesting that interventions might improve long-term neurocognitive outcome.
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Lin JHI, Kean AC, Cordes TM. The Risk of Thromboembolic Complications in Fontan Patients with Atrial Flutter/Fibrillation Treated with Electrical Cardioversion. Pediatr Cardiol 2016; 37:1351-60. [PMID: 27421846 DOI: 10.1007/s00246-016-1441-4] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/06/2016] [Accepted: 06/23/2016] [Indexed: 01/17/2023]
Abstract
Atrial flutter or fibrillation (AFF) remains a major chronic complication of the Fontan procedure. This complication further predisposes this patient population to thromboembolic events. However, the incidence of thromboembolic complications in Fontan patients with AFF prior to or acutely after electrical cardioversion is unknown. This study aimed to characterize the risk of post-cardioversion thromboembolic events in this population. We performed a retrospective medical record review of all patients with a history of Fontan operation treated with direct current cardioversion for AFF at Riley Children's Hospital between June 1992 and March 2014. A total of 57 patients were identified and reviewed. A total of 216 episodes of AFF required electrical cardioversion. Patients were treated with anticoagulation/antiplatelet therapy in 86.1 % (N = 186) of AFF episodes. Right atrial or Fontan conduit clots were observed in 33 patients (57.9 %) with 61 episodes of AFF. Approximately half (49.2 %, N = 30) of these episodes were treated immediately with electrical cardioversion. Twenty-five of 33 (75.8 %) patients with intracardiac thrombi had an atriopulmonary Fontan. Five (15.2 %) patients with a lateral caval tunnel had clots in the Fontan conduit, and three (9.1 %) patients with right atrium to right ventricular outflow tract (RVOT) connections presented with right atrial mural thrombi. Nine of the 57 (15.8 %) patients had documented stroke, and three (5.3 %) patients had pulmonary emboli during follow-up, although none of these emboli were associated with electrical cardioversion. The risk of thrombus and thromboembolism associated with AFF is high in the Fontan population. However, the risk of thromboembolism associated with cardioversion in the setting of anticoagulation is very low.
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Affiliation(s)
- Jiuann-Huey I Lin
- Division of Pediatric Cardiology, Department of Pediatrics, Indiana School of Medicine, 705 Riley Hospital Drive, RR 227, Indianapolis, IN, 46202-5225, USA.,Division of Pediatric Cardiac Critical Care, Children's Hospital of Pittsburgh of UPMC, 4401 Penn Ave, Pittsburgh, PA, USA
| | - Adam C Kean
- Division of Pediatric Cardiology, Department of Pediatrics, Indiana School of Medicine, 705 Riley Hospital Drive, RR 227, Indianapolis, IN, 46202-5225, USA
| | - Timothy M Cordes
- Division of Pediatric Cardiology, Department of Pediatrics, Indiana School of Medicine, 705 Riley Hospital Drive, RR 227, Indianapolis, IN, 46202-5225, USA.
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Abstract
This review attempts to answer the common questions faced by a clinician regarding thromboembolism and thromboprophylaxis in patients following Fontan surgery. The review is in an easy to understand question and answer format and discusses the currently available literature on the subject in an attempt to arrive at practical clinically relevant solutions. Patients who have undergone the Fontan operation are at a high risk for thromboembolism. Based on available evidence, there is a strong rationale for thromboprophylaxis. However, it is not clear as to which agent should be administered to prevent thromboembolic events. While the available evidence suggests that antiplatelet agents alone may be as good as oral anticoagulants, there is a need for a large multicenter randomized control trial comparing these two common strategies to deliver a clear verdict.
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Affiliation(s)
- Sangeetha Viswanathan
- Department of Paediatric Cardiology, SRM Institute of Medical Sciences, Chennai, Tamil Nadu, India
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15
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Abstract
OBJECTIVES The objective of this article is to review the particular tendencies as well as specific concerns of bleeding and clotting in children with critical cardiac disease. DATA SOURCE MEDLINE and PubMed. CONCLUSION Children with critical heart disease are at particular risk for bleeding and clotting secondary to intrinsic as well as extrinsic factors. We hope that this review will aid the clinician in managing the unique challenges of bleeding and clotting in this patient population, and serve as a springboard for much needed research in this area.
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Broomall E, McBride ME, Deal BJ, Ducharme-Crevier L, Shaw A, Mazwi M, Backer CL, Mongé MC, Costello J, Marino BS, DeFreitas A, Wainwright MS. Posterior Circulation Ischemia or Occlusion in Five Adults With Failing Fontan Circulation. Ann Thorac Surg 2016; 101:2315-20. [PMID: 27016841 DOI: 10.1016/j.athoracsur.2016.01.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/16/2015] [Revised: 11/24/2015] [Accepted: 01/04/2016] [Indexed: 10/22/2022]
Abstract
BACKGROUND Palliative procedures performed before the Fontan procedure may require ligation of the subclavian arteries, thereby affecting flow to the vertebral arteries. In adults with functionally univentricular heart disease, the implications of altered brainstem vascular anatomy for perioperative management of failing Fontan circulation are not known. METHODS We identified abnormal posterior circulation anatomy in an adult patient with failing Fontan circulation who experienced a brainstem stroke after Fontan conversion. We then changed our clinical practice to include detailed preoperative neurologic evaluation of adults with univentricular heart disease and failing Fontan circulation. Here, we report the clinical and neuroimaging findings in 5 consecutive patients before and after this change in practice. RESULTS Five patients ages 28 to 42 years had Fontan procedures performed in childhood, and underwent either Fontan conversion or cardiac transplantation. Patient 1 experienced an episode of decreased cerebral perfusion pressure on postoperative day 3, and experienced an ischemic brainstem stroke causing transient locked-in syndrome. A change in practice was made, and patients 2, 3, and 4 were evaluated preoperatively by the neurocritical care service. These patients then had higher target blood pressures perioperatively and no neurologic injury. Patient 5 was evaluated for symptoms consistent with subclavian steal. Neuroimaging in 3 patients was abnormal, with atrophic vertebral arteries, an occluded vertebral artery, and retrograde perfusion of a vertebral artery. CONCLUSIONS In adults with failing Fontan circulation there is a potential for neurologic complications as a result of venous congestion with elevated central venous pressures, and aberrant posterior circulation. The patient's history and brain imaging may be used to identify at-risk patients and to tailor perioperative management during Fontan conversion or heart transplantation to mitigate the risk for brainstem ischemia.
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Affiliation(s)
- Eileen Broomall
- Division of Neurology, Department of Pediatrics, Ann & Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, Illinois; Ruth D. & Ken M. Davee Pediatric Neurocritical Care Program, Ann & Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Mary E McBride
- Division of Cardiology, Department of Pediatrics, Ann & Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Barbara J Deal
- Division of Cardiology, Department of Pediatrics, Ann & Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Laurence Ducharme-Crevier
- Division of Neurology, Department of Pediatrics, Ann & Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, Illinois; Ruth D. & Ken M. Davee Pediatric Neurocritical Care Program, Ann & Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Alexandra Shaw
- Division of Neurology, Department of Pediatrics, Ann & Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Mjaye Mazwi
- Division of Cardiology, Department of Pediatrics, Ann & Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Carl L Backer
- Department of Cardiovascular Thoracic Surgery, Ann & Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Michael C Mongé
- Department of Cardiovascular Thoracic Surgery, Ann & Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - John Costello
- Division of Cardiology, Department of Pediatrics, Ann & Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Bradley S Marino
- Division of Cardiology, Department of Pediatrics, Ann & Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Andrew DeFreitas
- Division of Cardiology, Department of Pediatrics, Ann & Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Mark S Wainwright
- Division of Neurology, Department of Pediatrics, Ann & Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, Illinois; Ruth D. & Ken M. Davee Pediatric Neurocritical Care Program, Ann & Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, Illinois.
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17
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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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Weighing the risks: Thrombotic and bleeding events in adults with atrial arrhythmias and congenital heart disease. Int J Cardiol 2015; 186:315-20. [PMID: 25838183 DOI: 10.1016/j.ijcard.2015.02.024] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/13/2014] [Revised: 01/28/2015] [Accepted: 02/21/2015] [Indexed: 12/19/2022]
Abstract
INTRODUCTION Atrial arrhythmias are associated to thromboembolism and anticoagulant treatment is installed according to risk profile. This study aimed to assess the rate of thrombotic events and major bleedings in adults with congenital heart disease (CHD) and atrial arrhythmias, as well as to determine the predictive value of specific clinical features and two risk scores for thromboembolism and bleeding. METHODS AND RESULTS In this retrospective study, a total of 229 adult CHD patients with atrial arrhythmias, were included. Incidence and risk factors of thromboembolism were assessed in patients without a mechanical valve (n = 191), whereas bleeding incidence and risk factors were studied in patients receiving vitamin K antagonists (n = 164). In 13 patients without a mechanical valve thrombotic events occurred, the first thrombotic event rate per year being 1.4%. A total of 29 patients on vitamin K antagonists suffered from major bleedings, at an annual first event rate of 4.4%. CHA2DS2-VASc score and HAS-BLED score predicted thromboembolic and bleeding risk best in a dichotomized form. At a cut-off of ≥ 2 for high risk the rate of thrombotic events was 3.0% per year compared to 0.7% for a score of <2 (HR 3.7; 95%-CI 1.2-11.5; p = 0.021). A major bleeding rate of 10.8% per year was found in patients on vitamin K antagonists for HAS-BLED ≥ 2 as opposed to 3.5% with a score of <2 (HR 2.6; 95%-CI: 1.1-6.6; 0.017). CONCLUSION In adult CHD patients, thrombotic events and major bleedings are important complications of atrial arrhythmias and anticoagulant treatment. Assessment of thromboembolic and bleeding risk in this patients group can be performed with dichotomized CHA2DS2-VASc and HAS-BLED scores respectively.
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19
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Jones S, Ignjatovic V, Monagle P, Newall F. Central venous catheter-related thrombosis and thromboprophylaxis in children: a systematic review and meta-analysis: comment. J Thromb Haemost 2015; 13:160-1. [PMID: 25280232 DOI: 10.1111/jth.12745] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2014] [Indexed: 11/30/2022]
Affiliation(s)
- S Jones
- Department of Paediatrics, The University of Melbourne, Parkville, Vic., Australia; Clinical Sciences, Murdoch Childrens Research Institute, Parkville, Vic., Australia; Clinical Haematology, The Royal Children's Hospital, Parkville, Vic., Australia
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20
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Persistent fenestration may be a marker for physiologic intolerance after Fontan completion. J Thorac Cardiovasc Surg 2014; 148:2532-8. [DOI: 10.1016/j.jtcvs.2014.06.062] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/28/2014] [Revised: 05/31/2014] [Accepted: 06/27/2014] [Indexed: 11/19/2022]
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Giglia TM, Massicotte MP, Tweddell JS, Barst RJ, Bauman M, Erickson CC, Feltes TF, Foster E, Hinoki K, Ichord RN, Kreutzer J, McCrindle BW, Newburger JW, Tabbutt S, Todd JL, Webb CL. Prevention and Treatment of Thrombosis in Pediatric and Congenital Heart Disease. Circulation 2013; 128:2622-703. [DOI: 10.1161/01.cir.0000436140.77832.7a] [Citation(s) in RCA: 202] [Impact Index Per Article: 18.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
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23
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Xing Q, Shi L, Han L, Wu Q. Total cavopulmonary direct anastomosis in the beating heart without prosthetic material: preliminary experience with modified extracardiac fontan procedure. J Card Surg 2013; 28:576-9. [PMID: 23947635 DOI: 10.1111/jocs.12203] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
AIM To describe modified extracardiac Fontan procedure characterized with total cavopulmonary direct anastomosis in the beating heart without using prosthetic material in seven patients and summarize the clinical experiences and follow-up results. METHODS From April 2007 to April 2011, seven patients with complex cardiac anomalies underwent this operation. The main pulmonary artery (MPA) was transected at the base of the pulmonary valve and the pulmonary annulus was oversewn. Then the inferior vena cava (ICV) was transected at the junction with the atrium. The MPA was brought to the side of the ICV and anastomosed in an end-to-end fashion. The superior vena cava (SVC) was transected at its entrance into the right atrium and was anastomosed to the right pulmonary artery. Five patients received transcatheter device closure of the fenestration with either a small atrial septal defect or ventricular septal defect occluder. RESULTS All patients were in sinus rhythm and extubated on the first postoperative day. Immediate postoperative arterial oxygen saturation was 95% (93% to 96%). During the follow-up period from 17 to 65 months (median 48 months), there were no deaths and reoperations. Arterial oxygen saturation ranged from 88% to 92% on room air. The fenestration was closed in five patients postoperatively and the arterial oxygen saturation rose to 95%. CONCLUSION Total cavopulmonary direct anastomosis in the beating heart without the use of prosthetic material provides growth potential, and avoids the need for anticoagulation. Longer follow-up will be necessary to evaluate this modification.
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Affiliation(s)
- Quansheng Xing
- Heart Center, Children's Hospital of Qingdao University, Qingdao, China
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25
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Giglia TM, DiNardo J, Ghanayem NS, Ichord R, Niebler RA, Odegard KC, Massicotte MP, Yates AR, Laussen PC, Tweddell JS. Bleeding and Thrombotic Emergencies in Pediatric Cardiac Intensive Care. World J Pediatr Congenit Heart Surg 2012; 3:470-91. [DOI: 10.1177/2150135112460866] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
Children in the cardiac intensive care unit (CICU) with congenital or acquired heart disease are at risk for hematologic complications, both hemorrhage and thrombosis. The overall incidence of hematologic complications in the CICU is unknown, but risk factors and target groups have been identified where the essential physiologic balance between bleeding and clotting has been disrupted. Although the best management of life-threatening bleeding and clotting is prevention, the cardiac intensivist is often faced with managing life-threatening hematologic events involving patients from within the unit or those who present from outside. Part I of this review deals with the propensity of children with congenital and acquired heart disease to complications of both bleeding and clotting, and includes discussions of perioperative bleeding, thromboses in single-ventricle patients, clotting of Blalock-Taussig shunts and thrombotic complications of mechanical valves. Part II deals with the subject of stroke in children with heart disease. Part III reviews monitoring the effectiveness of anticoagulation and thrombolysis in the CICU. Currently available diagnostics modalities, medications and management strategies are reviewed and future directions discussed.
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Affiliation(s)
- Therese M. Giglia
- Division of Cardiology, Children's Hospital of Philadelphia, University of Pennsylvania School of Medicine, Philadelphia, PA, USA
| | - James DiNardo
- Division of Cardiac Anesthesia, Children's Hospital, Harvard Medical School, Boston, MA, USA
| | - Nancy S. Ghanayem
- Division of Critical Care, Children's Hospital of Wisconsin, Milwaukee, WI, USA
| | - Rebecca Ichord
- Division of Neurology, Children's Hospital of Philadelphia, University of Pennsylvania School of Medicine, Philadelphia, PA, USA
| | - Robert A. Niebler
- Division of Critical Care, Children's Hospital of Wisconsin, Milwaukee, WI, USA
| | - Kirsten C. Odegard
- Division of Cardiovascular Critical Care, Children's Hospital, Harvard Medical School, Boston, MA, USA
| | - M. Patricia Massicotte
- Department of Pediatrics, Stoller Children's Hospital, University of Alberta, Edmonton, Alberta, Canada
| | - Andrew R. Yates
- Sections of Cardiology and Critical Care Medicine, Nationwide Children's Hospital, The Ohio State University College of Medicine, Columbus, OH, USA
| | - Peter C. Laussen
- Division of Cardiovascular Critical Care, Children's Hospital, Harvard Medical School, Boston, MA, USA
| | - James S. Tweddell
- Division of Critical Care, Children's Hospital of Wisconsin, Milwaukee, WI, USA
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Imielski BR, Woods RK, Mussatto KA, Cao Y, Simpson PM, Tweddell JS. Fontan fenestration closure and event-free survival. J Thorac Cardiovasc Surg 2012; 145:183-7. [PMID: 23062415 DOI: 10.1016/j.jtcvs.2012.09.006] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/31/2012] [Revised: 08/15/2012] [Accepted: 09/12/2012] [Indexed: 11/24/2022]
Abstract
OBJECTIVES The purpose of the present study was to evaluate the association of open and closed Fontan fenestration status with event-free survival. METHODS All patients who underwent a fenestrated Fontan procedure at our institution from January 1994 through June 2007 were reviewed. Patient information was obtained from the medical records. The patients were assigned to 1 of 2 study groups, open or closed, according to their most recent fenestration status. Clinically relevant morbid events were tabulated, and Kaplan-Meier event analysis was used to create event-free probability curves with log-rank comparisons. RESULTS A total of 161 patients were classified as open and 51 as closed. The median interval to an event was 1.1 years (interquartile range, 0.1-3.3 years) after the Fontan procedure. The median interval to closure was 1.2 years (interquartile range, 0.7-3.3 years). The median interval to an event was 1.5 years (interquartile range, 0.1-4.6 years) in the closed group and 1.1 years (interquartile range, 0.1-3.3 years) in the open group. Event-free probability analysis revealed no significant difference between the 2 groups (P = .15). The median follow-up arterial oxygen saturation was greater in the closed group (96.0%; interquartile range, 94.0%-97.0%) than in the open group (91.0%; interquartile range, 86.0%-95.0%; P < .0001). CONCLUSIONS Fenestration closure was associated with greater arterial oxygen saturation but not greater event-free survival. The interval to an event was slightly less than the interval to fenestration closure, suggesting potential merit in the evaluation of earlier fenestration closure. Adoption of specific fenestration management guidelines might help improve the overall outcomes and enhance the quality of future studies.
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Affiliation(s)
- Bartlomiej R Imielski
- Division of Cardiothoracic Surgery, Department of Surgery, Medical College of Wisconsin and Herma Heart Center, Children's Hospital of Wisconsin, Milwaukee, Wis 53226, USA
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Sonomura T, Ikoma A, Kawai N, Suenaga T, Takeuchi T, Suzuki H, Uchita S, Nakai M, Minamiguchi H, Kishi K, Sato M. Usefulness of the Guglielmi detachable coil for embolization of a systemic venous collateral after Fontan operation: A case report. World J Radiol 2012; 4:418-20. [PMID: 23024844 PMCID: PMC3460230 DOI: 10.4329/wjr.v4.i9.418] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/11/2012] [Revised: 08/21/2012] [Accepted: 08/28/2012] [Indexed: 02/06/2023] Open
Abstract
Embolization of collateral veins is often treated with rigid coils (Gianturco and interlocking detachable coils type). However, when dealing with tortuous and dilated collateral veins, there is a high risk for technical failure and coil migration due to inflexibility of the coils. To safely and successfully solve this problem, Guglielmi detachable coils (GDC) can be used for embolization. Their flexibility allows for easy navigation in tortuous veins, low risk of unintended coil release or coil migration, and safe deployment. A 12-year-old girl with a single ventricle had severe cyanosis and a low exercise tolerance 5 years after Fontan procedure. The symptoms were caused by a tortuous and dilated collateral from the left phrenic vein into the left pulmonary vein, forming a right-to-left shunt. The collateral, which had a large diameter and high flow, and therefore a high risk of coil migration, was successfully embolized with 8 GDC. There were no complications such as coil migration or cerebral infarction. Transcatheter embolization increased her systemic oxygen saturation from 81%-84% to 94%-95%, and increased her ability to exercise. The embolization procedure using flexible GDC was low risk compared with other rigid coil embolization techniques when performing embolization of tortuous and dilated collateral veins.
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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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Makhija Z, Sharma R. Hematologic Alterations in Patients with Functionally Univentricular Hearts. World J Pediatr Congenit Heart Surg 2012; 3:350-8. [DOI: 10.1177/2150135112446356] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Affiliation(s)
- Zeena Makhija
- Division of Congenital Cardiac Surgery, Fortis Escorts Heart Research Institute, New Delhi, India
| | - Rajesh Sharma
- Division of Congenital Cardiac Surgery, Fortis Escorts Heart Research Institute, New Delhi, India
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Lee SY, Baek JS, Kim GB, Kwon BS, Bae EJ, Noh CI, Choi JY, Lim HK, Kim WH, Lee JR, Kim YJ. Clinical significance of thrombosis in an intracardiac blind pouch after a Fontan operation. Pediatr Cardiol 2012; 33:42-8. [PMID: 21818649 PMCID: PMC3248640 DOI: 10.1007/s00246-011-0074-x] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/20/2011] [Accepted: 07/13/2011] [Indexed: 11/30/2022]
Abstract
The univentricular heart after the Fontan operation may have a blind pouch formed by the pulmonary stump or rudimentary ventricle according to the anatomy before surgery. Thrombosis in an intracardiac blind pouch of patients with a univentricular heart is a hazardous complication. Because only a few reports have described this complication, the authors evaluated the clinical significance of thrombosis in an intracardiac blind pouch of a univentricular heart. They performed a retrospective review of medical records from August 1986 to December 2007. Four patients were confirmed as having thrombosis in a pulmonary artery stump and one patient as having thrombosis in a rudimentary ventricle shown by cardiac computed tomography (CT). This represents 1.85% (5/271) of patients with ongoing regular follow-up evaluation after the Fontan operation. The median age at diagnosis was 14.2 years. Two of the five patients were taking aspirin and one patient was taking warfarin when they were identified for the development of thrombosis. None of the patients demonstrated thrombosis in the Fontan tract or venous side of the circulation. Brain magnetic resonance imaging (MRI) showed that three patients had cerebral infarction and one patient had suggestive old ischemia. Three patients with thrombus in the pulmonary stump underwent pulmonary artery stump thrombectomy and pulmonary valve obliteration. One patient with thrombus in the rudimentary ventricle underwent ventricular septal defect (VSD) closure with thrombectomy. Thrombus in a blind pouch could cause systemic thromboembolism despite little blood communication. Therefore, surgical modification of the pulmonary stump and VSD closure of the rudimentary ventricle are required to reduce the risk of later thrombus formation. Clinicians should not overlook the possibility of thrombus in a ligated pulmonary artery stump or a rudimentary ventricle after the Fontan operation, which may increase the risk of embolic stroke for patients with single-ventricle physiology.
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Affiliation(s)
- Sang Yun Lee
- Department of Pediatrics, Seoul National University Children’s Hospital, 101 Daehang-Ro, Jongno-gu, Seoul, 110-744 South Korea
| | - Jae Suk Baek
- Department of Pediatrics, Seoul National University Children’s Hospital, 101 Daehang-Ro, Jongno-gu, Seoul, 110-744 South Korea
| | - Gi Beom Kim
- Department of Pediatrics, Seoul National University Children’s Hospital, 101 Daehang-Ro, Jongno-gu, Seoul, 110-744 South Korea
| | - Bo Sang Kwon
- Department of Pediatrics, Seoul National University Children’s Hospital, 101 Daehang-Ro, Jongno-gu, Seoul, 110-744 South Korea
| | - Eun Jung Bae
- Department of Pediatrics, Seoul National University Children’s Hospital, 101 Daehang-Ro, Jongno-gu, Seoul, 110-744 South Korea
| | - Chung Il Noh
- Department of Pediatrics, Seoul National University Children’s Hospital, 101 Daehang-Ro, Jongno-gu, Seoul, 110-744 South Korea
| | - Jung Yun Choi
- Department of Pediatrics, Seoul National University Children’s Hospital, 101 Daehang-Ro, Jongno-gu, Seoul, 110-744 South Korea
| | - Hong Kuk Lim
- Department of Thoracic and Cardiovascular Surgery, Seoul National University Children’s Hospital, 101 Daehang-Ro, Jongno-gu, Seoul, 110-744 South Korea
| | - Woong Han Kim
- Department of Thoracic and Cardiovascular Surgery, Seoul National University Children’s Hospital, 101 Daehang-Ro, Jongno-gu, Seoul, 110-744 South Korea
| | - Jeong Ryul Lee
- Department of Thoracic and Cardiovascular Surgery, Seoul National University Children’s Hospital, 101 Daehang-Ro, Jongno-gu, Seoul, 110-744 South Korea
| | - Yong Jin Kim
- Department of Thoracic and Cardiovascular Surgery, Seoul National University Children’s Hospital, 101 Daehang-Ro, Jongno-gu, Seoul, 110-744 South Korea
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Late status of Fontan patients with persistent surgical fenestration. J Am Coll Cardiol 2011; 57:2437-43. [PMID: 21658565 DOI: 10.1016/j.jacc.2011.01.031] [Citation(s) in RCA: 76] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/11/2010] [Revised: 11/17/2010] [Accepted: 01/02/2011] [Indexed: 11/20/2022]
Abstract
OBJECTIVES This study was undertaken to determine the effects of creating a systemic-to-pulmonary venous atrial-level communication (fenestration) at the time of the Fontan procedure on late outcomes. BACKGROUND Fenestrations are frequently performed during Fontan procedures, but late consequences are not well described. METHODS Patient characteristics were compared between those with and without surgical fenestration among 536 subjects (mean age 11.9 years) enrolled in the Pediatric Heart Network Fontan Cross-Sectional Study. The status of the fenestration and the association of a currently patent fenestration with health status and measures of ventricular performance were investigated. RESULTS Fenestration was performed in 361 patients (67%), and frequency differed by year and center (p < 0.001 for each). After adjustment for center, age at Fontan, year of Fontan, and prior superior cavopulmonary surgery, the fenestrated group had shorter length of Fontan hospital stay. At the time of cross-sectional testing 8 ± 3 years after Fontan, the fenestration remained open in 19% of subjects. Among those with confirmed fenestration closure, 59% were by catheter intervention and 1% by surgical intervention, and 40% had apparent spontaneous closure. Compared with those without evidence of a fenestration, subjects with a current fenestration were taking more medications (p = 0.02) and had lower resting oxygen saturation (median 89% vs. 95%, p < 0.001). Functional health status, exercise performance, echocardiographic variables, prevalence of post-Fontan stroke or thrombosis, and growth did not differ by current fenestration status. CONCLUSIONS Surgical fenestration is associated with well-demonstrated early post-operative benefits. This cross-sectional study found few associations between a persistent fenestration and deleterious later outcomes.
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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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Abstract
Advances in surgical techniques and perioperative management have led to dramatic improvements in outcomes for children with complex congenital heart disease (CHD). As the number of survivors continues to grow, clinicians are becoming increasingly aware that adverse neurodevelopmental outcomes after surgical repair of CHD represent a significant cause of morbidity, with widespread neuropsychologic deficits in as many as 50% of these children by the time they reach school age. Modifications of intraoperative management have yet to measurably impact long-term neurologic outcomes. However, exciting advances in our understanding of the underlying mechanisms of cellular injury and of the events that mediate endogenous cellular protection have provided a variety of new potential targets for the assessment, prevention, and treatment of neurologic injury in patients with CHD. In this review, we will discuss the unique challenges to developing neuroprotective strategies in children with CHD and consider how multisystem approaches to neuroprotection, such as ischemic preconditioning, will be the focus of ongoing efforts to develop new diagnostic tools and therapies. Although significant challenges remain, tremendous opportunity exists for the development of diagnostic and therapeutic interventions that can serve to limit neurologic injury and ultimately improve outcomes for infants and children with CHD.
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Affiliation(s)
- Erin L Albers
- Department of Pediatrics, Vanderbilt University School of Medicine, Nashville, Tennessee 37323, USA
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Egidy Assenza G, Krieger E, Valente AM, Landzberg MJ. Vascular Health and Cardiovascular Prevention in Adult Patients with Congenital Heart Disease. High Blood Press Cardiovasc Prev 2010. [DOI: 10.2165/11311720-000000000-00000] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/02/2022] Open
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Dur O, Lara M, Arnold D, Vandenberghe S, Keller BB, DeGroff C, Pekkan K. Pulsatile In Vitro Simulation of the Pediatric Univentricular Circulation for Evaluation of Cardiopulmonary Assist Scenarios. Artif Organs 2009; 33:967-76. [DOI: 10.1111/j.1525-1594.2009.00951.x] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
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Odegard KC, Zurakowski D, DiNardo JA, Castro RA, McGowan FX, Neufeld EJ, Laussen PC. Prospective longitudinal study of coagulation profiles in children with hypoplastic left heart syndrome from stage I through Fontan completion. J Thorac Cardiovasc Surg 2009; 137:934-41. [PMID: 19327521 DOI: 10.1016/j.jtcvs.2008.09.031] [Citation(s) in RCA: 78] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/11/2008] [Revised: 07/28/2008] [Accepted: 09/11/2008] [Indexed: 01/19/2023]
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Domi T, Edgell DS, McCrindle BW, Williams WG, Chan AK, MacGregor DL, Kirton A, deVeber GA. Frequency, predictors, and neurologic outcomes of vaso-occlusive strokes associated with cardiac surgery in children. Pediatrics 2008; 122:1292-8. [PMID: 19047248 DOI: 10.1542/peds.2007-1459] [Citation(s) in RCA: 68] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/19/2023] Open
Abstract
OBJECTIVE Our aim was to define the frequency, predictors, and outcomes of stroke associated with cardiac surgery in children with congenital heart disease. METHODS We performed a case-control study of children (term birth to 18 years) with congenital heart disease who underwent cardiac surgery at the Hospital for Sick Children between January 1, 1992, and March 1, 2001. Case subjects experienced stroke within 72 hours after cardiac surgery, and control subjects (2 for each case subjects) had cardiac surgery and no stroke. The frequency of arterial ischemic stroke/cerebral sinovenous thrombosis was calculated among children who underwent cardiac surgery during the study period. Predictors for stroke, including age, gender, simple versus complex procedure, reoperation, bypass duration, circulatory arrest, postoperative hematocrit level, and intraoperative activated clotting time, were tested. The presence of clinical and radiologically defined stroke was the main outcome. Neurologic outcomes were assessed in case subjects with the Pediatric Stroke Outcome Measure. RESULTS During the study period, 30 children with stroke (28 with arterial ischemic stroke and 2 with cerebral sinovenous thrombosis) were identified among 5526 children undergoing cardiac surgery. This yielded a risk for arterial ischemic stroke/cerebral sinovenous thrombosis of 5.4 strokes per 1000 children undergoing a cardiac operation. Univariate analysis revealed that older age at the time of the procedure, longer duration of cardiopulmonary bypass, number of days in the hospital postoperatively, and reoperation were associated with stroke. In multivariate analyses, only reoperation was associated with stroke. CONCLUSIONS The frequency of vaso-occlusive stroke in children with congenital heart disease undergoing cardiac surgery was 5.4 cases per 1000 children. Age, duration of bypass, and reoperation may be associated with stroke risk.
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Affiliation(s)
- Trish Domi
- Department of Child Health and Evaluative Sciences, Hospital for Sick Children, and Institute of Medical Sciences, University of Toronto, 555 University Ave, Toronto, Ontario, Canada M5G 1X8
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Carpenter J, Keating R, Weinstein S, Vezina G, Berger J, Bell MJ. Cerebral hemorrhage and vasospasm in a child with congenital heart disease. Neurocrit Care 2008; 8:276-9. [PMID: 17849089 DOI: 10.1007/s12028-007-9005-3] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
INTRODUCTION Intracerebral hemorrhages are relatively rare events in children and cerebral vasospasm after such hemorrhages is even more unusual. Children with structural congenital heart disease are particularly at risk for both thrombotic and embolic events but not to isolated hemorrhages. DISCUSSION We report a case of cerebral vasospasm in a child with structural congenital heart disease after a cerebral hemorrhage. CONCLUSION This case illustrates that this rare occurrence must be swiftly recognized and treated in order to maximize clinical outcome.
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Affiliation(s)
- Jessica Carpenter
- Division of Neurology, Children's National Medical Center, 111 Michigan Avenue, NW, Washington, DC 20010, USA.
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Abstract
OBJECTIVE Thrombosis has been widely described after the Fontan procedure. The vascular endothelium plays a central role in the control of coagulation and fibrinolysis. The aim of this study was to investigate if patients undergoing a modified Fontan procedure have impaired endothelial function and fibrinolysis in the late postoperative course. PATIENTS AND METHODS We compared 23 patients aged from 7 to 26 years with age-matched healthy volunteers, collecting blood samples prior to and following standardized venous occlusion testing. Plasma levels of von Willebrand factor antigen, tissue-type plasminogen activator antigen, plasminogen activator inhibitor-1, and D-dimer were measured with enzyme-linked immunosorbent assay. RESULTS We found increased plasma levels of von Willebrand factor antigen in patients when compared to controls (p = 0.003). At the basal condition, concentrations of tissue-type plasminogen activator antigen and plasminogen activator inhibitor-1 antigen in the plasma, as well as their activity, were not significantly different between patients and controls. Following venous occlusion, concentrations of tissue-type plasminogen activator antigen in the plasma were significantly increased both in patients and controls, compared to pre-occlusion values. D-dimer was within the reference range. Multivariate discriminant analysis differentiated patients and their controls on the basis of differences for plasminogen activator inhibitor-1 and von Willebrand factor antigen (p = 0.0016). CONCLUSIONS Our data suggest that patients with the Fontan circulation may have endothelial dysfunction, as indicated by raised levels of von Willebrand factor. Fibrinolysis seems to be relatively preserved, as suggested by appropriate response to venous occlusion.
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Crowley DI, Donnelly JP. Use of Amplatzer occlusion devices to occlude Fontan baffle leaks during fenestration closure procedures. Catheter Cardiovasc Interv 2008; 71:244-9. [DOI: 10.1002/ccd.21328] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
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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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Klimes K, Abdul-Khaliq H, Ovroutski S, Hui W, Alexi-Meskishvili V, Spors B, Hetzer R, Felix R, Lange PE, Berger F, Gutberlet M. Pulmonary and caval blood flow patterns in patients with intracardiac and extracardiac Fontan: a magnetic resonance study. Clin Res Cardiol 2006; 96:160-7. [PMID: 17180575 DOI: 10.1007/s00392-007-0470-z] [Citation(s) in RCA: 39] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/16/2006] [Accepted: 10/20/2006] [Indexed: 11/27/2022]
Abstract
AIMS We compared in vivo blood flow and pulsatility after different types of Fontan operation using magnetic resonance imaging. MATERIAL AND METHODS A total of 37 consecutive patients (mean age 19+/-7.9 years, 7.3+/-3.2 years after Fontan operation), 7 with atriopulmonary anastomosis (APC), 18 with intra-atrial lateral tunnel (LTFO) and 12 with extracardiac Fontan (ECFO) were studied using magnetic resonance phase-contrast velocity mapping. Blood flow (volume flow) in the superior vena cava (SVC), inferior vena cava (IVC) and both pulmonary arteries were measured and a pulsatility index was calculated for each vessel. RESULTS For all modifications, the blood flow distribution between the SVC and IVC was normal (1:2). Patients with APC had a normal pulsatility, a dilated right atrium, partial backward flow in the IVC and physiological blood flow distribution between the pulmonary arteries. LTFO and ECFO patients had no retrograde flow in the IVC, equal blood flow distribution between the pulmonary arteries and very low or absent pulsatility. CONCLUSIONS MRI allows hemodynamic quantification and characterization of various types of Fontan modifications and may be a valuable tool to predict Fontan failure. Despite showing normal pulsatility, patients with APC have right atrial dilatation and partial backward flow in the IVC, demonstrating suboptimal Fontan circulation. LTFO and ECFO both produce unidirectional antegrade flow in the IVC but pulsatility is very low or absent, which may promote poor pulmonary artery growth and increase of pulmonary vascular resistance contributing to late Fontan failure.
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Affiliation(s)
- K Klimes
- Department of Congenital Heart Defects/Paediatric Cardiology, Deutsches Herzzentrum Berlin, Augustenburger Platz 1, 13353, Berlin, Germany.
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Germanakis I, Sfyridaki C, Papadopoulou E, Raissaki M, Rammos S, Sarris G, Kalmanti M. Stroke following Glenn anastomosis in a child with inherited thrombophilia. Int J Cardiol 2006; 111:464-7. [PMID: 16209893 DOI: 10.1016/j.ijcard.2005.07.013] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/18/2005] [Revised: 07/05/2005] [Accepted: 07/24/2005] [Indexed: 01/19/2023]
Abstract
The optimal anticoagulation following Fontan operation and its modifications remain controversial and it is even less well defined as regards patients with inherited thrombophilia. We present a case of a child with bidirectional Glenn anastomosis for double inlet left ventricle that suffered a stroke despite aspirin prophylaxis; the patient was combined homozygous for prothrombin G20210A mutation and for methylenetetrahydrofolate reductase C677T mutation as well. The family history was positive for fetal loss and premature cardiovascular disease. Large-scale studies are needed to evaluate whether carriers of thrombophilia mutations need more intense thromboprophylaxis.
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Abstract
With significant advances in surgical technology and methodology, mortality from congenital heart surgery has been significantly reduced in recent decades. Therefore, focus has naturally turned towards predicting, evaluating, and preventing the neurodevelopmental morbidity associated with congenital heart disease and its treatment. This paper reviews recent publications evaluating preoperative neurologic abnormalities and injuries, current neurodevelopmental outcomes of congenital heart repair, and various neuromonitoring modalities that can be used to monitor neurologic function/dysfunction perioperatively. The rapidly advancing field of clinical neuromonitoring holds the promise of providing modalities that can detect injurious processes acutely to allow for intervention.
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Affiliation(s)
- Taeun Chang
- Department of Pediatrics & Neurology, George Washington University School of Medicine, Children's National Medical Center, 111 Michigan Avenue, Washington, DC 20010, USA.
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Wernovsky G. Current insights regarding neurological and developmental abnormalities in children and young adults with complex congenital cardiac disease. Cardiol Young 2006; 16 Suppl 1:92-104. [PMID: 16401370 DOI: 10.1017/s1047951105002398] [Citation(s) in RCA: 236] [Impact Index Per Article: 13.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Over a decade ago, I co-authored a review in Cardiology in the Young regarding neurological outcomes following surgery for congenital cardiac disease.1In that review, I placed much emphasis on the conduct of cardiopulmonary bypass, and its role in neurodevelopmental disabilities. Much has been learned in the intervening years regarding the multifactorial causes of abnormal school-age development, in particular, the role of prenatal, perioperative, socioeconomic, and genetic influences. In this update, I will highlight some of the recent advances in our understanding of the protean causes of neurological, behavioral, and developmental abnormalities in children and young adults with complex forms of congenital cardiac disease. In addition, I will summarize the current data on patients at particular high-risk for adverse neurodevelopmental outcomes, specifically those with a functionally univentricular heart who have had staged reconstruction with ultimate conversion to the Fontan circulation.
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Affiliation(s)
- Gil Wernovsky
- Division of Pediatric Cardiology, The Cardiac Center at The Children's Hospital of Philadelphia, Philadelphia 19104, USA.
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Abstract
The recent significant reduction in operative mortality associated with surgical completion of the Fontan circulation is clearly multi-factorial. Better understanding of the fundamental physiological and anatomical issues have led to refinements in operative technique, early neutralization of potential risk factors, widespread use of a staged approach, and selective application of the concept of fenestration or incomplete partitioning. While further reduction of operative mortality is important, and may be anticipated in the future, major emphasis now must be placed on optimizing functional outcome, and understanding and managing the late complications associated with the unique physiology produced by the Fontan circulation.
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Affiliation(s)
- Marshall L Jacobs
- Section of Cardiothoracic Surgery, St. Christopher's Hospital for Children, Drexel University, Philadelphia, Pennsylvania 19134, USA.
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Schreiber C, Kostolny M, Hörer J, Cleuziou J, Holper K, Tassani-Prell P, Eicken A, Lange R. Can we do without routine fenestration in extracardiac total cavopulmonary connections? Report on 84 consecutive patients. Cardiol Young 2006; 16:54-60. [PMID: 16454878 DOI: 10.1017/s104795110500209x] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/18/2005] [Indexed: 11/06/2022]
Abstract
Fenestration is still widely used in right heart bypass operations. Our study was conducted to assess its need in the most recent modification, the completion of a total cavopulmonary connection with an extracardiac tube. The extracardiac approach was introduced at our institution in January, 1999. Since June of 2000, no patient had a fenestration. If more than 1 risk factor amongst ventricular function being more than moderately impaired, atrioventricular valvar regurgitation more than moderate, mean pulmonary arterial pressure more than 15 millimetres of mercury, mean atrial pressure higher than 12 millimetres of mercury, pulmonary arterial distortion, or other than sinus rhythm was present preoperatively, the patient was considered a "high risk" candidate. Postoperatively elevated pulmonary arterial pressure higher than 16 millimetres of mercury, prolonged effusions and requirement for drainage longer than 7 days, and death were considered endpoints in the statistical analysis. Our study group included 84 patients who underwent surgery up to August, 2004. A previous bidirectional cavopulmonary anastomosis had been accomplished in 73 patients at a mean age of 27.01 plus or minus 32.60 months, with a median of 11.5 months, without creating an additional source of flow of blood to the lungs. At the time of the total cavopulmonary connection, the mean age was 66.4 plus or minus 60.1 months, with a median of 37.1 months, and a range from 17.3 to 251.2 months, with 50 patients being younger than 48 months. We deemed 16 patients to be at "high risk". These patients were older at the time of bidirectional cavopulmonary anstomosis (p smaller than 0.016), at the time of completion (p smaller than 0.019), and also differed in size at time of completion (p smaller than 0.020). They required a longer time on cardiopulmonary bypass (p smaller than 0.015), and reached higher early postoperative pulmonary arterial pressures after completion (p smaller than 0.025). There were no differences between groups of patients having up to 1 or more risk factors in regard to need for intubation (p smaller than 0.511), pulmonary arterial pressures after extubation (p smaller than 0.817), and duration of chest drainage (p smaller than 0.650). Three patients died, one in the group deemed at high risk. There was no death in the last 38 patients. We conclude that a total cavopulmonary connection with an extracardiac tube can be performed without fenestration, even if the patients are deemed to be at increased risk. Early staging of patients with functionally univentricular physiology might be one of the keys for these findings.
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Affiliation(s)
- Christian Schreiber
- Clinic of Cardiovascular Surgery, Department of Anesthesiology, German Heart Centre Munich at the Technical University, Munich, Germany.
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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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50
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Épidémiologie des accidents vasculaires cérébraux : son impact dans la pratique médicale. ACTA ACUST UNITED AC 2006. [DOI: 10.1016/s0246-0378(06)28757-8] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
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