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Pike NA, Avedissian T, Halnon NH, Lewis AB, Kumar R. Low pre-albumin but not thiamine predicts cognitive deficits in adolescents post-Fontan and healthy controls. Cardiol Young 2024; 34:803-808. [PMID: 37850442 DOI: 10.1017/s1047951123003396] [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] [Indexed: 10/19/2023]
Abstract
BACKGROUND Low pre-albumin, body mass index, and thiamine levels have been associated with poor nutritional status and cognitive/memory deficits in adult heart failure patients. However, the relationship of these nutritional/dietary intake biomarkers to cognition has not been assessed in adolescents post-Fontan procedure and healthy controls. METHODS This is a cross-sectional study. Adolescents (14-21 years of age) post-Fontan completion were recruited from paediatric cardiology clinics and controls from the community. The Montreal Cognitive Assessment was administered (normal ≥ 26), and blood draw (thiamine [normal 70-110 nmol/L] and pre-albumin levels [adolescent normal 23-45 mg/dL]) and the Thiamine Food Frequency Questionnaire were completed by all participants. RESULTS Seventy subjects, 40 post-Fontan (mean age 16 ± 1.6, female 51%, Hispanic 44%, hypoplastic left heart syndrome 26%) and 30 controls (mean age 16.8 ± 1.9, female 52%, Hispanic 66%), were participated. Post-Fontan group had lower median total cognitive scores (23 versus 29, p < 0.001), pre-albumin levels (23 versus 27, p = 0.013), and body mass index (20 versus 24, p = 0.027) than controls. Post-Fontan group had higher thiamine levels than controls (127 versus 103, p = 0.033). Lower pre-albumin levels (< 23) and underweight body mass index were associated with abnormal total cognitive scores (p = 0.030). Low pre-albumin level (p = .038) was an independent predictor of worse cognition. CONCLUSION Lower pre-albumin was an independent predictor for worse cognition in adolescents post-Fontan. Lower pre-albumin levels may reflect chronic liver changes or protein-losing enteropathy seen in Fontan physiology. These findings highlight the possibility for nutrition-induced cognitive changes.
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Affiliation(s)
- Nancy A Pike
- University of California Los Angeles, School of Nursing, Los Angeles, CA, USA
- Department of Cardiothoracic Surgery, Children's Hospital Los Angeles, Los Angeles, CA, USA
| | - Tamar Avedissian
- American University of Beirut, Hariri School of Nursing, Beirut, Lebanon
| | - Nancy H Halnon
- Department of Pediatric Cardiology, UCLA Mattel Children's Hospital, Los Angeles, CA, USA
| | - Alan B Lewis
- Department of Pediatric Cardiology, Children's Hospital Los Angeles, Los Angeles, CA, USA
| | - Rajesh Kumar
- Departments of Anesthesiology and Radiological Sciences, University of California, Los Angeles, CA, USA
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Thomson LM, Mancuso CA, Wolfe KR, Khailova L, Niemiec S, Ali E, DiMaria M, Mitchell M, Twite M, Morgan G, Frank BS, Davidson JA. The proteomic fingerprint in infants with single ventricle heart disease in the interstage period: evidence of chronic inflammation and widespread activation of biological networks. Front Pediatr 2023; 11:1308700. [PMID: 38143535 PMCID: PMC10748388 DOI: 10.3389/fped.2023.1308700] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/06/2023] [Accepted: 11/20/2023] [Indexed: 12/26/2023] Open
Abstract
Introduction Children with single ventricle heart disease (SVHD) experience significant morbidity across systems and time, with 70% of patients experiencing acute kidney injury, 33% neurodevelopmental impairment, 14% growth failure, and 5.5% of patients suffering necrotizing enterocolitis. Proteomics is a method to identify new biomarkers and mechanisms of injury in complex physiologic states. Methods Infants with SVHD in the interstage period were compared to similar-age healthy controls. Serum samples were collected, stored at -80°C, and run on a panel of 1,500 proteins in single batch analysis (Somalogic Inc., CO). Partial Least Squares-Discriminant Analysis (PLS-DA) was used to compare the proteomic profile of cases and controls and t-tests to detect differences in individual proteins (FDR <0.05). Protein network analysis with functional enrichment was performed in STRING and Cytoscape. Results PLS-DA readily discriminated between SVHD cases (n = 33) and controls (n = 24) based on their proteomic pattern alone (Accuracy = 0.96, R2 = 0.97, Q2 = 0.80). 568 proteins differed between groups (FDR <0.05). We identified 25 up-regulated functional clusters and 13 down-regulated. Active biological systems fell into six key groups: angiogenesis and cell proliferation/turnover, immune system activation and inflammation, altered metabolism, neural development, gastrointestinal system, and cardiac physiology and development. Conclusions We report a clear differentiation in the circulating proteome of patients with SVHD and healthy controls with >500 circulating proteins distinguishing the groups. These proteomic data identify widespread protein dysregulation across multiple biologic systems with promising biological plausibility as drivers of SVHD morbidity.
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Affiliation(s)
- Lindsay M. Thomson
- Department of Pediatrics, University of Colorado Anschutz Medical Campus, Aurora, CO, United States
| | - Christopher A. Mancuso
- Department of Biostatistics and Informatics, University of Colorado Anschutz Medical Campus, Aurora, CO, United States
| | - Kelly R. Wolfe
- Department of Pediatrics, University of Colorado Anschutz Medical Campus, Aurora, CO, United States
| | - Ludmila Khailova
- Department of Pediatrics, University of Colorado Anschutz Medical Campus, Aurora, CO, United States
| | - Sierra Niemiec
- Department of Biostatistics and Informatics, University of Colorado Anschutz Medical Campus, Aurora, CO, United States
| | - Eiman Ali
- Department of Pediatrics, University of Colorado Anschutz Medical Campus, Aurora, CO, United States
| | - Michael DiMaria
- Department of Pediatrics, University of Colorado Anschutz Medical Campus, Aurora, CO, United States
| | - Max Mitchell
- Department of Surgery, University of Colorado Anschutz Medical Campus, Aurora, CO, United States
| | - Mark Twite
- Department of Anesthesia, University of Colorado Anschutz Medical Campus, Aurora, CO, United States
| | - Gareth Morgan
- Department of Pediatrics, University of Colorado Anschutz Medical Campus, Aurora, CO, United States
| | - Benjamin S. Frank
- Department of Pediatrics, University of Colorado Anschutz Medical Campus, Aurora, CO, United States
| | - Jesse A. Davidson
- Department of Pediatrics, University of Colorado Anschutz Medical Campus, Aurora, CO, United States
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Smith KL, Gordon EB, Gunsaulus ME, Christopher A, Olivieri LJ, Tadros SS, Harris T, Saraf AP, Kreutzer J, Feingold B, Alsaied T. Surrogates of Muscle Mass on Cardiac MRI Correlate with Exercise Capacity in Patients with Fontan Circulation. J Clin Med 2023; 12:2689. [PMID: 37048773 PMCID: PMC10095035 DOI: 10.3390/jcm12072689] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2023] [Revised: 03/29/2023] [Accepted: 03/31/2023] [Indexed: 04/14/2023] Open
Abstract
BACKGROUND Sarcopenia is an increasingly recognized marker of frailty in cardiac patients. Patients with a history of congenital heart disease and Fontan procedure have a higher risk of developing progressive muscle wasting. Our objective was to determine if we could use routine cardiac MRI (CMR) for the surveillance of muscle wasting. METHODS A retrospective study of all Fontan patients (n = 75) was conducted at our institution, with CMR performed from 2010 to 2022 and exercise stress testing performed within 12 months (4.3 ± 4.2 months). The skeletal muscle area (SMA) for the posterior paraspinal and anterior thoracic muscles were traced and indexed for body surface area (BSA). Patients were stratified by percentile into the upper and lower quartiles, and the two groups were compared. Multivariable regression was performed to control for sex and age. RESULTS There was a significant positive association of both anterior (r = 0.34, p = 0.039) and paraspinal (r = 0.43, p = 0.007) SMA to peak VO2. Similarly, paraspinal but not anterior SMA was negatively associated with the VE/VCO2 (r = -0.45, p = 0.006). The upper quartile group had significantly more males (18/19 vs. 8/20; p = 0.0003) and demonstrated a significantly higher peak VO2 (32.2 ± 8.5 vs. 23.8 ± 4.7, p = 0.009), a higher peak RER (1.2 ± 0.1 vs. 1.1 ± 0.04, p = 0.007), and a significantly lower VE/VCO2 (32.9 ± 3.6 vs. 40.2 ± 6.2, p = 0.006) compared to the lowest quartile. The association of SMA to VO2 peak and VE/VCO2 was redemonstrated after controlling for sex and age. CONCLUSION Thoracic skeletal muscle area may be an effective surrogate of muscle mass and is correlated to several measures of cardiorespiratory fitness post-Fontan. CMR would be an effective tool for the surveillance of sarcopenia in post-Fontan patients given its accessibility and routine use in these patients.
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Affiliation(s)
- Kevin L. Smith
- Department of Pediatrics, UPMC Children’s Hospital of Pittsburgh, University of Pittsburgh School of Medicine, Pittsburgh, PA 15224, USA
| | - Emile B. Gordon
- Department of Radiology, UPMC Children’s Hospital of Pittsburgh, University of Pittsburgh School of Medicine, Pittsburgh, PA 15224, USA
| | - Megan E. Gunsaulus
- Department of Pediatric Cardiology, UPMC Children’s Hospital of Pittsburgh, University of Pittsburgh School of Medicine, Pittsburgh, PA 15224, USA
| | - Adam Christopher
- Department of Pediatric Cardiology, UPMC Children’s Hospital of Pittsburgh, University of Pittsburgh School of Medicine, Pittsburgh, PA 15224, USA
| | - Laura J. Olivieri
- Department of Pediatric Cardiology, UPMC Children’s Hospital of Pittsburgh, University of Pittsburgh School of Medicine, Pittsburgh, PA 15224, USA
| | - Sameh S. Tadros
- Department of Radiology, UPMC Children’s Hospital of Pittsburgh, University of Pittsburgh School of Medicine, Pittsburgh, PA 15224, USA
| | - Tyler Harris
- Department of Pediatric Cardiology, UPMC Children’s Hospital of Pittsburgh, University of Pittsburgh School of Medicine, Pittsburgh, PA 15224, USA
| | - Anita P. Saraf
- Department of Pediatric Cardiology, UPMC Children’s Hospital of Pittsburgh, University of Pittsburgh School of Medicine, Pittsburgh, PA 15224, USA
| | - Jacqueline Kreutzer
- Department of Pediatric Cardiology, UPMC Children’s Hospital of Pittsburgh, University of Pittsburgh School of Medicine, Pittsburgh, PA 15224, USA
| | - Brian Feingold
- Department of Pediatric Cardiology, UPMC Children’s Hospital of Pittsburgh, University of Pittsburgh School of Medicine, Pittsburgh, PA 15224, USA
| | - Tarek Alsaied
- Department of Pediatric Cardiology, UPMC Children’s Hospital of Pittsburgh, University of Pittsburgh School of Medicine, Pittsburgh, PA 15224, USA
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Stallard L, Siddiqui I, Muise A. Beyond IBD: the genetics of other early-onset diarrhoeal disorders. Hum Genet 2023; 142:655-667. [PMID: 36788146 PMCID: PMC10182111 DOI: 10.1007/s00439-023-02524-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2022] [Accepted: 01/19/2023] [Indexed: 02/16/2023]
Abstract
Diarrhoeal disorders in childhood extend beyond the inflammatory bowel diseases. Persistent and severe forms of diarrhoea can occur from birth and are associated with significant morbidity and mortality. These disorders can affect not only the gastrointestinal tract but frequently have extraintestinal manifestations, immunodeficiencies and endocrinopathies. Genomic analysis has advanced our understanding of these conditions and has revealed precision-based treatment options such as potentially curative haematopoietic stem cell transplant. Although many new mutations have been discovered, there is frequently no clear genotype-phenotype correlation. The functional effects of gene mutations can be studied in model systems such as patient-derived organoids. This allows us to further characterise these disorders and advance our understanding of the pathophysiology of the intestinal mucosa. In this review, we will provide an up to date overview of genes involved in diarrhoeal disorders of early onset, particularly focussing on the more recently described gene defects associated with protein loosing enteropathy.
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Affiliation(s)
- Lorraine Stallard
- SickKids Inflammatory Bowel Disease Centre, The Hospital for Sick Children, Toronto, ON, Canada
| | - Iram Siddiqui
- Division of Pathology, The Hospital for Sick Children, Toronto, ON, Canada
| | - Aleixo Muise
- SickKids Inflammatory Bowel Disease Centre, The Hospital for Sick Children, Toronto, ON, Canada. .,Cell Biology Program, Research Institute, The Hospital for Sick Children, Toronto, ON, Canada. .,Department of Pediatrics, Institute of Medical Science and Biochemistry, University of Toronto, The Hospital for Sick Children, Toronto, ON, Canada.
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Abstract
OBJECTIVES Management of "failing" and "failed" Fontan circulation, particularly the indications, timing, and type of re-intervention, currently remains nebulous. Factors contributing to pathogenesis and mortality following Fontan procedure differ between children and adults. METHODS Since organ systems in individual patients are affected differently, we searched the extant literature for a "failing" and "failed" Fontan reviewing the clinical phenotypes, diagnostic modalities, pharmacological, non-pharmacological, and surgical techniques employed, and their outcomes. RESULTS A total of 410 investigations were synthesised. Although proper candidate selection, thoughtful technical modifications, timely deployment of mechanical support devices, tissue-engineered conduits, and Fontan takedown have decreased the peri-operative mortality from 9 to 15% and 1 to 3% per cent in recent series, pernicious changes in organ function are causing long-term patient attrition. In the setting of a failed Fontan circulation, literature documents three surgical options: Fontan revision, Fontan conversion, or cardiac transplantation. The reported morbidity of 25% and mortality of 8-10% among Fontan conversion continue to improve in select institutions. While operative mortality following cardiac transplantation for Fontan failure is 30% higher than for other CHDs, there is no difference in long-term survival with actuarial 10-year survival of around 54%. Mechanical circulatory assistance, stem cells, and tissue-engineered Fontan conduit for destination therapy or as a bridge to transplantation are in infancy for failing Fontan circulation. CONCLUSIONS An individualised management strategy according to clinical phenotypes may delay the organ damage in patients with a failing Fontan circulation. At present, cardiac transplantation remains the last stage of palliation with gradually improving outcomes.
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Baldini L, Librandi K, D’Eusebio C, Lezo A. Nutritional Management of Patients with Fontan Circulation: A Potential for Improved Outcomes from Birth to Adulthood. Nutrients 2022; 14:nu14194055. [PMID: 36235705 PMCID: PMC9572747 DOI: 10.3390/nu14194055] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2022] [Revised: 09/23/2022] [Accepted: 09/24/2022] [Indexed: 11/30/2022] Open
Abstract
Fontan circulation (FC) is a surgically achieved palliation state offered to patients affected by a wide variety of congenital heart defects (CHDs) that are grouped under the name of univentricular heart. The procedure includes three different surgical stages. Malnutrition is a matter of concern in any phase of life for these children, often leading to longer hospital stays, higher mortality rates, and a higher risk of adverse neurodevelopmental and growth outcomes. Notwithstanding the relevance of proper nutrition for this subset of patients, specific guidelines on the matter are lacking. In this review, we aim to analyze the role of an adequate form of nutritional support in patients with FC throughout the different stages of their lives, in order to provide a practical approach to appropriate nutritional management. Firstly, the burden of faltering growth in patients with univentricular heart is analyzed, focusing on the pathogenesis of malnutrition, its detection and evaluation. Secondly, we summarize the nutritional issues of each life phase of a Fontan patient from birth to adulthood. Finally, we highlight the challenges of nutritional management in patients with failing Fontan.
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Affiliation(s)
- Letizia Baldini
- Postgraduate School of Pediatrics, University of Turin, 10126 Turin, Italy
- Pediatria Specialistica, Ospedale Infantile Regina Margherita, Piazza Polonia 94, 10126 Torino, Italy
- Correspondence:
| | - Katia Librandi
- Postgraduate School of Pediatrics, University of Turin, 10126 Turin, Italy
| | - Chiara D’Eusebio
- Dietetic and Clinical Nutrition Unit, Pediatric Hospital Regina Margherita, University of Turin, 10126 Turin, Italy
| | - Antonella Lezo
- Dietetic and Clinical Nutrition Unit, Pediatric Hospital Regina Margherita, University of Turin, 10126 Turin, Italy
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7
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Sagray E, Johnson JN, Schumacher KR, West S, Lowery RE, Simpson K. Protein-losing enteropathy recurrence after pediatric heart transplantation: Multicenter case series. Pediatr Transplant 2022; 26:e14295. [PMID: 35451219 DOI: 10.1111/petr.14295] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/13/2022] [Revised: 04/03/2022] [Accepted: 04/09/2022] [Indexed: 11/28/2022]
Abstract
BACKGROUND Protein-losing enteropathy (PLE) is a devastating complication of the Fontan circulation. Although orthotopic heart transplantation (HTx) typically results in resolution of PLE symptoms, isolated cases of PLE relapse have been described after HTx. METHODS Patients with Fontan-related PLE who had undergone HTx at participating centers and experienced relapse of PLE during follow-up were retrospectively identified. Available data related to pre- and post-HTx characteristics and PLE events were collected. RESULTS Eight patients from four different centers were identified. Median time from Fontan procedure to the development of PLE was 8 years, and median age at HTx was 17 years (range 7.7-21). In all patients, PLE resolved at a median time of 1 month after HTx (0.3-5). PLE recurrences occurred at a median time of 7.5 months after HTx (2-132). Each occurrence was associated with one or more significant clinical events; most commonly cellular- or antibody-mediated rejection; and less commonly graft dysfunction, infection, thrombosis, and posttransplant lymphoproliferative disease. PLE recurrences resolved after the successful treatment of the concomitant event, after a median time of 2 months in seven cases, while persisted and recurred in one patient in association with atypical mycobacterium infection and subsequent PTLD onset and relapses. Six patients were alive during follow-up at a median time of 4 years (1.3-22.5) after HTx. CONCLUSIONS This is the largest series of PLE recurrence after HTx. All cases were associated with one or more concomitant and significant clinical events. PLE typically resolved after resolution of the inciting clinical event.
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Affiliation(s)
- Ezequiel Sagray
- Division of Pediatric Cardiology, Department of Pediatric and Adolescent Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Jonathan N Johnson
- Division of Pediatric Cardiology, Department of Pediatric and Adolescent Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Kurt R Schumacher
- Division of Pediatric Cardiology, Department of Pediatrics, University of Michigan, Ann Arbor, Michigan, USA
| | - Shawn West
- Pediatric Cardiology, Children's Hospital of Pittsburgh, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Ray E Lowery
- Division of Pediatric Cardiology, Department of Pediatrics, University of Michigan, Ann Arbor, Michigan, USA
| | - Kathleen Simpson
- Division of Cardiology, Department of Pediatrics, Children's Hospital of Colorado, University of Colorado Denver, Aurora, Colorado, USA
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8
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Protein-losing enteropathy in Fontan circulation: Pathophysiology, outcome and treatment options of a complex condition. INTERNATIONAL JOURNAL OF CARDIOLOGY CONGENITAL HEART DISEASE 2022. [DOI: 10.1016/j.ijcchd.2022.100322] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023] Open
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9
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Brownell JN, Biko DM, Mamula P, Krishnamurthy G, Escobar F, Srinivasan A, Laje P, Piccoli DA, Pinto E, Smith CL, Dori Y. Dynamic Contrast Magnetic Resonance Lymphangiography Localizes Lymphatic Leak to the Duodenum in Protein-Losing Enteropathy. J Pediatr Gastroenterol Nutr 2022; 74:38-45. [PMID: 34406998 PMCID: PMC8714618 DOI: 10.1097/mpg.0000000000003287] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
OBJECTIVES Protein-losing enteropathy (PLE) is a disorder of intestinal lymphatic flow resulting in leakage of protein-rich lymph into the gut lumen. Our primary aim was to report the imaging findings of dynamic contrast magnetic resonance lymphangiography (DCMRL) in patients with PLE. Our secondary objective was to use these imaging findings to characterize lymphatic phenotypes. METHODS Single-center retrospective cohort study of patients with PLE unrelated to single-ventricle circulation who underwent DCMRL. We report imaging findings of intranodal (IN), intrahepatic (IH), and intramesenteric (IM) access points for DCMRL. RESULTS Nineteen patients 0.3-58 years of age (median 1.2 years) underwent 29 DCMRL studies. Primary intestinal lymphangiectasia (PIL) was the most common referring diagnosis (42%). Other etiologies included constrictive pericarditis, thoracic insufficiency syndrome, and genetic disorders. IN-DCMRL demonstrated a normal central lymphatic system in all patients with an intact thoracic duct and localized duodenal leak in one patient (1/19, 5%). IH-DCMRL detected a duodenal leak in 12 of 17 (71%), and IM-DCMRL detected duodenal leak in 5 of 6 (83%). Independent of etiology, lymphatic leak was only visualized in the duodenum. CONCLUSIONS In patients with PLE, imaging via DCMRL reveals that leak is localized to the duodenum regardless of etiology. Comprehensive imaging evaluation with three access points can provide detailed information about the site of duodenal leak.
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Affiliation(s)
- Jefferson N. Brownell
- Division of Gastroenterology, Hepatology and Nutrition, Department of Pediatrics, Children’s Hospital of Philadelphia and University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
| | - David M. Biko
- Department of Radiology, Children’s Hospital of Philadelphia and University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
| | - Petar Mamula
- Division of Gastroenterology, Hepatology and Nutrition, Department of Pediatrics, Children’s Hospital of Philadelphia and University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
| | - Ganesh Krishnamurthy
- Department of Radiology, Children’s Hospital of Philadelphia and University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
| | - Fernando Escobar
- Department of Radiology, Children’s Hospital of Philadelphia and University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
| | - Abhay Srinivasan
- Department of Radiology, Children’s Hospital of Philadelphia and University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
| | - Pablo Laje
- Department of Surgery, Children’s Hospital of Philadelphia and University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
| | - David A. Piccoli
- Division of Gastroenterology, Hepatology and Nutrition, Department of Pediatrics, Children’s Hospital of Philadelphia and University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
| | - Erin Pinto
- Division of Cardiology, Department of Pediatrics, Children’s Hospital of Philadelphia and University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
| | - Christopher L. Smith
- Division of Cardiology, Department of Pediatrics, Children’s Hospital of Philadelphia and University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
| | - Yoav Dori
- Division of Cardiology, Department of Pediatrics, Children’s Hospital of Philadelphia and University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
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Alsaied T, Lubert AM, Goldberg DJ, Schumacher K, Rathod R, Katz DA, Opotowsky AR, Jenkins M, Smith C, Rychik J, Amdani S, Lanford L, Cetta F, Kreutzer C, Feingold B, Goldstein BH. Protein losing enteropathy after the Fontan operation. INTERNATIONAL JOURNAL OF CARDIOLOGY CONGENITAL HEART DISEASE 2022. [DOI: 10.1016/j.ijcchd.2022.100338] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
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11
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Kamsheh AM, O'Connor MJ, Rossano JW. Management of circulatory failure after Fontan surgery. Front Pediatr 2022; 10:1020984. [PMID: 36425396 PMCID: PMC9679629 DOI: 10.3389/fped.2022.1020984] [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: 08/16/2022] [Accepted: 10/18/2022] [Indexed: 11/11/2022] Open
Abstract
With improvement in survival after Fontan surgery resulting in an increasing number of older survivors, there are more patients with a Fontan circulation experiencing circulatory failure each year. Fontan circulatory failure may have a number of underlying etiologies. Once Fontan failure manifests, prognosis is poor, with patient freedom from death or transplant at 10 years of only about 40%. Medical treatments used include traditional heart failure medications such as renin-angiotensin-aldosterone system blockers and beta-blockers, diuretics for symptomatic management, antiarrhythmics for rhythm control, and phosphodiesterase-5 inhibitors to decrease PVR and improve preload. These oral medical therapies are typically not very effective and have little data demonstrating benefit; if there are no surgical or catheter-based interventions to improve the Fontan circulation, patients with severe symptoms often require inotropic medications or mechanical circulatory support. Mechanical circulatory support benefits patients with ventricular dysfunction but may not be as useful in patients with other forms of Fontan failure. Transplant remains the definitive treatment for circulatory failure after Fontan, but patients with a Fontan circulation face many challenges both before and after transplant. There remains significant room and urgent need for improvement in the management and outcomes of patients with circulatory failure after Fontan surgery.
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Affiliation(s)
- Alicia M Kamsheh
- Division of Cardiology, Children's Hospital of Philadelphia, United States
| | - Matthew J O'Connor
- Division of Cardiology, Children's Hospital of Philadelphia, United States
| | - Joseph W Rossano
- Division of Cardiology, Children's Hospital of Philadelphia, United States
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12
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Inai K. Biomarkers for heart failure and prognostic prediction in patients with Fontan circulation. Pediatr Int 2022; 64:e14983. [PMID: 34480813 DOI: 10.1111/ped.14983] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/12/2021] [Revised: 08/10/2021] [Accepted: 09/02/2021] [Indexed: 01/06/2023]
Abstract
A wide variety of pathologies are involved in heart failure in patients with congenital heart disease (CHD). Specific causes of heart failure after the Fontan procedure include not only single-ventricle circulation, but also the function of the right ventricle as the systemic ventricle, atrioventricular or semilunar valve stenosis or regurgitation, pulmonary hypertension, and left ventricular dysfunction secondary to right ventricular enlargement or dysfunction. As heart failure can occur post-Fontan, for a variety of reasons, clarification of the pathophysiology is the first step in management and treatment. At the same time, it is important to understand each patient's current condition and treatment plan to make an accurate prognosis. Because of the wide variety of pathophysiologies in post-Fontan CHD patients, however, no single biomarker is useful in all situations. Relevant biomarkers must be selected according to each patient's disease state, and combinations of multiple biomarkers should also be considered. In this review, the author describes the clinical importance of various biomarkers for patients who have undergone a Fontan procedure.
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Affiliation(s)
- Kei Inai
- Department of Pediatric Cardiology and Adult Congenital Cardiology, Tokyo Women's Medical University, Shinjuku-ku, Japan
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13
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Krishnan GS, Gnanasekharan P, Sharma D, Chandrashekhar A, Rao KGS, Balakrishnan KR. Heart transplantation for patients with single ventricle physiology. Indian J Thorac Cardiovasc Surg 2021; 37:647-661. [PMID: 34642557 PMCID: PMC8495435 DOI: 10.1007/s12055-021-01241-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2021] [Revised: 07/12/2021] [Accepted: 07/13/2021] [Indexed: 11/29/2022] Open
Abstract
Background There is a growing population of palliated and unpalliated single ventricle physiology patients for whom heart transplantation is the only treatment option available. There is a paucity of reports of heart transplantation in this challenging and growing subset of patients from our part of the world. The purpose of the article is to briefly review our experience in the subgroup and compare it with the available literature. Methods This was a single-institution retrospective observational study of 16 patients with single ventricle physiology who were transplanted between 2016 and 2019 and their outcomes. The study groups were divided into those with ventricular dysfunction (group 1), who fare substantially better than those with normal ventricular function (group 2) whose short-term outcomes were poorer. Worsening cyanosis, poor candidature for completion Fontan procedure due to severe atrioventricular valve regurgitation or pulmonary artery anatomy, protein-losing enteropathy, plastic bronchitis, and worsening systemic venous congestion are indications in those with normal ventricular function. Results Patients with ventricular dysfunction as the main indication had excellent early survival with no early mortality compared to 40% mortality in patients with normal ventricular function. Patients who survived to leave the hospital had however similar long-term outcomes. Two patients with protein-losing enteropathy resolved completely by one month. Normal ventricular function, pulmonary artery stenting, early Fontan failure (6 months), ascites, and need for desensitization were risk factors for early mortality. After the early acute phase of increased risk, the mortality risk plateaued off. Conclusion Transplantation in patients with single ventricle and ventricular dysfunction can be offered with a good early and late outcome. There is a need to have multi-institutional and multi-disciplinary collaboration along with work in basic sciences to better understand the effects of failed Fontan physiology with normal ventricular function.
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Affiliation(s)
- Ganapathy Subramaniam Krishnan
- Institute of Heart and Lung Transplant and Mechanical Circulatory Support, MGM Healthcare, No. 72, Nelson Manickam Road, Aminjikarai, Chennai, 600029 Tamil -Nadu India
| | - Pradeep Gnanasekharan
- Institute of Heart and Lung Transplant and Mechanical Circulatory Support, MGM Healthcare, No. 72, Nelson Manickam Road, Aminjikarai, Chennai, 600029 Tamil -Nadu India
| | - Dhruva Sharma
- Department of Cardiothoracic and Vascular Surgery, SMS Medical College & Attached Hospitals, J L N Marg, Jaipur, 302001 Rajasthan India
| | - Anitha Chandrashekhar
- Institute of Heart and Lung Transplant and Mechanical Circulatory Support, MGM Healthcare, No. 72, Nelson Manickam Road, Aminjikarai, Chennai, 600029 Tamil -Nadu India
| | - Kemundel Genny Suresh Rao
- Cardiac Anaesthesia & Critical Care, MGM Healthcare, No. 72, Nelson Manickam Road, Aminjikarai, Chennai, 600029 Tamil-Nadu India
| | - Komarakshi Rajagopalan Balakrishnan
- Institute of Heart and Lung Transplant and Mechanical Circulatory Support, MGM Healthcare, No. 72, Nelson Manickam Road, Aminjikarai, Chennai, 600029 Tamil -Nadu India
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14
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Manning LN, Schumacher KR, Friedland-Little JM, Yu S, Lowery R, Goldstein BH, Charpie JR. Impact of Protein-Losing Enteropathy on Inflammatory Biomarkers and Vascular Dysfunction in Fontan Circulation. Am J Cardiol 2021; 155:128-134. [PMID: 34315570 DOI: 10.1016/j.amjcard.2021.06.022] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/06/2021] [Revised: 06/10/2021] [Accepted: 06/14/2021] [Indexed: 10/20/2022]
Abstract
Fontan palliation has improved survival for single ventricle patients, but long-term complications persist including cardiovascular dysfunction, neurohormonal abnormalities, and protein-losing enteropathy (PLE). Although chronic inflammation contributes to morbidity, an association between inflammation and vascular dysfunction has not been studied. We assessed inflammation and vascular function in 31 Fontan-palliated patients (52% male, median age 14.3 years), including 10 PLE+. Fontan circulation was associated with altered inflammatory cytokines (TNF-α: mean 2.5 ± 1.4 vs. 0.7 ± 0.2 pg/ml, p < 0.0001; sTNFR2: 371 ± 108 vs. 2694 ± 884 pg/ml, p < 0.0001) and vascular dysfunction [log-transformed reactive hyperemia index (lnRHI) 0.28 ± 0.19 vs. 0.47 ± 0.26, p < 0.01; augmentation index (AI) -2.9 ± 13.8 vs. -16.3 ± 12.0, p = 0.001; circulating endothelial progenitor cells (cEPCs) 5.0 ± 8.1 vs. 22.8 ± 15.9, p = 0.0002)]. Furthermore, PLE+ patients showed greater inflammation (IFN-γ 6.3 ± 2.2 vs. 11.5 ± 7.9 pg/ml, p = 0.01; sTNFR1: 1181 ± 420 vs. 771 ± 350 pg/ml, p = 0.01) and decreased arterial compliance (AI: 5.4 ± 17.1 vs. -6.8 ± 10.2, p = 0.02) than PLE- patients. Circulating EPCs, but not inflammatory cytokines, were inversely associated with arterial stiffness in Fontan patients. In conclusion, chronic inflammation and vascular dysfunction are observed after Fontan operation, with greater inflammation and arterial stiffness in Fontan patients with active PLE. However, there is no clear association between inflammatory cytokines and vascular dysfunction, suggesting these pathophysiologic processes are not mechanistically linked.
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15
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American College of Cardiology Body Mass Index Counseling Quality Improvement Initiative. Pediatr Cardiol 2021; 42:1190-1199. [PMID: 33856499 DOI: 10.1007/s00246-021-02600-6] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/15/2020] [Accepted: 04/01/2021] [Indexed: 10/21/2022]
Abstract
Overweight/obesity, prevalent cardiovascular risk factors in children, can be associated with increased risk of adverse outcomes in children with heart disease. The American College of Cardiology (ACC) developed quality metrics including a BMI metric related to identifying and counseling overweight and obese children presenting to cardiology clinics. This metric was used for a multicenter collaborative learning Quality improvement (QI) Project through the ACC Quality Network (QNet). Our aim was to increase the percentage of children between ages 3 and 18 years presenting to cardiology clinics at participating centers with BMI > 85th percentile who received appropriate counseling. Participating centers submitted data quarterly to QNet for a sample of patients who received counseling. A Key Driver Diagram was created to help teams drive improvement. Individual centers customized interventions and participated in network-wide educational learning sessions about QI and shared experience. Statistical process control charts were used. From 04/01/2017 to 09/30/2019, 27,511 patient visits were included. Among 32 participating centers, overall counseling rate was 54%. The BMI counseling rate increased from 25% in 2017Q2 to 54% in 2019Q3. There was a wide variation from 10 to 100% in the performance of individual centers. The overall rate of identification and counseling of overweight and obese children presenting to ambulatory cardiology clinics in participating centers is low. There is wide variation in the performance of centers, providing an opportunity for improvement. Using this multicenter learning approach, individual centers have demonstrated improvement. This demonstrates that collaborative learning approaches in QI can increase implementation of the metric.
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16
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Hauser JA, Muthurangu V, Pandya B, Michel-Behnke I, Taylor AM, Demyanets S. Postprandial variability of novel heart failure biomarkers in Fontan patients compared to healthy volunteers. INTERNATIONAL JOURNAL OF CARDIOLOGY CONGENITAL HEART DISEASE 2021. [DOI: 10.1016/j.ijcchd.2021.100127] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
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17
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Mourato MF, Mourato FA, Mattos SDS, Neves JR. Echocardiographic and Ultrasonographic Parameters Associated with Protein-losing Enteropathy in Patients with Fontan Physiology: a Systematic Review with Meta-analysis. INTERNATIONAL JOURNAL OF CARDIOVASCULAR SCIENCES 2021. [DOI: 10.36660/ijcs.20200047] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
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18
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Lubert AM, Alsaied T, Palermo JJ, Anwar N, Urbina EM, Brown NM, Alexander C, Almeneisi H, Wu F, Leventhal AR, Aldweib N, Mendelson M, Opotowsky AR. Fontan-Associated Dyslipidemia. J Am Heart Assoc 2021; 10:e019578. [PMID: 33787283 PMCID: PMC8174355 DOI: 10.1161/jaha.120.019578] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
Background Hypocholesterolemia is a marker of liver disease, and patients with a Fontan circulation may have hypocholesterolemia secondary to Fontan‐associated liver disease or inflammation. We investigated circulating lipids in adults with a Fontan circulation and assessed the associations with clinical characteristics and adverse events. Methods and Results We enrolled 164 outpatients with a Fontan circulation, aged ≥18 years, in the Boston Adult Congenital Heart Disease Biobank and compared them with 81 healthy controls. The outcome was a combined outcome of nonelective cardiovascular hospitalization or death. Participants with a Fontan (median age, 30.3 [interquartile range, 22.8–34.3 years], 42% women) had lower total cholesterol (149.0±30.1 mg/dL versus 190.8±41.4 mg/dL, P<0.0001), low‐density lipoprotein cholesterol (82.5±25.4 mg/dL versus 102.0±34.7 mg/dL, P<0.0001), and high‐density lipoprotein cholesterol (42.8±12.2 mg/dL versus 64.1±16.9 mg/dL, P<0.0001) than controls. In those with a Fontan, high‐density lipoprotein cholesterol was inversely correlated with body mass index (r=−0.30, P<0.0001), high‐sensitivity C‐reactive protein (r=−0.27, P=0.0006), and alanine aminotransferase (r=−0.18, P=0.02) but not with other liver disease markers. Lower high‐density lipoprotein cholesterol was independently associated with greater hazard for the combined outcome adjusting for age, sex, body mass index, and functional class (hazard ratio [HR] per decrease of 10 mg/dL, 1.37; 95% CI, 1.04–1.81 [P=0.03]). This relationship was attenuated when log high‐sensitivity C‐reactive protein was added to the model (HR, 1.26; 95% CI, 0.95–1.67 [P=0.10]). Total cholesterol, low‐density lipoprotein cholesterol, and triglycerides were not associated with the combined outcome. Conclusions The Fontan circulation is associated with decreased cholesterol levels, and lower high‐density lipoprotein cholesterol is associated with adverse outcomes. This association may be driven by inflammation. Further studies are needed to understand the relationship between the severity of Fontan‐associated liver disease and lipid metabolism.
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Affiliation(s)
- Adam M Lubert
- Department of Pediatrics Cincinnati Children's Hospital Heart InstituteUniversity of Cincinnati College of Medicine Cincinnati OH
| | - Tarek Alsaied
- Department of Pediatrics Cincinnati Children's Hospital Heart InstituteUniversity of Cincinnati College of Medicine Cincinnati OH
| | - Joseph J Palermo
- Department of Pediatrics Division of Gastroenterology Cincinnati Children's Hospital Medical CenterUniversity of Cincinnati College of Medicine Cincinnati OH
| | - Nadeem Anwar
- Department of Medicine Digestive Disease Division University of Cincinnati College of Medicine Cincinnati OH
| | - Elaine M Urbina
- Department of Pediatrics Cincinnati Children's Hospital Heart InstituteUniversity of Cincinnati College of Medicine Cincinnati OH
| | - Nicole M Brown
- Department of Pediatrics Cincinnati Children's Hospital Heart InstituteUniversity of Cincinnati College of Medicine Cincinnati OH
| | - Craig Alexander
- Department of Pediatrics Cincinnati Children's Hospital Heart InstituteUniversity of Cincinnati College of Medicine Cincinnati OH
| | - Hassan Almeneisi
- Department of Pediatrics Cincinnati Children's Hospital Heart InstituteUniversity of Cincinnati College of Medicine Cincinnati OH
| | - Fred Wu
- Department of Cardiology Boston Children's HospitalHarvard Medical School Boston MA.,Department of Medicine Division of Cardiovascular Medicine Brigham and Women's Hospital Harvard Medical School Boston MA
| | | | - Nael Aldweib
- Department of Cardiology Boston Children's HospitalHarvard Medical School Boston MA.,Department of Medicine Division of Cardiovascular Medicine Brigham and Women's Hospital Harvard Medical School Boston MA
| | - Michael Mendelson
- Department of Cardiology Boston Children's HospitalHarvard Medical School Boston MA
| | - Alexander R Opotowsky
- Department of Pediatrics Cincinnati Children's Hospital Heart InstituteUniversity of Cincinnati College of Medicine Cincinnati OH.,Department of Cardiology Boston Children's HospitalHarvard Medical School Boston MA.,Department of Medicine Division of Cardiovascular Medicine Brigham and Women's Hospital Harvard Medical School Boston MA
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19
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Kumar P, Bhatia M. Computed Tomography in the Evaluation of Fontan Circulation. J Cardiovasc Imaging 2021; 29:108-122. [PMID: 33605094 PMCID: PMC8099570 DOI: 10.4250/jcvi.2020.0119] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2020] [Revised: 09/09/2020] [Accepted: 09/15/2020] [Indexed: 11/22/2022] Open
Abstract
The Fontan procedure is a well-established surgical technique to improve survival in patients with univentricular heart disease. The procedure reroutes the systemic venous flow to the lungs, bypassing the right ventricle. The originally proposed method involved direct anastomosis of the right atrium to the pulmonary artery. Since then, several modifications have been made in the original technique leading to the modern Fontan, or total cavopulmonary connection. The modern Fontan technique has shown improved surgical outcomes and increased life expectancy in patients with univentricular disease. Due to the increased survival of these patients, long-term complications are becoming more prevalent. Common complications of Fontan procedure include right atrial dilatation and thrombosis; conduit stenosis and thrombosis; right-to-left and left-to-right shunts; hepatic congestion and cirrhosis; and lymphovascular. Computed tomography (CT) can reliably depict the normal Fontan anatomy and various postoperative complications. A fundamental understanding of the techniques of CT, including imaging protocols and common interpretive pitfalls, allows targeted imaging and precise reporting of clinically significant findings. Radiologists should be familiar with the multiple stages of single-ventricle palliation, normal Fontan anatomy, pathophysiology, and imaging features of common Fontan-related complications.
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Affiliation(s)
- Parveen Kumar
- Department of Radiodiagnosis & Imaging, Fortis Escort Heart Institute, New Delhi, India.
| | - Mona Bhatia
- Department of Radiodiagnosis & Imaging, Fortis Escort Heart Institute, New Delhi, India
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20
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Wu FM, Valente AM, Nigrovic PA, Rutherford AE, Singh MN. Intraperitoneal corticosteroids for recurrent ascites in patients with Fontan circulation: Initial clinical experience. J Card Surg 2020; 36:735-738. [PMID: 33305839 DOI: 10.1111/jocs.15244] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2020] [Accepted: 11/24/2020] [Indexed: 11/30/2022]
Abstract
Individuals with single-ventricle congenital heart disease who are palliated to a Fontan circulation are at risk for heart failure and liver disease, with recurrent ascites being a potentially debilitating cause of late morbidity. Although ascites associated with heart failure or liver failure is usually characterized by a high serum-ascites albumin gradient (SAAG), we have observed multiple instances of ascites in Fontan patients with low SAAG, suggesting an inflammatory process. We present three cases in which recalcitrant ascites severely and adversely impacted the quality of life and describe our initial experience with intraperitoneal corticosteroids in this setting.
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Affiliation(s)
- Fred M Wu
- Department of Medicine, Division of Cardiology, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA.,Department of Cardiology, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Anne M Valente
- Department of Medicine, Division of Cardiology, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA.,Department of Cardiology, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Peter A Nigrovic
- Department of Medicine, Division of Rheumatology, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Anna E Rutherford
- Department of Medicine, Division of Gastroenterology, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Michael N Singh
- Department of Medicine, Division of Cardiology, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA.,Department of Cardiology, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts, USA
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21
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Abstract
Purpose of Review Lymphatic disorders have received an increasing amount of attention over the last decade. Sparked primarily by improved imaging modalities and the dawn of lymphatic interventions, understanding, diagnostics, and treatment of lymphatic complications have undergone considerable improvements. Thus, the current review aims to summarize understanding, diagnostics, and treatment of lymphatic complications in individuals with congenital heart disease. Recent Findings The altered hemodynamics of individuals with congenital heart disease has been found to profoundly affect morphology and function of the lymphatic system, rendering this population especially prone to the development of lymphatic complications such as chylous and serous effusions, protein-losing enteropathy and plastic bronchitis. Summary Although improved, a full understanding of the pathophysiology and targeted treatment for lymphatic complications is still wanting. Future research into pharmacological improvement of lymphatic function and continued implementation of lymphatic imaging and interventions may improve knowledge, treatment options, and outcome for affected individuals.
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22
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Hauser JA, Jones A, Pandya B, Taylor AM, Muthurangu V. Comprehensive MRI assessment of the cardiovascular responses to food ingestion in Fontan physiology. Am J Physiol Heart Circ Physiol 2020; 319:H808-H813. [PMID: 32857602 PMCID: PMC7654659 DOI: 10.1152/ajpheart.00500.2020] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/28/2020] [Revised: 07/23/2020] [Accepted: 08/25/2020] [Indexed: 11/22/2022]
Abstract
In univentricular (Fontan) physiology, peripheral and splanchnic vascular tone may be raised to counteract reduced cardiac output (CO) and elevated central venous pressure and thus maintain vital organ perfusion. This could negatively affect the normal cardiovascular response to food ingestion, where mesenteric vasodilation and a concurrent rise in CO are central. We sought to elucidate this using rapid cardiovascular MRI. Thirty fasting subjects (50% controls, 40% women and 60% men) ingested a standardized meal. Responses over ~50 min in mean arterial pressure (MAP), CO, and blood flow in all major aortic branches were measured, and regional vascular impedance (Z0) was calculated. Differences from baseline and between groups were assessed by repeated-measures mixed models. Compared with the control group, the Fontan patient group had greater fasting Z0 of the legs and kidneys, resulting in greater systemic Z0 and similar MAP. They further had similar blood flow to the digestive organs at baseline, despite larger variation in mesenteric resistance. Postprandially, blood flow to the legs decreased in the control group but not in the Fontan patient group. Increases in CO and superior mesenteric blood flow were similar in both groups, but the celiac response was blunted in the Fontan patient group. No significant differences in MAP responses were observed. In conclusion, alterations in vascular tone to counteract adverse hemodynamics and raised hepatic afterload may blunt vasoreactivity in the legs and the celiac axis in Fontan physiology. Further study is needed to determine whether blunted celiac or mesenteric vasoreactivity is linked to deteriorating hemodynamics and poor prognosis in Fontan patients.NEW & NOTEWORTHY Novel data on cardiovascular physiology in response to a meal in Fontan patients are presented. Using a previously validated dynamic MRI protocol, we demonstrated that the usual increase in cardiac output and the dilation of the superior mesenteric artery are preserved in clinically well Fontan patients. In contrast, vasoconstriction of the legs may have prevented redistribution of blood flow from this region in response to the meal. This may also affect responses to other types of stress. Celiac vasodilation was also absent in Fontan patients. This may be due to abnormal hepatic circulation. The proposed protocol may be used to study Fontan complications secondary to abnormal regional hemodynamics.
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Affiliation(s)
- Jakob A Hauser
- Centre for Translational Cardiovascular Imaging, University College London, London, United Kingdom
- Division of Pediatric Cardiology, Department of Pediatrics and Adolescent Medicine, Medical University of Vienna, Vienna, Austria
| | - Alexander Jones
- Centre for Translational Cardiovascular Imaging, University College London, London, United Kingdom
- Department of Pediatrics, University of Oxford, Oxford, United Kingdom
| | | | - Andrew M Taylor
- Centre for Translational Cardiovascular Imaging, University College London, London, United Kingdom
- Great Ormond Street Hospital for Children National Health Service Foundation Trust, London, United Kingdom
| | - Vivek Muthurangu
- Centre for Translational Cardiovascular Imaging, University College London, London, United Kingdom
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23
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Abstract
The authors summarize the most important anatomic and physiologic substrates of Fontan circulation. Common anatomic substrates include hypoplastic left heart syndrome, tricuspid atresia, double inlet left ventricle, and unbalanced atrioventricular septal defects. After the Fontan operation exercise capacity is limited and the key hemodynamic drivers is limited preload due to a relatively fixed pulmonary vascular resistance. The authors provide contemporary data on survival, morbidity, and need for reintervention. Operative morality is now expected to be less than 1% and 30 year survival approximately 89%. The authors delineate potential therapeutic approaches for the potential late complications.
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Affiliation(s)
- Ahmed AlZahrani
- Adult Congenital Heart Disease Program, Paediatric Cardiology, Prince Sultan Cardiac Centre, PO Box 7897 - G352, Riyadh 11159, Saudi Arabia
| | - Rahul Rathod
- Department of Pediatrics, Harvard Medical School, Boston Children's Hospital, 300 Longwood Avenue, Boston, MA 02115, USA
| | - Ahmed Krimly
- Department of Cardiology, King Faisal Cardiac Center, King Abdulaziz Medical City, Ministry of National Guard Health Affairs, 6412 ibn Mashhur Street, Alsalama District, Jeddah 23436 2946, Saudi Arabia; Department of Medical Research, King Abdullah International Medical Research Center, Jeddah, Saudi Arabia; Department of Medical Research, King Saud Bin Abdulaziz University for Health Science, Jeddah, Saudi Arabia
| | - Yezan Salam
- College of Medicine, Alfaisal University, Takhassusi Street, Riyadh-11533, Saudi Arabia
| | - AlJuhara Thaar AlMarzoog
- Adult Congenital Heart Disease Service, King Faisal Specialist Hospital and Research Centre, Zahrawi Street, Al Maather, Al Maazer, Riyadh 12713, Saudi Arabia
| | - Gruschen R Veldtman
- Adult Congenital Heart Disease, Heart Centre, King Faisal Specialist Hospital and Research Centre, Zahrawi Street, Al Maather, Al Maazer, Riyadh 12713, Saudi Arabia.
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24
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Michel M, Dubowy KO, Zlamy M, Karall D, Adam MG, Entenmann A, Keller MA, Koch J, Odri Komazec I, Geiger R, Salvador C, Niederwanger C, Müller U, Scholl-Bürgi S, Laser KT. Targeted metabolomic analysis of serum phospholipid and acylcarnitine in the adult Fontan patient with a dominant left ventricle. Ther Adv Chronic Dis 2020; 11:2040622320916031. [PMID: 32426103 PMCID: PMC7222265 DOI: 10.1177/2040622320916031] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2019] [Accepted: 02/19/2020] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND Patients with a Fontan circulation have altered cholesterol and lipoprotein values. We analysed small organic molecules in extended phopsholipid and acylcarnitine metabolic pathways ('metabolomes') in adult Fontan patients with a dominant left ventricle, seeking differences between profiles in baseline and Fontan circulations. METHODS In an observational matched cross-sectional study, we compared phosphatidylcholine (PC), sphingomyelin (SM), and acylcarnitine metabolomes (105 analytes; AbsoluteIDQ® p180 kit (Biocrates Life Sciences AG, Innsbruck, Austria) in 20 adult Fontan patients having a dominant left ventricle with those in 20 age- and sex-matched healthy controls. RESULTS Serum levels of total PC (q-value 0.01), total SM (q-value 0.0002) were significantly lower, and total acylcarnitines (q-value 0.02) were significantly higher in patients than in controls. After normalisation of data, serum levels of 12 PC and 1 SM Fontan patients were significantly lower (q-values <0.05), and concentrations of 3 acylcarnitines were significantly higher than those in controls (q-values <0.05). CONCLUSION Metabolomic profiling can use small specimens to identify biomarker patterns that track derangement in multiple metabolic pathways. The striking alterations in the phospholipid and acylcarnitine metabolome that we found in Fontan patients may reflect altered cell signalling and metabolism as found in heart failure in biventricular patients, chronic low-level inflammation, and alteration of functional or structural properties of lymphatic or blood vessels. TRIAL REGISTRATION NUMBER ClinicalTrials.gov Identifier NCT03886935.
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Affiliation(s)
- Miriam Michel
- Department of Pediatrics III, Division of Pediatric Cardiology, Medical University of Innsbruck, Anichstraße 35, Innsbruck, 6020, Austria Center of Pediatric Cardiology and Congenital Heart Disease, Heart and Diabetes Center North Rhine-Westphalia, Ruhr-University of Bochum, Georgstraße, Bad Oeynhausen, Germany
| | - Karl-Otto Dubowy
- Center of Pediatric Cardiology and Congenital Heart Disease, Heart and Diabetes Center North Rhine-Westphalia, Ruhr-University of Bochum, Georgstraße, Bad Oeynhausen, Germany
| | - Manuela Zlamy
- Department of Pediatrics I, Division of Inherited Metabolic Disorders, Medical University of Innsbruck, Innsbruck, Austria
| | - Daniela Karall
- Department of Pediatrics I, Division of Inherited Metabolic Disorders, Medical University of Innsbruck, Innsbruck, Austria
| | | | - Andreas Entenmann
- Department of Pediatrics I, Division of Gastroenterology and Hepatology, Medical University of Innsbruck, Innsbruck, Austria
| | | | - Jakob Koch
- Institute of Human Genetics, Medical University of Innsbruck, Innsbruck, Austria
| | - Irena Odri Komazec
- Department of Pediatrics III, Division of Pediatric Cardiology, Medical University of Innsbruck, Innsbruck, Austria
| | - Ralf Geiger
- Department of Pediatrics III, Division of Pediatric Cardiology, Medical University of Innsbruck, Innsbruck, Austria
| | - Christina Salvador
- Department of Pediatrics I, Division of Inherited Metabolic Disorders, Medical University of Innsbruck, Innsbruck, Austria
| | - Christian Niederwanger
- Department of Pediatrics I, Division of Inherited Metabolic Disorders, Medical University of Innsbruck, Innsbruck, Austria
| | - Udo Müller
- Biocrates Life Sciences AG, Innsbruck, Austria
| | - Sabine Scholl-Bürgi
- Department of Pediatrics I, Division of Inherited Metabolic Disorders, Medical University of Innsbruck, Innsbruck, Austria
| | - Kai Thorsten Laser
- Center of Pediatric Cardiology and Congenital Heart Disease, Heart and Diabetes Center North Rhine-Westphalia, Ruhr-University of Bochum, Georgstraße, Bad Oeynhausen, Germany
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25
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Rodríguez de Santiago E, Téllez L, Garrido-Lestache Rodríguez-Monte E, Garrido-Gómez E, Aguilera-Castro L, Álvarez-Fuente M, Del Cerro MJ, Albillos A, Romera R, Olavarria A, Martínez J, Sánchez I. Fontan protein-losing enteropathy is associated with advanced liver disease and a proinflammatory intestinal and systemic state. Liver Int 2020; 40:638-645. [PMID: 31912956 DOI: 10.1111/liv.14375] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/30/2019] [Revised: 01/02/2020] [Accepted: 01/03/2020] [Indexed: 02/13/2023]
Abstract
BACKGROUND AND AIMS Protein-losing enteropathy (PLE) after Fontan surgery carries significant morbimortality. Its pathophysiology and association with other Fontan complications are poorly understood. Our aims were to examine whether Fontan-PLE is associated with greater liver damage and to assess the presence of systemic and intestinal inflammation. METHODS Fontan patients with PLE and Fontan controls without PLE matched for age and Fontan surgery procedure were included. Data were prospectively compiled on blood and stool tests, liver imaging, elastography, cardiac-MRI and cardiac catheterization. RESULTS Twenty-nine Fontan patients were enrolled (14 with PLE and 15 controls without PLE). Patients with PLE had more advanced liver disease estimated by non-invasive methods: blunt liver margins on ultrasonography (71.4% vs 26.7%, P = .027), greater median liver stiffness (25.4 vs 14.5 kPa, P = .003) and higher FIB-4 (P = .016). Portal hypertension-related signs were more common in patients with PLE including ascites (P = .035), larger spleen size (P = .005), oesophageal varices/splanchnic collateral shunts (P = .03), higher liver stiffness-spleen size-to-platelet ratio risk score (P < .001) and lower platelet count (P = .01). Systemic proinflammatory cytokines (TNF-α, interleukin-6), biomarkers of intestinal permeability (intestinal fatty-acid binding protein) and faecal calprotectin concentrations were also significantly increased in Fontan-PLE (P < .05). Faecal calprotectin directly correlated with alpha-1 antitrypsin clearance and inversely with cardiac index, total serum proteins and body mass index. CONCLUSION Fontan-PLE is associated with advanced liver disease and increased markers of systemic inflammation and intestinal permeability. Faecal calprotectin is elevated and correlates with Fontan-PLE severity. Liver assessment is mandatory in all Fontan patients, and especially in those with PLE.
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Affiliation(s)
- Enrique Rodríguez de Santiago
- Department of Gastroenterology and Hepatology, Hospital Universitario Ramón y Cajal, University of Alcala, Madrid, Spain.,Instituto Ramón y Cajal de Investigación Biosanitaria, IRYCIS, Madrid, Spain
| | - Luis Téllez
- Department of Gastroenterology and Hepatology, Hospital Universitario Ramón y Cajal, University of Alcala, Madrid, Spain.,Instituto Ramón y Cajal de Investigación Biosanitaria, IRYCIS, Madrid, Spain.,Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBEREHD), Instituto de Salud Carlos III, Madrid, Spain
| | - Elvira Garrido-Lestache Rodríguez-Monte
- Instituto Ramón y Cajal de Investigación Biosanitaria, IRYCIS, Madrid, Spain.,Paediatric Cardiology Department and Grown Up Congenital Heart Disease, Hospital Universitario Ramón y Cajal, University of Alcala, Madrid, Spain
| | - Elena Garrido-Gómez
- Department of Gastroenterology and Hepatology, Hospital Universitario Ramón y Cajal, University of Alcala, Madrid, Spain.,Instituto Ramón y Cajal de Investigación Biosanitaria, IRYCIS, Madrid, Spain
| | - Lara Aguilera-Castro
- Department of Gastroenterology and Hepatology, Hospital Universitario Ramón y Cajal, University of Alcala, Madrid, Spain
| | - María Álvarez-Fuente
- Instituto Ramón y Cajal de Investigación Biosanitaria, IRYCIS, Madrid, Spain.,Paediatric Cardiology Department and Grown Up Congenital Heart Disease, Hospital Universitario Ramón y Cajal, University of Alcala, Madrid, Spain
| | - María Jesús Del Cerro
- Instituto Ramón y Cajal de Investigación Biosanitaria, IRYCIS, Madrid, Spain.,Paediatric Cardiology Department and Grown Up Congenital Heart Disease, Hospital Universitario Ramón y Cajal, University of Alcala, Madrid, Spain
| | - Agustín Albillos
- Department of Gastroenterology and Hepatology, Hospital Universitario Ramón y Cajal, University of Alcala, Madrid, Spain.,Instituto Ramón y Cajal de Investigación Biosanitaria, IRYCIS, Madrid, Spain.,Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBEREHD), Instituto de Salud Carlos III, Madrid, Spain
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Nagy O, Tóthová C, Mudroň P. The impact of chronic diarrhoea in Mycobacterium avium subsp. paratuberculosis seropositive dairy cows on serum protein fractions and selected acute phase proteins. JOURNAL OF APPLIED ANIMAL RESEARCH 2020. [DOI: 10.1080/09712119.2020.1714631] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Affiliation(s)
- Oskar Nagy
- Clinic of Ruminants, University of Veterinary Medicine and Pharmacy, Košice, Slovak Republic
| | - Csilla Tóthová
- Clinic of Ruminants, University of Veterinary Medicine and Pharmacy, Košice, Slovak Republic
| | - Pavol Mudroň
- Clinic of Ruminants, University of Veterinary Medicine and Pharmacy, Košice, Slovak Republic
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de Lange C. Imaging of complications following Fontan circulation in children - diagnosis and surveillance. Pediatr Radiol 2020; 50:1333-1348. [PMID: 32468285 PMCID: PMC7445207 DOI: 10.1007/s00247-020-04682-5] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/02/2020] [Revised: 03/08/2020] [Accepted: 04/16/2020] [Indexed: 12/27/2022]
Abstract
The Fontan operation is performed for various cardiac lesions with single-ventricle physiology. The survival rate of Fontan patients is increasing for adolescents and young adults, with an expected 30-year survival of >80%. Medical health care providers including specialists in organ systems and pediatric radiologists need to improve their knowledge about the Fontan circulation and the various organ complications to monitor care. In this review the author explains the basic anatomical and functional features of Fontan palliation and gives an overview of the multiple long-term organ complications that might present in the pediatric population. These include decreased physical capacity, ventricular dysfunction, atrioventricular valve regurgitation and arrhythmia, as well as protein-losing enteropathy, plastic bronchitis, growth/bone composition disturbances, renal dysfunction, and the recently recognized and important liver fibrosis (Fontan-associated liver disease). Neuropsychological and behavioral deficits occur frequently. This review focuses on the key role of radiology in making the diagnosis of these complications, monitoring therapy and predicting outcomes in the pediatric age group. The author discusses how and when radiology is important in Fontan patients, as well as how new techniques enabling quantitative measures in imaging with US, MRI and CT are adapted for pediatric use, and how they contribute to urgently needed surveillance strategies.
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Affiliation(s)
- Charlotte de Lange
- Department of Radiology and Clinical Physiology, Queen Silvia Children's Hospital, Rondv.10, S-41516, Gothenburg, Sweden. .,Department of Radiology and Nuclear Medicine, Oslo University Hospital, Oslo, Norway.
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Kewcharoen J, Mekraksakit P, Limpruttidham N, Kanitsoraphan C, Charoenpoonsiri N, Poonsombudlert K, Pattison RJ, Rattanawong P. Budesonide for Protein Losing Enteropathy in Patients with Fontan Circulation: A Systematic Review and Meta-Analysis. World J Pediatr Congenit Heart Surg 2019; 11:85-91. [DOI: 10.1177/2150135119872196] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Abstract
Background: Recent studies have shown that oral budesonide can be used to improve albumin level in patients with protein-losing enteropathy (PLE) following Fontan procedure. However, there has never been a systematic review and meta-analysis to confirm this finding. We performed a systematic review and meta-analysis to explore the therapeutic effect of budesonide in patients with PLE post-Fontan procedure. Methods: We searched the databases of MEDLINE and EMBASE from inception to January 2019. Included studies were published studies that evaluate albumin level before and after budesonide therapy in patients with PLE following Fontan procedure. Data from each study were combined using the random-effects model. Results: Five studies with 36 post-Fontan operation patients with PLE were included. In random-effects model, there was a statistically significant difference in albumin level between before and after budesonide treatment (weighted mean difference = 1.28, 95% confidence interval: 0.76-1.79). No publication bias was observed on a funnel plot and Egger test with a P value of .676. Conclusions: The results of this systematic review and meta-analysis show that budesonide can be used to increase albumin level in patients with PLE following Fontan operation. Further studies may focus on the impact of outcome of budesonide in this population.
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Affiliation(s)
- Jakrin Kewcharoen
- University of Hawaii Internal Medicine Residency Program, Honolulu, HI, USA
| | | | - Nath Limpruttidham
- University of Hawaii Internal Medicine Residency Program, Honolulu, HI, USA
| | | | | | | | - Robert J. Pattison
- University of Hawaii Internal Medicine Residency Program, Honolulu, HI, USA
| | - Pattara Rattanawong
- University of Hawaii Internal Medicine Residency Program, Honolulu, HI, USA
- Faculty of Medicine, Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
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Rychik J, Atz AM, Celermajer DS, Deal BJ, Gatzoulis MA, Gewillig MH, Hsia TY, Hsu DT, Kovacs AH, McCrindle BW, Newburger JW, Pike NA, Rodefeld M, Rosenthal DN, Schumacher KR, Marino BS, Stout K, Veldtman G, Younoszai AK, d'Udekem Y. Evaluation and Management of the Child and Adult With Fontan Circulation: A Scientific Statement From the American Heart Association. Circulation 2019; 140:e234-e284. [PMID: 31256636 DOI: 10.1161/cir.0000000000000696] [Citation(s) in RCA: 407] [Impact Index Per Article: 81.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
It has been 50 years since Francis Fontan pioneered the operation that today bears his name. Initially designed for patients with tricuspid atresia, this procedure is now offered for a vast array of congenital cardiac lesions when a circulation with 2 ventricles cannot be achieved. As a result of technical advances and improvements in patient selection and perioperative management, survival has steadily increased, and it is estimated that patients operated on today may hope for a 30-year survival of >80%. Up to 70 000 patients may be alive worldwide today with Fontan circulation, and this population is expected to double in the next 20 years. In the absence of a subpulmonary ventricle, Fontan circulation is characterized by chronically elevated systemic venous pressures and decreased cardiac output. The addition of this acquired abnormal circulation to innate abnormalities associated with single-ventricle congenital heart disease exposes these patients to a variety of complications. Circulatory failure, ventricular dysfunction, atrioventricular valve regurgitation, arrhythmia, protein-losing enteropathy, and plastic bronchitis are potential complications of the Fontan circulation. Abnormalities in body composition, bone structure, and growth have been detected. Liver fibrosis and renal dysfunction are common and may progress over time. Cognitive, neuropsychological, and behavioral deficits are highly prevalent. As a testimony to the success of the current strategy of care, the proportion of adults with Fontan circulation is increasing. Healthcare providers are ill-prepared to tackle these challenges, as well as specific needs such as contraception and pregnancy in female patients. The role of therapies such as cardiovascular drugs to prevent and treat complications, heart transplantation, and mechanical circulatory support remains undetermined. There is a clear need for consensus on how best to follow up patients with Fontan circulation and to treat their complications. This American Heart Association statement summarizes the current state of knowledge on the Fontan circulation and its consequences. A proposed surveillance testing toolkit provides recommendations for a range of acceptable approaches to follow-up care for the patient with Fontan circulation. Gaps in knowledge and areas for future focus of investigation are highlighted, with the objective of laying the groundwork for creating a normal quality and duration of life for these unique individuals.
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Shiroshita A, Uegami W, Otsuki A, Nakashima K, Sunagawa K, Fukuoka J, Kami S, Saito A, Aoshima M. A case of protein-losing gastroenteropathy caused by systemic AA amyloidosis secondary to undifferentiated carcinoma of unknown primary origin. Oxf Med Case Reports 2019; 2019:5545647. [PMID: 31398725 PMCID: PMC6688888 DOI: 10.1093/omcr/omz074] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2019] [Revised: 06/15/2019] [Accepted: 06/24/2019] [Indexed: 11/25/2022] Open
Abstract
We report the case of a 61-year-old woman with Kartagener syndrome who presented with a 3-month history of chronic watery diarrhoea and severe hypoalbuminaemia. Histopathological examination of duodenum and large intestine biopsies showed amyloid A (AA) amyloid deposition. Scintigraphy and alpha-1 anti-trypsin clearance evaluations revealed protein-losing gastroenteropathy. Computed tomography with contrast and positron emission tomography showed a pelvic mass with multiple para-aortic lymph node enlargement. We suspected protein-losing gastroenteropathy secondary to AA amyloid produced related to malignant tumours. Following tumour resection, histopathological examination of the lesion revealed undifferentiated carcinoma of unknown origin. Postoperatively, the patient’s nutritional condition improved. There has been no recurrence of protein-losing gastroenteropathy 6 months postoperatively. This is the first report of protein-losing gastroenteropathy and AA amyloidosis secondary to undifferentiated carcinoma. Early recognition and intervention could increase the likelihood of amyloidosis remission.
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Affiliation(s)
- Akihiro Shiroshita
- Department of Pulmonology, Kameda Medical Center, 929 Higashi-cho, Kamogawa 296-8602, Chiba Prefecture, Japan
| | - Wataru Uegami
- Department of Anatomic Pathology, Kameda Medical Center, 929 Higashi-cho, Kamogawa 296-8602, Chiba Prefecture, Japan
| | - Ayumu Otsuki
- Department of Pulmonology, Kameda Medical Center, 929 Higashi-cho, Kamogawa 296-8602, Chiba Prefecture, Japan
| | - Kei Nakashima
- Department of Pulmonology, Kameda Medical Center, 929 Higashi-cho, Kamogawa 296-8602, Chiba Prefecture, Japan
| | - Keishin Sunagawa
- Department of Anatomic Pathology, Kameda Medical Center, 929 Higashi-cho, Kamogawa 296-8602, Chiba Prefecture, Japan
| | - Junya Fukuoka
- Department of Anatomic Pathology, Kameda Medical Center, 929 Higashi-cho, Kamogawa 296-8602, Chiba Prefecture, Japan
| | - Shota Kami
- Postgraduate Clinical Training Center, Kameda Medical Center, 929 Higashi-cho, Kamogawa 296-8602, Chiba Prefecture, Japan
| | - Ayumi Saito
- Department of Medical Oncology, Kameda Medical Center, 929 Higashi-cho, Kamogawa 296-8602, Chiba Prefecture, Japan
| | - Masahiro Aoshima
- Department of Pulmonology, Kameda Medical Center, 929 Higashi-cho, Kamogawa 296-8602, Chiba Prefecture, Japan
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Michel M, Zlamy M, Entenmann A, Pichler K, Scholl-Bürgi S, Karall D, Geiger R, Salvador C, Niederwanger C, Ohuchi H. Impact of the Fontan Operation on Organ Systems. Cardiovasc Hematol Disord Drug Targets 2019; 19:205-214. [PMID: 30747084 DOI: 10.2174/1871529x19666190211165124] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2018] [Revised: 01/09/2019] [Accepted: 01/29/2019] [Indexed: 02/06/2023]
Abstract
In patients having undergone the Fontan operation, besides the well discussed changes in the cardiac, pulmonary and gastrointestinal system, alterations of further organ systems including the hematologic, immunologic, endocrinological and metabolic are reported. As a medical adjunct to Fontan surgery, the systematic study of the central role of the liver as a metabolizing and synthesizing organ should allow for a better understanding of the pathomechanism underlying the typical problems in Fontan patients, and in this context, the profiling of endocrinological and metabolic patterns might offer a tool for the optimization of Fontan follow-up, targeted monitoring and specific adjunct treatment.
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Affiliation(s)
- Miriam Michel
- Department of Pediatrics III, Division of Cardiology, Pulmology, Allergology, and Cystic Fibrosis, Innsbruck Medical University, Anichstraße 35, 6020 Innsbruck, Austria
| | - Manuela Zlamy
- Department of Pediatrics I, Innsbruck Medical University, Anichstraße 35, 6020 Innsbruck, Austria
| | - Andreas Entenmann
- Department of Pediatrics I, Innsbruck Medical University, Anichstraße 35, 6020 Innsbruck, Austria
| | - Karin Pichler
- Department of Pediatrics, Vienna Medical University, Währinger Gürtel 16, 1090 Vienna, Austria
| | - Sabine Scholl-Bürgi
- Department of Pediatrics I, Innsbruck Medical University, Anichstraße 35, 6020 Innsbruck, Austria
| | - Daniela Karall
- Department of Pediatrics I, Innsbruck Medical University, Anichstraße 35, 6020 Innsbruck, Austria
| | - Ralf Geiger
- Department of Pediatrics III, Division of Cardiology, Pulmology, Allergology, and Cystic Fibrosis, Innsbruck Medical University, Anichstraße 35, 6020 Innsbruck, Austria
| | - Christina Salvador
- Department of Pediatrics I, Innsbruck Medical University, Anichstraße 35, 6020 Innsbruck, Austria
| | - Christian Niederwanger
- Department of Pediatrics I, Innsbruck Medical University, Anichstraße 35, 6020 Innsbruck, Austria
| | - Hideo Ohuchi
- Department for Pediatric Cardiology, National Cerebral and Cardiovascular Center, 5-7-1 Fujishiro-dai, Suita, Osaka 565-8565, Japan
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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]
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Lubert AM, Lu JC, Rocchini AP, Norris MD, Yu S, Agarwal PP, Ghadimi Mahani M, Dorfman AL. Relation of Increased Epicardial Fat After Fontan Palliation to Cardiac Output and Systemic Ventricular Ejection Fraction. Am J Cardiol 2018; 121:862-866. [PMID: 29433731 DOI: 10.1016/j.amjcard.2017.12.026] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/25/2017] [Revised: 12/15/2017] [Accepted: 12/29/2017] [Indexed: 10/18/2022]
Abstract
Epicardial fat produces multiple proinflammatory cytokines and is associated with adverse cardiovascular events. Inflammation and resultant endothelial dysfunction may play a role in progressive myocardial dysfunction among adults with single ventricle physiology after Fontan palliation, but the potential impact of increased epicardial fat volume (EFV) has not been studied. This study sought to determine if there is greater EFV in Fontan patients compared with a group of repaired tetralogy of Fallot (rTOF) patients. We retrospectively measured EFV manually on cardiac magnetic resonance imaging in Fontan patients, ≥15 years, and 1:1 age, sex, and body mass index-matched patients with rTOF. EFV was indexed to body surface area. A random subset of studies was re-measured to assess intra- and interobserver reliability. Fontan patients (n = 63, median age 21.6 years, 51% male, mean body mass index 24.2 ± 5.6 kg/m2) had a larger indexed EFV compared with matched rTOF patients (75.3 ± 29.2 ml/m2 vs 60.0 ± 19.9 ml/m2, p = 0.001). In Fontan patients, indexed EFV was inversely correlated with ventricular ejection fraction (r = -0.26, p = 0.04) and cardiac index (r = -0.33, p = 0.01). Intra- and interobserver reliabilities of the indexed EFV measurements in both groups were excellent (intraclass correlation coefficient ranges from 0.93 to 0.97). In conclusion, indexed EFV is higher in Fontan patients compared with patients with rTOF and is associated with lower ventricular ejection fraction and cardiac index. Increased EFV could play a role in the failing Fontan circulation, but longitudinal studies are necessary to establish any causative role.
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The Use of Fecal Calprotectin Levels in the Fontan population. Pediatr Cardiol 2018; 39:591-594. [PMID: 29282492 DOI: 10.1007/s00246-017-1796-1] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/01/2017] [Accepted: 12/15/2017] [Indexed: 10/18/2022]
Abstract
The Fontan procedure was first performed in the seventies as a palliation for patients with single ventricle physiology. A feared complication after a Fontan procedure is the development of protein losing enteropathy (PLE). Systemic inflammation has a negative effect on the intestinal barrier integrity, which has supported the use of steroids in this setting. To the best of our knowledge there are no studies linking intestinal inflammation in patients with PLE after Fontan. The objective of this study was to identify the presence of intestinal inflammation measured by FC in patients with PLE after a Fontan procedure. A cross-sectional analysis was performed examining 23 stool samples from 23 Fontan patients for both Fecal alpha-1-antitrypsin (FA1AT) and FC with and without PLE. The median FC was 21 mcg/gm of stool (IQR: 15.7-241 mcg/gm of stool), and the median FA1AT was 40 mg/dL (IQR: 30-220 mg/dL). The median FC and FA1AT were significantly higher in the PLE group than in the Non-PLE group (p = 0.002 and p < 0.0001, respectively). Significantly elevated levels of FC were demonstrated in Fontan patients with PLE, which correlated with the elevated levels of FA1AT. Inversely, levels of FC in Fontan patients without suspected PLE were within the normal range. To our knowledge, this is the first study to demonstrate intestinal inflammation using FC in the setting of PLE within this cohort, and may prove to be useful as a diagnostic tool in its treatment.
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Abstract
Fontan-associated liver disease is a hepatic disorder arising from hemodynamic changes and systemic venous congestion following Fontan surgery. The histological changes produced in the liver are similar but not equivalent to those seen in other forms of cardiac liver disease. While the natural history of this form of liver disease is not well established, over time many Fontan patients develop portal hypertension-related complications such as ascites, variceal hemorrhage or encephalopathy. Fontan survivors also show an increased risk of hepatocellular carcinoma. Early diagnosis of advanced liver disease is mandatory for the prevention and treatment of complications such as hepatocellular carcinoma, esophageal varices and malnutrition. This review updates current knowledge of the pathophysiology and management of Fontan-associated liver disease including new diagnostic methods and treatments.
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Affiliation(s)
- Luis Téllez
- Hospital Universitario Ramón y Cajal. Universidad de Alcalá. Servicio de Gastroenterología y Hepatología
| | - Enrique Rodríguez-Santiago
- Hospital Universitario Ramón y Cajal. Universidad de Alcalá. Servicio de Gastroenterología y Hepatología
| | - Agustín Albillos
- Hospital Universitario Ramón y Cajal. Universidad de Alcalá. Servicio de Gastroenterología y Hepatología
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Téllez L, Rodríguez de Santiago E, Albillos A. Fontan-associated Liver Disease. ACTA ACUST UNITED AC 2018; 71:192-202. [PMID: 29433942 DOI: 10.1016/j.rec.2017.10.052] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2017] [Accepted: 10/11/2017] [Indexed: 02/07/2023]
Abstract
Fontan-associated liver disease refers to the disturbance in the liver secondary to hemodynamic changes and systemic venous congestion following Fontan surgery. Although the natural history of this disease has not yet been established, patients with more advanced liver injury develop the complications of portal hypertension, such as ascites, variceal haemorrhage, or encephalopathy. Moreover, patients with Fontan surgery may have an increased risk of hepatocellular carcinoma. Periodic liver monitoring is essential to prevent this disease and provide early treatment of liver complications.
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Affiliation(s)
- Luis Téllez
- Servicio de Gastroenterología y Hepatología, Hospital Universitario Ramón y Cajal, Universidad de Alcalá, Madrid, Spain
| | | | - Agustín Albillos
- Centro de Investigación Biomédica en Red Área de Enfermedades Digestivas (CIBERehd).
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Breatnach CR, Cleary A, Prendiville T, Crumlish K, Murchan H, McMahon CJ. Prevalence of Subclinical Enteric Alpha-1-Antitrypsin Loss in Children with Univentricular Circulation Following Total Cavopulmonary Connection. Pediatr Cardiol 2018; 39:33-37. [PMID: 28879464 DOI: 10.1007/s00246-017-1720-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/04/2017] [Accepted: 08/31/2017] [Indexed: 12/13/2022]
Abstract
Protein-Losing Enteropathy post Fontan palliation is associated with significant morbidity and mortality. To date, very little research has been carried out to improve early identification of enteric protein loss in these patients. We hypothesise that subclinical enteric protein loss may occur in patients post Fontan surgery. A cross-sectional study was performed on 43 patients post Fontan surgery. We collected specimens of stool and blood from patients with no symptoms of protein-losing enteropathy post Fontan. Stool samples were assessed for alpha one antitrypsin. The stool samples of two patients were discarded, leaving 41 stool samples. Blood samples were also collected to review albumin, C-reactive protein, liver and renal function. Twenty-eight (65%) of those enrolled were male. The median (IQR) age between Fontan and collection of study specimens was 3.5 (2-7) years. Two (5%) patients had elevated levels of alpha-1-antitrypsin. There was no correlation between blood biochemistry and elevated stool alpha-1-antitrypsin. Subclinical protein loss is rare in asymptomatic children after Fontan procedure with only 5% of patients having elevated stool alpha-1-antitrypsin but no other symptoms. These findings may relate to our small cohort size and the time to testing post cardiac surgery. Future longitudinal follow-up studies should assess the ability of alpha-1-antitrypsin to provide earlier detection of protein-losing enteropathy in asymptomatic patients post Fontan. Given the serious prognosis of protein-losing enteropathy in this patient group, further work is warranted.
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Affiliation(s)
- Colm R Breatnach
- Department of Paediatric Cardiology, Our Lady's Hospital for Sick Children, Crumlin, Dublin 4, Ireland
- University College Dublin, Dublin 4, Ireland
| | - Aoife Cleary
- Department of Paediatric Cardiology, Our Lady's Hospital for Sick Children, Crumlin, Dublin 4, Ireland
- University College Dublin, Dublin 4, Ireland
| | - Terence Prendiville
- Department of Paediatric Cardiology, Our Lady's Hospital for Sick Children, Crumlin, Dublin 4, Ireland
- University College Dublin, Dublin 4, Ireland
| | - Kathleen Crumlish
- Department of Paediatric Cardiology, Our Lady's Hospital for Sick Children, Crumlin, Dublin 4, Ireland
- University College Dublin, Dublin 4, Ireland
| | - Helene Murchan
- Department of Paediatric Cardiology, Our Lady's Hospital for Sick Children, Crumlin, Dublin 4, Ireland
- University College Dublin, Dublin 4, Ireland
| | - Colin J McMahon
- Department of Paediatric Cardiology, Our Lady's Hospital for Sick Children, Crumlin, Dublin 4, Ireland.
- University College Dublin, Dublin 4, Ireland.
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Diagnosis and Management of Noncardiac Complications in Adults With Congenital Heart Disease: A Scientific Statement From the American Heart Association. Circulation 2017; 136:e348-e392. [DOI: 10.1161/cir.0000000000000535] [Citation(s) in RCA: 106] [Impact Index Per Article: 15.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
Life expectancy and quality of life for those born with congenital heart disease (CHD) have greatly improved over the past 3 decades. While representing a great advance for these patients, who have been able to move from childhood to successful adult lives in increasing numbers, this development has resulted in an epidemiological shift and a generation of patients who are at risk of developing chronic multisystem disease in adulthood. Noncardiac complications significantly contribute to the morbidity and mortality of adults with CHD. Reduced survival has been documented in patients with CHD with renal dysfunction, restrictive lung disease, anemia, and cirrhosis. Furthermore, as this population ages, atherosclerotic cardiovascular disease and its risk factors are becoming increasingly prevalent. Disorders of psychosocial and cognitive development are key factors affecting the quality of life of these individuals. It is incumbent on physicians who care for patients with CHD to be mindful of the effects that disease of organs other than the heart may have on the well-being of adults with CHD. Further research is needed to understand how these noncardiac complications may affect the long-term outcome in these patients and what modifiable factors can be targeted for preventive intervention.
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Du Bois F, Stiller B, Borth-Bruhns T, Unseld B, Kubicki R, Hoehn R, Reineker K, Grohmann J, Fleck T. Echocardiographic characteristics in Fontan patients before the onset of protein-losing enteropathy or plastic bronchitis. Echocardiography 2017; 35:79-84. [PMID: 29082544 DOI: 10.1111/echo.13737] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
BACKGROUND It was this study's objective to evaluate the echocardiographic characteristics and flow patterns in abdominal arteries of Fontan patients before the onset of protein-losing enteropathy (PLE) or plastic bronchitis (PB). DESIGN In this retrospective cohort investigation, we examined 170 Fontan patients from 32 different centers who had undergone echocardiographic and Doppler ultrasound examinations between June 2006 and May 2013. Follow-up questionnaires were completed by 105 patients a median of 5.3 (1.5-8.5) years later to evaluate whether one of the complications had occurred since the examinations. RESULTS A total of 91 patients never developed PLE or PB ("non-PLE/PB"); they were compared to 14 affected patients. Eight of the 14 patients had already been diagnosed with "present PLE/PB" when examined. Six "future PLE/PB" patients developed those complications later on and were identified on follow-up. The "future PLE/PB" patients presented significantly slower diastolic flow velocities in the celiac artery (0.1 (0.1-0.5) m/s vs 0.3 (0.1-1.0) m/s (P = .04) and in the superior mesenteric artery (0.0 (0.0-0.2) m/s vs 0.2 (0.0-0.6) m/s, P = .02) than the "non-PLE/PB" group. Median resistance indices in the celiac artery were significantly higher (0.9 (0.8-0.9) m/s vs 0.8 (0.6-0.9) m/s, (P = .01)) even before the onset of PLE or PB. CONCLUSION An elevated flow resistance in the celiac artery may prevail in Fontan patients before the clinical manifestation of PLE or PB.
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Affiliation(s)
- Florian Du Bois
- University Heart Center Freiburg-Bad Krozingen, Department of Congenital Heart Disease and Pediatric Cardiology, Medical Center-University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Brigitte Stiller
- University Heart Center Freiburg-Bad Krozingen, Department of Congenital Heart Disease and Pediatric Cardiology, Medical Center-University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | | | - Bettina Unseld
- University Heart Center Freiburg-Bad Krozingen, Department of Congenital Heart Disease and Pediatric Cardiology, Medical Center-University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Rouven Kubicki
- University Heart Center Freiburg-Bad Krozingen, Department of Congenital Heart Disease and Pediatric Cardiology, Medical Center-University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - René Hoehn
- University Heart Center Freiburg-Bad Krozingen, Department of Congenital Heart Disease and Pediatric Cardiology, Medical Center-University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Katja Reineker
- University Heart Center Freiburg-Bad Krozingen, Department of Congenital Heart Disease and Pediatric Cardiology, Medical Center-University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Jochen Grohmann
- University Heart Center Freiburg-Bad Krozingen, Department of Congenital Heart Disease and Pediatric Cardiology, Medical Center-University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Thilo Fleck
- University Heart Center Freiburg-Bad Krozingen, Department of Congenital Heart Disease and Pediatric Cardiology, Medical Center-University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
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Kagiyama Y, Kishimoto S, Yoshimoto H, Kudo Y, Gotoh K, Suda K. Successful combined intravenous and subcutaneous immunoglobulin treatment for intractable protein-losing enteropathy in a patient long after Fontan-type operation. J Cardiol Cases 2017; 17:52-55. [PMID: 30279854 DOI: 10.1016/j.jccase.2017.09.007] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2017] [Revised: 08/29/2017] [Accepted: 09/14/2017] [Indexed: 11/24/2022] Open
Abstract
A 20-year-old patient, who had double outlet right ventricle, mitral atresia, pulmonary atresia, and bilateral superior vena cava and underwent successful lateral tunnel total cavo-pulmonary connection at 6 years old, presented with frequent watery diarrhea, general malaise, and tetany. He was known to have intractable protein-losing enteropathy (PLE) from 7 years of age that was resistant to various treatments. To keep hemodynamics stable, he required intravenous albumin infusion every day. Fontan fenestration partially improved his condition and allowed to stop albumin infusion, however still he showed muddy stool and cachexia with low serum albumin <20 g/L and immunoglobulin <3 g/L. Because of serious risk of infection, we placed him on regular subcutaneous immunoglobulin supplementation with rescue intravenous immunoglobulin that improved his PLE within a month and allowed him to be discharged. This case illustrates that immunoglobulin supplementation can be one of the choices of treatment for intractable PLE. <Learning objective: Combined subcutaneous and intravenous immunoglobulin infusion therapy can be one of the choices of treatment for intractable protein-losing enteropathy that does not respond to multiple medications.>.
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Affiliation(s)
| | | | | | - Yoshiyuki Kudo
- Kurume University School of Medicine, Kurume City, Japan
| | - Kenji Gotoh
- Kurume University School of Medicine, Kurume City, Japan
| | - Kenji Suda
- Kurume University School of Medicine, Kurume City, Japan
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Gastrointestinal haemorrhage due to lymphangiectasia caused by protein-losing enteropathy in the Fontan circulation. Cardiol Young 2017; 27:1641-1643. [PMID: 28651669 DOI: 10.1017/s1047951117000853] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
We report the case of a 14-year-old boy with severe protein-losing enteropathy after Fontan surgery that led to lymphangiectasia, which caused gastrointestinal haemorrhage and required invasive treatment to stop the bleeding. Through this case and a review of the literature on protein-losing enteropathy after Fontan surgery, we highlight a rare and serious presentation of the disease and the difficulties of diagnosis and management.
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Puelz C, Acosta S, Rivière B, Penny DJ, Brady KM, Rusin CG. A computational study of the Fontan circulation with fenestration or hepatic vein exclusion. Comput Biol Med 2017; 89:405-418. [PMID: 28881280 DOI: 10.1016/j.compbiomed.2017.08.024] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2017] [Revised: 08/02/2017] [Accepted: 08/22/2017] [Indexed: 12/14/2022]
Abstract
Fontan patients may undergo additional surgical modifications to mitigate complications like protein-losing enteropathy, liver cirrhosis, and other issues in their splanchnic circulation. Recent case reports show promise for several types of modifications, but the subtle effects of these surgeries on the circulation are not well understood. In this paper, we employ mathematical modeling of blood flow to systematically quantify the impact of these surgical changes on extracardiac Fontan hemodynamics. We investigate two modifications: (1) the fenestrated Fontan and (2) the Fontan with hepatic vein exclusion. Closed-loop hemodynamic models are used, which consist of one-dimensional networks for the major vessels and zero-dimensional models for the heart and organ beds. Numerical results suggest the hepatic vein exclusion has the greatest overall impact on the hemodynamics, followed by the largest sized fenestration. In particular, the hepatic vein exclusion drastically lowers portal venous pressure while the fenestration decreases pulmonary artery pressure. Both modifications increase flow to the intestines, a finding consistent with their utility in clinical practice for combating complications in the splanchnic circulation.
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Affiliation(s)
- Charles Puelz
- Department of Computational and Applied Mathematics, Rice University, Houston, TX, USA.
| | - Sebastián Acosta
- Department of Pediatrics-Cardiology, Baylor College of Medicine and Texas Children's Hospital, Houston, TX, USA
| | - Béatrice Rivière
- Department of Computational and Applied Mathematics, Rice University, Houston, TX, USA
| | - Daniel J Penny
- Department of Pediatrics-Cardiology, Baylor College of Medicine and Texas Children's Hospital, Houston, TX, USA
| | - Ken M Brady
- Department of Anesthesiology, Baylor College of Medicine and Texas Children's Hospital, Houston, TX, USA
| | - Craig G Rusin
- Department of Pediatrics-Cardiology, Baylor College of Medicine and Texas Children's Hospital, Houston, TX, USA
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Levitt DG, Levitt MD. Protein losing enteropathy: comprehensive review of the mechanistic association with clinical and subclinical disease states. Clin Exp Gastroenterol 2017; 10:147-168. [PMID: 28761367 PMCID: PMC5522668 DOI: 10.2147/ceg.s136803] [Citation(s) in RCA: 79] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
Protein losing enteropathy (PLE) has been associated with more than 60 different conditions, including nearly all gastrointestinal diseases (Crohn’s disease, celiac, Whipple’s, intestinal infections, and so on) and a large number of non-gut conditions (cardiac and liver disease, lupus, sarcoidosis, and so on). This review presents the first attempt to quantitatively understand the magnitude of the PLE in relation to the associated pathology for three different disease categories: 1) increased lymphatic pressure (e.g., lymphangiectasis); 2) diseases with mucosal erosions (e.g., Crohn’s disease); and 3) diseases without mucosal erosions (e.g., celiac disease). The PLE with lymphangiectasis results from rupture of the mucosal lymphatics, with retrograde drainage of systemic lymph into the intestinal lumen with the resultant loss of CD4 T cells, which is diagnostic. Mucosal erosion PLE results from macroscopic breakdown of the mucosal barrier, with the epithelial capillaries becoming the rate-limiting factor in albumin loss. The equation derived to describe the relationship between the reduction in serum albumin (CP) and PLE indicates that gastrointestinal albumin clearance must increase by at least 17 times normal to reduce the CP by half. The strengths and limitations of the two quantitative measures of PLE (51Cr-albumin or α1-antitrypsin [αAT] clearance) are reviewed. αAT provides a simple quantitative diagnostic test that is probably underused clinically. The strong, unexplained correlation between minor decreases in CP and subsequent mortality in seemingly healthy individuals raises the question of whether subclinical PLE could account for the decreased CP and, if so, could the mechanism responsible for PLE play a role in the increased mortality? A large-scale study correlating αAT clearance with serum albumin concentrations will be required in order to determine the role of PLE in the regulation of the serum albumin concentration of seemingly healthy subjects.
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Affiliation(s)
- David G Levitt
- Department of Integrative Biology and Physiology, University of Minnesota
| | - Michael D Levitt
- Research Service, Veterans Affairs Medical Center, Minneapolis, MN, USA
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45
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Menon S, Chennapragada M, Ugaki S, Sholler GF, Ayer J, Winlaw DS. The Lymphatic Circulation in Adaptations to the Fontan Circulation. Pediatr Cardiol 2017; 38:886-892. [PMID: 28210768 DOI: 10.1007/s00246-017-1576-y] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/18/2016] [Accepted: 01/20/2017] [Indexed: 11/25/2022]
Abstract
Failing Fontan continues to be major problem for patients on the univentricular pathway. Failing Fontan is often complicated by chylothorax, plastic bronchitis and protein loosing enteropathy. The role of lymphatic circulation in Fontan circulation is still being researched. Newer imaging modalities give insight into the role of abnormal dilatation and retrograde flow in lymphatic channels post Fontan. Interventional strategies targeting abnormal lymphatic channels, provides an alternative management strategy for patients with failing Fontan. This review focuses on the role of lymphatic system in adaptations to Fontan circulation.
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Affiliation(s)
- Sabarinath Menon
- The Heart Centre for Children, The Children's Hospital at Westmead, Sydney, NSW, Australia
- Sree Chitra Tirunal Institute of Medical sciences and Technology, Thiruvananthapuram, Kerala, 695,011, India
- Sydney Children's Hospital Network, The Children's Hospital at Westmead, 212 Hawkesbury Road, Westmead, NSW, 2145, Australia
| | - Murthy Chennapragada
- Sydney Children's Hospital Network, The Children's Hospital at Westmead, 212 Hawkesbury Road, Westmead, NSW, 2145, Australia
- Discipline of Child and Adolescent Health, Sydney Medical School, University of Sydney, Camperdown, NSW, 2006, Australia
| | - Shinya Ugaki
- The Heart Centre for Children, The Children's Hospital at Westmead, Sydney, NSW, Australia
- Sydney Children's Hospital Network, The Children's Hospital at Westmead, 212 Hawkesbury Road, Westmead, NSW, 2145, Australia
| | - Gary F Sholler
- The Heart Centre for Children, The Children's Hospital at Westmead, Sydney, NSW, Australia
- Sydney Children's Hospital Network, The Children's Hospital at Westmead, 212 Hawkesbury Road, Westmead, NSW, 2145, Australia
- Discipline of Child and Adolescent Health, Sydney Medical School, University of Sydney, Camperdown, NSW, 2006, Australia
| | - Julian Ayer
- The Heart Centre for Children, The Children's Hospital at Westmead, Sydney, NSW, Australia
- Sydney Children's Hospital Network, The Children's Hospital at Westmead, 212 Hawkesbury Road, Westmead, NSW, 2145, Australia
- Discipline of Child and Adolescent Health, Sydney Medical School, University of Sydney, Camperdown, NSW, 2006, Australia
| | - David S Winlaw
- The Heart Centre for Children, The Children's Hospital at Westmead, Sydney, NSW, Australia.
- Sydney Children's Hospital Network, The Children's Hospital at Westmead, 212 Hawkesbury Road, Westmead, NSW, 2145, Australia.
- Discipline of Child and Adolescent Health, Sydney Medical School, University of Sydney, Camperdown, NSW, 2006, Australia.
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Friedland-Little JM, Gajarski RJ, Schumacher KR. Dopamine as a potential rescue therapy for refractory protein-losing enteropathy in Fontan-palliated patients. Pediatr Transplant 2017; 21. [PMID: 28370952 DOI: 10.1111/petr.12925] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 02/24/2017] [Indexed: 12/18/2022]
Abstract
PLE is an important cause of morbidity and mortality in patients who have undergone Fontan palliation. While multiple PLE therapies have been reported, none has proved consistently effective. Patients who do not respond to "standard" PLE therapies face poor long-term outcomes. We report here a significant response to dopamine infusion in three patients with chronic, refractory PLE. We hypothesize that this response may be at least partially due to a dopamine effect on lymphatic receptors rather than to an augmentation of cardiac output.
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Affiliation(s)
- Joshua M Friedland-Little
- Division of Pediatric Cardiology, Seattle Children's Hospital, University of Washington, Seattle, WA, USA
| | - Robert J Gajarski
- Division of Pediatric Cardiology, Nationwide Children's Hospital, Ohio State University, Columbus, OH, USA
| | - Kurt R Schumacher
- Division of Pediatric Cardiology, Mott Children's Hospital, University of Michigan, Ann Arbor, MI, USA
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Ohuchi H, Hayama Y, Negishi J, Noritake K, Miyazaki A, Yamada O, Shiraishi I. Determinants of Aortic Size and Stiffness and the Impact on Exercise Physiology in Patients After the Fontan Operation. Int Heart J 2017; 58:73-80. [DOI: 10.1536/ihj.16-183] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Affiliation(s)
- Hideo Ohuchi
- Department of Pediatric Cardiology, National Cerebral and Cardiovascular Center
- Department of Adult Congenital Heart Disease, National Cerebral and Cardiovascular Center
| | - Yosuke Hayama
- Department of Pediatric Cardiology, National Cerebral and Cardiovascular Center
| | - Jun Negishi
- Department of Pediatric Cardiology, National Cerebral and Cardiovascular Center
| | - Kanae Noritake
- Department of Pediatric Cardiology, National Cerebral and Cardiovascular Center
| | - Aya Miyazaki
- Department of Pediatric Cardiology, National Cerebral and Cardiovascular Center
| | - Osamu Yamada
- Department of Pediatric Cardiology, National Cerebral and Cardiovascular Center
| | - Isao Shiraishi
- Department of Pediatric Cardiology, National Cerebral and Cardiovascular Center
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Abstract
Antibody deficiencies can occur in the context of primary disorders due to inherited genetic defects; however, secondary immune disorders are far more prevalent and can be caused by various diseases and their treatment, certain medications and surgical procedures. Immunoglobulin replacement therapy has been shown to be effective in reducing infections, morbidity and mortality in primary antibody deficiencies but secondary antibody deficiencies are in general poorly defined and there are no guidelines for the management of patients with this condition. Clinical decisions are based on experience from primary antibody deficiencies. Both primary and secondary antibody deficiencies can be associated with infections, immune dysregulation and end-organ damage, causing significant morbidity and mortality. Therefore, it is important to diagnose and treat these patients promptly to minimise adverse effects and improve quality of life. We focus on secondary antibody deficiency and describe the causes, diagnosis and treatment of this disorder.
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Affiliation(s)
- Sapna Srivastava
- Department of Clinical Immunology and Allergy, St James's University Hospital, Leeds, UK
| | - Philip Wood
- Department of Clinical Immunology and Allergy, St James's University Hospital, Leeds, UK
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Sakamoto T, Nagashima M, Hiramatsu T, Matsumura G, Park IS, Yamazaki K. Fontan circulation over 30 years. What should we learn from those patients? Asian Cardiovasc Thorac Ann 2016; 24:765-771. [DOI: 10.1177/0218492316667771] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
Background This study aimed to evaluate Fontan circulation which was observed over 30 years. Methods Forty patients who underwent a Fontan operation between 1974 and 1986 and survived (group S, n = 20) or died in the late period (group LD, n = 20) were evaluated. The median age at operation was 10 years (range 2–32 years). The diagnoses were tricuspid atresia in 21, single ventricle in 9, and others in 10. The Fontan procedure was a right atrium-pulmonary artery graft in 2, atriopulmonary connection in 28, and right atrium-right ventricle anastomosis in 10 (Björk in 4, graft in 6). Results Causes of late death were congestive heart failure in 6, sudden death in 4, arrhythmia in 4, and others in 6. Sixteen patients underwent reoperation 23.3 ± 6.5 years after Fontan. Cardiac catheterization was performed at 1 month and 12 years. There were no significant differences in central venous pressure, ventricular ejection fraction, or pulmonary vascular resistance between the two groups. However, changes in ventricular end-diastolic volume suggested volume and pressure overload in group LD. In group S, the latest chest radiographs showed cardiothoracic ratio 51.3% ± 7.6%, oxygen saturation 94% ± 2%, brain natriuretic peptide 153 ± 111 pg ċ mL−1, and Holter monitoring revealed sinus rhythm in 10 patients. New York Heart Association class was I in 12 patients, II in 6, and III in 2. Conclusions For long-term Fontan survival, timely total cavopulmonary connection conversion and medication to decrease ventricular volume and pressure load might be important.
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Affiliation(s)
- Takahiko Sakamoto
- Division of Pediatric Cardiovascular Surgery, The Heart Institute of Japan, Tokyo Women’s Medical University, Tokyo, Japan
- Department of Cardiovascular Surgery, The Heart Institute of Japan, Tokyo Women’s Medical University, Tokyo, Japan
| | - Mitsugi Nagashima
- Division of Pediatric Cardiovascular Surgery, The Heart Institute of Japan, Tokyo Women’s Medical University, Tokyo, Japan
- Department of Cardiovascular Surgery, The Heart Institute of Japan, Tokyo Women’s Medical University, Tokyo, Japan
| | - Takeshi Hiramatsu
- Division of Pediatric Cardiovascular Surgery, The Heart Institute of Japan, Tokyo Women’s Medical University, Tokyo, Japan
- Department of Cardiovascular Surgery, The Heart Institute of Japan, Tokyo Women’s Medical University, Tokyo, Japan
| | - Goki Matsumura
- Division of Pediatric Cardiovascular Surgery, The Heart Institute of Japan, Tokyo Women’s Medical University, Tokyo, Japan
- Department of Cardiovascular Surgery, The Heart Institute of Japan, Tokyo Women’s Medical University, Tokyo, Japan
| | - In-Sam Park
- Department of Pediatric Cardiology, The Heart Institute of Japan, Tokyo Women’s Medical University, Tokyo, Japan
| | - Kenji Yamazaki
- Department of Cardiovascular Surgery, The Heart Institute of Japan, Tokyo Women’s Medical University, Tokyo, Japan
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Abstract
BACKGROUND Limited data exist on the vitamin D status in Fontan patients. We determined the prevalence and potential risk factors of vitamin D deficiency in this patient subset. Methods and results Data were collected from 27 Fontan patients (55.6% male, mean age 8.1±5.3 years). Protein-losing enteropathy was diagnosed in six patients (22.2%). Vitamin D deficiency was defined as a serum 25-hydroxyvitamin D level of <20 ng/ml. The neutrophil-to-lymphocyte ratio, a marker of systemic inflammation, was calculated. Associations between laboratory measurements and patient characteristics were explored. Mean serum 25-hydroxyvitamin D level was 14.1±10.4 ng/ml. Vitamin D deficiency was found in 19/27 patients (70.3%). Only skin type was associated with vitamin D deficiency (p=0.04). Hyperparathyroidism was present in 5/21 (23.8%) patients, and was more prevalent in patients with protein-losing enteropathy (p<0.001). Parathyroid hormone levels correlated with parameters of systemic inflammation (neutrophil-to-lymphocyte ratio: r=0.484, p=0.026; relative lymphocyte count: r=-0.635, p=0.002). Vitamin D supplementation significantly increased serum 25-hydroxyvitamin D levels (p<0.0001), and was accompanied by a reduction in parathyroid hormone concentrations (p=0.032). CONCLUSIONS A high prevalence of vitamin D deficiency was found among Fontan patients, independent of age, time after Fontan procedure, ventricular morphology, and presence of protein-losing enteropathy. A potentially important link between parathyroid hormone levels and systemic inflammation is suggested.
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