1
|
Marshall KH, d'Udekem Y, Winlaw DS, Zannino D, Celermajer DS, Justo R, Iyengar A, Cordina R, Sholler GF, Woolfenden SR, Kasparian NA. Quality of Life and Well-Being in Adults With Fontan Physiology: Findings From the Australian and New Zealand Fontan Registry Quality of Life Study. J Am Heart Assoc 2024; 13:e033818. [PMID: 39011952 DOI: 10.1161/jaha.123.033818] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/02/2023] [Accepted: 05/29/2024] [Indexed: 07/17/2024]
Abstract
BACKGROUND To characterize global and health-related quality of life (QOL) among adults with Fontan physiology enrolled in the Australian and New Zealand Fontan Registry (ANZFR), and identify sociodemographic, clinical, psychological, and relational factors associated with outcomes. METHODS AND RESULTS Using a cross-sectional survey design, 66 adults with Fontan physiology (58% women; mean age, 29.6±7.7 years; range, 18-50 years) completed validated self-report measures. Health-related QOL was assessed using the Pediatric Quality of Life Inventory, and global QOL was assessed using a visual analog scale (0-10). Participants reported lower total health-related QOL (P<0.001), as well as lower physical (P<0.001) and social (P=0.002) functioning compared with normative data. Median global QOL was 7.0 (interquartile range: 5.0-8.0) and most participants (71%) rated their QOL ≥6. For health-related QOL, age, sex, university education, and length of hospital stay in the past 12 months explained 27% of the variance in scores, while general psychological stress, medical traumatic stress, communication problems, and access to emotional support explained a further 44% of variance (final model: 71% of variance explained). For global QOL, sociodemographic and clinical factors explained 20% of the variance in scores, while psychological stress and sense of coherence explained a further 24% (final model: 44% of variance explained). CONCLUSIONS Adults with Fontan physiology reported lower overall health-related QOL compared with community-based norms. Variance in QOL outcomes were predominantly attributable to psychological and relational factors. Tailored screening and assessment to identify Fontan patients at greatest risk of lower QOL, and a proactive approach to supportive care, are needed.
Collapse
Affiliation(s)
- Kate H Marshall
- Heart Centre for Children The Sydney Children's Hospitals Network Sydney NSW Australia
- School of Clinical Medicine University of New South Wales Sydney NSW Australia
| | - Yves d'Udekem
- Division of Cardiac Surgery Children's National Hospital Washington DC United States
| | - David S Winlaw
- Heart Center, Ann & Robert H. Lurie Children's Hospital Chicago IL United States
| | - Diana Zannino
- Clinical Epidemiology and Biostatistics Unit Murdoch Children's Research Institute Melbourne VIC Australia
| | - David S Celermajer
- Sydney Medical School The University of Sydney NSW Australia
- Department of Cardiology Royal Prince Alfred Hospital Sydney NSW Australia
| | - Robert Justo
- Queensland Pediatric Cardiac Service Queensland Children's Hospital Brisbane QLD Australia
- Faculty of Medicine The University of Queensland Brisbane QLD Australia
| | - Ajay Iyengar
- Pediatric and Congenital Cardiac Service Starship Children's Hospital Auckland New Zealand
- Department of Surgery The University of Auckland New Zealand
| | - Rachael Cordina
- Sydney Medical School The University of Sydney NSW Australia
- Department of Cardiology Royal Prince Alfred Hospital Sydney NSW Australia
| | - Gary F Sholler
- Heart Centre for Children The Sydney Children's Hospitals Network Sydney NSW Australia
- Sydney Medical School The University of Sydney NSW Australia
| | - Susan R Woolfenden
- Sydney Medical School The University of Sydney NSW Australia
- Institute for Women, Children and their Families Sydney Local Health District Sydney NSW Australia
| | - Nadine A Kasparian
- Heart and Mind Wellbeing Center Heart Institute and Division of Behavioral Medicine and Clinical Psychology, Cincinnati Children's Hospital Medical Center and Department of Pediatrics, University of Cincinnati College of Medicine Cincinnati OH United States
| |
Collapse
|
2
|
Hock J, Bessar M, Ewert P, Hager A. Body plethysmography - additional information on exercise capacity in patients with congenital heart disease? Clin Res Cardiol 2024:10.1007/s00392-024-02385-7. [PMID: 38315211 DOI: 10.1007/s00392-024-02385-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/11/2023] [Accepted: 01/23/2024] [Indexed: 02/07/2024]
Abstract
AIMS In each cardiopulmonary exercise test (CPET), resting spirometry is performed in advance. In patients with a congenital heart defect (CHD), lung volumes are often impaired. This study investigates correlations between lung volumes and CPET parameters and determines, whether body plethysmography provides substantial additional information for these patients. METHODS Data from 102 patients (23.8 ± 10.4 years of age, 39 female) with various forms of CHD were examined from April 2018 to October 2022. All patients underwent spirometry (measuring forced vital capacity, FVC and forced expiratory volume in 1 s, FEV1), body plethysmography (measuring total lung capacity, TLC) and an exhausting CPET. Data is presented as the median and interquartile range (z-scores) and correlated with Spearman's rho. RESULTS Fifty-five% of all patients had normal results in lung function and 45% had normal peak oxygen uptake (≥ 80% predicted in peak VO2). Patients with impaired lung function were significantly more likely to have low exercise capacity (Fisher's exact test: p = 0.028). FVC z-values and %predicted peak VO2 (r = 0.365, p < 0.001) correlated significantly as well as FEV1_z and %predicted peak VO2 (r = 0.320, p = 0.001), and TLC z-values and %predicted peak VO2 (r = 0.249, p = 0.012). No correlation was found between FEV1/FVC z-values and %predicted peak VO2 (r = -0.043, p = 0.670). CONCLUSION Spirometry and exercise capacity positively correlate, also in CHD patients. However, body plethysmography does not provide additional or improved prediction and is therefore only recommended in noteworthy results in spirometry to exclude further lung co-morbidities.
Collapse
Affiliation(s)
- Julia Hock
- Department of Pediatric Cardiology and Congenital Heart Disease, Deutsches Herzzentrum München, Technische Universität München, Lazarettstr. 36, 80636, Munich, Germany.
| | - Mohammed Bessar
- Department of Pediatric Cardiology and Congenital Heart Disease, Deutsches Herzzentrum München, Technische Universität München, Lazarettstr. 36, 80636, Munich, Germany
| | - Peter Ewert
- Department of Pediatric Cardiology and Congenital Heart Disease, Deutsches Herzzentrum München, Technische Universität München, Lazarettstr. 36, 80636, Munich, Germany
- DZHK (German Centre for Cardiovascular Research), Partner Site Munich Heart Alliance, Munich, Germany
| | - Alfred Hager
- Department of Pediatric Cardiology and Congenital Heart Disease, Deutsches Herzzentrum München, Technische Universität München, Lazarettstr. 36, 80636, Munich, Germany
| |
Collapse
|
3
|
Laubham M, Blais B, Kamp AN. Atrial Arrhythmias in Adults with Fontan Palliation. Cardiol Ther 2023; 12:473-487. [PMID: 37495769 PMCID: PMC10423191 DOI: 10.1007/s40119-023-00326-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2023] [Accepted: 07/14/2023] [Indexed: 07/28/2023] Open
Abstract
Single ventricle physiology is a rare form of congenital heart disease and was, historically, a uniformly lethal condition. However, the atriopulmonary Fontan operation, and its successive iterations, the lateral tunnel and extracardiac conduit Fontan, became the fundamental approach to treating single ventricle heart disease. Over time, dysrhythmias are some of the most common complications with Fontan physiology, compounding morbidity and mortality. Atrial arrhythmias are prevalent in the Fontan population and occur in about 15-60% of patients with Fontan palliation, increasingly with age. Diagnosing atrial arrhythmias in patients with Fontan palliation may be challenging because of low voltage amplitudes arising from myopathic atrial tissue making it difficult to clearly assess atrial depolarization on surface electrocardiograms (ECG), vague symptoms not suggestive of tachyarrhythmia, or atrial arrhythmia with ventricular rates below 100 beats per minute. Intra-atrial reentrant tachycardia (IART) is the most common type of supraventricular tachycardia in adults with Fontan palliation. Acute management of atrial arrhythmias in patients with Fontan palliation involves prompt assessment of a patient's hemodynamic stability, anticoagulation and thrombosis risk, systemic ventricular function, and risk of sedation or anesthesia if needed. Long-term management of atrial arrhythmias is often multifactorial and may include long-term anti-arrhythmic therapy, permanent pacing, and ablation. The best approach for the management of atrial arrhythmias in adults with Fontan palliation is patient-specific and involves collaboration between congenital electrophysiologists, adult congenital cardiologists, and the patient.
Collapse
Affiliation(s)
- Matthew Laubham
- Nationwide Children's Hospital, 700 Children's Drive, Columbus, OH, 43205, USA.
| | - Ben Blais
- Nationwide Children's Hospital, 700 Children's Drive, Columbus, OH, 43205, USA
- The Ohio State University School of Medicine, Columbus, OH, USA
| | - Anna N Kamp
- Nationwide Children's Hospital, 700 Children's Drive, Columbus, OH, 43205, USA
- The Ohio State University School of Medicine, Columbus, OH, USA
| |
Collapse
|
4
|
Skorek P, Skubera M, Natorska J, Ząbczyk M, Trojnarska O, Pająk J, Mazurek-Kula A, Bartczak-Rutkowska A, Podolec P, Tomkiewicz-Pająk L. Dissimilarity in coagulation system in adults after Fontan surgery based on thrombin generations. EUROPEAN JOURNAL OF CARDIO-THORACIC SURGERY : OFFICIAL JOURNAL OF THE EUROPEAN ASSOCIATION FOR CARDIO-THORACIC SURGERY 2022; 63:6887143. [PMID: 36495203 DOI: 10.1093/ejcts/ezac550] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/28/2022] [Revised: 10/29/2022] [Accepted: 11/24/2022] [Indexed: 12/14/2022]
Abstract
OBJECTIVES The Fontan procedure is the treatment of choice in congenital cardiac malformations defined as the single ventricle. Fontan patients are at high risk of thromboembolism, but the exact mechanism of this is poorly understood. The aim of this study was to evaluate an involvement of thrombin generations and microparticles (MPs) in prothrombotic state in adults with Fontan circulation. METHODS This study included hospitalized patients after Fontan procedure and healthy volunteers. We assessed laboratory tests including thrombin generation by calibrated automated thrombography in three variants [platelet-poor plasma (impact of coagulation factors), platelet-rich plasma (PRP) (influence of platelets) and related with MPs]. The technique allows for a comprehensive evaluation of the coagulation system. RESULTS The study groups consisted of 81 adult Fontan patients [41 females (50.6%); median age 22 interquartile range [20-27] years] and 54 control subjects. In patients with Fontan circulation, higher values of endogenous thrombin potential and peak values were observed for both platelet-poor plasma (+17% and +33%) and MPs (+29% and 41%) compared to controls (all P < 0.05). Moreover, in the Fontan group, we found a 64.9% shorter lag time and a 70.4% time to peak for MP variant (both P < 0.001). Contrarily, analysis in the PRP showed 17.1% of reduced endogenous thrombin potential in Fontan. Furthermore, there were no differences in thrombin synthesis in PRP in Fontan patients receiving aspirin or those with thrombocytopaenia (all P > 0.05). CONCLUSIONS This study for the first time showed that thrombin generation associated with MPs may be an important contributor to the prothrombotic state in the Fontan population.
Collapse
Affiliation(s)
- Paweł Skorek
- Department of Cardiac and Vascular Diseases, John Paul II Hospital, Kraków, Poland.,Institute of Cardiology, Jagiellonian University Medical College, Kraków, Poland
| | - Maciej Skubera
- Department of Cardiac and Vascular Diseases, John Paul II Hospital, Kraków, Poland.,Institute of Cardiology, Jagiellonian University Medical College, Kraków, Poland
| | - Joanna Natorska
- Institute of Cardiology, Jagiellonian University Medical College, Kraków, Poland.,Center for Research and Innovative Technology, John Paul II Hospital, Kraków, Poland
| | - Michał Ząbczyk
- Institute of Cardiology, Jagiellonian University Medical College, Kraków, Poland.,Center for Research and Innovative Technology, John Paul II Hospital, Kraków, Poland
| | - Olga Trojnarska
- 1st Department of Cardiology, Poznan University of Medical Sciences, Poznań, Poland
| | - Jacek Pająk
- Institute of Medical Sciences, Department of Surgery, Medical College of Rzeszow University, Rzeszow, Poland
| | - Anna Mazurek-Kula
- Department of Cardiology, Polish Mother's Memorial Hospital, Research Institute, Łódź, Poland
| | | | - Piotr Podolec
- Department of Cardiac and Vascular Diseases, John Paul II Hospital, Kraków, Poland.,Institute of Cardiology, Jagiellonian University Medical College, Kraków, Poland
| | - Lidia Tomkiewicz-Pająk
- Department of Cardiac and Vascular Diseases, John Paul II Hospital, Kraków, Poland.,Institute of Cardiology, Jagiellonian University Medical College, Kraków, Poland
| |
Collapse
|
5
|
Association of Health Status Metrics with Clinical Outcomes in Patients with Adult Congenital Heart Disease and Atrial Arrhythmias. J Clin Med 2022; 11:jcm11206181. [PMID: 36294501 PMCID: PMC9605619 DOI: 10.3390/jcm11206181] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2022] [Revised: 10/07/2022] [Accepted: 10/18/2022] [Indexed: 11/24/2022] Open
Abstract
The prognostic value of health status metrics in patients with adult congenital heart disease (ACHD) and atrial arrhythmias is unclear. In this retrospective cohort study of an ongoing national, multicenter registry (PROTECT-AR, NCT03854149), ACHD patients with atrial arrhythmias on apixaban are included. At baseline, health metrics were assessed using the physical component summary (PCS), the mental component summary (MCS) of the Short-Form-36 (SF-36) Health Survey, and the modified European Heart Rhythm Association (mEHRA) score. Patients were divided into groups according to their SF-36 PCS and MCS scores, using the normalized population mean of 50 on the PCS and MCS as a threshold. The primary outcome was the composite of mortality from any cause, major thromboembolic events, major/clinically relevant non-major bleedings, or hospitalizations. Multivariable Cox-regression analyses using clinically relevant parameters (age greater than 60 years, anatomic complexity, ejection fraction of the systemic ventricle, and CHA₂DS₂-VASc and HAS-BLED scores) were performed to examine the association of health metrics with the composite outcome. Over a median follow-up period of 20 months, the composite outcome occurred in 50 of 158 (32%) patients. The risk of the outcome was significantly higher in patients with SF-36 PCS ≤ 50 compared with those with PCS > 50 (adjusted hazard ratio (aHR), 1.98; 95% confidence interval [CI], 1.02−3.84; p = 0.04) after adjusting for possible confounders. The SF-36 MCS ≤ 50 was not associated with the outcome. The mEHRA score was incrementally associated with a higher risk of the composite outcome (aHR = 1.44 per 1 unit increase in score; 95% CI, 1.03−2.00; p = 0.03) in multivariable analysis. In ACHD patients with atrial arrhythmias, the SF-36 PCS ≤ 50 and mEHRA scores predicted an increased risk of adverse events.
Collapse
|
6
|
Grosch IB, Andresen B, Diep LM, Diseth TH, Möller T. Quality of life and emotional vulnerability in a national cohort of adolescents living with Fontan circulation. Cardiol Young 2022; 32:874-882. [PMID: 34387177 DOI: 10.1017/s1047951121003188] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
INTRODUCTION To investigate quality of life and mental health after Fontan completion, we aimed to characterise outcomes in a representative group of adolescent patients. The study was part of the pre-transition clinical work-up in adolescents with Fontan-type palliation of univentricular CHD. The programme covers the entire paediatric Fontan patient population in Norway. METHODS Our cross-sectional study included 42 adolescents with Fontan circulation aged 15-18. We recruited a control group of 29 healthy peers. Quality of life was measured by the Pediatric Quality of Life Inventory Questionnaire, while mental health was assessed with the Strength and Difficulties Questionnaire. RESULTS Fontan patients scored lower than healthy controls on the Pediatric Quality of Life Inventory total (p = 0.004), the physical (p < 0.001) and social (p = 0.001) functioning subscale, and the Strength and Difficulties Questionnaire subscale of emotional symptoms (p = 0.035). Compared to two of the healthy teens (7%), seven patients (16%) in the Fontan group scored as having impaired mental health (p = 0.224). The female/male ratio for individuals with impaired health was 7:2 (p = 0.003). CONCLUSIONS Compared to healthy controls, adolescents after Fontan-type palliation in Norway have good health-related quality of life and mental health, despite having slightly lower score than healthy individuals, mainly in physical domains and school functioning. Compared to healthy controls and healthy teenagers, these adolescents have somewhat more emotional problems, and compared to male patients, female patients more often have impaired mental health.
Collapse
Affiliation(s)
| | - Brith Andresen
- Department of Thoracic Surgery, Oslo University Hospital, Oslo, Norway
| | - Lien My Diep
- Oslo Centre for Biostatistics and Epidemiology, Oslo, Norway
| | - Trond H Diseth
- Department of Child and Adolescent Mental Health in Hospitals, Division of Paediatric and Adolescent Medicine, Oslo University Hospital, Oslo, Norway
- Institute of Clinical Medicine, University of Oslo, Oslo, Norway
| | - Thomas Möller
- Department of Paediatric Cardiology, Oslo University Hospital, Oslo, Norway
| |
Collapse
|
7
|
Health-related quality of life in adults with tetralogy of Fallot repair: a systematic review and meta-analysis. Qual Life Res 2021; 30:2715-2725. [PMID: 34021473 DOI: 10.1007/s11136-021-02875-5] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/04/2021] [Indexed: 02/07/2023]
Abstract
BACKGROUND With the advancement in diagnostics and clinical management, patients with Tetralogy of Fallot (ToF) are surviving till adulthood. Hence, assessing the impact of ToF repair on health-related quality of life (HRQOL) of these patients is becoming increasingly important. The objective of this paper is to conduct a systematic review and meta-analysis of the HRQOL in patients who have undergone ToF repair. METHODS A systematic search was conducted using PubMed, CINAHL, Medline and Web of Science databases. Studies that compared the HRQOL of adult patients (mean age ≥ 18 years) who had previously undergone ToF repair with healthy controls were included. Analysis was done via Revman V5.3 using a random effects model. RESULTS The 16 studies (15 using SF-36) included in the meta-analysis, comprised 1818 patients and 50,265 healthy controls. There was a higher proportion of males (59%). The mean ages at surgery and at HRQOL assessment were 5.37 years and 30.3 years, respectively. We found that repaired ToF patients had a statistically significantly lower score in the physical component summary (SMD = - 0.92 CI = - 1.54, - 0.30) and physical functioning (SMD = - 0.27 CI = - 0.50, - 0.03) compared to healthy controls. However, these patients had statistically significantly higher scores in the bodily pain domain (SMD = 0.35 CI = 0.12, 0.58) and social functioning (SMD = 0.23 CI = 0.01, 0.46), while there was no significant difference in other domains. CONCLUSION Overall, physical domain of HRQOL was statistically significantly lower in repaired ToF patients compared to healthy controls. However, repaired ToF patients scored significantly higher on bodily pain and Social Functioning. There was additionally no difference in the HRQOL between the two groups in other domains of HRQOL.
Collapse
|
8
|
Girnius A, Zentner D, Valente AM, Pieper PG, Economy KE, Ladouceur M, Roos-Hesselink JW, Warshak C, Partington SL, Gao Z, Ollberding N, Faust M, Girnius S, Kaemmerer H, Nagdyman N, Cohen S, Canobbio M, Akagi T, Grewal J, Bradley E, Buber Y, Palumbo J, Walker N, Aboulhosn J, Oechslin E, Baumgartner H, Kurdi W, Book WM, Mulder BJM, Veldtman GR. Bleeding and thrombotic risk in pregnant women with Fontan physiology. Heart 2021; 107:1390-1397. [PMID: 33234672 PMCID: PMC10367127 DOI: 10.1136/heartjnl-2020-317397] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/27/2020] [Revised: 10/16/2020] [Accepted: 10/21/2020] [Indexed: 02/03/2023] Open
Abstract
BACKGROUND/OBJECTIVES Pregnancy may potentiate the inherent hypercoagulability of the Fontan circulation, thereby amplifying adverse events. This study sought to evaluate thrombosis and bleeding risk in pregnant women with a Fontan. METHODS We performed a retrospective observational cohort study across 13 international centres and recorded data on thrombotic and bleeding events, antithrombotic therapies and pre-pregnancy thrombotic risk factors. RESULTS We analysed 84 women with Fontan physiology undergoing 108 pregnancies, average gestation 33±5 weeks. The most common antithrombotic therapy in pregnancy was aspirin (ASA, 47 pregnancies (43.5%)). Heparin (unfractionated (UFH) or low molecular weight (LMWH)) was prescribed in 32 pregnancies (30%) and vitamin K antagonist (VKA) in 10 pregnancies (9%). Three pregnancies were complicated by thrombotic events (2.8%). Thirty-eight pregnancies (35%) were complicated by bleeding, of which 5 (13%) were severe. Most bleeds were obstetric, occurring antepartum (45%) and postpartum (42%). The use of therapeutic heparin (OR 15.6, 95% CI 1.88 to 129, p=0.006), VKA (OR 11.7, 95% CI 1.06 to 130, p=0.032) or any combination of anticoagulation medication (OR 13.0, 95% CI 1.13 to 150, p=0.032) were significantly associated with bleeding events, while ASA (OR 5.41, 95% CI 0.73 to 40.4, p=0.067) and prophylactic heparin were not (OR 4.68, 95% CI 0.488 to 44.9, p=0.096). CONCLUSIONS Current antithrombotic strategies appear effective at attenuating thrombotic risk in pregnant women with a Fontan. However, this comes with high (>30%) bleeding risk, of which 13% are life threatening. Achieving haemostatic balance is challenging in pregnant women with a Fontan, necessitating individualised risk-adjusted counselling and therapeutic approaches that are monitored during the course of pregnancy.
Collapse
Affiliation(s)
- Andrea Girnius
- Anesthesiology, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
| | - Dominica Zentner
- Department of Cardiology and Department of Genomic Medicine, Royal Melbourne Hospital, Melbourne, Victoria, Australia.,Faculty of Medicine, Dentistry and Health Sciences, University of Melbourne, Melbourne, Victoria, Australia
| | - Anne Marie Valente
- Brigham and Women's Hospital, Department of Medicine, Division of Cardiovascular Disease, Department of Cardiology Harvard Medical School, Boston, Massachusetts, USA
| | - Petronella G Pieper
- Department of Cardiology, University Medical Center Groningen, Groningen, The Netherlands
| | - Katherine E Economy
- Brigham and Women's Hospital, Department of Obstetrics and Gynecology, Division Maternal Fetal Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Magalie Ladouceur
- Cardiology, Hopital Europeen Georges Pompidou, Paris, France.,Pediatric Cardiology, Hopital Universitaire Necker-Enfants Malades, Paris, France
| | | | - Carri Warshak
- Obstetrics and Gynecology, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
| | - Sara L Partington
- Division of Cardiovascular Medicine, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA.,Division of Cardiology, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Zhiqian Gao
- Heart Institute, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
| | - Nicholas Ollberding
- Department of Pediatrics, Cincinnati Children's Hospital Medical Centre, Cincinnati, Ohio, USA.,Division of Biostatistics and Epidemiology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
| | - Michelle Faust
- Heart Institute, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
| | - Saulius Girnius
- Department of Hematology, Trihealth Cancer Institute, Cincinnati, Ohio, USA
| | | | | | - Scott Cohen
- Department of Cardiology, The Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | - Mary Canobbio
- School of Nursing, University of California Los Angeles, Los Angeles, California, USA
| | - Teiji Akagi
- Cardiovascular Medicine, Okayama University, Okayama, Japan
| | - Jasmine Grewal
- Cardiology, The University of British Columbia Faculty of Medicine, Vancouver, British Columbia, Canada
| | - Elisa Bradley
- Adult Congenital Heart Disease, The Ohio State University & Nationwide Children's Hospital, Nationwide Children's Hospital, Columbus, Ohio, USA
| | - Yonathan Buber
- Department of Medicine, Division of Cardiology, University of Washington School of Medicine, Seattle, Washington, USA
| | - Joseph Palumbo
- Haematology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
| | | | - Jamil Aboulhosn
- Ahmanson/UCLA ACHD Center, David Geffen School of Medicine at UCLA, Los Angeles, California, USA
| | - Erwin Oechslin
- Toronto Congenital Cardiac Centre for Adults, Peter Munk Cardiac Centre, University Heatlh Network and University of Toronto, Toronto, Ontario, Canada.,Bitove Family Professorship of Adult Congenital Heart Disease, Toronto General Hospital, Toronto, Ontario, Canada
| | - Helmut Baumgartner
- Department of Cardiology III: Adult Congenital and Valvular Heart Disease, University Hospital Muenster, Muenster, Albert Schweitzer Campus 1, Building A1, 48149 Muenster, Germany
| | - Wesam Kurdi
- King Faisal Specialist Hospital and Research Center, Riyadh, Saudi Arabia
| | - Wendy M Book
- Internal Medicine, Division of Cardiology, Emory University, Atlanta, Georgia, USA
| | | | - Gruschen R Veldtman
- Adult Congenital Heart Disease, King Faisal Specialist Hospital and Research Centre, Riyadh, Saudi Arabia
| |
Collapse
|
9
|
Abstract
BACKGROUND Progress in the management of complex congenital heart disease (CHD) led to an improvement in survival rates of adults with a Fontan-like circulation. The objective of this study was to assess the subjective health status and quality of life of this population. METHODS AND RESULTS Patients aged more than 18 years at the time of the study, who underwent a Fontan-like procedure. Subjective health status was assessed by the SF-36 questionnaire and a linear analog scale was used to score patients' self-perception of their quality of life; cardiac and demographic parameters were collected. RESULTS Among 65 eligible patients, 60 (23 females; mean ± SD age: 25.7 ± 7.2 years) answered the SF-36 questionnaire and 46 of these were interviewed to evaluate their perceived quality of life. Among them, 20 (33.3%) were working full-time and 21 (35%) experienced arrhythmias. The physical SF-36 scores were lower in patients than in the general population (p ≤ 0.05). The New York Hear Association (NYHA) class and occupation were correlated with SF-36 scores of physical activity (respectively, p = 0.0001 and p = 0.025). SF-36 scores of psychological status were associated with the number of drugs and occupation (respectively, p = 0.0001 and p = 0.02). The mean ± SD quality of life score measured using a linear analog scale was 7.02 ± 1.6 and was linked to education and occupation (p ≤ 0.05) but not with cardiac parameters. CONCLUSION Adult Fontan patients perceive an impaired physical health but report a good overall quality of life. Education and occupation impacts significantly on Fontan patients' quality of life.
Collapse
|
10
|
Cardiovascular and abdominal flow alterations in adults with morphologic evidence of liver disease post Fontan palliation. Int J Cardiol 2020; 317:63-69. [PMID: 32470536 DOI: 10.1016/j.ijcard.2020.05.064] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/23/2019] [Revised: 03/11/2020] [Accepted: 05/18/2020] [Indexed: 01/16/2023]
Abstract
BACKGROUND Although morphologic abnormalities in the liver are commonly encountered post Fontan palliation, the relationships between hepatic morphology, vascular flows, and clinical status remain incompletely understood. We therefore aimed to explore flow characteristics in hepatic and intestinal vessels and to examine cardiovascular associations with liver disease. METHODS This was a retrospective study of adults post Fontan palliation undergoing clinically indicated cardiovascular magnetic resonance imaging (MRI). Patients were included if MRI flow quantification was available for cardiac, hepatic and intestinal vessels; patients were excluded if phase-contrast flow imaging was insufficient for analysis. RESULTS Thirty patients were studied (median age at MRI 28.5 years [range 19-47]). Eighteen subjects (60%) were classified as having morphologic liver disease according to validated criteria based on available MRI imaging. Abdominal and cardiovascular flows were quantified. Patients with morphologic liver disease had a 41% reduction in superior mesenteric artery (211 ± 124 versus 358 ± 181 mL/min/m2, p = .004), a 36% reduction in hepatic vein (496 ± 247 versus 778 ± 220 mL/min/m2, p = .01), a 31% reduction in portal vein (399 ± 133 versus 580 ± 159 mL/min/m2, p = .004), and an 18% reduction in Fontan pathway flows (1358 ± 429 versus 1651 ± 270 mL/min/m2, p = .04) compared with the remaining population. Adverse cardiovascular events were not associated with morphologic liver disease. CONCLUSION Morphologic liver disease appears to be associated with flow alterations within the heart, liver and intestine post Fontan palliation. These novel observations suggest that a potential relationship exists between morphologic disease and vascular flows thereby providing further insights into the pathophysiology of liver disease in this high-risk population.
Collapse
|
11
|
Abstract
Our understanding of the development of congenital heart disease (CHD) across the lifespan has evolved. These include the evidence for the change in demographics of CHD, the observations that lifelong complications of CHD result in CHD as a lifespan disease, and the concept of long windows of exposure to risk that start in foetal life and magnify the expression of risk in adulthood. These observations set the stage for trajectories as an emerging construct to target health-service interventions. The lifelong cardiovascular and systemic complications of CHD make the long-term care of these patients challenging for cardiologists and internists alike. A life-course approach is thus required to facilitate our understanding of the natural history and to orient our clinical efforts. Three specific examples are illustrated: neurocognition; cancer resulting from exposure to low-dose ionizing radiation; and cardiovascular disease acquired in ageing adults. As patients grow, they do not just want to live longer, they want to live well. With the need to move beyond the mortality outcome, a shift in paradigm is needed. A life-course health development framework is developed for CHD. Trajectories are used as a complex construct to illustrate the patient's healthcare journey. There is a need to define disease trajectories, wellness trajectories and ageing trajectories in this population. Disease trajectories for repaired tetralogy of Fallot, transposition of the great arteries and the Fontan operation are hypothetically constructed. For clinicians, the life-course horizon helps to frame the patient's history and plan for the future. For researchers, life-course epidemiology offers a framework that will help increase the relevance of clinical enquiry and improve study design and analyses. A health-service policy framework is proposed for a growing number of conditions that start in the before birth and extend as long as contemporary survival now permits. Ultimately, the goal is the precision delivery of health services that enables lifelong health management, organization of developmental health services, and integration of vertical and horizontal health-service delivery.
Collapse
Affiliation(s)
- A Marelli
- McGill University Health Centre, RVH/Glen Site, Cardiology, McGill University Health Centre, Montreal, Québec, Canada
| |
Collapse
|
12
|
Marshall KH, D'Udekem Y, Sholler GF, Opotowsky AR, Costa DSJ, Sharpe L, Celermajer DS, Winlaw DS, Newburger JW, Kasparian NA. Health-Related Quality of Life in Children, Adolescents, and Adults With a Fontan Circulation: A Meta-Analysis. J Am Heart Assoc 2020; 9:e014172. [PMID: 32172648 PMCID: PMC7335513 DOI: 10.1161/jaha.119.014172] [Citation(s) in RCA: 36] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background People with a Fontan circulation experience a range of physical, psychosocial and neurodevelopmental challenges alongside, or caused by, their cardiac condition, with significant consequences for health‐related quality of life (HRQOL). We meta‐analyzed HRQOL outcomes reported by people with a Fontan circulation or their proxies and evaluated predictors of poorer HRQOL. Methods and Results Six electronic databases were searched for peer‐reviewed, English‐language articles published before March 2019. Standardized mean differences (SMD) were calculated using fixed and random‐effects models. Fifty articles reporting on 29 unique studies capturing HRQOL outcomes for 2793 people with a Fontan circulation and 1437 parent‐proxies were analyzed. HRQOL was lower in individuals with a Fontan circulation compared with healthy referents or normative samples (SMD, −0.92; 95% CI, −1.36 to −0.48; P<0.001). Lower scores were reported across all HRQOL domains, with the largest differences found for physical (SMD, −0.90; 95% CI, −1.13 to −0.67; P<0.001) and school/work functioning (SMD, −0.71; 95% CI, −0.90 to −0.52; P<0.001). Meta‐regression analyses found no significant predictors of self‐reported physical functioning, but older age at Fontan operation was associated with poorer emotional functioning (β=−0.124; P=0.004), and diagnosis of hypoplastic left heart was associated with poorer social functioning (β=−0.007; P=0.048). Sensitivity analyses showed use of the PedsQL Core Module was associated with lower HRQOL scores compared with the Short‐Form Health Survey‐36. Conclusions HRQOL outcomes for people with a Fontan circulation are lower than the general population. Optimal care acknowledges the lifelong impact of the Fontan circulation on HRQOL and offers targeted strategies to improve outcomes for this growing population.
Collapse
Affiliation(s)
- Kate H Marshall
- Heart Centre for Children The Children's Hospital at Westmead Sydney New South Wales Australia.,Discipline of Paediatrics School of Women's and Children's Health University of New South Wales Medicine The University of New South Wales Sydney New South Wales Australia
| | - Yves D'Udekem
- Heart Research Group Murdoch Children's Research Institute Melbourne Victoria Australia.,Department of Cardiac Surgery The Royal Children's Hospital Melbourne Victoria Australia
| | - Gary F Sholler
- Heart Centre for Children The Children's Hospital at Westmead Sydney New South Wales Australia.,Sydney Medical School The University of Sydney New South Wales Australia
| | - Alexander R Opotowsky
- Department of Pediatrics University of Cincinnati College of Medicine Cincinnati Ohio United States.,Cincinnati Adult Congenital Heart Disease Program Heart Institute Cincinnati Children's Hospital Cincinnati Ohio United States.,Department of Cardiology Boston Children's Hospital Boston Massachusetts United States.,Harvard Medical School Boston Massachusetts United States
| | - Daniel S J Costa
- Sydney Medical School The University of Sydney New South Wales Australia.,Pain Management Research Institute Royal North Shore Hospital Sydney New South Wales Australia
| | - Louise Sharpe
- School of Psychology The University of Sydney New South Wales Australia
| | - David S Celermajer
- Sydney Medical School The University of Sydney New South Wales Australia.,Department of Cardiology Royal Prince Alfred Hospital Sydney New South Wales Australia
| | - David S Winlaw
- Heart Centre for Children The Children's Hospital at Westmead Sydney New South Wales Australia.,Sydney Medical School The University of Sydney New South Wales Australia
| | - Jane W Newburger
- Department of Cardiology Boston Children's Hospital Boston Massachusetts United States.,Harvard Medical School Boston Massachusetts United States
| | - Nadine A Kasparian
- Heart Centre for Children The Children's Hospital at Westmead Sydney New South Wales Australia.,Discipline of Paediatrics School of Women's and Children's Health University of New South Wales Medicine The University of New South Wales Sydney New South Wales Australia.,Department of Pediatrics University of Cincinnati College of Medicine Cincinnati Ohio United States.,Cincinnati Children's Center for Heart Disease and the Developing Mind Heart Institute and Division of Behavioral Medicine & Clinical Psychology Cincinnati Children's Hospital Cincinnati Ohio United States
| |
Collapse
|
13
|
Di Maria MV, Patel SS, Fernie JC, Rausch CM. Exercise Performance at Increased Altitude After Fontan Operation: Comparison to Normal Controls and Correlation with Cavopulmonary Hemodynamics. Pediatr Cardiol 2020; 41:642-649. [PMID: 32006081 DOI: 10.1007/s00246-020-02311-4] [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: 11/13/2019] [Accepted: 01/22/2020] [Indexed: 11/28/2022]
Abstract
Exercise performance declines as patients who have undergone Fontan operation enter adolescence. However, the effect of altitude on functional capacity after Fontan remains inadequately studied. Our aim was to describe exercise performance in a cohort of patients with Fontan physiology living at increased altitude and compare to a normal control group and relate these data to invasively derived hemodynamics. We hypothesized that peak oxygen consumption ([Formula: see text]) would be decreased, in association with elevated mean pulmonary artery pressure (mPAP) and pulmonary vascular resistance (PVRi). Patients were evaluated in a multidisciplinary clinic for patients with Fontan physiology. Evaluation included cardiopulmonary exercise test and cardiac catheterization at predetermined intervals. Descriptive statistics were calculated. Associations of catheterization and exercise testing measures with [Formula: see text] were estimated with Spearman correlation coefficients. One hundred patients with age- and gender-matched controls were included in the analysis. The mean age was 13.3 ± 3.9 years, with mean weight of 47.1 ± 18.4 kg. The mean [Formula: see text] was 29.0 ± 7.8 ml/kg/min, significantly lower than the control group, 40.2 ± 8.4 ml/kg/min (p < 0.0001). There was no statistically significant linear correlation between [Formula: see text] and mPAP or PVRi. We characterized exercise performance in a large cohort with Fontan physiology living at increased altitude and showed a decrease in [Formula: see text] compared to controls. Our data do not support the hypothesis that moderately increased altitude has a detrimental effect on exercise performance, nor is there a substantial link between poor cavopulmonary hemodynamics and exercise in this setting.
Collapse
Affiliation(s)
- Michael V Di Maria
- Section of Pediatric Cardiology, Department of Pediatrics, Heart Institute, Children's Hospital Colorado, University of Colorado School of Medicine, Aurora, CO, USA. .,Children's Hospital Colorado, 13123 E. 16th Ave., Box 100, Aurora, CO, 80045, USA.
| | - Sonali S Patel
- Section of Pediatric Cardiology, Department of Pediatrics, Heart Institute, Children's Hospital Colorado, University of Colorado School of Medicine, Aurora, CO, USA
| | - Julie C Fernie
- Section of Pediatric Cardiology, Department of Pediatrics, Heart Institute, Children's Hospital Colorado, University of Colorado School of Medicine, Aurora, CO, USA
| | - Christopher M Rausch
- Section of Pediatric Cardiology, Department of Pediatrics, Heart Institute, Children's Hospital Colorado, University of Colorado School of Medicine, Aurora, CO, USA
| |
Collapse
|
14
|
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]
|
15
|
Regenerative and durable small-diameter graft as an arterial conduit. Proc Natl Acad Sci U S A 2019; 116:12710-12719. [PMID: 31182572 DOI: 10.1073/pnas.1905966116] [Citation(s) in RCA: 43] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023] Open
Abstract
Despite significant research efforts, clinical practice for arterial bypass surgery has been stagnant, and engineered grafts continue to face postimplantation challenges. Here, we describe the development and application of a durable small-diameter vascular graft with tailored regenerative capacity. We fabricated small-diameter vascular grafts by electrospinning fibrin tubes and poly(ε-caprolactone) fibrous sheaths, which improved suture retention strength and enabled long-term survival. Using surface topography in a hollow fibrin microfiber tube, we enable immediate, controlled perfusion and formation of a confluent endothelium within 3-4 days in vitro with human endothelial colony-forming cells, but a stable endothelium is noticeable at 4 weeks in vivo. Implantation of acellular or endothelialized fibrin grafts with an external ultrathin poly(ε-caprolactone) sheath as an interposition graft in the abdominal aorta of a severe combined immunodeficient Beige mouse model supports normal blood flow and vessel patency for 24 weeks. Mechanical properties of the implanted grafts closely approximate the native abdominal aorta properties after just 1 week in vivo. Fibrin mediated cellular remodeling, stable tunica intima and media formation, and abundant matrix deposition with organized collagen layers and wavy elastin lamellae. Endothelialized grafts evidenced controlled healthy remodeling with delayed and reduced macrophage infiltration alongside neo vasa vasorum-like structure formation, reduced calcification, and accelerated tunica media formation. Our studies establish a small-diameter graft that is fabricated in less than 1 week, mediates neotissue formation and incorporation into the native tissue, and matches the native vessel size and mechanical properties, overcoming main challenges in arterial bypass surgery.
Collapse
|
16
|
|
17
|
Dahlqvist JA, Wiklund U, Karlsson M, Hanséus K, Strömvall-Larsson E, Nygren A, Eliasson H, Rydberg A. Sinus node dysfunction in patients with Fontan circulation: could heart rate variability be a predictor for pacemaker implantation? Pediatr Cardiol 2019; 40:685-693. [PMID: 30918992 PMCID: PMC6451711 DOI: 10.1007/s00246-019-02092-5] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/14/2019] [Accepted: 03/13/2019] [Indexed: 11/03/2022]
Abstract
Sinus node dysfunction (SND) causes significant morbidity in patients after Fontan surgery. Heart rate variability (HRV) reflects the autonomic regulation of the heart, and changes in HRV have been associated with SND in adults. We aimed to study whether changes in HRV could be detected in 24-h electrocardiographic (ECG) recordings in Fontan patients with SND. We compared HRV results from two patient groups; patients with Fontan circulation who later required a pacemaker due to severe SND (n = 12) and patients with Fontan circulation and SND, without indication for pacemaker treatment (n = 11), with two control groups; patients with Fontan circulation without SND (n = 90) and healthy controls (n = 66). The Poincaré plot index SD2 (representing changes in heart rate over 24-h) and the very low-frequency (VLF) HRV component were significantly higher in both SND groups, both compared with healthy controls and patients with Fontan circulation without SND. In SND patients with pacemakers, SD2 and VLF were slightly reduced compared to SND patients without pacemaker (p = 0.06). In conclusion, in Fontan patients with SND the HRV is significantly higher compared to healthy controls and Fontan patients without SND. However, in patients with severe SND requiring pacemaker, SD2 and VLF tended to be lower than in patients with SND without pacemaker, which could indicate a reduced diurnal HRV in addition to the severe bradycardia. This is a small study, but our results indicate that HRV analysis might be a useful method in the follow-up of Fontan patients regarding development of SND.
Collapse
Affiliation(s)
| | - Urban Wiklund
- 0000 0001 1034 3451grid.12650.30Department of Radiation Sciences, Biomedical Engineering, Umeå University, Umeå, Sweden
| | - Marcus Karlsson
- 0000 0001 1034 3451grid.12650.30Department of Radiation Sciences, Biomedical Engineering, Umeå University, Umeå, Sweden
| | - Katarina Hanséus
- 0000 0001 0930 2361grid.4514.4Department of Clinical Sciences Lund, Children Heart Centre, Skåne University Hospital, Lund University, Lund, Sweden
| | - Eva Strömvall-Larsson
- 0000 0000 9919 9582grid.8761.8Department of Cardiology, The Queen Silvia Children’s Hospital, Sahlgrenska University Hospital, Institute of Clinical Sciences, Gothenburg University, Gothenburg, Sweden
| | - Anders Nygren
- 0000 0000 9919 9582grid.8761.8Department of Cardiology, The Queen Silvia Children’s Hospital, Sahlgrenska University Hospital, Institute of Clinical Sciences, Gothenburg University, Gothenburg, Sweden
| | - Håkan Eliasson
- 0000 0000 9241 5705grid.24381.3cDepartment of Women’s and Children’s Health, Karolinska Institutet, Karolinska University Hospital, Stockholm, Sweden
| | - Annika Rydberg
- 0000 0001 1034 3451grid.12650.30Department of Clinical Sciences, Pediatrics, Umeå University, 901 85 Umeå, Sweden
| |
Collapse
|
18
|
Anesthetic Considerations for Pediatric Patients With Fontan Physiology Undergoing Noncardiac Surgery. Int Anesthesiol Clin 2019; 57:42-60. [DOI: 10.1097/aia.0000000000000250] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
|
19
|
du Plessis K, Peters R, King I, Robertson K, Mackley J, Maree R, Stanley T, Pickford L, Rose B, Orchard M, Stewart H, d'Udekem Y. "How long will I continue to be normal?" Adults with a Fontan circulation's greatest concerns. Int J Cardiol 2018; 260:54-59. [PMID: 29622455 DOI: 10.1016/j.ijcard.2018.01.098] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/24/2017] [Revised: 01/16/2018] [Accepted: 01/22/2018] [Indexed: 12/31/2022]
Abstract
BACKGROUND Little is known about adults living with a Fontan circulation's concerns outside the scope of their clinical outcomes. We examined adults with a Fontan circulations' greatest concerns, as well as their concerns around anti-coagulation, pregnancy and finances. METHODS Adults with a Fontan circulation in the Australian and New Zealand Fontan Registry were invited to complete an anonymous online survey, of which 57 participated. A qualitative method approach using thematic analyses was used. RESULTS The greatest concerns for adults living with a Fontan circulation were fear of death/uncertainty around life expectancy which for many individuals colored their concerns around physical health, pregnancy and having children, quality of life and finances. Improving information about outcomes to patients with a Fontan circulation might alleviate uncertainties about their future. CONCLUSIONS Fear of death is the primary concern of adults with a Fontan circulation. It may require improved communication and targeted psychological interventions. Physical exercise incorporated as part of their lifestyle should be encouraged to alleviate physical concerns and also improve psychological well-being.
Collapse
Affiliation(s)
- Karin du Plessis
- Murdoch Children's Research Institute, Melbourne, Victoria, Australia
| | - Rebecca Peters
- Murdoch Children's Research Institute, Melbourne, Victoria, Australia; Australian and New Zealand Fontan Advisory Committee, Australia and New Zealand
| | - Ingrid King
- Murdoch Children's Research Institute, Melbourne, Victoria, Australia; Australian and New Zealand Fontan Advisory Committee, Australia and New Zealand
| | - Kirsty Robertson
- Australian and New Zealand Fontan Advisory Committee, Australia and New Zealand
| | - Jonathan Mackley
- Australian and New Zealand Fontan Advisory Committee, Australia and New Zealand
| | - Rachel Maree
- Australian and New Zealand Fontan Advisory Committee, Australia and New Zealand
| | - Tracy Stanley
- Australian and New Zealand Fontan Advisory Committee, Australia and New Zealand
| | - Louise Pickford
- Australian and New Zealand Fontan Advisory Committee, Australia and New Zealand
| | - Brian Rose
- Australian and New Zealand Fontan Advisory Committee, Australia and New Zealand
| | - Matthew Orchard
- Australian and New Zealand Fontan Advisory Committee, Australia and New Zealand
| | - Helen Stewart
- Australian and New Zealand Fontan Advisory Committee, Australia and New Zealand
| | - Yves d'Udekem
- Murdoch Children's Research Institute, Melbourne, Victoria, Australia; Australian and New Zealand Fontan Advisory Committee, Australia and New Zealand; Cardiac Surgery Department, Royal Children's Hospital, Melbourne, Victoria, Australia; Department of Pediatrics, Faculty of Medicine, The University of Melbourne, Melbourne, Victoria, Australia.
| |
Collapse
|
20
|
Foeller ME, Foeller TM, Druzin M. Maternal Congenital Heart Disease in Pregnancy. Obstet Gynecol Clin North Am 2018; 45:267-280. [PMID: 29747730 DOI: 10.1016/j.ogc.2018.01.011] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Congenital heart disease comprises most maternal cardiac diseases in pregnancy and is an important cause of maternal, fetal, and neonatal morbidity and mortality worldwide. Pregnancy is often considered a high-risk state for individuals with structural heart disease as a consequence of a limited ability to adapt to the major hemodynamic changes associated with pregnancy. Preconception counseling and evaluation are of utmost importance, as pregnancy is contraindicated in certain cardiac conditions. Pregnancy can be safely accomplished in most individuals with careful risk assessment before conception and multidisciplinary care throughout pregnancy and the postpartum period.
Collapse
Affiliation(s)
- Megan E Foeller
- Obstetrics and Gynecology, Stanford University, Stanford Hospital, 300 Pasteur Drive, Room G302, 5317, Stanford, CA 94305-5317, USA.
| | - Timothy M Foeller
- Internal Medicine, Stanford Health Care-ValleyCare, 5555 West Positas Boulevard, 1 West Hospitalist Room 1, Pleasanton, CA 94588, USA
| | - Maurice Druzin
- Obstetrics and Gynecology, Stanford University, Stanford Hospital, 300 Pasteur Drive, Room G302, 5317, Stanford, CA 94305-5317, USA
| |
Collapse
|
21
|
Depressive and Anxiety Symptoms in Adult Congenital Heart Disease: Prevalence, Health Impact and Treatment. Prog Cardiovasc Dis 2018; 61:294-299. [DOI: 10.1016/j.pcad.2018.07.015] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/12/2018] [Accepted: 07/12/2018] [Indexed: 12/14/2022]
|
22
|
Bridging the psychological issues of living with the Fontan circulation. Int J Cardiol 2018; 260:72-73. [PMID: 29622457 DOI: 10.1016/j.ijcard.2018.02.105] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/22/2018] [Accepted: 02/26/2018] [Indexed: 11/21/2022]
|
23
|
Holbein CE, Fogleman ND, Hommel K, Apers S, Rassart J, Moons P, Luyckx K, Sluman MA, Enomoto J, Johansson B, Yang HL, Dellborg M, Subramanyan R, Jackson JL, Budts W, Kovacs AH, Morrison S, Tomlin M, Gosney K, Soufi A, Eriksen K, Thomet C, Berghammer M, Alday L, Callus E, Fernandes SM, Caruana M, Menahem S, Cook SC, Rempel GR, White K, Khairy P, Kutty S, Veldtman G. A multinational observational investigation of illness perceptions and quality of life among patients with a Fontan circulation. CONGENIT HEART DIS 2018; 13:392-400. [PMID: 29457362 PMCID: PMC5993574 DOI: 10.1111/chd.12583] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/07/2017] [Accepted: 12/19/2017] [Indexed: 11/30/2022]
Abstract
OBJECTIVE First, to compare QOL and illness perceptions between patients with a Fontan circulation and patients with anatomically simple defects (ie, atrial septal defects [ASD] or ventricular septal defects [VSD]). Second, to explore illness perceptions as a mediator of the association between congenital heart disease (CHD) diagnosis and QOL. DESIGN Cross-sectional observational study. SETTING Twenty-four cardiology centers from 15 countries across five continents. PATIENTS Four hundred thirty-five adult patients with congenital heart disease (177 Fontan and 258 ASD/VSD) ages 18-83 years. OUTCOME MEASURES QOL and illness perceptions were assessed by the Satisfaction With Life Scale and the Brief Illness Perceptions Questionnaire, respectively. RESULTS Patients with a Fontan circulation reported lower QOL (Wald Z = -3.59, p = <.001) and more negative perceptions of their CHD (Wald Z = -7.66, p < .001) compared with patients with ASD/VSD. After controlling for demographics, anxiety, depressive symptoms, and New York Heart Association functional class, path analyses revealed a significant mediation model, αβ = 0.15, p = .002, 95% CI = 0.06-0.25, such that CHD diagnosis was indirectly related to QOL through illness perceptions. CONCLUSIONS The Fontan sample's more negative perceptions of CHD were likely a reflection of life with a more complex defect. Illness perceptions appear to account for unique differences in QOL between groups of varying CHD complexity. Psychosocial screening and interventions may be important treatment components for patients with CHD, particularly those with Fontan circulations.
Collapse
Affiliation(s)
| | - Nicholas D. Fogleman
- Cincinnati Children's Hospital Medical Center, Cincinnati, USA
- University of Louisville, Louisville, USA
| | - Kevin Hommel
- Cincinnati Children's Hospital Medical Center, Cincinnati, USA
| | | | | | - Philip Moons
- KU Leuven, Leuven, Belgium
- University of Gothenburg, Gothenburg, Sweden
| | | | | | | | | | | | - Mikael Dellborg
- University of Gothenburg, Gothenburg, Sweden
- Adult Congenital Heart Unit, Sahlgrenska University Hospital, Gothenburg, Sweden
| | | | | | - Werner Budts
- KU Leuven, Leuven, Belgium
- University Hospitals Leuven and Department of Cardiovascular Sciences, Leuven, Belgium
| | | | - Stacey Morrison
- Cincinnati Children's Hospital Medical Center, Cincinnati, USA
| | - Martha Tomlin
- Cincinnati Children's Hospital Medical Center, Cincinnati, USA
| | - Kathy Gosney
- Cincinnati Children's Hospital Medical Center, Cincinnati, USA
| | | | | | - Corina Thomet
- KU Leuven, Leuven, Belgium
- University Hospital Bern, University of Bern, Bern, Switzerland
| | - Malin Berghammer
- University of Gothenburg, Gothenburg, Sweden
- University West, Trollhättan, Sweden
| | | | | | | | | | | | | | | | - Kamila White
- Washington University and Barnes Jewish Heart & Vascular Center, University of Missouri, Saint Louis, USA
| | | | - Shelby Kutty
- Children's Hospital & Medical Center, Omaha, USA
| | | |
Collapse
|
24
|
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.
Collapse
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
| |
Collapse
|
25
|
Menon SC, Al-Dulaimi R, McCrindle BW, Goldberg DJ, Sachdeva R, Goldstein BH, Seery T, Uzark KC, Chelliah A, Butts R, Henderson H, Johnson T, Williams RV. Delayed puberty and abnormal anthropometry and its associations with quality of life in young Fontan survivors: A multicenter cross-sectional study. CONGENIT HEART DIS 2018. [DOI: 10.1111/chd.12597] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Affiliation(s)
- Shaji C. Menon
- University of Utah and Primary Children's Hospital; Salt Lake City Utah USA
| | - Ragheed Al-Dulaimi
- University of Utah and Primary Children's Hospital; Salt Lake City Utah USA
| | | | | | | | | | | | | | | | - Ryan Butts
- Medical University of South Carolina; Charleston South Carolina USA
| | | | | | | |
Collapse
|
26
|
Hock J, Reiner B, Neidenbach RC, Oberhoffer R, Hager A, Ewert P, Müller J. Functional outcome in contemporary children with total cavopulmonary connection – Health-related physical fitness, exercise capacity and health-related quality of life. Int J Cardiol 2018; 255:50-54. [DOI: 10.1016/j.ijcard.2017.11.092] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/15/2016] [Revised: 10/22/2017] [Accepted: 11/27/2017] [Indexed: 10/18/2022]
|
27
|
Tree M, Wei ZA, Trusty PM, Raghav V, Fogel M, Maher K, Yoganathan A. Using a Novel In Vitro Fontan Model and Condition-Specific Real-Time MRI Data to Examine Hemodynamic Effects of Respiration and Exercise. Ann Biomed Eng 2018; 46:135-147. [PMID: 29067563 PMCID: PMC5756106 DOI: 10.1007/s10439-017-1943-0] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2017] [Accepted: 10/09/2017] [Indexed: 12/20/2022]
Abstract
Several studies exist modeling the Fontan connection to understand its hemodynamic ties to patient outcomes (Chopski in: Experimental and Computational Assessment of Mechanical Circulatory Assistance of a Patient-Specific Fontan Vessel Configuration. Dissertation, 2013; Khiabani et al. in J Biomech 45:2376-2381, 2012; Taylor and Figueroa in Annu Rev Biomed 11:109-134, 2009; Vukicevic et al. in ASAIO J 59:253-260, 2013). The most patient-accurate of these studies include flexible, patient-specific total cavopulmonary connections. This study improves Fontan hemodynamic modeling by validating Fontan model flexibility against a patient-specific bulk compliance value, and employing real-time phase contrast magnetic resonance flow data. The improved model was employed to acquire velocity field information under breath-held, free-breathing, and exercise conditions to investigate the effect of these conditions on clinically important Fontan hemodynamic metrics including power loss and viscous dissipation rate. The velocity data, obtained by stereoscopic particle image velocimetry, was visualized for qualitative three-dimensional flow field comparisons between the conditions. Key hemodynamic metrics were calculated from the velocity data and used to quantitatively compare the flow conditions. The data shows a multi-factorial and extremely patient-specific nature to Fontan hemodynamics.
Collapse
Affiliation(s)
- Michael Tree
- George W. Woodruff School of Mechanical Engineering, Georgia Institute of Technology, Atlanta, GA, USA
| | - Zhenglun Alan Wei
- Wallace H. Coulter School of Biomedical Engineering, Georgia Institute of Technology, Atlanta, GA, USA
- Institute of Computational Science and Cardiovascular Disease, Nanjing Medical University, Nanjing, China
| | - Phillip M Trusty
- Wallace H. Coulter School of Biomedical Engineering, Georgia Institute of Technology, Atlanta, GA, USA
| | - Vrishank Raghav
- Wallace H. Coulter School of Biomedical Engineering, Georgia Institute of Technology, Atlanta, GA, USA
| | - Mark Fogel
- Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Kevin Maher
- Children's Healthcare of Atlanta, Atlanta, GA, USA
| | - Ajit Yoganathan
- Wallace H. Coulter School of Biomedical Engineering, Georgia Institute of Technology, Atlanta, GA, USA.
| |
Collapse
|
28
|
Poh CL, d'Udekem Y. Life After Surviving Fontan Surgery: A Meta-Analysis of the Incidence and Predictors of Late Death. Heart Lung Circ 2017; 27:552-559. [PMID: 29402692 DOI: 10.1016/j.hlc.2017.11.007] [Citation(s) in RCA: 73] [Impact Index Per Article: 10.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2016] [Accepted: 11/18/2017] [Indexed: 12/29/2022]
Abstract
AIM We now know that 20-40% of patients with a single ventricle will develop heart failure after the second decade post-Fontan surgery. However, we remain unable to risk-stratify the cohort to identify patients at highest risk of late failure and death. We conducted a systematic review of all reported late outcomes for patients with a Fontan circulation to identify predictors of late death. METHODS We searched MEDLINE, Embase and PubMed with subject terms ("single ventricle", "Hypoplastic left heart syndrome", "congenital heart defects" or "Fontan procedure") AND ("heart failure", "post-operative complications", "death", "cause of death", "transplantation" or "follow-up studies") for relevant studies between January 1990 and December 2015. Variables identified as significant predictors of late death on multivariate analysis were collated for meta-analysis. Survival data was extrapolated from Kaplan-Meier survival curves to generate a distribution-free summary survival curve. RESULTS Thirty-four relevant publications were identified, with a total of 7536 patients included in the analysis. Mean follow-up duration was 114 months (range 24-269 months). There were 688 (11%) late deaths. Predominant causes of death were late Fontan failure (34%), sudden death (19%) and perioperative death (16%). Estimated mean survival at 5, 10 and 20 years post Fontan surgery were 95% (95%CI 93-96), 91% (95%CI 89-93) and 82% (95%CI 77-85). Significant predictors of late death include prolonged pleural effusions post Fontan surgery (HR1.18, 95%CI 1.09-1.29, p<0.001), protein losing enteropathy (HR2.19, 95%CI 1.69-2.84, p<0.001), increased ventricular end diastolic volume (HR1.03 per 10ml/BSA increase, 95%CI 1.02-1.05, p<0.001) and having a permanent pacemaker (HR12.63, 95%CI 6.17-25.86, p<0.001). CONCLUSIONS Over 80% of patients who survive Fontan surgery will be alive at 20 years. Developing late sequelae including protein losing enteropathy, ventricular dysfunction or requiring a pacemaker predict a higher risk of late death.
Collapse
Affiliation(s)
- C L Poh
- Department of Cardiac Surgery, The Royal Children's Hospital, Melbourne, Vic, Australia; Department of Paediatrics, The University of Melbourne, Melbourne, Vic, Australia; Heart Research, Murdoch Childrens Research Institute, Melbourne, Vic, Australia
| | - Y d'Udekem
- Department of Cardiac Surgery, The Royal Children's Hospital, Melbourne, Vic, Australia; Department of Paediatrics, The University of Melbourne, Melbourne, Vic, Australia; Heart Research, Murdoch Childrens Research Institute, Melbourne, Vic, Australia.
| |
Collapse
|
29
|
Fogleman ND, Apers S, Moons P, Morrison S, Wittekind SG, Tomlin M, Gosney K, Sluman MA, Johansson B, Enomoto J, Dellborg M, Lu CW, Subramanyan R, Luyckx K, Budts W, Jackson J, Kovacs A, Soufi A, Eriksen K, Thomet C, Berghammer M, Callus E, Fernandes SM, Caruana M, Cook SC, Mackie AS, White KS, Khairy P, Kutty S, Veldtman G. Regional variation in quality of life in patients with a Fontan circulation: A multinational perspective. Am Heart J 2017; 193:55-62. [PMID: 29129255 DOI: 10.1016/j.ahj.2017.07.019] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/07/2017] [Accepted: 07/28/2017] [Indexed: 11/30/2022]
Abstract
BACKGROUND Impaired quality of life (QOL) is associated with congenital heart disease (CHD) and country of residence; however, few studies have compared QOL in patients with differing complexities of CHD across regional populations. The current study examined regional variation in QOL outcomes in a large multinational sample of patients with a Fontan relative to patients with atrial septal defects (ASDs) and ventricular septal defects (VSDs). METHODS From the Assessment of Patterns of Patient-Reported Outcomes in Adults with Congenital Heart disease-International Study (APPROACH-IS), 405 patients (163 Fontan and 242 ASD/VSD) across Asia, Europe, and North America provided consent for access to their medical records and completed a survey evaluating QOL (0 to 100 linear analog scale). Primary CHD diagnosis, disease complexity, surgical history, and documented history of mood and anxiety disorders were recorded. Differences in QOL, medical complications, and mood and anxiety disorders between Fontan and ASD/VSD patients, and across geographic regions, were examined using analysis of covariance. Hierarchical regression analyses were conducted to identify variables associated with the QOL ratings. RESULTS Patients with a Fontan reported significantly lower QOL, and greater medical complications and mood and anxiety disorders relative to patients with ASD/VSD. Inpatient cardiac admissions, mood disorders, and anxiety disorders were associated with lower QOL among patients with a Fontan, and mood disorders were associated with lower QOL among patients with ASD/VSD. Regional differences for QOL were not observed in patients with a Fontan; however, significant differences were identified in patients with ASD/VSD. CONCLUSIONS Regional variation of QOL is commonplace in adults with CHD; however, it appears affected by greater disease burden. Among patients with a Fontan, regional variation of QOL is lost. Specific attempts to screen for QOL and mood and anxiety disorders among CHD patients may improve the care of patients with the greatest disease burden.
Collapse
Affiliation(s)
- Nicholas D Fogleman
- Cincinnati Children's Hospital Medical Center, Cincinnati, OH; Department of Psychological and Brain Sciences, University of Louisville, Louisville, KY
| | - Silke Apers
- KU Leuven Department of Public Health and Primary Care, Leuven, Belgium; KU Leuven Department of Development and Regeneration, Leuven, Belgium
| | - Philip Moons
- KU Leuven Department of Public Health and Primary Care, Leuven, Belgium; The Sahlgrenska Academy at University of Gothenburg, Institute of Health and Care Sciences, Gothenburg, Sweden
| | - Stacey Morrison
- Cincinnati Children's Hospital Medical Center, Cincinnati, OH
| | | | - Martha Tomlin
- Cincinnati Children's Hospital Medical Center, Cincinnati, OH
| | - Kathy Gosney
- Cincinnati Children's Hospital Medical Center, Cincinnati, OH
| | - Maayke A Sluman
- Academic Medical Center, Department of Cardiology, Amsterdam, the Netherlands
| | | | - Junko Enomoto
- Department of Adult Congenital Heart Disease, Chiba Cardiovascular Center, Chiba, Japan
| | - Mikael Dellborg
- The Sahlgrenska Academy at University of Gothenburg, Institute of Health and Care Sciences, Gothenburg, Sweden
| | - Chun-Wei Lu
- Department of Pediatrics, National Taiwan University Hospital, Taipei, Taiwan
| | | | - Koen Luyckx
- School Psychology and Child and Adolescent Development, KU Leuven, Leuven, Belgium
| | - Werner Budts
- Division of Congenital and Structural Cardiology, University Hospitals Leuven, Leuven, Belgium
| | - Jamie Jackson
- Columbus Ohio Adult Congenital Heart Disease Program, Nationwide Children's Hospital, The Ohio State College of Medicine, Columbus, OH
| | - Adrienne Kovacs
- Toronto Congenital Cardiac Centre for Adults, Peter Munk Cardiac Centre, University Health Network, Toronto, Ontario, Canada
| | | | | | - Corina Thomet
- Center for Congenital Heart Disease, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Malin Berghammer
- Centre for Person-Centred Care (GPCC), University of Gothenburg, Gothenburg, Sweden; Department of Health Science, University West, Trollhättan, Sweden
| | - Edward Callus
- Clinical Psychology Services IRCCS Policlinico San Donato, Milan, Italy
| | | | | | - Stephen C Cook
- Adult Congenital Heart Disease Center, Heart Institute, Children's Hospital of Pittsburgh of UPMC, Pittsburgh, PA
| | | | - Kamila S White
- Washington University and Barnes Jewish Heart & Vascular Center, and University of Missouri, Saint Louis, MO
| | - Paul Khairy
- Congenital Heart Center, Montreal Heart Institute, Montreal, Quebec, Canada
| | - Shelby Kutty
- University of Nebraska Medical Center/Children's Hospital and Medical Center, Omaha, NE
| | | |
Collapse
|
30
|
Lin Z, Ge H, Xue J, Wu G, Du J, Hu X, Zhao Q. Comparison of extracardiac conduit and lateral tunnel for functional single-ventricle patients: A meta-analysis. CONGENIT HEART DIS 2017; 12:711-720. [PMID: 28845580 DOI: 10.1111/chd.12503] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/09/2016] [Revised: 04/11/2017] [Accepted: 05/20/2017] [Indexed: 12/29/2022]
Abstract
OBJECTIVE This study aims to assess and compare the early and long-term effects of extracardiac conduit (EC) and lateral tunnel (LT) in patients with a functional single ventricle through meta-analysis. DESIGN A systematic search was performed in PubMed, Embase, Cochrane Library, CNKI, VIP, CBM, and WanFang databases for papers that were published until August 1, 2016. Cochrane systematic review method was used for paper screening and information retrieve, and RevMan 5.3 software was applied for the meta-analysis. RESULTS Data for 10 studies with a total of 3814 patients were retrieved. The advantages of EC comparing to LT include: lower 30 day postsurgery supraventricular arrhythmia incidence (Relative Risk [RR] = 0.31 [0.17, 0.55], P < .001), lower protein loss enteropathy incidence (RR = 0.33 [0.11, 0.96], P = .04), and requiring no cardiopulmonary bypass. However, the chest drainage time was longer (mean difference [MD] = 1.99 [1.83, 2.15], P < .001) in EC. There were no significant differences in early postoperative mortality, long-term mortality, long-term arrhythmia, Fontan takedown, ventilator-assisted ventilation, ICU stay, thrombosis, pleural effusion, and pericardial effusion between EC and LT. CONCLUSIONS EC had a lower incidence of supraventricular arrhythmia (30 days after operation) and the rate of protein losing enteropathy than LT, and requiring no cardiopulmonary bypass. These show that EC has an advantage over the LT in patients with a functional single ventricle.
Collapse
Affiliation(s)
- Zhiyong Lin
- The Children's Department of Cardiovascular and Thoracic Surgery, Children's Heart Center, the Second Affiliated Hospital & Yuying Children's Hospital, Institute of Cardiovascular Development and Translational Medicine, Wenzhou Medical University, Wenzhou, P.R. China
| | - Hanwei Ge
- The Children's Department of Cardiovascular and Thoracic Surgery, Children's Heart Center, the Second Affiliated Hospital & Yuying Children's Hospital, Institute of Cardiovascular Development and Translational Medicine, Wenzhou Medical University, Wenzhou, P.R. China
| | - Jiyang Xue
- The Children's Department of Cardiovascular and Thoracic Surgery, Children's Heart Center, the Second Affiliated Hospital & Yuying Children's Hospital, Institute of Cardiovascular Development and Translational Medicine, Wenzhou Medical University, Wenzhou, P.R. China
| | - Guowei Wu
- The Children's Department of Cardiovascular and Thoracic Surgery, Children's Heart Center, the Second Affiliated Hospital & Yuying Children's Hospital, Institute of Cardiovascular Development and Translational Medicine, Wenzhou Medical University, Wenzhou, P.R. China
| | - Jie Du
- The Children's Department of Cardiovascular and Thoracic Surgery, Children's Heart Center, the Second Affiliated Hospital & Yuying Children's Hospital, Institute of Cardiovascular Development and Translational Medicine, Wenzhou Medical University, Wenzhou, P.R. China
| | - Xingti Hu
- The Children's Department of Cardiovascular and Thoracic Surgery, Children's Heart Center, the Second Affiliated Hospital & Yuying Children's Hospital, Institute of Cardiovascular Development and Translational Medicine, Wenzhou Medical University, Wenzhou, P.R. China
| | - Qifeng Zhao
- The Children's Department of Cardiovascular and Thoracic Surgery, Children's Heart Center, the Second Affiliated Hospital & Yuying Children's Hospital, Institute of Cardiovascular Development and Translational Medicine, Wenzhou Medical University, Wenzhou, P.R. China
| |
Collapse
|
31
|
Heusch A, Kahl HJ, Hensel KO, Calaminus G. Health-related quality of life in paediatric patients with congenital heart defects: association with the type of heart defect and the surgical technique. Qual Life Res 2017; 26:3111-3117. [PMID: 28730300 DOI: 10.1007/s11136-017-1653-y] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/13/2017] [Indexed: 01/08/2023]
Abstract
The aim of the study was to investigate the impact of a number of surgical interventions for a various congenital cardiac defects (CHDs) on self-reported HRQoL. METHODS Patients who had received corrective surgery of several congenital heart defects (surgical VSD closure, Fallot, TGA after atrial or arterial switch or Fontan-type circulation for univentricular AV-connection) were interviewed in the office of their home peadiatric cardiologist. HRQoL in children along 7 dimensions was assessed using a standardised questionnaire (PEDQoL); information on the medical case history of each respondent was also collected. STATISTICS HRQoL was assessed in the questionnaire by asking about the frequency (never, rarely, often, always) of specific negative experiences; more frequent experiences indicate a lower quality of life. Frequency expressions were transformed into numerical values (25, 50, 75, 100%), and mean values for HRQoL were calculated for each patient and for each domain. Differences in HRQoL among patients with different types of interventions were analysed using the Mann-Whitney Test or the Kruskal-Wallis Test as appropriate; p values <0.05 were considered to indicate significant differences, while p values <0.1 were considered to indicate notable trends. RESULTS Patients: 169 patients (60% male, 40% female) were part of the study. The mean age was 11.6 years; 50 patients had surgical VSD closure, 52 surgeries for Tetralogy of Fallot (22 transannular patch, 18 no transannular patch, 12 inaccurate description), 40 had complete transposition of the great arteries (28 atrial switch, 12 arterial switch), 22 had a Fontan-type procedure for univentricular AV-connection. HRQoL differed little among patients with different CHDs for the items "relation to friends," "interactions in the affected families", and "own body image". For other items, notable differences emerged: patients with univentricular hearts rated their physical capacity worse and showed a tendency towards negative ratings in other domains. On the other hand, patients after Fallot or TGA correction tended to rate their HRQoL in several domains as relatively high. Focusing on the mode of surgery for Fallot repair, respectively, TGA correction the only significant difference was found for "physical capacity" in TGA (atrial vs. arterial repair). Mustard patients tended to rate most items worse. Physical capacity was rated worst by patients with a Fontan circulation. Repeated surgery led to lower ratings for all domains except "physical capacity" and "body image". CONCLUSIONS Different surgical techniques for CHD do not affect children's and adolescents' self-reported HRQoL to the extent that one would expect. This observation is in line with observations in groups of children with different chronic diseases. Specialised psychosocial support is necessary in order to maintain this positive self-evaluation and to ensure patients are able to lead autonomous personal and professional lives.
Collapse
|
32
|
Tree M, Wei ZA, Munz B, Maher K, Deshpande S, Slesnick T, Yoganathan A. A Method for In Vitro TCPC Compliance Verification. J Biomech Eng 2017; 139:2621590. [DOI: 10.1115/1.4036474] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2016] [Indexed: 01/29/2023]
Abstract
The Fontan procedure is a common palliative intervention for sufferers of single ventricle congenital heart defects that results in an anastomosis of the venous return to the pulmonary arteries called the total cavopulmonary connection (TCPC). Local TCPC and global Fontan circulation hemodynamics are studied with in vitro circulatory models because of hemodynamic ties to Fontan patient long-term complications. The majority of in vitro studies, to date, employ a rigid TCPC model. Recently, a few studies have incorporated flexible TCPC models, but provide no justification for the model material properties. The method set forth in this study successfully utilizes patient-specific flow and pressure data from phase contrast magnetic resonance images (PCMRI) (n = 1) and retrospective pulse-pressure data from an age-matched patient cohort (n = 10) to verify the compliance of an in vitro TCPC model. These data were analyzed, and the target compliance was determined as 1.36 ± 0.78 mL/mm Hg. A method of in vitro compliance testing and computational simulations was employed to determine the in vitro flexible TCPC model material properties and then use those material properties to estimate the wall thickness necessary to match the patient-specific target compliance. The resulting in vitro TCPC model compliance was 1.37 ± 0.1 mL/mm Hg—a value within 1% of the patient-specific compliance. The presented method is useful to verify in vitro model accuracy of patient-specific TCPC compliance and thus improve patient-specific hemodynamic modeling.
Collapse
Affiliation(s)
- Mike Tree
- The George W. Woodruff School of Mechanical Engineering, Georgia Institute of Technology, Atlanta, GA 30332
| | - Zhenglun Alan Wei
- Wallace H. Coulter Department of Biomedical Engineering, Georgia Institute of Technology and Emory University, Atlanta, GA 30332
| | - Brady Munz
- School of Chemical and Biomolecular Engineering, Georgia Institute of Technology, Atlanta, GA 30332
| | - Kevin Maher
- Department of Pediatrics, Emory University School of Medicine and Children's Healthcare of Atlanta, Atlanta, GA 30332
| | - Shriprasad Deshpande
- Department of Pediatrics, Emory University School of Medicine and Children's Healthcare of Atlanta, Atlanta, GA 30332
| | - Timothy Slesnick
- Department of Pediatrics, Emory University School of Medicine and Children's Healthcare of Atlanta, Atlanta, GA 30332
| | - Ajit Yoganathan
- Wallace H. Coulter Department of Biomedical Engineering, Georgia Institute of Technology and Emory University, Atlanta, GA 30332
| |
Collapse
|
33
|
Egbe AC, Connolly HM, Niaz T, Yogeswaran V, Taggart NW, Qureshi MY, Poterucha JT, Khan AR, Driscoll DJ. Prevalence and outcome of thrombotic and embolic complications in adults after Fontan operation. Am Heart J 2017; 183:10-17. [PMID: 27979032 DOI: 10.1016/j.ahj.2016.09.014] [Citation(s) in RCA: 45] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/30/2016] [Accepted: 09/06/2016] [Indexed: 11/15/2022]
Abstract
There are limited studies of thrombotic and embolic complications (TEC) in the adult Fontan population. The purpose of the study was to determine the prevalence, risk factors, and outcomes of TECs in this population. METHODS Retrospective review of adults with a previous Fontan operation, with follow-up at Mayo Clinic, 1994-2014. Systemic TEC was defined as intracardiac thrombus, ischemic stroke, or systemic arterial embolus. Nonsystemic TEC was defined as Fontan conduit/right atrial thrombus or pulmonary embolus. RESULTS We identified 387 patients with a mean (SD) age of 28 (7) years and a mean follow-up of 8 (2) years. An atriopulmonary connection (APC) was done for 286 patients (74%). Atrial arrhythmias were present in 278 (72%). There were 121 TECs (systemic n=36, nonsystemic n=85) in 98 patients (25%). Risk factors for systemic TEC were atrial arrhythmia (hazard ratio 2.28, P=.001) and APC (hazard ratio 1.98, P=.02); nonsystemic TEC also had similar risk factors. All 98 patients received warfarin. Warfarin was discontinued in 10 of 98 because of bleeding, and 8 of these 10 subsequently had a second TEC. Among the 82 patients who had follow-up imaging, 16 (20%) had resolution of thrombus. In total, 24 of 98 patients had a second TEC, most of whom had inadequate anticoagulation. CONCLUSIONS Thrombotic and embolic complication was not uncommon; risk factors for TEC were APC and atrial arrhythmias. Most patients were treated successfully with warfarin alone. A second TEC occurred in most patients whose anticoagulation was discontinued because of bleeding events.
Collapse
Affiliation(s)
- Alexander C Egbe
- Division of Cardiovascular Diseases, Mayo Clinic, Rochester, MN.
| | | | - Talha Niaz
- Department of Pediatric, Mayo Clinic, Rochester, MN
| | | | | | | | | | | | | |
Collapse
|
34
|
Egbe AC, Connolly HM, McLeod CJ, Ammash NM, Niaz T, Yogeswaran V, Poterucha JT, Qureshi MY, Driscoll DJ. Thrombotic and Embolic Complications Associated With Atrial Arrhythmia After Fontan Operation. J Am Coll Cardiol 2016; 68:1312-9. [DOI: 10.1016/j.jacc.2016.06.056] [Citation(s) in RCA: 53] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/02/2016] [Revised: 05/25/2016] [Accepted: 06/21/2016] [Indexed: 10/21/2022]
|
35
|
Spector LG, Menk JS, Vinocur JM, Oster ME, Harvey BA, St Louis JD, Moller J, Kochilas LK. In-Hospital Vital Status and Heart Transplants After Intervention for Congenital Heart Disease in the Pediatric Cardiac Care Consortium: Completeness of Ascertainment Using the National Death Index and United Network for Organ Sharing Datasets. J Am Heart Assoc 2016; 5:e003783. [PMID: 27506544 PMCID: PMC5015299 DOI: 10.1161/jaha.116.003783] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/17/2016] [Accepted: 07/14/2016] [Indexed: 12/29/2022]
Abstract
BACKGROUND The long-term outcomes of patients undergoing interventions for congenital heart disease (CHD) remain largely unknown. We linked the Pediatric Cardiac Care Consortium (PCCC) with the National Death Index (NDI) and the United Network for Organ Sharing Dataset (UNOS) registries to study mortality and transplant occurring up to 32 years postintervention. The objective of the current analysis was to determine the sensitivity of this linkage in identifying patients who are known to have died or undergone heart transplant. METHODS AND RESULTS We used direct identifiers from 59 324 subjects registered in the PCCC between 1982 and 2003 to test for completeness of case ascertainment of subjects with known vital and heart transplant status by linkage with the NDI and UNOS registries. Of the 4612 in-hospital deaths, 3873 were identified by the NDI as "true" matches for a sensitivity of 84.0% (95% CI, 82.9-85.0). There was no difference in sensitivity across 25 congenital cardiovascular conditions after adjustment for age, sex, race, presence of first name, death year, and residence at death. Of 455 known heart transplants in the PCCC, there were 408 matches in the UNOS registry, for a sensitivity of 89.7% (95% CI, 86.9-92.3). An additional 4851 deaths and 363 transplants that occurred outside the PCCC were identified through 2014. CONCLUSIONS The linkage of the PCCC with the NDI and UNOS national registries is feasible with a satisfactory sensitivity. This linkage provides a conservative estimate of the long-term death and heart transplant events in this cohort.
Collapse
Affiliation(s)
- Logan G Spector
- Department of Pediatrics, University of Minnesota, Minneapolis, MN
| | - Jeremiah S Menk
- Biostatistical Design and Analysis Center, University of Minnesota, Minneapolis, MN
| | | | - Matthew E Oster
- Department of Pediatrics, Emory University School of Medicine and Children's Health Care of Atlanta, GA
| | - Brian A Harvey
- Department of Pediatrics, University of Minnesota, Minneapolis, MN
| | - James D St Louis
- Department of Pediatric Surgery, University of Missouri-Kansas School of Medicine, Kansas City, MO
| | - James Moller
- Department of Pediatrics, University of Minnesota, Minneapolis, MN
| | - Lazaros K Kochilas
- Department of Pediatrics, Emory University School of Medicine and Children's Health Care of Atlanta, GA
| |
Collapse
|
36
|
Abstract
BACKGROUND Hypoplastic left heart syndrome (HLHS) is an etiologically multifactorial congenital heart disease affecting one in 5,000 newborns. Thirty years ago there were no treatment options for this pathology and the natural course of the disease led to death, usually within the first weeks of life. Recently surgical palliative techniques have been developed allowing for a five-year survival in more than half the cases. MATERIALS AND METHODS We reviewed literature available on HLHS, specifically its anatomy, embryology and pathophysiology, and treatment. The Pubmed and ClinicalKey databases were searched using the key words hypoplastic left heart syndrome, foetal aortic valvuloplasty, foetal septoplasty, Norwood procedure, bidirectional Glenn procedure, Fontan procedure, hybrid procedure. The relevant literature was reviewed and included in the article. We reported a case from Children's Clinical University Hospital, Riga, to illustrate treatment tactics in Latvia. RESULTS There are three possible directions for therapy in newborns with HLHS: orthotopic heart transplantation, staged surgical palliation and palliative non-surgical treatment or comfort care. Another treatment mode - foetal therapy - has arisen. Staged palliation and full Fontan circulation is a temporary solution, however, the only means for survival until heart transplantation. Fifty to 70% of patients who have gone through all three stages of palliation live to the age of five years. CONCLUSIONS The superior mode of treatment is not yet clear and the management must be based on each individual case, the experience of each clinic, as well as the financial aspects and will of the patient's parents.
Collapse
Affiliation(s)
| | | | - Ingūna Lubaua
- Riga Stradiņš University, Riga, Latvia.,Department of Cardiology and Cardio Surgery, Children's Clinical University Hospital, Riga, Latvia
| |
Collapse
|
37
|
Uzark K, Zak V, Shrader P, McCrindle BW, Radojewski E, Varni JW, Daniels K, Handisides J, Hill KD, Lambert LM, Margossian R, Pemberton VL, Lai WW, Atz AM. Assessment of Quality of Life in Young Patients with Single Ventricle after the Fontan Operation. J Pediatr 2016; 170:166-72.e1. [PMID: 26685073 PMCID: PMC4769899 DOI: 10.1016/j.jpeds.2015.11.016] [Citation(s) in RCA: 65] [Impact Index Per Article: 8.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/02/2015] [Revised: 10/12/2015] [Accepted: 11/05/2015] [Indexed: 01/22/2023]
Abstract
OBJECTIVES To assess self-reported quality of life (QOL) in a large multicenter cohort of adolescent and young adults surviving Fontan. STUDY DESIGN Cross-sectional. The Pediatric Quality of Life Inventory (PedsQL) was administered to 408 survivors of Fontan ages 13-25 years enrolled in the Pediatric Heart Network Fontan Follow-up Study. Subjects also completed either the Child Health Questionnaire (age <19 years) or Short Form Health Survey (age ≥ 19 years). PedsQL data were compared with matched controls without a chronic health condition. Correlations between the measures were examined. RESULTS Mean PedsQL scores for subjects receiving Fontan were significantly lower than those for the control group for physical and psychosocial QOL (P < .001). Overall, 45% of subjects receiving Fontan had scores in the clinically significant impaired range for physical QOL with 30% in the impaired range for psychosocial QOL. For each 1 year increase in age, the physical functioning score decreased by an average of 0.76 points (P = .004) and the emotional functioning score decreased by an average of 0.64 points (P = .03). Among subjects ≥19 years of age, the physical functioning score decreased by an average of 2 points for each year increase in age (P = .02). PedsQL scale scores were significantly correlated with conceptually related Child Health Questionnaire (P < .001) and Short Form Health Survey scores (P < .001). CONCLUSIONS Survivors of Fontan are at risk for significantly impaired QOL which may decline with advancing age. Routine assessment of QOL is essential to inform interventions to improve health outcomes. The PedsQL allowed QOL assessment from pediatrics to young adulthood. TRIAL REGISTRATION ClinicalTrials.gov: NCT00132782.
Collapse
Affiliation(s)
- Karen Uzark
- University of Michigan Mott Children's Hospital, Ann Arbor, MI.
| | - Victor Zak
- New England Research Institutes, Watertown, MA
| | | | - Brian W McCrindle
- University of Toronto Hospital for Sick Children, Toronto, Ontario, Canada
| | | | | | | | | | | | | | | | | | - Wyman W Lai
- Columbia University Medical Center, New York, NY
| | - Andrew M Atz
- Medical University of South Carolina, Charleston, SC
| |
Collapse
|
38
|
Abstract
PURPOSE It is important to identify those children with a Fontan circulation who are at risk for impaired health-related quality of life. We aimed to determine the predictive value of functional health status - medical history and present medical status - on both physical and psychosocial domains of health-related quality of life, as reported by patients themselves and their parents. METHODS We carried out a prospective cross-sectional multi-centre study in Fontan patients aged between 8 and 15, who had undergone staged completion of total cavopulmonary connection according to a current technique before the age of 7 years. Functional health status was assessed as medical history - that is, age at Fontan, type of Fontan, ventricular dominance, and number of cardiac surgical procedures - and present medical status - assessed with magnetic resonance imaging, exercise testing, and rhythm assessment. Health-related quality of life was assessed with The TNO/AZL Child Questionnaire Child Form and Parent Form. RESULTS In multivariate prediction models, several medical history variables, such as more operations post-Fontan completion, lower age at Fontan completion, and dominant right ventricle, and present medical status variables, such as smaller end-diastolic volume, a higher score for ventilatory efficiency, and the presence of sinus node dysfunction, predicted worse outcomes on several parent-reported and self-reported physical as well as psychosocial health-related quality of life domains. CONCLUSIONS Medical history and worse present medical status not only predicted worse physical parent-reported and self-reported health-related quality of life but also worse psychosocial health-related quality of life and subjective cognitive functioning. These findings will help in identifying patients who are at risk for developing impaired health-related quality of life.
Collapse
|
39
|
Averin K, Hirsch R, Seckeler MD, Whiteside W, Beekman RH, Goldstein BH. Diagnosis of occult diastolic dysfunction late after the Fontan procedure using a rapid volume expansion technique. Heart 2016; 102:1109-14. [DOI: 10.1136/heartjnl-2015-309042] [Citation(s) in RCA: 36] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/20/2015] [Accepted: 02/04/2016] [Indexed: 11/04/2022] Open
|
40
|
Kukreja M, Bryant AS, Cleveland DC, Dabal R, Hingorani N, Kirklin JK. Health-Related Quality of Life in Adult Survivors After the Fontan Operation. Semin Thorac Cardiovasc Surg 2015; 27:299-306. [PMID: 26708372 DOI: 10.1053/j.semtcvs.2015.08.007] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/08/2015] [Indexed: 11/11/2022]
Abstract
The primary objective of this study was to ascertain the long-term health-related quality of life (HRQOL) of adult patients who underwent a childhood Fontan operation for palliation of univentricular cardiac anomalies. The secondary objective was to compare the long-term HRQOL of Fontan survivors to that of pediatric heart transplant recipients. This cross-sectional study examined adult survivors (>19 years) who underwent a Fontan operation during childhood (Fontan group) or a pediatric heart transplant (HT group) between 1988 and 2011 (23-year span). HRQOL was assessed using the short form 36 survey. The study group consisted of 49 Fontan group patients and 13 HT group patients who responded to the survey. HRQOL scores of the Fontan group were similar to those of an age-controlled healthy US population in social and mental functioning, energy or vitality, and overall mental component score (P ≥ 0.2). However, Fontan scores in physical functioning, bodily pain, general health, and overall by physical component were significantly lower than those of the age-controlled US population (P < 0.05). No differences were identified between Fontan and HT patients. This favorable life-satisfaction period (average 18 years) should be considered when informing patients and families of expectations with the Fontan pathway vs certain higher-risk procedures.
Collapse
Affiliation(s)
- Manisha Kukreja
- Department of Surgery, University of Alabama at Birmingham, Birmingham, AL
| | - Ayesha S Bryant
- Department of Surgery, University of Alabama at Birmingham, Birmingham, AL
| | - David C Cleveland
- Department of Surgery, University of Alabama at Birmingham, Birmingham, AL
| | - Robert Dabal
- Department of Surgery, University of Alabama at Birmingham, Birmingham, AL
| | - Neha Hingorani
- Department of Surgery, University of Alabama at Birmingham, Birmingham, AL
| | - James K Kirklin
- Department of Surgery, University of Alabama at Birmingham, Birmingham, AL.
| |
Collapse
|
41
|
Berghammer MC, Brink E, Rydberg AM, Dellborg M, Ekman I. Committed to Life: Adolescents' and Young Adults' Experiences of Living with Fontan Circulation. CONGENIT HEART DIS 2015; 10:403-12. [PMID: 25564938 DOI: 10.1111/chd.12244] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 11/28/2014] [Indexed: 11/28/2022]
Affiliation(s)
- Malin C. Berghammer
- Institute of Medicine; Sahlgrenska Academy; Gothenburg Sweden
- Institute of Caring, Health and Culture; University West; Trollhättan Sweden
- Centre for Person-Centred Care; University of Gothenburg; Gothenburg Sweden
| | - Eva Brink
- Institute of Caring, Health and Culture; University West; Trollhättan Sweden
- Centre for Person-Centred Care; University of Gothenburg; Gothenburg Sweden
- Institute of Health and Care Sciences; Sahlgrenska Academy; University of Gothenburg; Gothenburg Sweden
| | - Annika M. Rydberg
- Department of Clinical Sciences; Pediatrics; University of Umeå; Umeå Sweden
| | - Mikael Dellborg
- Institute of Medicine; Sahlgrenska Academy; Gothenburg Sweden
- Adult Congenital Heart Unit; Sahlgrenska University Hospital/Östra; Gothenburg Sweden
| | - Inger Ekman
- Centre for Person-Centred Care; University of Gothenburg; Gothenburg Sweden
- Institute of Health and Care Sciences; Sahlgrenska Academy; University of Gothenburg; Gothenburg Sweden
| |
Collapse
|
42
|
Mavroudis C, Stulak JM, Ad N, Siegel A, Giamberti A, Harris L, Backer CL, Tsao S, Dearani JA, Weerasena N, Deal BJ. Prophylactic atrial arrhythmia surgical procedures with congenital heart operations: review and recommendations. Ann Thorac Surg 2014; 99:352-9. [PMID: 25442995 DOI: 10.1016/j.athoracsur.2014.07.026] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/29/2014] [Revised: 07/03/2014] [Accepted: 07/09/2014] [Indexed: 10/24/2022]
Abstract
Specific congenital heart anomalies significantly increase the risk for late atrial arrhythmias, raising the question whether prophylactic arrhythmia operations should be incorporated into reparative open heart procedures. Currently no consensus exists regarding standard prophylactic arrhythmia procedures. Questions remain concerning the arrhythmia-specific lesions to perform, energy sources to use, need for atrial appendectomy, and choosing a right, left, or biatrial Maze procedure. These considerations are important because prophylactic arrhythmia procedures are performed without knowing if the patient will actually experience an arrhythmia. This review identifies congenital defects with a risk for the development of atrial arrhythmias and proposes standardizing lesion sets for prophylactic arrhythmia operations.
Collapse
Affiliation(s)
- Constantine Mavroudis
- Johns Hopkins Children's Heart Surgery, Florida Hospital for Children, Orlando, Florida.
| | - John M Stulak
- Division of Cardiovascular Surgery, Department of Surgery, Mayo Clinic, Rochester, Minnesota
| | - Niv Ad
- Inova Fairfax Hospital, Cardiac Surgery Inova Heart and Vascular Institute, Falls Church, Virginia
| | - Allison Siegel
- Johns Hopkins Children's Heart Surgery, Florida Hospital for Children, Orlando, Florida
| | - Alessandro Giamberti
- Pediatric and Adult Congenital Heart Surgery, IRCSS Policlinico San Donato, San Donato M.se (MI), Italy
| | - Louise Harris
- Division of Cardiology, Peter Munk Cardiac Centre, Toronto Congenital Cardiac Centre for Adults, Toronto, Ontario, Canada
| | - Carl L Backer
- Cardiovascular-Thoracic Surgery, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois
| | - Sabrina Tsao
- Division of Cardiology and the Department of Pediatrics, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois
| | - Joseph A Dearani
- Division of Cardiovascular Surgery, Department of Surgery, Mayo Clinic, Rochester, Minnesota
| | - Nihal Weerasena
- Division of Cardiothoracic Surgery, The General Infirmary, Leeds, United Kingdom
| | - Barbara J Deal
- Division of Cardiology and the Department of Pediatrics, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois
| |
Collapse
|
43
|
McCrindle BW, Zak V, Breitbart RE, Mahony L, Shrader P, Lai WW, Burns KM, Colan SD, Williams RV, Goldberg D, Hill KD, Khaikin S, Atz AM. The relationship of patient medical and laboratory characteristics to changes in functional health status in children and adolescents after the Fontan procedure. Pediatr Cardiol 2014; 35:632-40. [PMID: 24264999 PMCID: PMC3959245 DOI: 10.1007/s00246-013-0831-0] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/16/2013] [Accepted: 10/26/2013] [Indexed: 10/26/2022]
Abstract
Despite hypothesized concerns about deterioration beginning in adolescence, longitudinal data and associated factors regarding standardized assessment of physical functioning are not available for Fontan patients. Parents who participated in the Fontan Cross-Sectional Study completed the Child Health Questionnaire at 2 time points for 245 subjects ages 6-18 years. Associations between change in Physical Functioning Summary Score and baseline patient, medical, and laboratory characteristics (mean age 9.5 ± 1.7 years) and follow-up patient and medical characteristics (mean age 16.2 ± 1.6 years) were determined by regression analyses. During a mean of 6.7 ± 0.4 years, a small (not clinically important) but statistically significant decrease in score from 46.2 ± 11.7 to 44.5 ± 12.1 (p < 0.03) was noted. Subjects with higher baseline scores had a greater decrease in score (r = -0.48; p < 0.001). A multivariable model of patient and medical characteristics (R(2) = 0.11) showed that a greater decrease in score was significantly associated with interim development of asthma (n = 13; parameter estimate [PE] -6.6; p < 0.05) or other chronic respiratory, lung, or breathing problems (n = 13; PE -12.5; p < 0.001) and the presence of protein-losing enteropathy at any time (n = 12; PE -9.4; p = 0.006). Change in score was not significantly associated with baseline laboratory measures of exercise capacity and ventricular characteristics and function. Therefore, although physical functioning may be stable during adolescence for many Fontan patients, deterioration occurs in some in association with respiratory conditions and protein-losing enteropathy. Further longitudinal study is necessary to better understand the relationship between clinical morbidities and functional health status as these patients transition into adulthood.
Collapse
Affiliation(s)
| | - Victor Zak
- New England Research Institutes, Watertown, MA
| | | | - Lynn Mahony
- University of Texas Southwestern Medical Center, Dallas, TX
| | | | - Wyman W. Lai
- Columbia University Medical Center, New York, NY
| | | | | | | | | | | | - Svetlana Khaikin
- University of Toronto, The Hospital for Sick Children, Toronto, Canada
| | - Andrew M. Atz
- Medical University of South Carolina, Charleston, SC
| | | |
Collapse
|
44
|
Dahlqvist JA, Karlsson M, Wiklund U, Hörnsten R, Rydberg A. Handheld ECG in analysis of arrhythmia and heart rate variability in children with Fontan circulation. J Electrocardiol 2014; 47:374-82. [PMID: 24674760 DOI: 10.1016/j.jelectrocard.2014.02.006] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2013] [Indexed: 10/25/2022]
Abstract
BACKGROUND Our aim was to evaluate the intermittent use of a handheld ECG system for detecting silent arrhythmias and cardiac autonomic dysfunction in children with univentricular hearts. METHODS Twenty-seven patients performed intermittent ECG recordings with handheld devices during a 14-day period. A manual arrhythmia analysis was performed. We analyzed heart rate variability (HRV) using scatter plots of all interbeat intervals (Poincaré plots) from the total observation period. Reference values of HRV indices were determined from Holter-ECGs in 41 healthy children. RESULTS One asymptomatic patient had frequent ventricular extra systoles. Another patient had episodes with supraventricular tachycardia (with concomitant palpitations). Seven patients showed reduced HRV. CONCLUSIONS Asymptomatic arrhythmia was detected in one patient. The proposed method for pooling of intermittent recordings from handheld or similar devices may be used for detection of arrhythmias as well as for cardiac autonomic dysfunction.
Collapse
Affiliation(s)
| | - Marcus Karlsson
- Department of Radiation Sciences, Biomedical Engineering, Umeå University, Sweden
| | - Urban Wiklund
- Department of Radiation Sciences, Biomedical Engineering, Umeå University, Sweden
| | - Rolf Hörnsten
- Clinical Physiology, Heart Centre and Department of Surgical and Perioperative Sciences, Umeå University, Sweden
| | - Annika Rydberg
- Department of Clinical Sciences, Umeå University, Sweden
| |
Collapse
|
45
|
Effect of Fontan fenestration on regional venous oxygen saturation during exercise: further insights into Fontan fenestration closure. Pediatr Cardiol 2014; 35:514-20. [PMID: 24150685 DOI: 10.1007/s00246-013-0817-y] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/19/2013] [Accepted: 10/03/2013] [Indexed: 10/26/2022]
Abstract
Fontan fenestration closure is a topic of great debate. The body of data regarding the risks and benefits of fenestration closure is limited yet growing. Previous studies have demonstrated that Fontan patients have less exercise capacity than those with normal cardiovascular anatomy. Differences also have been noted within various subgroups of Fontan patients such as whether Fontan is fenestrated or not. This study aimed to compare trends in regional oxygen saturations using near-infrared spectroscopy (NIRS) in patients with Fontan circulations during ramping exercise to further delineate differences between patients with and without a fenestration. It was hypothesized that Fontan patients with fenestrations have better exercise times, higher absolute regional oxygen venous saturations, and smaller arteriovenous differences than Fontan patients without fenestrations. For this study, 50 consecutive Fontan patients and 51 consecutive patients with normal cardiovascular anatomy were recruited. Placement of NIRS probes was performed to obtain regional oxygen saturations from the brain and the kidney. Readings were obtained at 1-min intervals during rest, exercise, and recovery. A standard Bruce protocol was used with a 5-min recovery period. Absolute regional tissue oxygenation values (rSO2) and arterial-venous oxygen saturation differences (AVDO2) calculated as arterial oxygen saturation (SPO2)--rSO2 for normal versus Fontan patients and for fenestrated versus unfenestrated Fontan patients were compared using independent t tests. When normal and Fontan patients were compared, the Fontan patients had a significantly shorter duration of exercise (9.3 vs 13.2 min; p < 0.001). No statistically significant difference in rSO2 change or AVDO2 was evident at the time of peak exercise, at 2 min into the recovery, or at 5 min into the recovery. A small oxygen debt also was paid back to the brain in the Fontan patients after exercise, as evidenced by a narrower AVDO2 than at baseline. The comparison of Fontan patients with and without fenestration showed no statistically significant difference in exercise time, rSO2 change, or AVDO2. The Fontan patients were noted to have shorter exercise times than the normal patients and also appeared to have an alteration in postexertional regional blood flow. However, when the various Fontan subtypes were compared by presence or absence of a fenestration, no significant differences were noted with regard to change in regional oxygen saturation or arteriovenous oxygen saturation. Thus, for patients with Fontan physiology, closure of the fenestration does not seem to have an impact on the dynamics of regional oxygen extraction during exercise or recovery.
Collapse
|
46
|
Associations between knowledge of disease, depression and anxiety, social support, sense of coherence and optimism with health-related quality of life in an ambulatory sample of adolescents with heart disease. Cardiol Young 2014; 24:126-33. [PMID: 23402427 DOI: 10.1017/s1047951113000012] [Citation(s) in RCA: 56] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
INTRODUCTION Advances in overall management have led to an increasing number of adolescents with congenital heart disease reaching adulthood. This study aimed to evaluate the health-related quality of life in adolescents with heart disease, and examine its relationship with the adolescents' knowledge and understanding of their congenital heart disease, its severity, and its relationship to the degree of anxiety and depression, feeling of optimism and sense of coherence experienced by the adolescents together with their social support. METHODS AND RESULTS Adolescents with heart disease were recruited from an ambulatory setting at a tertiary centre. Patients completed self-report questionnaires including the Paediatric Quality of Life Inventory 3.0-Cardiac Module, a questionnaire assessing the adolescents' knowledge of their cardiac condition, the Hospital Anxiety and Depression Scale, Multidimensional Scale of Perceived Social Support, Life Orientation Test-Revised, and Sense of Coherence-13, supplemented by clinical information provided by the attending cardiologists. A total of 114 patients aged 12-20 years were recruited over 15 months. In all, 98% of patients were in New York Heart Association class I. Their health-related quality of life was found to positively correlate with a low level of anxiety and depression (Pearson correlation, r = -0.57, p < 0.001), a good knowledge of their cardiac condition (r = 0.31, p < 0.01), feelings of optimism (r = 0.39, p < 0.001), adequate social support (r = 0.27, p < 0.01), and a strong sense of coherence (r = 0.24, p < 0.01). CONCLUSIONS Adolescents' knowledge and understanding of their cardiac abnormality together with an improved sense of well-being had a positive influence on their health-related quality of life.
Collapse
|
47
|
SUN QI, LIU JINLONG, ZHANG HAIBO, ZHENG JINGHAO, HONG HAIFA, SUN YANJUN, CHEN HUIWEN, LIU JINFEN, WANG QIAN, LIU YINGZHENG. INFLUENCE OF EXERCISE ON THREE TYPES OF FONTAN MODIFICATIONS: COMPARISON BY NUMERICAL SIMULATIONS. J MECH MED BIOL 2014. [DOI: 10.1142/s0219519414500079] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
Low energy efficiency of Fontan-type connections in exercise conditions may lead to limited post-operative exercise capacity of patients. The objective of this study was to compare the energy efficiency of different types of Fontan modifications in exercise conditions. In this study, the flow rate of the inferior vena cava (IVC) was increased artificially to simulate exercise conditions. The control volume power loss and energy efficiency were investigated in three types of Fontan modifications using the method of computational fluid dynamics (CFD). In the intracardiac tunnel Fontan, the power loss was 7.9 times of that calculated in resting state when the flow rate of IVC increased to three times of that measured at the right pulmonary artery flow ratio of 50%. The energy efficiency of it decreased prominently from 91.9% to 79.9%. On the contrary, in the extracardiac Fontan with direct cavopulmonary anastomosis (direct Fontan), the magnitude of power loss was only 2.9 times of that in resting state and the energy efficiency changed only from 91.8% to 89.1%. The results of extracardiac conduit Fontan fell in between. It showed that direct Fontan had higher energy efficiency than intracardiac tunnel or extracardiac conduit Fontan in exercise conditions.
Collapse
Affiliation(s)
- QI SUN
- Department of Cardiothoracic Surgery, Shanghai Children's Medical Center, Shanghai Jiao Tong University School of Medicine, 1678# Dongfang Road, Shanghai, P. R. China
| | - JINLONG LIU
- Department of Cardiothoracic Surgery, Shanghai Children's Medical Center, Shanghai Jiao Tong University School of Medicine, 1678# Dongfang Road, Shanghai, P. R. China
| | - HAIBO ZHANG
- Department of Cardiothoracic Surgery, Shanghai Children's Medical Center, Shanghai Jiao Tong University School of Medicine, 1678# Dongfang Road, Shanghai, P. R. China
| | - JINGHAO ZHENG
- Department of Cardiothoracic Surgery, Shanghai Children's Medical Center, Shanghai Jiao Tong University School of Medicine, 1678# Dongfang Road, Shanghai, P. R. China
| | - HAIFA HONG
- Department of Cardiothoracic Surgery, Shanghai Children's Medical Center, Shanghai Jiao Tong University School of Medicine, 1678# Dongfang Road, Shanghai, P. R. China
| | - YANJUN SUN
- Department of Cardiothoracic Surgery, Shanghai Children's Medical Center, Shanghai Jiao Tong University School of Medicine, 1678# Dongfang Road, Shanghai, P. R. China
| | - HUIWEN CHEN
- Department of Cardiothoracic Surgery, Shanghai Children's Medical Center, Shanghai Jiao Tong University School of Medicine, 1678# Dongfang Road, Shanghai, P. R. China
| | - JINFEN LIU
- Department of Cardiothoracic Surgery, Shanghai Children's Medical Center, Shanghai Jiao Tong University School of Medicine, 1678# Dongfang Road, Shanghai, P. R. China
| | - QIAN WANG
- Department of Medical Imaging, Shanghai Children's Medical Center, Shanghai Jiao Tong University School of Medicine, 1678# Dongfang Road, Shanghai, P. R. China
| | - YINGZHENG LIU
- School of Mechanical Engineering, Shanghai Jiao Tong University, 800# Dongchuan Road, Shanghai, P. R. China
| |
Collapse
|
48
|
Firdouse M, Agarwal A, Chan AK, Mondal T. Thrombosis and Thromboembolic Complications in Fontan Patients. Clin Appl Thromb Hemost 2014; 20:484-92. [DOI: 10.1177/1076029613520464] [Citation(s) in RCA: 46] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023] Open
Abstract
Hemodynamic fluctuations and thromboembolic complications are significant areas of concern during the postoperative management of patients with univentricular hearts. The objective of this study is to review the incidence and risk factors associated with thrombosis and thromboembolic complications following total cavopulmonary anastomosis, the third stage of the palliative surgical procedure. A literature search of published evidence was conducted on OvidSP MEDLINE(R) and Embase followed by paired title, abstract, and full-text screening based on specific inclusion criteria. High risks of thromboembolic outcomes were identified across studies, with variable incidences between 3% and 20%, high mortality rates up to 38%, and an inverse relationship with prophylaxis treatment administration. Several risk factors for thrombotic complications, including chronic systemic venous hypertension, protein-losing enteropathy, passive blood flow, atrial arrhythmias, conduit stenosis, prosthetic material use, coagulation factor abnormalities, and several patient characteristics were identified. Based on these findings, a prophylactic anticoagulation algorithm has been proposed.
Collapse
Affiliation(s)
| | - Arnav Agarwal
- Faculty of Health Sciences, McMaster University, Hamilton, Canada
| | - Anthony K. Chan
- Department of Pediatrics, McMaster Children’s Hospital, McMaster University, Hamilton, Canada
| | - Tapas Mondal
- Department of Pediatrics, McMaster Children’s Hospital, McMaster University, Hamilton, Canada
| |
Collapse
|
49
|
Heart Failure in Adults who had the Fontan Procedure: Natural History, Evaluation, and Management. CURRENT TREATMENT OPTIONS IN CARDIOVASCULAR MEDICINE 2013; 15:587-601. [DOI: 10.1007/s11936-013-0257-2] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
|
50
|
Abstract
AIMS This review explores the quality of life of adult congenital heart disease patients and the relationship between disease severity and quality of life. METHODS We searched seven electronic databases and the bibliography of articles. The 31 selected studies fulfilled the following criteria: adult population; quantitative; assessment of quality of life and/or impact of disease severity on quality of life using validated measures; English language. Data extraction forms were used to summarise the results. RESULTS There are evident methodological limitations within the reviewed studies such as heterogeneous populations, designs, and quality of life conceptualisations and measurements. Despite these problems, findings suggest that the quality of life of adult congenital heart disease patients is compromised in the physical domain compared with their healthy counterparts, whereas no differences were found in relation to the psychosocial and environmental/occupational domain. Some severity variables appear to be significant correlates of quality of life and could be considered in a future standardised classification of disease severity. CONCLUSION The methodological limitations of past research in relation to the definition and measurement of quality of life, the study designs, and disease severity classifications need to be addressed in future studies in order to provide robust evidence and valid conclusions in this area of study. This will enable the development of targeted interventions for the improvement of quality of life in the adult population of congenital heart disease patients.
Collapse
|