1
|
Husnain A, Aadam AA, Reiland A, Salem R, Baker J, Nemcek AA, Green J, Ganger D, De Freitas RA, Riaz A. Combined Percutaneous Transhepatic Lymphatic Embolization and Peroral Duodenal Mucosal Radiofrequency Ablation to Manage Protein-Losing Enteropathy. J Vasc Interv Radiol 2024; 35:1351-1356.e1. [PMID: 38901491 DOI: 10.1016/j.jvir.2024.06.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2024] [Revised: 06/07/2024] [Accepted: 06/13/2024] [Indexed: 06/22/2024] Open
Abstract
Percutaneous transhepatic lymphatic embolization (PTLE) and peroral esophagogastroduodenoscopy (EGD) duodenal mucosal radiofrequency (RF) ablation were performed to manage protein-losing enteropathy (PLE) in patients with congenital heart disease. Five procedures were performed in 4 patients (3 men and 1 woman; median age, 49 years; range, 31-71 years). Transhepatic lymphangiography demonstrated abnormal periduodenal lymphatic channels. After methylene blue injection through transhepatic access, subsequent EGD evaluation showed methylene blue extravasation at various sites in the duodenal mucosa. Endoscopic RF ablation of the leakage sites followed by PTLE using 3:1 ethiodized oil-to-n-butyl cyanoacrylate glue ratio resulted in improved symptoms and serum albumin levels (before procedure, 2.6 g/dL [SD ± 0.2]; after procedure, 3.5 g/dL [SD ± 0.4]; P = .004) over a median follow-up of 16 months (range, 5-20 months). Transhepatic lymphangiography and methylene blue injection with EGD evaluation of the duodenal mucosa can help diagnose PLE. Combined PTLE and EGD-RF ablation is an option to treat patients with PLE.
Collapse
Affiliation(s)
- Ali Husnain
- Section of Interventional Radiology, Department of Radiology, Northwestern Memorial Hospital, Chicago, Illinois
| | - Abdul Aziz Aadam
- Section of Gastroenterology and Hepatology, Department of Medicine, Northwestern Memorial Hospital, Chicago, Illinois
| | - Allison Reiland
- Section of Interventional Radiology, Department of Radiology, Northwestern Memorial Hospital, Chicago, Illinois
| | - Riad Salem
- Section of Interventional Radiology, Department of Radiology, Northwestern Memorial Hospital, Chicago, Illinois
| | - Joe Baker
- Section of Interventional Radiology, Department of Radiology, Lurie Children's Hospital, Chicago, Illinois
| | - Albert A Nemcek
- Section of Interventional Radiology, Department of Radiology, Northwestern Memorial Hospital, Chicago, Illinois
| | - Jared Green
- Department of Radiology, Memorial Healthcare System, Miami, Florida
| | - Daniel Ganger
- Section of Gastroenterology and Hepatology, Department of Medicine, Northwestern Memorial Hospital, Chicago, Illinois
| | - Roger Andrew De Freitas
- Section of Cardiology, Department of Medicine, Northwestern Memorial Hospital, Chicago, Illinois
| | - Ahsun Riaz
- Section of Interventional Radiology, Department of Radiology, Northwestern Memorial Hospital, Chicago, Illinois.
| |
Collapse
|
2
|
Hammer V, Schaeffer T, Staehler H, Heinisch PP, Burri M, Piber N, Lemmer J, Hager A, Ewert P, Hörer J, Ono M. Protein-Losing Enteropathy and Plastic Bronchitis Following the Total Cavopulmonary Connections. World J Pediatr Congenit Heart Surg 2023; 14:691-698. [PMID: 37551120 DOI: 10.1177/21501351231185111] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/09/2023]
Abstract
BACKGROUND We aimed to evaluate incidence, outcomes, and predictors of protein-losing enteropathy (PLE) and plastic bronchitis (PB) in a cohort of total cavopulmonary connection (TCPC). METHODS We included 620 consecutive patients undergoing TCPC between 1994 and 2021. Prevalence and predictors for onset of PLE/PB were evaluated. Death and heart transplantation after onset of PLE/PB were examined. RESULTS A total of 41 patients presented with PLE/PB (31 with PLE, 15 with PB, and 5 developed both PLE and PB). Their median age at TCPC was 2.2 (interquartile ranges [IQRs], 1.7-3.7) years, and time period to onset for PLE was 2.6 (IQR: 1.0-6.6) years and for PB was 1.1 (IQR: 0.3-4.1) years after TCPC. Independent factors for developing PLE/PB were dominant right ventricle (RV, hazard ratio [HR], 2.243; 95% confidence interval [CI], 1.129-4.458, P = .021) and prolonged pleural effusion after TCPC (HR, 2.101; 95% CI, 1.090-4.049, P = .027). In PLE/PB population, freedom from death or transplantation after PLE/PB diagnosis at 5 and 10 years were 88.7% and 76.4%, respectively. Eleven surgical interventions were performed in 10 patients, comprising atrioventricular valve repairs (n = 4), Fontan pathway revisions (n = 2), pacemaker implantation (n = 2), secondary fenestration (n = 1), diaphragm plication (n = 1), and ventricular assist device implantation (n = 1). In nine patients, a recovery from PLE with the resolution of PLE symptoms and normal protein levels was achieved. Eight patients died and the remaining continued to have challenging protein loss. CONCLUSIONS Protein-losing enteropathy and PB remain severe complications in the cohort of TCPC. Patients with dominant RV, and prolonged pleural effusions, were at risk for PLE/PB.
Collapse
Affiliation(s)
- Veronika Hammer
- Department of Congenital and Pediatric Heart Surgery, German Heart Center Munich, Technische Universität München, Munich, Germany
- Division of Congenital and Pediatric Heart Surgery, University Hospital of Munich, Ludwig-Maximilians-Universität, Munich, Germany
| | - Thibault Schaeffer
- Department of Congenital and Pediatric Heart Surgery, German Heart Center Munich, Technische Universität München, Munich, Germany
- Division of Congenital and Pediatric Heart Surgery, University Hospital of Munich, Ludwig-Maximilians-Universität, Munich, Germany
| | - Helena Staehler
- Department of Congenital and Pediatric Heart Surgery, German Heart Center Munich, Technische Universität München, Munich, Germany
- Division of Congenital and Pediatric Heart Surgery, University Hospital of Munich, Ludwig-Maximilians-Universität, Munich, Germany
| | - Paul Philipp Heinisch
- Department of Congenital and Pediatric Heart Surgery, German Heart Center Munich, Technische Universität München, Munich, Germany
- Division of Congenital and Pediatric Heart Surgery, University Hospital of Munich, Ludwig-Maximilians-Universität, Munich, Germany
| | - Melchior Burri
- Department of Cardiovascular Surgery, German Heart Center Munich, Technische Universität München, Munich, Germany
| | - Nicole Piber
- Department of Cardiovascular Surgery, German Heart Center Munich, Technische Universität München, Munich, Germany
| | - Julia Lemmer
- Department of Congenital Heart Disease and Pediatric Cardiology, German Heart Center Munich at the Technical University of Munich, Munich, Germany
| | - Alfred Hager
- Department of Congenital Heart Disease and Pediatric Cardiology, German Heart Center Munich at the Technical University of Munich, Munich, Germany
| | - Peter Ewert
- Department of Congenital Heart Disease and Pediatric Cardiology, German Heart Center Munich at the Technical University of Munich, Munich, Germany
| | - Jürgen Hörer
- Department of Congenital and Pediatric Heart Surgery, German Heart Center Munich, Technische Universität München, Munich, Germany
- Division of Congenital and Pediatric Heart Surgery, University Hospital of Munich, Ludwig-Maximilians-Universität, Munich, Germany
| | - Masamichi Ono
- Department of Congenital and Pediatric Heart Surgery, German Heart Center Munich, Technische Universität München, Munich, Germany
- Division of Congenital and Pediatric Heart Surgery, University Hospital of Munich, Ludwig-Maximilians-Universität, Munich, Germany
| |
Collapse
|
3
|
Bauer C, Scala M, Sekyra P, Fellner F, Tulzer G. Non-Contrast MR Lymphography and Intranodal Dynamic Contrast MR Lymphangiography in Children with Congenital Heart Disease-Imaging Findings as well as Impact on Patient Management and Outcome. Int J Mol Sci 2023; 24:14827. [PMID: 37834274 PMCID: PMC10573489 DOI: 10.3390/ijms241914827] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2023] [Revised: 09/15/2023] [Accepted: 09/25/2023] [Indexed: 10/15/2023] Open
Abstract
Lymphatic flow disorders are rare but devastating complications in children with congenital heart disease. T2-weighted magnetic resonance lymphography and intranodal dynamic contrast magnetic resonance lymphangiography are imaging modalities that can depict central lymphatic anatomy and flow pattern. Our objective was to describe the technical aspects and our imaging findings of central lymphatic abnormalities and their impact on patient management and outcomes: We conducted a retrospective review of 26 children with congenital heart disease who presented for lymphatic imaging between 2015 and 2020 at our institution. Eleven had postoperative chylothorax, six had plastic bronchitis, seven had protein-losing enteropathy and three had Noonan syndrome. Our lymphatic imaging demonstrated severely abnormal lymphatic flow in all of the children, but only minor abnormalities in protein-losing enteropathy. No major procedure-related complication occurred. Lymphatic interventions were performed in six patients, thoracic duct decompression in two patients and chylothorax revision in three patients. This led to symptomatic improvements in all of the patients: Lymphatic imaging is safe and essential for the diagnosis of lymphatic flow disorders and therapy planning. Our intranodal lymphangiography depicts an abnormal lymphatic flow pattern from the central lymphatics but failed to demonstrate an abnormal lymphatic flow in protein-losing enteropathy. These imaging techniques are the basis for selective lymphatic interventions, which are promising to treat lymphatic flow disorders.
Collapse
Affiliation(s)
- Christoph Bauer
- Department of Paediatric Cardiology, Kepler University Hospital GmbH, Krankenhausstrasse 26–30, 4020 Linz, Austria (G.T.)
- Johannes Kepler University Linz, Altenbergerstrasse 68, 4040 Linz, Austria; (P.S.); (F.F.)
| | - Mario Scala
- Johannes Kepler University Linz, Altenbergerstrasse 68, 4040 Linz, Austria; (P.S.); (F.F.)
- Central Radiology Institute, Kepler University Hospital GmbH, Krankenhausstrasse 9, 4020 Linz, Austria
| | - Pavel Sekyra
- Johannes Kepler University Linz, Altenbergerstrasse 68, 4040 Linz, Austria; (P.S.); (F.F.)
- Central Radiology Institute, Kepler University Hospital GmbH, Krankenhausstrasse 9, 4020 Linz, Austria
| | - Franz Fellner
- Johannes Kepler University Linz, Altenbergerstrasse 68, 4040 Linz, Austria; (P.S.); (F.F.)
- Central Radiology Institute, Kepler University Hospital GmbH, Krankenhausstrasse 9, 4020 Linz, Austria
| | - Gerald Tulzer
- Department of Paediatric Cardiology, Kepler University Hospital GmbH, Krankenhausstrasse 26–30, 4020 Linz, Austria (G.T.)
- Johannes Kepler University Linz, Altenbergerstrasse 68, 4040 Linz, Austria; (P.S.); (F.F.)
| |
Collapse
|
4
|
Bauer C, Dori Y, Scala M, Tulzer A, Tulzer G. Current diagnostic and therapeutic strategies for the management of lymphatic insufficiency in patients with hypoplastic left heart syndrome. Front Pediatr 2023; 11:1058567. [PMID: 36911024 PMCID: PMC9999027 DOI: 10.3389/fped.2023.1058567] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/30/2022] [Accepted: 01/31/2023] [Indexed: 03/14/2023] Open
Abstract
Children with hypoplastic left heart syndrome share unique hemodynamic features that alter lymphatic integrity at all stages of palliation. Lymphatic congestion is almost universal in this patient group to some extent. It may lead to reversal of lymphatic flow, the development of abnormal lymphatic channels and ultimately decompression and loss of protein rich lymphatic fluid into extra lymphatic compartments in prone individuals. Some of the most devastating complications that are associated with single ventricle physiology, notably plastic bronchitis and protein losing enteropathy, have now been proven to be lymphatic in origin. Based on the new pathophysiologic concept new diagnostic and therapeutic strategies have recently been developed. Dynamic contrast magnetic resonance lymphangiography is now mainstay in diagnosis of lymphatic insufficiency and allows a thorough assessment of anatomy and function of the main lymphatic compartments through intranodal, intrahepatic and intramesenteric lymphatic imaging. Contrast enhanced ultrasound can evaluate thoracic duct patency and conventional fluoroscopic lymphangiography has been refined for evaluation of patients where magnetic resonance imaging cannot be performed. Novel lymphatic interventional techniques, such as thoracic duct embolization, selective lymphatic duct embolization and liver lymphatic embolization allow to seal abnormal lymphatic networks minimally invasive and have shown to resolve symptoms. Innominate vein turn-down procedures, whether surgical or interventional, have been designed to reduce lymphatic afterload and increase systemic preload effectively in the failing Fontan circulation. Outflow obstruction can now be managed with new microsurgical techniques that create lympho-venous anastomosis. Short term results for all of these new approaches are overall promising but evidence is sparse and long-term outcome still has to be defined. This review article aims to summarize current concepts of lymphatic flow disorders in single ventricle patients, discuss new emerging diagnostic and therapeutic strategies and point out lacks in evidence and needs for further research on this rapidly growing topic.
Collapse
Affiliation(s)
- Christoph Bauer
- Department of Paediatric Cardiology, Kepler University Hospital GmbH, Linz, Austria.,Johannes Kepler University Linz, Linz, Austria
| | - Yoav Dori
- Department of Cardiology, Jill and Mark Fishman Center for Lymphatic Disorders, Children's Hospital of Philadelphia, Philadelphia, PA, United States
| | - Mario Scala
- Johannes Kepler University Linz, Linz, Austria.,Central Radiology Institute, Kepler University Hospital GmbH, Linz, Austria
| | - Andreas Tulzer
- Department of Paediatric Cardiology, Kepler University Hospital GmbH, Linz, Austria.,Johannes Kepler University Linz, Linz, Austria
| | - Gerald Tulzer
- Department of Paediatric Cardiology, Kepler University Hospital GmbH, Linz, Austria.,Johannes Kepler University Linz, Linz, Austria
| |
Collapse
|
5
|
Blissett S, Kheiwa A, Mahadevan VS. Extracardiac manifestations of the Fontan circulation in adults: Beyond the liver. INTERNATIONAL JOURNAL OF CARDIOLOGY CONGENITAL HEART DISEASE 2022. [DOI: 10.1016/j.ijcchd.2022.100358] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022] Open
|
6
|
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
|
7
|
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
|
8
|
Alsaied T, Rathod RH, Aboulhosn JA, Budts W, Anderson JB, Baumgartner H, Brown DW, Cordina R, D'udekem Y, Ginde S, Goldberg DJ, Goldstein BH, Lubert AM, Oechslin E, Opotowsky AR, Rychik J, Schumacher KR, Valente AM, Wright G, Veldtman GR. Reaching consensus for unified medical language in Fontan care. ESC Heart Fail 2021; 8:3894-3905. [PMID: 34190428 PMCID: PMC8497335 DOI: 10.1002/ehf2.13294] [Citation(s) in RCA: 36] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2020] [Revised: 02/03/2021] [Accepted: 02/19/2021] [Indexed: 02/04/2023] Open
Abstract
Aims The Fontan operation has resulted in improved survival in patients with single‐ventricle congenital heart disease. As a result, there is a growing population of teenagers and adults with a Fontan circulation. Many co‐morbidities have been increasingly recognized in this population due to the unique features of the Fontan circulation. Standardization of how Fontan co‐morbid conditions are defined will help facilitate understanding, consistency and interpretability of research and clinical experience. Unifying common language usage in Fontan is a critical precursor step for data comparison of research findings and clinical outcomes and ultimately accelerating improvements in management for this growing group of patients. This manuscript aimed to create unified definitions for morbidities seen after the Fontan palliation. Methods In association of many congenital heart disease organizations, this work used Delphi methodology to reach a broad consensus among recognized experts regarding commonly used terms in Fontan care and research. Each definition underwent at least three rounds of revisions to reach a final definition through surveys sent to experts in the field of single‐ventricle care. Results The process of reaching a consensus on multiple morbidities associated with the Fontan procedure is summarized in this manuscript. The different versions that preceded reaching the consensus are also presented in the Supporting Information. Table 1 represents the final definitions according to the consensus. Conclusions We propose the use of these definitions for clinical care, future research studies, registry development and clinical trials.
Collapse
Affiliation(s)
- Tarek Alsaied
- Heart Institute, Department of Pediatrics, Pittsburgh Children's Hospital Medical Center, Pittsburgh, PA, USA.,Heart Institute, Department of Pediatrics, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - Rahul H Rathod
- Department of Cardiology, Boston Children's Hospital, Boston, MA, USA
| | - Jamil A Aboulhosn
- Ahmanson/UCLA Adult Congenital Heart Disease Center, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA
| | - Werner Budts
- Division of Congenital and Structural Cardiology, University Hospitals Leuven, Leuven, Belgium
| | - Jeffrey B Anderson
- Heart Institute, Department of Pediatrics, Pittsburgh Children's Hospital Medical Center, Pittsburgh, PA, USA
| | - Helmut Baumgartner
- Department of Cardiology: Adult Congenital and Valvular Heart Disease, University Hospital Muenster, Muenster, Germany
| | - David W Brown
- Department of Cardiology, Boston Children's Hospital, Boston, MA, USA
| | - Rachael Cordina
- Adult Congenital Heart Disease Service and Pulmonary Hypertension Service, Royal Prince Alfred Hospital, Sydney, Australia
| | - Yves D'udekem
- Department of Cardiac Surgery and Children's National Heart Institute, Children's National Hospital, Washington, DC, USA
| | - Salil Ginde
- Division of Pediatric Cardiology, Department of Pediatrics, Medical College of Wisconsin, Milwaukee, WI, USA
| | - David J Goldberg
- Division of Cardiology, Department of Pediatrics, The Children's Hospital of Philadelphia, Perelman School of Medicine, University of Pennsylvania School of Medicine, Philadelphia, PA, USA
| | - Bryan H Goldstein
- Heart Institute, UPMC Children's Hospital of Pittsburgh, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Adam M Lubert
- Heart Institute, Department of Pediatrics, Pittsburgh Children's Hospital Medical Center, Pittsburgh, PA, USA
| | - Erwin Oechslin
- Congenital Cardiac Centre for Adults, Peter Munk Cardiac Centre, University Health Network, Toronto, Canada
| | - Alexander R Opotowsky
- Heart Institute, Department of Pediatrics, Pittsburgh Children's Hospital Medical Center, Pittsburgh, PA, USA
| | - Jack Rychik
- Division of Cardiology, Department of Pediatrics, The Children's Hospital of Philadelphia, Perelman School of Medicine, University of Pennsylvania School of Medicine, Philadelphia, PA, USA
| | - Kurt R Schumacher
- Congenital Heart Center, C.S. Mott Children's Hospital, University of Michigan, Ann Arbor, MI, USA
| | | | - Gail Wright
- Division of Cardiology, Department of Pediatrics, Stanford University School of Medicine, Santa Clara, CA, USA
| | - Gruschen R Veldtman
- Adult Congenital Heart Disease Service, Heart Centre, King Faisal Specialist Hospital and Research Centre, Riyadh, Saudi Arabia
| |
Collapse
|
9
|
Hubrechts J, Dooms C, Maleux G, Gewillig M. Direct EBUS-guided transtracheal lymphosclerosis for plastic bronchitis after Fontan. Catheter Cardiovasc Interv 2021; 97:E371-E375. [PMID: 32990404 DOI: 10.1002/ccd.29284] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/02/2020] [Revised: 09/01/2020] [Accepted: 09/14/2020] [Indexed: 01/31/2023]
Abstract
We report on a new puncture technique with direct transtracheal mediastinal lymphatic access to treat plastic bronchitis after Fontan repair. High resolution contrast-enhanced spiral CT identified enlarged lymph nodes in the paratracheal region. Inguinal intranodal Gadolinium Dynamic Contrast-enhanced Magnetic Resonance lymphangiography (DCMRL) confirmed the pathologic centrifugal lymph flow passing through these lymph nodes before leaking into the bronchial tree. The abnormal hypertrophic paratracheal, subcarinal, and hilar lymph nodes were punctured with a 22G needle through an endobronchial ultrasound bronchoscope. Occlusion of the lymph vessels was obtained by injecting a mixture of lipiodol/NBCA N-butyl cyanoacrylate (Histoacryl) 5/1 under fluoroscopic control. There was a total remission of PB with now 10 months of follow-up.
Collapse
Affiliation(s)
- Jelena Hubrechts
- Department of Pediatric and Congenital Cardiology, Leuven University Hospital, Leuven, Belgium
| | - Christophe Dooms
- Department of Respiratory Diseases, Leuven University Hospital, Leuven, Belgium
| | - Geert Maleux
- Interventional Radiology, Leuven University Hospital, Leuven, Belgium
| | - Marc Gewillig
- Department of Pediatric and Congenital Cardiology, Leuven University Hospital, Leuven, Belgium
| |
Collapse
|
10
|
Kreutzer C, Klinger DA, Chiostri B, Sendoya S, Daneri ML, Gutierrez A, Fraire RA, Torres SF. Lymphatic Decompression Concomitant With Fontan/Kreutzer Procedure: Early Experience. World J Pediatr Congenit Heart Surg 2021; 11:284-292. [PMID: 32294012 DOI: 10.1177/2150135120905656] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
OBJECTIVE To present a strategy for identifying patients at risk of lymphatic failure in the setting of planned Fontan/Kreutzer completion, allowing a tailored surgical approach. METHODS Since January 2017, clinical evaluation before performance of the Fontan/Kreutzer procedure included T2-weighted magnetic resonance imaging (MRI) lymphangiography. Thoracic lymphatic abnormalities were categorized using a scale of I to IV according to progression of severity. Patients with severe lymphatic abnormalities (types III and IV) underwent Fontan/Kreutzer with lymphatic decompression via connection of the left jugular-subclavian junction containing the thoracic duct to the systemic atrium (group A). RESULTS Thirteen patients were enrolled. Magnetic resonance imaging showed type I abnormalities in four cases (30.7%), II in four (30.7%), III in two (15.3%), and IV in three (23.3%). Patients in types III and IV underwent a Fontan/Kreutzer with lymphatic decompression (group A, n = 5), while patients in types I and II underwent a fenestrated extracardiac Fontan/Kreutzer procedure without lymphatic decompression (group B, n = 8). Preoperatively, there were no differences in age, weight, ventricular dominance (right vs left), superior vena cava pressure, incidence of chylothorax after previous superior cavopulmonary anastomosis (Glenn), or need for concomitant procedures at Fontan/Kreutzer completion. There were no differences in procedural times between the groups, nor were there differences in mortalities and Fontan/Kreutzer takedowns. There were no statistically significant differences in early and late morbidity between the two groups with the exception of total volume of effusions output postoperatively. At median follow-up of 18 months (range, 4-28 months), all patients in group A are in New York Heart Association class 1 with no differences between groups in arterial oxygen saturation. CONCLUSIONS Lymphatic decompression during Fontan/Kreutzer procedure was successfully performed in patients identified by MRI as predisposed to lymphatic failure. A larger cohort of patients and longer follow-up are required to determine the efficacy of this approach in preventing early- and long-term Fontan/Kreutzer failure.
Collapse
Affiliation(s)
- Christian Kreutzer
- Division of Pediatric Cardiovascular Surgery, Hospital Universitario Austral, Pilar, Buenos Aires, Argentina
| | - Daniel Alberto Klinger
- Division of Pediatric Cardiovascular Surgery, Hospital Universitario Austral, Pilar, Buenos Aires, Argentina
| | - Benjamin Chiostri
- Division of Pediatric Cardiovascular Surgery, Hospital Universitario Austral, Pilar, Buenos Aires, Argentina
| | - Santiago Sendoya
- Division of Pediatric Cardiology, Hospital Universitario Austral, Pilar, Buenos Aires, Argentina
| | - Mariana Lopez Daneri
- Division of Pediatric Cardiology, Hospital Universitario Austral, Pilar, Buenos Aires, Argentina
| | - Augusto Gutierrez
- Division of Pediatric Cardiology, Hospital Universitario Austral, Pilar, Buenos Aires, Argentina
| | - Rafael Alfredo Fraire
- Division of Pediatric Critical Care, Hospital Universitario Austral, Pilar, Buenos Aires, Argentina
| | - Silvio Fabio Torres
- Division of Pediatric Critical Care, Hospital Universitario Austral, Pilar, Buenos Aires, Argentina
| |
Collapse
|
11
|
Wen Z, Tong G, Liu Y. Potential Utilization of Lymphoscintigraphy in Patients With Klippel-Trenaunay Syndrome. Clin Nucl Med 2021; 46:25-30. [PMID: 33156055 DOI: 10.1097/rlu.0000000000003361] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
PURPOSE Klippel-Trenaunay syndrome (KTS) is a rare disease that was characterized by vascular malformation. Lymphatic malformation was also commonly associated with KTS. However, the application of lymphoscintigraphy in the management of patients with KTS was rarely described. The purpose of this study is to assess whether the findings of lymphoscintigraphy can aid the management of the patients with KTS. METHODS A total of 28 patients with known KTS who underwent Tc-dextran lymphoscintigraphy with lower extremity tracer injection were included in this retrospective analysis. The images from lymphoscintigraphy were reviewed for any abnormalities in the body with the attention on the region of left subclavian-jugular venous angle. RESULTS In addition to abnormal activity in the other regions, abnormal activity in the left subclavian-jugular venous angle was visualized in over half of the patients (53.6%, 15/28). Based on the findings of the lymphoscintigraphy, 7 patients with left subclavian-jugular venous angle activity underwent thoracic duct decompression. In 4 patients with postsurgery follow-up, 3 achieved significant, measurable symptomatic relief. CONCLUSIONS Lymphoscintigraphy can be used to assess potential candidates for thoracic duct decompression to alleviate the symptoms in patients with KTS.
Collapse
Affiliation(s)
- Zhe Wen
- From the Departments of Nuclear Medicine
| | | | - Yong Liu
- Ultrasonography, Beijing Shijitan Hospital, Capital Medical University, Beijing, People's Republic of China
| |
Collapse
|
12
|
Lymphatic Disorders and Management in Patients with Congenital Heart Disease. Ann Thorac Surg 2020; 113:1101-1111. [PMID: 33373590 DOI: 10.1016/j.athoracsur.2020.10.058] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/07/2020] [Revised: 09/11/2020] [Accepted: 10/05/2020] [Indexed: 11/20/2022]
Abstract
Congenital heart disease can lead to significant lymphatic complications such as chylothorax, plastic bronchitis, protein losing enteropathy and ascites. Recent improvements in lymphatic imaging and the development of new lymphatic procedures can help alleviate symptoms and improve outcomes.
Collapse
|
13
|
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.
Collapse
|
14
|
Mejia EJ, Otero HJ, Smith CL, Shipman M, Liu M, Pinto E, DeWitt A, Rome JJ, Dori Y, Biko DM. Use of Contrast-Enhanced Ultrasound to Determine Thoracic Duct Patency. J Vasc Interv Radiol 2020; 31:1670-1674. [PMID: 32919824 DOI: 10.1016/j.jvir.2020.05.022] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2019] [Revised: 04/24/2020] [Accepted: 05/17/2020] [Indexed: 11/30/2022] Open
Abstract
The aim of this study was to determine the feasibility of using contrast-enhanced ultrasound (CEUS) evaluation to determine thoracic duct (TD) outlet patency. Nine patients referred for lymphatic imaging and intervention underwent percutaneous intranodal ultrasound contrast injection and conventional lymphangiography (CL). Eight of 9 patients had a patent TD by CEUS and CL. One patient did not have a patent TD. There was 100% agreement between CEUS and CL. These results suggest that CEUS is an imaging modality that might be as accurate as CL in determining TD patency.
Collapse
Affiliation(s)
- Erika J Mejia
- Cardiac Center, The Children's Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania, 3401 Civic Center Boulevard Philadelphia, PA, 19104.
| | - Hansel J Otero
- Cardiac Center, The Children's Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania, 3401 Civic Center Boulevard Philadelphia, PA, 19104
| | - Christopher L Smith
- Cardiac Center, The Children's Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania, 3401 Civic Center Boulevard Philadelphia, PA, 19104
| | - Molly Shipman
- Cardiac Center, The Children's Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania, 3401 Civic Center Boulevard Philadelphia, PA, 19104
| | - Mandi Liu
- Cardiac Center, The Children's Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania, 3401 Civic Center Boulevard Philadelphia, PA, 19104
| | - Erin Pinto
- Cardiac Center, The Children's Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania, 3401 Civic Center Boulevard Philadelphia, PA, 19104
| | - Aaron DeWitt
- Cardiac Center, The Children's Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania, 3401 Civic Center Boulevard Philadelphia, PA, 19104
| | - Jonathan J Rome
- Cardiac Center, The Children's Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania, 3401 Civic Center Boulevard Philadelphia, PA, 19104
| | - Yoav Dori
- Cardiac Center, The Children's Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania, 3401 Civic Center Boulevard Philadelphia, PA, 19104
| | - David M Biko
- Cardiac Center, The Children's Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania, 3401 Civic Center Boulevard Philadelphia, PA, 19104
| |
Collapse
|
15
|
Bauer C, Mair R, Mair R, Tulzer G. Thoracic duct decompression and jugular vein banding-an effective treatment option for protein-losing enteropathy and plastic bronchitis in severe failing Fontan circulation: a case report. EUROPEAN HEART JOURNAL-CASE REPORTS 2020; 4:1-4. [PMID: 33204944 PMCID: PMC7649443 DOI: 10.1093/ehjcr/ytaa170] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/02/2020] [Revised: 03/16/2020] [Accepted: 05/20/2020] [Indexed: 02/05/2023]
Abstract
Background Plastic bronchitis (PB) and protein-losing enteropathy (PLE) are devastating complications after Fontan palliation that lead to uncontrolled loss of protein-rich lymphatic fluid into extra lymphatic compartments. Decompression of the thoracic duct is a new treatment option that effectively restores lymphatic system integrity by redirecting lymphatic flow into the low-pressure levels of the common atrium. Case summary We report a patient with severe failing Fontan circulation where surgical thoracic duct decompression leads to resolution of PLE and PB symptoms but worsening hypoxaemia that could be managed with banding of internal jugular vein. Discussion Thoracic duct decompression in patients with failing Fontan circulation can be a simple and effective treatment for PLE and PB. Hypoxaemia may occur but can be managed with banding of internal jugular vein.
Collapse
Affiliation(s)
- Christoph Bauer
- Department of Pediatric Cardiology, Johannes Kepler University Linz, Krankenhausstrasse 26-30, 4020 Linz, Austria
| | - Roland Mair
- Department of Pediatric Cardiac Surgery, Johannes Kepler University Linz, Krankenhausstrasse 26-30, 4020 Linz, Austria
| | - Rudolf Mair
- Department of Pediatric Cardiac Surgery, Johannes Kepler University Linz, Krankenhausstrasse 26-30, 4020 Linz, Austria
| | - Gerald Tulzer
- Department of Pediatric Cardiology, Johannes Kepler University Linz, Krankenhausstrasse 26-30, 4020 Linz, Austria
| |
Collapse
|
16
|
Abstract
OBJECTIVE Protein-losing enteropathy is an infrequent but severe condition occurring after Fontan procedure. The multifactorial pathogenesis remains unclear and no single proposed treatment strategy has proven universally successful. Therefore, we sought to describe different treatment strategies and their effect on clinical outcome and mortality. MATERIAL AND METHODS We performed a retrospective observational study. From the total cohort of 439 Fontan patients treated in our institution during the study period 1986-2019, 30 patients (6.8%) with protein-losing enteropathy were identified. Perioperative, clinical, echocardiographic, laboratory, and invasive haemodynamic findings and treatment details were analysed. RESULTS Median follow-up after disease onset was 13.1 years [interquartile range 10.6]. Twenty-five patients received surgical or interventional treatment for haemodynamic restrictions. Medical treatment, predominantly pulmonary vasodilator and/or systemic anti-inflammatory therapy with budesonide, was initiated in 28 patients. In 15 patients, a stable remission could be achieved by medical or surgical procedures (n = 3 each), by combined multimodal therapy (n = 8), or ultimately by cardiac transplantation (n = 1). Phrenic palsy, bradyarrhythmia, Fontan pathway stenosis, and absence of a fenestration were significantly associated with development of protein-losing enteropathy (p = 0.001-0.48). Ten patients (33.3%) died during follow-up; 5-year survival estimate was 96.1%. In unadjusted analysis, medical therapy with budesonide and pulmonary vasodilator therapy in combination was associated with improved survival. CONCLUSIONS Protein-losing enteropathy is a serious condition limiting survival after the Fontan procedure. Comprehensive assessment and individual treatment strategies are mandatory to achieve best possible outcome. Nevertheless, relapse is frequent and long-term mortality substantial. Cardiac transplantation should be considered early as treatment option.
Collapse
|
17
|
Fragata JIG. Lymphatic Decompression for Fontan/Kreutzer Procedures-Indeed, a Clever Concept, But Will It Truly Work in Practice? World J Pediatr Congenit Heart Surg 2020; 11:293-294. [PMID: 32294006 DOI: 10.1177/2150135120908863] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Affiliation(s)
- José I G Fragata
- Hospital de Santa Marta / Hospital CUF, Miraflores-Alges, Portugal
| |
Collapse
|
18
|
Ing RJ, Mclennan D, Twite MD, DiMaria M. Anesthetic Considerations for Fontan-Associated Liver Disease and the Failing Fontan Circuit. J Cardiothorac Vasc Anesth 2020; 34:2224-2233. [PMID: 32249074 DOI: 10.1053/j.jvca.2020.02.040] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/16/2018] [Revised: 02/19/2020] [Accepted: 02/23/2020] [Indexed: 12/13/2022]
Affiliation(s)
- Richard J Ing
- Department of Anesthesiology, Children's Hospital Colorado, Anschutz Medical Campus, Aurora, CO; School of Medicine, University of Colorado, Aurora, CO.
| | - Daniel Mclennan
- Stead Family Children's Hospital, University of Iowa, Iowa City, IA
| | - Mark D Twite
- Department of Anesthesiology, Children's Hospital Colorado, Anschutz Medical Campus, Aurora, CO; School of Medicine, University of Colorado, Aurora, CO
| | - Michael DiMaria
- Department of Anesthesiology, Children's Hospital Colorado, Anschutz Medical Campus, Aurora, CO; School of Medicine, University of Colorado, Aurora, CO
| |
Collapse
|
19
|
Zentner D, Celermajer DS, Gentles T, d’Udekem Y, Ayer J, Blue GM, Bridgman C, Burchill L, Cheung M, Cordina R, Culnane E, Davis A, du Plessis K, Eagleson K, Finucane K, Frank B, Greenway S, Grigg L, Hardikar W, Hornung T, Hynson J, Iyengar AJ, James P, Justo R, Kalman J, Kasparian N, Le B, Marshall K, Mathew J, McGiffin D, McGuire M, Monagle P, Moore B, Neilsen J, O’Connor B, O’Donnell C, Pflaumer A, Rice K, Sholler G, Skinner JR, Sood S, Ward J, Weintraub R, Wilson T, Wilson W, Winlaw D, Wood A. Management of People With a Fontan Circulation: a Cardiac Society of Australia and New Zealand Position statement. Heart Lung Circ 2020; 29:5-39. [DOI: 10.1016/j.hlc.2019.09.010] [Citation(s) in RCA: 24] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2019] [Accepted: 09/16/2019] [Indexed: 02/07/2023]
|
20
|
Ozen A. CHAPLE syndrome uncovers the primary role of complement in a familial form of Waldmann's disease. Immunol Rev 2019; 287:20-32. [PMID: 30565236 DOI: 10.1111/imr.12715] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2018] [Accepted: 08/31/2018] [Indexed: 12/17/2022]
Abstract
Primary intestinal lymphangiectasia (PIL) or Waldmann's disease was described in 1961 as an important cause of protein-losing enteropathy (PLE). PIL can be the sole finding in rare individuals or occur as part of a multisystemic genetic syndrome. Although genetic etiologies of many lymphatic dysplasia syndromes associated with PIL have been identified, the pathogenesis of isolated PIL (with no associated syndromic features) remains unknown. Familial cases and occurrence at birth suggest genetic etiologies in certain cases. Recently, CD55 deficiency with hyperactivation of complement, angiopathic thrombosis, and PLE (the CHAPLE syndrome) has been identified as a monogenic form of PIL. Surprisingly, loss of CD55, a key regulator of complement system leads to a predominantly gut condition. Similarly to other complement disorders, namely paroxysmal nocturnal and hemoglobinuria (PNH) and atypical hemolytic uremic syndrome (aHUS), CHAPLE disease involves pathogenic cross-activation of the coagulation system, predisposing individuals to severe thrombosis. The observation that complement system is overly active in CHAPLE disease introduced a novel concept into the management of PLE; anti-complement therapy. While CD55 deficiency constitutes a treatable subgroup in the larger pool of patients with isolated PIL, the etiology remains to be identified in the remaining patients with intact CD55.
Collapse
Affiliation(s)
- Ahmet Ozen
- Division of Allergy and Immunology, Marmara University School of Medicine, Istanbul, Turkey.,The Istanbul Jeffrey Modell Diagnostic Center for Primary Immunodeficiency Diseases, Istanbul, Turkey
| |
Collapse
|
21
|
Kylat RI, Witte MH, Barber BJ, Dori Y, Ghishan FK. Resolution of Protein-Losing Enteropathy after Congenital Heart Disease Repair by Selective Lymphatic Embolization. Pediatr Gastroenterol Hepatol Nutr 2019; 22:594-600. [PMID: 31777727 PMCID: PMC6856498 DOI: 10.5223/pghn.2019.22.6.594] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/20/2018] [Revised: 12/27/2018] [Accepted: 01/01/2019] [Indexed: 11/29/2022] Open
Abstract
With improving survival of children with complex congenital heart disease (CCHD), postoperative complications, like protein-losing enteropathy (PLE) are increasingly encountered. A 3-year-old girl with surgically corrected CCHD (ventricular inversion/L-transposition of the great arteries, ventricular septal defect, pulmonary atresia, post-double switch procedure [Rastelli and Glenn]) developed chylothoraces. She was treated with pleurodesis, thoracic duct ligation and subsequently developed chylous ascites and PLE (serum albumin ≤0.9 g/dL) and was malnourished, despite nutritional rehabilitation. Lymphangioscintigraphy/single-photon emission computed tomography showed lymphatic obstruction at the cisterna chyli level. A segmental chyle leak and chylous lymphangiectasia were confirmed by gastrointestinal endoscopy, magnetic resonance (MR) enterography, and MR lymphangiography. Selective glue embolization of leaking intestinal lymphatic trunks led to prompt reversal of PLE. Serum albumin level and weight gain markedly improved and have been maintained for over 3 years. Selective interventional embolization reversed this devastating lymphatic complication of surgically corrected CCHD.
Collapse
Affiliation(s)
- Ranjit I Kylat
- Department of Pediatrics, The University of Arizona College of Medicine, Tucson, AZ, USA
| | - Marlys H Witte
- Department of Surgery, The University of Arizona College of Medicine, Tucson, AZ, USA
| | - Brent J Barber
- Department of Pediatrics, The University of Arizona College of Medicine, Tucson, AZ, USA
| | - Yoav Dori
- Center for Lymphatic Imaging and Interventions, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Fayez K Ghishan
- Department of Pediatrics, The University of Arizona College of Medicine, Tucson, AZ, USA
| |
Collapse
|
22
|
Maleux G, Storme E, Cools B, Heying R, Boshoff D, Louw JJ, Frerich S, Malekzadeh‐Milanii S, Hubrechts J, Brown SC, Gewillig M. Percutaneous embolization of lymphatic fistulae as treatment for protein‐losing enteropathy and plastic bronchitis in patients with failing Fontan circulation. Catheter Cardiovasc Interv 2019; 94:996-1002. [DOI: 10.1002/ccd.28501] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/01/2019] [Revised: 09/04/2019] [Accepted: 09/07/2019] [Indexed: 12/14/2022]
Affiliation(s)
- Geert Maleux
- Interventional RadiologyUniversity Hospitals Leuven Leuven Belgium
| | - Emma Storme
- Department of Paediatric and Congenital CardiologyUniversity Hospitals Leuven Leuven Belgium
| | - Bjorn Cools
- Department of Paediatric and Congenital CardiologyUniversity Hospitals Leuven Leuven Belgium
| | - Ruth Heying
- Department of Paediatric and Congenital CardiologyUniversity Hospitals Leuven Leuven Belgium
| | - Derize Boshoff
- Department of Paediatric and Congenital CardiologyUniversity Hospitals Leuven Leuven Belgium
| | - Jacoba J. Louw
- Paediatric CardiologyUniversity Hospital Maastricht Maastricht the Netherlands
| | - Stefan Frerich
- Paediatric CardiologyUniversity Hospital Maastricht Maastricht the Netherlands
| | | | - Jelena Hubrechts
- Department of Paediatric and Congenital CardiologyUniversity Hospitals Leuven Leuven Belgium
| | - Stephen C. Brown
- Department of Paediatric and Congenital CardiologyUniversity Hospitals Leuven Leuven Belgium
- Paediatric CardiologyUniversity of the Free State Bloemfontein South Africa
| | - Marc Gewillig
- Department of Paediatric and Congenital CardiologyUniversity Hospitals Leuven Leuven Belgium
| |
Collapse
|
23
|
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: 429] [Impact Index Per Article: 85.8] [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.
Collapse
|
24
|
Jobes DR, Brown LA, Dori Y, Itkin M, Nicolson SC. Lymphatic imaging and intervention in a pediatric population: Anesthetic considerations. Paediatr Anaesth 2018; 28:507-512. [PMID: 29687529 DOI: 10.1111/pan.13385] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/23/2018] [Indexed: 11/29/2022]
Abstract
The recent adoption of an improved lymphatic access technique coupled with Dynamic Contrast-enhanced Magnetic Resonance Lymphangiography has introduced the ability to diagnose and treat severe lymphatic disorders unresponsive to other therapies. All pediatric patients presenting for lymphatic procedures require general anesthesia presenting challenges in managing highly morbid and comorbid conditions both from logistical as well as medical aspects. General anesthesia is used because of the procedural requirement for immobility to accurately place needles and catheters, treat pain secondary to contrast and glue injections, and to accommodate additional procedures. We reviewed a one-year cohort of all pediatric patients in a newly created Center for Lymphatic Imaging and Intervention at a tertiary care children's hospital presenting for lymphatic procedures. The patients ranged in age from 4 days to 17 years and weighed from 2.5 to 92 kg. There were 106 anesthetics for 68 patients. Patients were functionally impaired (98% ASA 3 or 4) and included significant comorbidities (79.4%). Concurrent with lymphatic imaging and intervention additional procedures were frequently performed (76%). They included cardiac catheterization, bronchoscopy, endoscopy, and drain placement (thoracic or abdominal). Paralysis and controlled ventilation was used for all interventions. Reversal of paralysis and tracheal extubation occurred in all patients not previously managed by invasive respiratory support. All patients having an intervention were admitted to intensive care for observation where escalation of care or complications (fever, hypotension, bleeding, or stroke) occurred in 25% in the first 24 hours.
Collapse
Affiliation(s)
- David R Jobes
- Department of Anesthesiology and Critical Care, Division of Cardiothoracic Anesthesiology, The Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Lauren A Brown
- Department of Anesthesiology and Critical Care, Division of Cardiothoracic Anesthesiology, The Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Yoav Dori
- Department of Pediatrics, Division of Cardiology, The Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Maxim Itkin
- Department of Radiology, Division of Interventional Radiology, The Perelman School of Medicine, The University of Pennsylvania, Philadelphia, PA, USA
| | - Susan C Nicolson
- Department of Anesthesiology and Critical Care, Division of Cardiothoracic Anesthesiology, The Children's Hospital of Philadelphia, Philadelphia, PA, USA
| |
Collapse
|
25
|
Ohuchi H. Where Is the "Optimal" Fontan Hemodynamics? Korean Circ J 2017; 47:842-857. [PMID: 29035429 PMCID: PMC5711675 DOI: 10.4070/kcj.2017.0105] [Citation(s) in RCA: 40] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2017] [Accepted: 06/23/2017] [Indexed: 12/25/2022] Open
Abstract
Fontan circulation is generally characterized by high central venous pressure, low cardiac output, and slightly low arterial oxygen saturation, and it is quite different from normal biventricular physiology. Therefore, when a patient with congenital heart disease is selected as a candidate for this type of circulation, the ultimate goals of therapy consist of 2 components. One is a smooth adjustment to the new circulation, and the other is long-term circulatory stabilization after adjustment. When either of these goals is not achieved, the patient is categorized as having "failed" Fontan circulation, and the prognosis is dismal. For the first goal of smooth adjustment, a lot of effort has been made to establish criteria for patient selection and intensive management immediately after the Fontan operation. For the second goal of long-term circulatory stabilization, there is limited evidence of successful strategies for long-term hemodynamic stabilization. Furthermore, there have been no data on optimal hemodynamics in Fontan circulation that could be used as a reference for patient management. Although small clinical trials and case reports are available, the results cannot be generalized to the majority of Fontan survivors. We recently reported the clinical and hemodynamic characteristics of early and late failing Fontan survivors and their association with all-cause mortality. This knowledge could provide insight into the complex Fontan pathophysiology and might help establish a management strategy for long-term hemodynamic stabilization.
Collapse
Affiliation(s)
- Hideo Ohuchi
- Departments of Pediatric Cardiology and Adult Congenital Heart Disease, National Cerebral and Cardiovascular Center, Suita, Japan.
| |
Collapse
|
26
|
Kreutzer C, Kreutzer G. The Lymphatic System: The Achilles Heel of the Fontan-Kreutzer Circulation. World J Pediatr Congenit Heart Surg 2017; 8:613-623. [DOI: 10.1177/2150135117720685] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
In spite of excellent long term survival the Fontan Kreutzer procedure commonly presents late failure due to end-organ damage. Several advances have been described to refine single ventricle management and surgical techniques. However, very little research has been dedicated to the lymphatic circulation in the precarious Fontan hemodynamic state. The lymphatic circulation is clearly affected since there is increased lymph production, which requires to be drained at a similar or higher pressure than it is produced, commonly resulting in chronic lymphedema. Chronic lymphedema induces fibrosis and end-organ failure even in normal circulation. Diverting lymph drainage to the low-pressured systemic atrium in Fontan may represent a valid alternative for the treatment of devastating complications as protein-losing enteropathy and plastic bronchitis and may prevent or decrease the development of end-organ fibrosis or failure.
Collapse
Affiliation(s)
- Christian Kreutzer
- Division of Pediatric Cardiovascular Surgery, Hospital Universitario Austral, Pilar, Buenos Aires, Argentina
| | - Guillermo Kreutzer
- Division of Pediatric Cardiovascular Surgery, Clinica Bazterrica, Ciudad Autonoma de Buenos Aires, Buenos Aires, Argentina
| |
Collapse
|
27
|
Sung C, Bass JL, Berry JM, Shepard CW, Lindgren B, Kochilas LK. The thoracic duct and the Fontan patient. Echocardiography 2017; 34:1347-1352. [DOI: 10.1111/echo.13639] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022] Open
|
28
|
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.
Collapse
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
| |
Collapse
|
29
|
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.
Collapse
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.
| |
Collapse
|
30
|
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.
Collapse
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
| |
Collapse
|
31
|
Clift P, Celermajer D. Managing adult Fontan patients: where do we stand? Eur Respir Rev 2016; 25:438-450. [PMID: 27903666 PMCID: PMC9487559 DOI: 10.1183/16000617.0091-2016] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2016] [Accepted: 10/13/2016] [Indexed: 01/10/2023] Open
Abstract
The Fontan operation is performed as a palliative procedure to improve survival in infants born with a functionally univentricular circulation. The success of the operation is demonstrated by a growing adult Fontan population that exists with this unique physiology. Late follow-up has demonstrated expected and unexpected sequelae, and has shown multisystem effects of this circulation. This review discusses the challenges of managing the late complications in terms of understanding this unique physiology and the innovative therapeutic interventions that are being investigated. The challenge remains to maintain quality of life for adult survivors, as well as extending life expectancy. Innovative solutions are required to meet the challenges of the Fontan circulation faced in adult lifehttp://ow.ly/XTSm305oH8b
Collapse
|