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Ko H, Song J, Chi SA, Lee SY, Kim SJ, Lee CH, Park CS, Choi ES, An HS, Kang IS, Yoon JK, Baek JS, Lee JY, Lee J, Huh J, Ahn KJ, Jung SY, Cha SG, Kim YH, Lee YS. The long-term effects of the fenestration in patients with extracardiac Fontan circulation-a multicenter Korean cohort study based on national Fontan registry. Front Cardiovasc Med 2024; 11:1341882. [PMID: 38774663 PMCID: PMC11106450 DOI: 10.3389/fcvm.2024.1341882] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2023] [Accepted: 04/22/2024] [Indexed: 05/24/2024] Open
Abstract
Introduction The long-term effects of fenestration in patients with Fontan circulation remain unclear. We aim to evaluate the fenestration impact on early and late outcomes in patients with extracardiac Fontan (ECF) using a propensity score matching analysis. Methods We performed an extensive retrospective multicenter clinical data review of the Korean Fontan registry and included 1,233 patients with surgical ECF (779 fenestrated, 454 non-fenestrated). Demographics, baseline, and follow-up data were collected and comprehensively analyzed. Patients were divided into two groups according to the baseline presence or absence of surgical fenestration. Subsequently, patients were sub-divided according to the fenestration status at the last follow-up. Propensity-score matching was performed to account for collected data between the 2 groups using a multistep approach. The primary outcomes were survival and freedom from Fontan failure (FFF). We also looked at postoperative hemodynamics, cardiopulmonary exercise test results, oxygen saturations, and functional status. Results After propensity-score matching (454 matched pairs), there was no difference in survival or FFF between the 2 groups. However, ECF patients with baseline fenestration had significantly lower oxygen saturation (p = 0.001) and lower functional status (p < 0.001). Patients with fenestration had significantly longer bypass times, higher postoperative central venous pressure, higher postoperative left atrial pressure, and less prolonged pleural effusion in the early postoperative period. The propensity score matching according to the fenestration status at the last follow-up (148 matched pairs) showed that patients with a persistent fenestration had significantly lower oxygen saturation levels (p < 0.001). However there were no intergroup differences in the functional status, survival and FFF. Conclusions Our results showed no long-term benefits of the Fenestration in terms of survival and FFF. Patients with persistent fenestration showed oxygen desaturation but no difference in exercise intolerance was shown between the 2 groups.
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Affiliation(s)
- Hoon Ko
- Department of Pediatrics, Pusan National University Yangsan Hospital, Pusan National University School of Medicine, Yangsan, Republic of Korea
| | - Jinyoung Song
- Department of Pediatrics, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Sang Ah Chi
- Department of Health Sciences and Technology, Samsung Advanced Institute for Health Sciences & Technology, Sungkyunkwan University, Seoul, Republic of Korea
- Biomedical Statistics Center, Samsung Medical Center, Research Institute for Future Medicine, Seoul, Republic of Korea
| | - Sang-Yun Lee
- Department of Pediatrics, College of Medicine, Seoul National University Children’s Hospital, Seoul, Republic of Korea
| | - Soo-Jin Kim
- Department of Pediatrics, Sejong General Hospital, Bucheon, Republic of Korea
| | - Chang-Ha Lee
- Department of Thoracic and Cardiovascular Surgery, Sejong General Hospital, Bucheon, Republic of Korea
| | - Chun Soo Park
- Department of Thoracic and Cardiovascular Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Eun Seok Choi
- Department of Thoracic and Cardiovascular Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Hyo Soon An
- Department of Pediatrics, College of Medicine, Seoul National University Children’s Hospital, Seoul, Republic of Korea
| | - I. Seok Kang
- Department of Pediatrics, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Ja Kyoung Yoon
- Department of Pediatrics, Sejong General Hospital, Bucheon, Republic of Korea
| | - Jae-Suk Baek
- Department of Pediatrics, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Jae-Young Lee
- Department of Pediatrics, College of Medicine, Seoul St. Mary’s Hospital, The Catholic University of Korea, Seoul, Republic of Korea
| | - Joowon Lee
- Department of Pediatrics, College of Medicine, Seoul National University Bundang Hospital, Sungnam, Republic of Korea
| | - June Huh
- Department of Pediatrics, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Kyung-Jin Ahn
- Department of Pediatric Cardiology, Gachon University Gil Medical Center, Incheon, Republic of Korea
| | - Se Yong Jung
- Department of Pediatrics, Severance Cardiovascular Hospital, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Seul Gi Cha
- Department of Pediatrics, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Yeo-Hyang Kim
- Department of Pediatrics, Kyungbook National University School of Medicine, Daegu, Republic of Korea
| | - Young-Seok Lee
- Department of Pediatrics, Dong-A University Hospital, Busan, Republic of Korea
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Pula G, Harris KC. The Fontan Fenestration: What Are Its Long-term Implications? Can J Cardiol 2024:S0828-282X(24)00306-4. [PMID: 38663528 DOI: 10.1016/j.cjca.2024.04.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/29/2024] [Revised: 04/17/2024] [Accepted: 04/17/2024] [Indexed: 06/24/2024] Open
Affiliation(s)
- Giulia Pula
- Division of Cardiology, British Columbia Children's Hospital, Department of Pediatrics, University of British Columbia, Vancouver, British Columbia, Canada
| | - Kevin C Harris
- Division of Cardiology, British Columbia Children's Hospital, Department of Pediatrics, University of British Columbia, Vancouver, British Columbia, Canada.
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Maslova V, Demming T, Nonnenmacher M, Voges I, Lyan E. Ablation of atrial flutter in a patient after Fontan procedure: a case report of challenging access to the common atrium. Eur Heart J Case Rep 2024; 8:ytae048. [PMID: 38332919 PMCID: PMC10852018 DOI: 10.1093/ehjcr/ytae048] [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: 09/06/2023] [Revised: 01/07/2024] [Accepted: 01/23/2024] [Indexed: 02/10/2024]
Abstract
Background In patients with a total cavopulmonary connection in Fontan circulation, the access to the common atrium (CA) during a catheter ablation can be challenging, even in the presence of fenestration in an intra-atrial lateral tunnel (IALT). In our department, the fenestration is typically marked with metal clips (MCs). To the best of our knowledge, there is no previous report of balloonoplasty of clipped fenestration. Case summary A 19-year-old male with hypoplastic left heart syndrome (HLHS) was scheduled for catheter ablation of recurrent atrial tachycardia. He was diagnosed with HLHS prenatally and underwent a stepwise surgical palliation. Fontan circulation was completed with the creation of a fenestrated IALT. The fenestration was marked by four MCs. During the ablation procedure, the passage of the steerable sheath with mapping catheter to the CA was prevented by a small fenestration size and rigidness of the edges of the fenestration caused by the MCs. Multiple attempts to dilate the fenestration using a peripheric angioplasty balloon failed. Only angioplasty with the 'balloon-against-dilator' technique was finally successful. Activation map showed a counterclockwise atrial flutter in the CA; successful ablation was performed. Discussion We present a case of challenging access to the CA through a clipped fenestration in a polytetrafluoroethylene baffle for atrial tachycardia ablation. Even though a tunnel fenestration in Fontan patients facilitates access to the CA, the passage of a steerable introducer with a mapping catheter may be challenging due to diameter mismatch and the rigidity of its edges caused by MCs. The balloon-against-dilator technique might be helpful when conventional balloon angioplasty fails.
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Affiliation(s)
- Vera Maslova
- Department of Internal Medicine III, Cardiology and Angiology, University Hospital Schleswig-Holstein, Arnold-Heller str. 3, Kiel 24105, Germany
| | - Thomas Demming
- Department of Internal Medicine III, Cardiology and Angiology, University Hospital Schleswig-Holstein, Arnold-Heller str. 3, Kiel 24105, Germany
| | - Marc Nonnenmacher
- Department of Congenital Heart Disease and Pediatric Cardiology, University Hospital Schleswig-Holstein, Arnold-Heller str. 3, Kiel 24105, Germany
| | - Inga Voges
- Department of Congenital Heart Disease and Pediatric Cardiology, University Hospital Schleswig-Holstein, Arnold-Heller str. 3, Kiel 24105, Germany
| | - Evgeny Lyan
- Department of Internal Medicine III, Cardiology and Angiology, University Hospital Schleswig-Holstein, Arnold-Heller str. 3, Kiel 24105, Germany
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Dib N, Samuel M, Levesque S, Zaidi A, Cohen S, Opotowsky AR, Mongeon FP, Mondésert B, Kay J, Ibrahim R, Hamilton RM, Fournier A, Jameson SM, Dore A, Cook SC, Cohen S, Chaix MA, Broberg CS, Aboulhosn J, Poirier N, Khairy P. Impact of Fontan Fenestration on Adverse Cardiovascular Outcomes: A Multicentre Study. Can J Cardiol 2024:S0828-282X(24)00079-5. [PMID: 38309467 DOI: 10.1016/j.cjca.2024.01.031] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2023] [Revised: 01/24/2024] [Accepted: 01/26/2024] [Indexed: 02/05/2024] Open
Abstract
BACKGROUND Fenestrating a Fontan baffle has been associated with improved perioperative outcomes in patients with univentricular hearts. However, longer-term potential adverse effects remain debated. We sought to assess the impact of a fenestrated Fontan baffle on adverse cardiovascular events including all-cause mortality, cardiac transplantation, atrial arrhythmias, and thromboemboli. METHODS A multicentre North American retrospective cohort study was conducted on patients with total cavopulmonary connection Fontan baffle, with and without fenestration. All components of the composite outcome were independently adjudicated. Potential static and time-varying confounders were taken into consideration, along with competing risks. RESULTS A total of 407 patients were followed for 10.4 (7.1-14.4) years; 70.0% had fenestration of their Fontan baffle. The fenestration spontaneously closed or was deliberately sealed in 79.9% of patients a median of 2.0 years after Fontan completion. In multivariable analysis in which a persistent fenestration was modelled as a time-dependent variable, an open fenestration did not confer a higher risk of the composite outcome (hazard ratio, 1.18; 95% confidence interval, 0.71-1.97; P = 0.521). In secondary analyses, an open fenestration was not significantly associated with components of the primary outcome: that is, mortality or transplantation, atrial arrhythmias, or thromboemboli. However, sensitivity analyses to assess the possible range of error resulting from imprecise dates for spontaneous fenestration closures could not rule out significant associations between an open fenestration and atrial arrhythmias or thromboemboli. CONCLUSIONS In this multicentre study, no significant association was identified between an open fenestration in the Fontan baffle and major adverse cardiovascular events.
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Affiliation(s)
- Nabil Dib
- Montreal Heart Institute, Université de Montréal, Montréal, Québec, Canada
| | - Michelle Samuel
- Montreal Heart Institute, Université de Montréal, Montréal, Québec, Canada
| | - Sylvie Levesque
- Montreal Health Innovations Coordinating Center, Montréal, Québec, Canada
| | - Ali Zaidi
- Nationwide Children's Hospital, Ohio State University, Columbus, Ohio, USA
| | - Sarah Cohen
- Hôpital Marie-Lannelongue, Groupe Hospitalier Saint-Joseph, Le Plessis Robinson, Paris, France
| | - Alexander R Opotowsky
- Boston Adult Congenital Heart Service, Boston Children's Hospital and Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA; The Cincinnati Adult Congenital Heart Disease Program, Cincinnati Children's Hospital, Cincinnati, Ohio, USA
| | | | - Blandine Mondésert
- Montreal Heart Institute, Université de Montréal, Montréal, Québec, Canada
| | - Joseph Kay
- University of Colorado Denver, Aurora, Colorado, USA
| | - Reda Ibrahim
- Montreal Heart Institute, Université de Montréal, Montréal, Québec, Canada
| | - Robert M Hamilton
- The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
| | - Anne Fournier
- Hôpital Sainte-Justine, Université de Montréal, Montréal, Québec, Canada
| | - Susan M Jameson
- Stanford Adult Congenital Heart Program, Lucile Packard Children's Hospital Stanford and Stanford Health Care, Stanford University School of Medicine, Palo Alto, California, USA
| | - Annie Dore
- Montreal Heart Institute, Université de Montréal, Montréal, Québec, Canada
| | - Stephen C Cook
- Indiana University Health Medical Center, Indianapolis, Indiana, USA
| | - Scott Cohen
- The Wisconsin Adult Congenital Heart (WAtCH) Program, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | - Marie-A Chaix
- Montreal Heart Institute, Université de Montréal, Montréal, Québec, Canada
| | | | - Jamil Aboulhosn
- Ahmanson/UCLA Adult Congenital Heart Program, University of California, Los Angeles, California, USA
| | - Nancy Poirier
- Montreal Heart Institute, Université de Montréal, Montréal, Québec, Canada
| | - Paul Khairy
- Montreal Heart Institute, Université de Montréal, Montréal, Québec, Canada.
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Miwa K, Iwai S, Kanaya T, Kawai S. Impact of Optimal Fenestration Size on Outcomes of High-Risk Fontan Patients. World J Pediatr Congenit Heart Surg 2024; 15:65-73. [PMID: 37899580 DOI: 10.1177/21501351231203928] [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] [Indexed: 10/31/2023]
Abstract
BACKGROUND We aimed to analyze mid-term outcomes of the fenestrated Fontan procedure, focusing on the fenestration size. METHODS We retrospectively reviewed the outcomes of the fenestrated Fontan procedure. Among 165 patients who underwent the Fontan procedure from 2011 to 2021, fenestration was created in 27 patients with the highest risks, including those with hypoplastic left heart syndrome, hypoplastic pulmonary arteries, heterotaxy syndrome with high pulmonary vascular resistance, and pulmonary arterial pressure >15 mm Hg. The patients underwent the procedure at a median age of three years (body weight, 11.4 kg; body surface area, 0.54 m2). Fenestration sizes were 3.5 to 5 mm. RESULTS Spontaneous fenestration closure occurred within one year postoperatively in nine patients. Among them, three experienced Fontan failure, necessitating refenestration. Although fenestration size did not differ, the size corrected by body surface area at the time of surgery was smaller in patients with fenestration closure (6.4 mm/m2 vs 8.3 mm/m2, P < .05). Patients with a fenestration <7 mm/m2 were more likely to have fenestration closure within one year postoperatively, and those with a fenestration >9 mm/m2 were more likely to have severe desaturation and require home oxygen therapy following discharge. CONCLUSIONS Spontaneous fenestration closure affected the frequency of Fontan complications. A very small fenestration size corrected by body surface area was a significant risk factor for spontaneous closure. Conversely, a very large fenestration size corrected by body surface area resulted in severe desaturation. The optimal fenestration size to prevent early spontaneous closure and severe desaturation is approximately 8 mm/m2.
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Affiliation(s)
- Koji Miwa
- Department of Cardiovascular Surgery, Osaka Women's and Children's Hospital, Izumi, Osaka, Japan
| | - Shigemitsu Iwai
- Department of Cardiovascular Surgery, Osaka Women's and Children's Hospital, Izumi, Osaka, Japan
| | - Tomomitsu Kanaya
- Department of Cardiovascular Surgery, Osaka Women's and Children's Hospital, Izumi, Osaka, Japan
| | - Shota Kawai
- Department of Cardiovascular Surgery, Osaka Women's and Children's Hospital, Izumi, Osaka, Japan
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Gutiérrez-Gil JA, Torres-Canchala LA, Castro-Viáfara LD, Uribe-Mora M, Vélez-Moreno JF, Mejía-Quiñones V, Mosquera-Álvarez W. 20 years of experience with the Fontan procedure: characteristics and clinical outcomes of children in a tertiary referral hospital. Cardiol Young 2023; 33:1378-1382. [PMID: 36205146 DOI: 10.1017/s1047951122002475] [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: 11/07/2022]
Abstract
INTRODUCTION Without participating in a contractile chamber, the Fontan procedure seeks to create a separation of oxygenated and deoxygenated blood in patients with univentricular heart, reducing the risks of long-term hypoxemia and improving their survival. This study describes the clinical outcomes of children undergoing the Fontan procedure between 2000 and 2020 in a tertiary referral hospital care centre in southwestern Colombia. MATERIALS AND METHODS A retrospective observational descriptive study. The 81 patients who underwent the Fontan procedure were included. Categorical variables were presented with percentages and continuous variables with measures of central tendency according to the distribution of the data evaluated through the Shapiro-Wilk test. Sociodemographic, clinical, surgical variables, complications, and mortality were described. RESULTS Between 2000 and 2020, 81 patients underwent the Fontan procedure: 43 (53.1%) males and a median age of 5.3 years (interquartile range 4.3-6.6). The most common diagnosis was tricuspid atresia (49.4%). The median mean pulmonary arterial pressure was 12 mmHg (interquartile range 10-15), the Nakata index 272 mm2/m2 (interquartile range 204-327), and the McGoon index (interquartile range 1.86-2.3). Seventy-two (88.9%) patients underwent extracardiac Fontan and 44 (54.3%) patients underwent fenestration. The median hospitalisation days were 19 days. The main complication was coagulopathy (19.8%), mortality in the first month between 2000 and 2010 was 8.6%, and after 2010 was 1.2%. CONCLUSION The Fontan procedure is a palliative surgery for children with complex heart disease. According to anatomical and physiological variables, the proper choice of patients determines the short- and long-term results.
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Affiliation(s)
| | | | | | | | - Juan F Vélez-Moreno
- Departamento de Cardiología Pediátrica, Fundación Valle del Lili, Cali, Colombia
| | - Valentina Mejía-Quiñones
- Fundación Valle del Lili, Centro de Investigaciones Clínicas, Cali, Colombia
- Facultad de Ciencias de la Salud, Universidad Icesi, Cali, Colombia
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Müller N, Herberg U, Breuer J, Kratz T, Härtel JA. Fitness to fly for children and adolescents after Fontan palliation. Front Cardiovasc Med 2023; 10:1170275. [PMID: 37424899 PMCID: PMC10326614 DOI: 10.3389/fcvm.2023.1170275] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2023] [Accepted: 06/02/2023] [Indexed: 07/11/2023] Open
Abstract
Introduction At cruising altitude, the cabin pressure of passenger aircraft needs to be adjusted and, therefore, the oxygen content is equivalent to ambient air at 2,500 masl, causing mild desaturation and a rising pulmonary vascular resistance (PVR) in healthy subjects. For Fontan patients with passive pulmonary perfusion, a rising PVR can cause serious medical problems. The purpose of this fitness to fly investigation (FTF) is to assess the risk of air travel for children and adolescents after Fontan palliation. Methods We investigated 21 Fontan patients [3-14y] in a normobaric hypoxic chamber at a simulated altitude of 2,500 m for 3 h. Oxygen saturation, heart rate, and regional tissue saturation in the forehead (NIRS) were measured continuously. Before entering the chamber, after 90 and 180 min in the hypoxic environment, blood gas analysis and echocardiography were performed. Results Heart rate and blood pressure did not show significant intraindividual changes. Capillary oxygen saturation (SaO2) decreased significantly after 90 min by a mean of 5.6 ± 2.87% without further decline. Lactate, pH, base excess, and tissue saturation in the frontal brain did not reach any critical values. In the case of open fenestration between the tunnel and the atrium delta, P did not increase, indicating stable pulmonary artery pressure. Conclusion All 21 children finished the investigation successfully without any adverse events, so flying short distance seems to be safe for most Fontan patients with good current health status. As the baseline oxygen saturation does not allow prediction of the maximum extent of desaturation and adaption to a hypoxic environment takes up to 180 min, the so-called hypoxic challenge test is not sufficient for these patients. Performing an FTF examination over a period of 180 min allows for risk assessment and provides safety to the patients and their families, as well as the airline companies.
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Affiliation(s)
- N. Müller
- Department for Pediatric Cardiology, Children’s Heart Center UK Bonn, University Hospital Bonn, Bonn, Germany
| | - U. Herberg
- Department for Pediatric Cardiology, Children’s Heart Center UK Bonn, University Hospital Bonn, Bonn, Germany
- Department for Pediatric Cardiology, University Hospital Aachen, Aachen, Germany
| | - J. Breuer
- Department for Pediatric Cardiology, Children’s Heart Center UK Bonn, University Hospital Bonn, Bonn, Germany
| | - T. Kratz
- Department for Pediatric Cardiology, Children’s Heart Center UK Bonn, University Hospital Bonn, Bonn, Germany
| | - J. A. Härtel
- Department for Pediatric Cardiology, Children’s Heart Center UK Bonn, University Hospital Bonn, Bonn, Germany
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Rasooli R, Giljarhus KET, Hiorth A, Jolma IW, Vinningland JL, de Lange C, Brun H, Holmstrom H. In Silico Evaluation of a Self-powered Venous Ejector Pump for Fontan Patients. Cardiovasc Eng Technol 2023; 14:428-446. [PMID: 36877450 PMCID: PMC10412470 DOI: 10.1007/s13239-023-00663-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/06/2022] [Accepted: 02/06/2023] [Indexed: 03/07/2023]
Abstract
PURPOSE The Fontan circulation carries a dismal prognosis in the long term due to its peculiar physiology and lack of a subpulmonic ventricle. Although it is multifactorial, elevated IVC pressure is accepted to be the primary cause of Fontan's high mortality and morbidity. This study presents a self-powered venous ejector pump (VEP) that can be used to lower the high IVC venous pressure in single-ventricle patients. METHODS A self-powered venous assist device that exploits the high-energy aortic flow to lower IVC pressure is designed. The proposed design is clinically feasible, simple in structure, and is powered intracorporeally. The device's performance in reducing IVC pressure is assessed by conducting comprehensive computational fluid dynamics simulations in idealized total cavopulmonary connections with different offsets. The device was finally applied to complex 3D reconstructed patient-specific TCPC models to validate its performance. RESULTS The assist device provided a significant IVC pressure drop of more than 3.2 mm Hg in both idealized and patient-specific geometries, while maintaining a high systemic oxygen saturation of more than 90%. The simulations revealed no significant caval pressure rise (< 0.1 mm Hg) and sufficient systemic oxygen saturation (> 84%) in the event of device failure, demonstrating its fail-safe feature. CONCLUSIONS A self-powered venous assist with promising in silico performance in improving Fontan hemodynamics is proposed. Due to its passive nature, the device has the potential to provide palliation for the growing population of patients with failing Fontan.
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Affiliation(s)
- Reza Rasooli
- Department of Energy Resources, Faculty of Science and Technology, University of Stavanger, 4036, Stavanger, Norway.
| | - Knut Erik Teigen Giljarhus
- Department of Mechanical and Structural Engineering and Materials Science, University of Stavanger, 4036, Stavanger, Norway
| | - Aksel Hiorth
- Department of Energy Resources, Faculty of Science and Technology, University of Stavanger, 4036, Stavanger, Norway
| | - Ingunn Westvik Jolma
- Department of Chemistry, Bioscience and Environmental Engineering, University of Stavanger, 4036, Stavanger, Norway
| | | | - Charlotte de Lange
- Department of Paediatric Radiology, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Henrik Brun
- Section for Medical Cybernetics and Image Processing, The Intervention Centre, Oslo University Hospital Rikshospitalet, Oslo, Norway
- Department of Paediatric Cardiology, Division of Paediatric and Adolescent Medicine, Oslo University Hospital, Oslo, Norway
| | - Henrik Holmstrom
- Department of Paediatric Cardiology, Division of Paediatric and Adolescent Medicine, Oslo University Hospital, Oslo, Norway
- Institute of Clinical Medicine, Faculty of Medicine, University of Oslo, Oslo, Norway
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Song Y, Wang L, Zhang M, Chen X, Pang Y, Liu J, Xu Z. Predictive factors contributing to prolonged recovery in patients after Fontan operation. BMC Pediatr 2022; 22:501. [PMID: 36002809 PMCID: PMC9404579 DOI: 10.1186/s12887-022-03537-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/05/2022] [Accepted: 07/31/2022] [Indexed: 11/10/2022] Open
Abstract
Background Prolonged recovery is a severe issue in patients after Fontan operation. However, predictive factors related to this issue are not adequately evaluated. The present study aimed to investigate potential predictive factors which can predict Fontan postoperative recovery. Methods We retrospectively reviewed the perioperative medical records of patients with Fontan surgery between January 2015 and December 2018, and divided patients with > 75%ile cardiac intensive care unit stay into prolonged recovery group. The others were assigned to standard recovery group. Patients that died or underwent a Fontan takedown were excluded. Statistical analysis was performed to compare data difference of the two groups. Results 282/307 cases fulfilled the inclusion criteria. Seventy patients were considered in prolonged recovery and 212 patients were defined as standard recovery. Pre- and intra-operative data showed a higher incidence of heterotaxy syndrome, longer cardiopulmonary bypass and aortic cross-clamp time in the prolonged recovery group. Postoperative information analysis displayed that ventilation time, oxygen index after extubation, hemodynamic data, inotropic score (IS), drainage volume, volume resuscitation, pulmonary hypertension (PH) treatment, and surgical reintervention were significantly different between the two groups. Higher IS postoperatively, and PH treatment and higher fluid resuscitation within two days were independent predictive factors for prolonged recovery in our multivariate model. C-statistic model showed a high predictive ability in prolonged recovery by using the three factors. Conclusions Ventilation time, higher IS in postoperative day, and PH treatment and higher fluid resuscitation within two days were independent risk factors and have a high predictability for Fontan prolonged recovery.
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Affiliation(s)
- Yixiao Song
- Department of Thoracic and Cardiovascular Surgery, Shanghai Children's Medical Center, School of Medicine, Shanghai Jiao Tong University, 1678 Dongfang Road, Shanghai, 200127, China
| | - Liping Wang
- Department of Thoracic and Cardiovascular Surgery, Shanghai Children's Medical Center, School of Medicine, Shanghai Jiao Tong University, 1678 Dongfang Road, Shanghai, 200127, China
| | - Mingjie Zhang
- Department of Thoracic and Cardiovascular Surgery, Shanghai Children's Medical Center, School of Medicine, Shanghai Jiao Tong University, 1678 Dongfang Road, Shanghai, 200127, China
| | - Xi Chen
- Department of Thoracic and Cardiovascular Surgery, Shanghai Children's Medical Center, School of Medicine, Shanghai Jiao Tong University, 1678 Dongfang Road, Shanghai, 200127, China
| | - Yachang Pang
- Department of Thoracic and Cardiovascular Surgery, Shanghai Children's Medical Center, School of Medicine, Shanghai Jiao Tong University, 1678 Dongfang Road, Shanghai, 200127, China
| | - Jiaqi Liu
- Department of Thoracic and Cardiovascular Surgery, Shanghai Children's Medical Center, School of Medicine, Shanghai Jiao Tong University, 1678 Dongfang Road, Shanghai, 200127, China
| | - Zhuoming Xu
- Department of Thoracic and Cardiovascular Surgery, Shanghai Children's Medical Center, School of Medicine, Shanghai Jiao Tong University, 1678 Dongfang Road, Shanghai, 200127, China.
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El-Khouri M, Arabi M, El Rassi I, Bulbul Z, Sawaya F, Bitar F. Transcatheter occlusion of a hepatic vein-to-left atrium fistula: Should we close venovenous collateral vessels following Fontan operation? Ann Pediatr Cardiol 2022; 15:415-418. [PMID: 36935823 PMCID: PMC10015390 DOI: 10.4103/apc.apc_193_21] [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: 09/27/2021] [Revised: 12/08/2021] [Accepted: 06/14/2022] [Indexed: 01/08/2023] Open
Abstract
Right-to-left shunt due to abnormal systemic venous drainage to the left heart is among the causes of hypoxemia following Fontan operation. There are conflicting data regarding the closure of the venovenous collaterals (VVCs) post-Fontan, showing decreased survival in older patients. In a child with visceral heterotaxy, we describe a rare fistula draining a right-sided hepatic vein into hepatic venous plexus and a right-sided pulmonary venous atrium. The patient presented with severe hypoxemia post-Fontan and underwent fistula occlusion with AMPLATZER™ Vascular Plug II, successfully improving hemodynamic status with resolution of the hypoxemia. Younger patients with cyanosis due to VVCs may benefit from percutaneous occlusion post-Fontan.
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Affiliation(s)
- Maya El-Khouri
- Department of Pediatrics and Adolescent Medicine, The American University of Beirut-Medical Center, Beirut, Lebanon
- The Children's Heart Center, The American University of Beirut-Medical Center, Beirut, Lebanon
| | - Mariam Arabi
- Department of Pediatrics and Adolescent Medicine, The American University of Beirut-Medical Center, Beirut, Lebanon
- The Children's Heart Center, The American University of Beirut-Medical Center, Beirut, Lebanon
| | - Issam El Rassi
- The Children's Heart Center, The American University of Beirut-Medical Center, Beirut, Lebanon
- Department of Surgery, The American University of Beirut-Medical Center, Lebanon
| | - Ziad Bulbul
- Department of Pediatrics and Adolescent Medicine, The American University of Beirut-Medical Center, Beirut, Lebanon
- The Children's Heart Center, The American University of Beirut-Medical Center, Beirut, Lebanon
| | - Fadi Sawaya
- Department of Medicine, The American University of Beirut-Medical Center, Beirut, Lebanon
| | - Fadi Bitar
- Department of Pediatrics and Adolescent Medicine, The American University of Beirut-Medical Center, Beirut, Lebanon
- The Children's Heart Center, The American University of Beirut-Medical Center, Beirut, Lebanon
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11
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Heidendael JF, Engele LJ, Bouma BJ, Dipchand AI, Thorne SA, McCrindle BW, Mulder BJM. Coagulation and Anticoagulation in Fontan Patients. Can J Cardiol 2022; 38:1024-1035. [PMID: 35122939 DOI: 10.1016/j.cjca.2022.01.028] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2021] [Revised: 01/17/2022] [Accepted: 01/27/2022] [Indexed: 01/22/2023] Open
Abstract
Patients with a Fontan circulation for single-ventricle physiology are at increased risk of developing thromboembolic events. Thromboembolic events can lead to failure of the Fontan circulation, chronic sequelae in case of stroke, and early mortality. Controversies exist regarding the substrates, risk factors, and optimal detection methods for thromboembolic events. Despite the major clinical implications, there is currently no consensus regarding the optimal antithrombotic therapy to prevent or treat thromboembolic events after the Fontan procedure. In this review we aimed to untangle the available literature regarding antithrombotic prophylaxis and treatment for pediatric and adult Fontan patients. A decision-tree algorithm for thromboprophylaxis in Fontan patients is proposed. Additionally, the current state of knowledge is reviewed with respect to the epidemiology, pathophysiology, and detection of thromboembolic events in Fontan patients, and important evidence gaps are highlighted.
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Affiliation(s)
- Josephine F Heidendael
- Department of Cardiology, Amsterdam University Medical Center, Amsterdam, The Netherlands.
| | - Leo J Engele
- Department of Cardiology, Amsterdam University Medical Center, Amsterdam, The Netherlands
| | - Berto J Bouma
- Department of Cardiology, Amsterdam University Medical Center, Amsterdam, The Netherlands
| | - Anne I Dipchand
- Department of Pediatrics, Labatt Family Heart Centre, The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
| | - Sara A Thorne
- Department of Cardiology, Peter Munk Cardiac Center, University Health Network, Toronto General Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Brian W McCrindle
- Department of Pediatrics, Labatt Family Heart Centre, The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
| | - Barbara J M Mulder
- Department of Cardiology, Amsterdam University Medical Center, Amsterdam, The Netherlands
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12
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Risk factors for prolonged ventilation after the modified Fontan procedure. Cardiol Young 2022; 32:969-974. [PMID: 34429179 DOI: 10.1017/s1047951121003498] [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] [Indexed: 11/05/2022]
Abstract
OBJECTIVE To investigate the risk factors associated with prolonged ventilation after Fontan surgery. DESIGN Retrospective case series. SETTING Tertiary childrens hospital. PATIENTS We included 123 children who underwent Fontan surgery without delayed sternal closure or extracorporeal membrane oxygenation between 2011 and 2017. INTERVENTION Fontan surgery. MEASUREMENTS AND MAIN RESULTS Prolonged ventilation was defined as intubation for more than 24 hours after surgery. Preoperative, intraoperative, and perioperative data were collected retrospectively from medical records. Multivariate logistic regression analysis was used to identify risk factors for prolonged ventilation. The median age and weight of patients were 2.2 years and 10.0 kg, respectively. Seventeen per cent of the patients (n = 21) received prolonged mechanical ventilation, and the median intubation period was 2.9 days. There were no 90-day or in-hospital deaths. The independent predictors of prolonged ventilation identified were fenestration (p < 0.01), low pulmonary artery index (p = 0.02), and advanced atrioventricular regurgitation (p < 0.01). The duration of ICU stay was significantly longer in the prolonged ventilation group than in the early extubation group (10 days versus 6 days, p < 0.01). CONCLUSION Fenestration, low pulmonary artery index, and significant atrioventricular regurgitation are risk factors for prolonged ventilation after Fontan surgery. Careful preoperative and perioperative management that considers the risk factors for prolonged ventilation in each individual is important.
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13
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Daley M, Buratto E, King G, Grigg L, Iyengar A, Alphonso N, Bullock A, Celermajer DS, Ayer J, Robertson T, d'Udekem Y, Konstantinov IE. Impact of Fontan Fenestration on Long-Term Outcomes: A Propensity Score-Matched Analysis. J Am Heart Assoc 2022; 11:e026087. [PMID: 35621213 PMCID: PMC9238726 DOI: 10.1161/jaha.122.026087] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background The long-term impact of fenestration at the time of Fontan operation remains unclear. We aimed to review the early and long-term impact of Fontan fenestration in the Australia and New Zealand cohort. Methods and Results We reviewed 1443 patients (621 fenestrated, 822 nonfenestrated) from the Australia and New Zealand Fontan registry. Data were collected on preoperative demographics, operative details, and follow-up. Propensity-score matching was performed to account for the various preoperative and operative differences and risk factors. Primary outcomes were survival and freedom from failure. Median follow-up was 10.6 years. After propensity-score matching (407 matched pairs), there was no difference in survival (87% versus 90% at 20 years; P=0.16) or freedom from failure (73% versus 80% at 20 years; P=0.10) between patients with and without fenestration, respectively. Although patients with fenestration had longer bypass and cross-clamp times (P<0.001), there was no difference in hospital length of stay or prolonged pleural effusions (P=0.80 and P=0.46, respectively). Freedom from systemic and Fontan circuit thromboembolism was higher in the nonfenestrated group (89%; 95% CI, 88%-95%) than the fenestrated group (84%; 95% CI, 77%-89%; P=0.03). There was no difference in incidence of plastic bronchitis, protein-losing enteropathy, New York Heart Association Class III/IV symptoms, or Fontan takedown. Conclusions In the propensity score-matched analysis we have demonstrated no difference in long-term survival or freedom from Fontan failure in patients with and without fenestration. There was a higher incidence of long-term thromboembolic events in patients with fenestration. Overall, it appears that fenestration in Fontan circulation does not bring long-term benefits.
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Affiliation(s)
- Michael Daley
- Department of Cardiac Surgery Royal Children's Hospital Melbourne Australia.,Department of Paediatrics University of Melbourne Melbourne Australia.,Heart Research Group Murdoch Children's Research Institute Melbourne Australia
| | - Edward Buratto
- Department of Cardiac Surgery Royal Children's Hospital Melbourne Australia.,Department of Paediatrics University of Melbourne Melbourne Australia.,Heart Research Group Murdoch Children's Research Institute Melbourne Australia
| | - Gregory King
- Department of Cardiac Surgery Royal Children's Hospital Melbourne Australia.,Department of Paediatrics University of Melbourne Melbourne Australia.,Heart Research Group Murdoch Children's Research Institute Melbourne Australia
| | - Leeanne Grigg
- Department of Cardiology Royal Melbourne Hospital Melbourne Australia
| | - Ajay Iyengar
- Green Lane Paediatric and Congenital Cardiac Service Starship Children's Health Auckland New Zealand.,Department of Surgery University of Auckland Auckland New Zealand
| | - Nelson Alphonso
- Department of Cardiac Surgery Queensland Children's Hospital Brisbane Australia.,Queensland Paediatric Cardiac ResearchChild Health Research CentreUniversity of Queensland Brisbane Australia
| | - Andrew Bullock
- Department of Cardiology Perth Children's Hospital Perth Australia.,Adult Congenital Cardiology Division Cardiovascular Medicine Sir Charles Gardiner Hospital Perth Australia
| | - David S Celermajer
- Department of Medicine The University of Sydney Sydney Australia.,Department of Cardiology Royal Prince Alfred Hospital Sydney Australia
| | - Julian Ayer
- The Heart Centre for Children The Children's Hospital at Westmead Sydney Australia.,Discipline of Paediatrics and Child Health The University of Sydney Sydney Australia
| | - Terry Robertson
- Department of Cardiology, Women and Children's Hospital Adelaide Australia
| | - Yves d'Udekem
- The Division of Cardiovascular Surgery Children's National Heart InstituteChildren's National Hospital Washington DC
| | - Igor E Konstantinov
- Department of Cardiac Surgery Royal Children's Hospital Melbourne Australia.,Department of Paediatrics University of Melbourne Melbourne Australia.,Heart Research Group Murdoch Children's Research Institute Melbourne Australia
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14
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Şimşek B, Özyüksel A, Demiroluk Ş, Saygı M, Bilal MS. Early outcomes of fenestrated intra-extracardiac Fontan procedure: Insights, experiences, and expectations. J Card Surg 2022; 37:1301-1308. [PMID: 35226377 DOI: 10.1111/jocs.16366] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2021] [Revised: 01/04/2022] [Accepted: 01/18/2022] [Indexed: 11/29/2022]
Abstract
BACKGROUND Intraextracardiac Fontan procedure (FP) aimed to combine the advantages of lateral tunnel and extracardiac conduit modifications of the original technique. Herein, we present our early outcomes in patients with intraextracardiac fenestrated FP. METHODS A retrospective analysis was performed to evaluate intraextracardiac fenestrated Fontan patients between 2014 and 2021. Seventeen patients were operated on with a mean age and body weight of 9.1 ± 5.5 years and 28.6 ± 14.6 kg. RESULTS Sixteen patients (94%) were palliated as univentricular physiology with hypoplasia of one of the ventricles. One patient (6%) with well-developed two ventricles with double outlet right ventricle and complete atrioventricular septal defect had straddling of the chordae prohibiting a biventricular repair. All of the patients had cavopulmonary anastomosis before Fontan completion, except one case. Fenestration was performed in all cases. Postoperative mean pulmonary artery pressures and arterial oxygen saturation levels at follow-up were 10 ± 2.4 mmHg and 91.3 ± 2.7%, respectively. Mean duration of pleural drainage was 5.4 ± 2.3 days. All of the fenestrations are patent at a mean follow-up period of 4.8 ± 7.7 years, except one case. Any morbidity and mortality were not encountered. CONCLUSIONS Early outcomes of intraextracardiac fenestrated FP are encouraging. This procedure may improve the results in a patient population who should be palliated as univentricular physiology, especially in cases with complex cardiac anatomy.
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Affiliation(s)
- Baran Şimşek
- Department of Cardiovascular Surgery, Medicana International Hospital, Istanbul, Turkey
| | - Arda Özyüksel
- Department of Cardiovascular Surgery, Medicana International Hospital, Istanbul, Turkey.,Department of Cardiovascular Surgery, Biruni University, Istanbul, Turkey
| | - Şener Demiroluk
- Department of Anesthesiology, Medicana International Hospital, Istanbul, Turkey
| | - Murat Saygı
- Department of Pediatric Cardiology, Medicana International Hospital, Istanbul, Turkey
| | - Mehmet S Bilal
- Department of Cardiovascular Surgery, Medicana International Hospital, Istanbul, Turkey
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15
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Prather R, Das A, Farias M, Divo E, Kassab A, DeCampli W. Parametric investigation of an injection-jet self-powered Fontan circulation. Sci Rep 2022; 12:2161. [PMID: 35140260 PMCID: PMC8828777 DOI: 10.1038/s41598-022-05985-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2021] [Accepted: 01/17/2022] [Indexed: 12/04/2022] Open
Abstract
Approximately \documentclass[12pt]{minimal}
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\begin{document}$$1/2500$$\end{document}1/2500 babies are born with only one functioning ventricle and the Fontan is the third and, ideally final staged palliative operation for these patients. This altered circulation is prone to failure with survival rates below \documentclass[12pt]{minimal}
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\begin{document}$$50\%$$\end{document}50% into adulthood. Chronically elevated inferior vena cava (IVC) pressure is implicated as one cause of the mortality and morbidity in this population. An injection jet shunt (IJS) drawing blood-flow directly from the aortic arch to significantly lower IVC pressure is proposed. A computer-generated 3D model of a 2–4 year old patient with a fenestrated Fontan and a cardiac output of 2.3 L/min was generated. The detailed 3D pulsatile hemodynamics are resolved in a zero-dimensional lumped parameter network tightly-coupled to a 3D computational fluid dynamics model accounting for non-Newtonian blood rheology and resolving turbulence using large eddy simulation. IVC pressure and systemic oxygen saturation were tracked for various IJS-assisted Fontan configurations, altering design parameters such as shunt and fenestration diameters and locations. A baseline “failing” Fontan with a 4 mm fenestration was tuned to have an elevated IVC pressure (+ 17.8 mmHg). Enlargement of the fenestration to 8 mm resulted in a 3 mmHg IVC pressure drop but an unacceptable reduction in systemic oxygen saturation below 80%. Addition of an IJS with a 2 mm nozzle and minor volume load to the ventricle improved the IVC pressure drop to 3.2 mmHg while increasing systemic oxygen saturation above 80%. The salutary effects of the IJS to effectively lower IVC pressure while retaining acceptable levels of oxygen saturation are successfully demonstrated.
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Affiliation(s)
- Ray Prather
- Department of Mechanical and Aerospace Engineering, University of Central Florida, 4000 Central Florida Blvd., Orlando, FL, 32816, USA. .,Department of Mechanical Engineering, Embry-Riddle Aeronautical University, 1 Aerospace Blvd., Daytona Beach, FL, 32114, USA. .,The Heart Center, Arnold Palmer Hospital for Children, 92 West Miller Street, Orlando, FL, 32806, USA.
| | - Arka Das
- Department of Mechanical Engineering, Embry-Riddle Aeronautical University, 1 Aerospace Blvd., Daytona Beach, FL, 32114, USA
| | - Michael Farias
- The Heart Center, Arnold Palmer Hospital for Children, 92 West Miller Street, Orlando, FL, 32806, USA
| | - Eduardo Divo
- Department of Mechanical Engineering, Embry-Riddle Aeronautical University, 1 Aerospace Blvd., Daytona Beach, FL, 32114, USA
| | - Alain Kassab
- Department of Mechanical and Aerospace Engineering, University of Central Florida, 4000 Central Florida Blvd., Orlando, FL, 32816, USA
| | - William DeCampli
- The Heart Center, Arnold Palmer Hospital for Children, 92 West Miller Street, Orlando, FL, 32806, USA.,College of Medicine, University of Central Florida, 6850 Lake Nona Blvd, Orlando, FL, 32827, USA
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16
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Ciliberti P, Ciancarella P, Bruno P, Curione D, Bordonaro V, Lisignoli V, Panebianco M, Chinali M, Secinaro A, Galletti L, Guccione P. Cardiac Imaging in Patients After Fontan Palliation: Which Test and When? Front Pediatr 2022; 10:876742. [PMID: 35652057 PMCID: PMC9149285 DOI: 10.3389/fped.2022.876742] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/15/2022] [Accepted: 04/13/2022] [Indexed: 11/13/2022] Open
Abstract
The Fontan operation represents the final stage of a series of palliative surgical procedures for children born with complex congenital heart disease, where a "usual" biventricular physiology cannot be restored. The palliation results in the direct connection of the systemic venous returns to the pulmonary arterial circulation without an interposed ventricle. In this unique physiology, systemic venous hypertension and intrathoracic pressures changes due to respiratory mechanics play the main role for propelling blood through the pulmonary vasculature. Although the Fontan operation has dramatically improved survival in patients with a single ventricle congenital heart disease, significant morbidity is still a concern. Patients with Fontan physiology are in fact suffering from a multitude of complications mainly due to the increased systemic venous pressure. Consequently, these patients need close clinical and imaging monitoring, where cardiac exams play a key role. In this article, we review the main cardiac imaging modalities available, summarizing their main strengths and limitations in this peculiar setting. The main purpose is to provide a practical approach for all clinicians involved in the care of these patients, even for those less experienced in cardiac imaging.
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Affiliation(s)
- Paolo Ciliberti
- Department of Cardiac Surgery, Cardiology, Heart and Lung Transplantation Bambino Gesu' Children's Hospital, IRCCS, Rome, Italy
| | - Paolo Ciancarella
- Advanced Cardiothoracic Imaging Unit, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
| | - Pasqualina Bruno
- Department of Cardiac Surgery, Cardiology, Heart and Lung Transplantation Bambino Gesu' Children's Hospital, IRCCS, Rome, Italy
| | - Davide Curione
- Advanced Cardiothoracic Imaging Unit, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
| | - Veronica Bordonaro
- Advanced Cardiothoracic Imaging Unit, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
| | - Veronica Lisignoli
- Department of Cardiac Surgery, Cardiology, Heart and Lung Transplantation Bambino Gesu' Children's Hospital, IRCCS, Rome, Italy
| | - Mario Panebianco
- Department of Cardiac Surgery, Cardiology, Heart and Lung Transplantation Bambino Gesu' Children's Hospital, IRCCS, Rome, Italy
| | - Marcello Chinali
- Department of Cardiac Surgery, Cardiology, Heart and Lung Transplantation Bambino Gesu' Children's Hospital, IRCCS, Rome, Italy
| | - Aurelio Secinaro
- Advanced Cardiothoracic Imaging Unit, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
| | - Lorenzo Galletti
- Department of Cardiac Surgery, Cardiology, Heart and Lung Transplantation Bambino Gesu' Children's Hospital, IRCCS, Rome, Italy
| | - Paolo Guccione
- Department of Cardiac Surgery, Cardiology, Heart and Lung Transplantation Bambino Gesu' Children's Hospital, IRCCS, Rome, Italy
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17
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Greenleaf CE, Lim ZN, Li W, LaPar DJ, Salazar JD, Corno AF. Impact on clinical outcomes from transcatheter closure of the Fontan fenestration: A systematic review and meta-analysis. Front Pediatr 2022; 10:915045. [PMID: 36268038 PMCID: PMC9576841 DOI: 10.3389/fped.2022.915045] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/07/2022] [Accepted: 08/26/2022] [Indexed: 11/25/2022] Open
Abstract
BACKGROUND Meta-analysis of the impact on clinical outcome from transcatheter closure of Fontan fenestration. METHODS Cochrane, Embase, MEDLINE, and Open-Gray were searched. Parameters such as changes in oxygen saturation, cavo-pulmonary pressure, maximum heart rate during exercise, exercise duration, and oxygen saturation after fenestration closure were pooled and statistical analysis performed. RESULTS Among 922 publications, 12 retrospective observational studies were included. The included studies involved 610 patients, of which 552 patients (90.5%) had a fenestration. Of those patients, 505 patients (91.5%) underwent attempt at trans-catheter closure. When it could be estimated, the pooled overall mean age at trans-catheter fenestration closure was 6.6 ± 7.4 years, and the mean follow-up time was 34.4 ± 10.7 months. There were 32 minor (6.3%) and 20 major (4.0%) complications during or after trans-catheter Fontan fenestration closure. The forest plots demonstrate that following fenestration closure, there was a significant increase in the mean arterial oxygen saturation of 7.9% (95% CI 6.4-9.4%, p < 0.01). There was also a significant increase in the mean cavo-pulmonary pressure of 1.4 mmHg (95% CI 1.0-1.8 mmHg, p < 0.01) following fenestration closure. The exercise parameters reported in 3 studies also favored closing the fenestration as well, yet the exercise duration increase of 1.7 min (95% CI 0.7-2.8 min, p < 0.01) after fenestration closure is probably clinically insignificant. CONCLUSION Late closure of a Fontan fenestration has the impact of improving resting oxygen saturation, exercise oxygen saturation, and a modest improvement of exercise duration. These clinical benefits, however, may be at the expense of tolerating slightly higher cavo-pulmonary mean pressures.
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Affiliation(s)
- Christopher E Greenleaf
- Pediatric and Congenital Cardiac Surgery, Children's Heart Institute, Memorial Hermann Children's Hospital, UTHealth, McGovern Medical School, Houston, TX, United States
| | - Zhia Ning Lim
- University College of London (UCL) Great Ormond Street Institute of Child Health, University College London, London, United Kingdom
| | - Wen Li
- Division of Clinical and Translational Sciences, Department of Internal Medicine, UTHealth, McGovern Medical School, Houston, TX, United States
| | - Damien J LaPar
- Pediatric and Congenital Cardiac Surgery, Children's Heart Institute, Memorial Hermann Children's Hospital, UTHealth, McGovern Medical School, Houston, TX, United States
| | - Jorge D Salazar
- Pediatric and Congenital Cardiac Surgery, Children's Heart Institute, Memorial Hermann Children's Hospital, UTHealth, McGovern Medical School, Houston, TX, United States
| | - Antonio F Corno
- Pediatric and Congenital Cardiac Surgery, Children's Heart Institute, Memorial Hermann Children's Hospital, UTHealth, McGovern Medical School, Houston, TX, United States
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18
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Martin SD, Lande MB, Kuebler JD, Cholette JM. Case report and review of the literature: Successful transition from acute continuous veno-venous hemodiafiltration therapy to chronic peritoneal dialysis in a chronically ventilated child with hypoplastic left heart syndrome following fontan. Front Pediatr 2022; 10:1040869. [PMID: 36389394 PMCID: PMC9664216 DOI: 10.3389/fped.2022.1040869] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/09/2022] [Accepted: 10/12/2022] [Indexed: 11/24/2022] Open
Abstract
Fontan palliation depends on low pulmonary vascular resistance in order to maintain pulmonary blood flow and adequate oxygenation. This physiology results in higher central venous pressures with limited renal perfusion pressure and cardiac output. Positive pressure ventilation with mechanical ventilation increases intrathoracic pressure and raises central venous pressure and can further limit pulmonary and renal perfusion. Fluid removal with intermittent hemodialysis can be challenging in Fontan patients and can cause intolerable hypotension, however the increased abdominal filling pressures during peritoneal dialysis dwells can exacerbate systemic venous hypertension seen in Fontan patients and threaten adequate pulmonary blood flow and cardiac output. Successful transition to peritoneal dialysis in a chronically ventilated patient with hypoplastic left heart syndrome, end-stage renal disease and Fontan physiology has not been described. We present details outlining the successful transition across multiple modalities of renal replacement therapy to assist other teams faced with similar challenges in chronically ventilated Fontan patients with end-stage renal disease.
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Affiliation(s)
- Susan D Martin
- Department of Pediatrics, University of Rochester Medical Center, Rochester, NY, United States
| | - Marc B Lande
- Department of Pediatrics, University of Rochester Medical Center, Rochester, NY, United States
| | - Joseph D Kuebler
- Department of Pediatrics, University of Rochester Medical Center, Rochester, NY, United States
| | - Jill M Cholette
- Department of Pediatrics, University of Rochester Medical Center, Rochester, NY, United States
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19
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Becker K, Uebing A, Hansen JH. Pulmonary vascular disease in Fontan circulation-is there a rationale for pulmonary vasodilator therapies? Cardiovasc Diagn Ther 2021; 11:1111-1121. [PMID: 34527537 DOI: 10.21037/cdt-20-431] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2020] [Accepted: 06/29/2020] [Indexed: 12/21/2022]
Abstract
The Fontan circulation is a palliative concept for patients with univentricular hearts. The central veins are connected directly to the pulmonary arteries (cavo-pulmonary connection) to separate the pulmonary and the systemic circulation. There is no sub-pulmonary ventricle that generates pressure to drive blood through the pulmonary arteries. Pulmonary blood flow is determined by central venous pressure (CVP) and pulmonary vascular resistance (PVR). The capability of the Fontan circulation to compensate for alterations in PVR is limited, as CVP can only be increased within narrow ranges without adverse clinical consequences. Consequently, systemic ventricular preload and cardiac output are dependent on a healthy lung with low PVR. Failure of the Fontan circulation is relatively common. In addition to ventricular dysfunction, maladaptive pulmonary vascular remodeling resulting in increased pulmonary resistance may play a key role. The pathophysiology of the maladaptive vascular processes remains largely unclear and diagnosis of an increased PVR is challenging in Fontan circulation as accurate measurement of pulmonary arterial blood flow is difficult. In the absence of a sub-pulmonary ventricle, pulmonary artery pressure will almost never reach the threshold conventionally used to define pulmonary arterial hypertension. There is a need for markers of pulmonary vascular disease complementary to invasive hemodynamic data in Fontan patients. In order to treat or prevent failure of the Fontan circulation, pathophysiological considerations support the use of pulmonary vasodilators to augment pulmonary blood flow and systemic ventricular preload and lower CVP. However, to date the available trial data have neither yielded enough evidence to support routine use of pulmonary vasodilators in every Fontan patient nor have they been helpful in defining subgroups of patients that might benefit from such therapies. This review discusses potential pathomechanisms of pulmonary vascular disease; it summarizes the current knowledge of the effects and efficacy of pulmonary vasodilator therapy in Fontan patients and tries to outline areas of potential future research on the diagnosis and treatment of pulmonary vascular disease and Fontan failure.
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Affiliation(s)
- Kolja Becker
- Department of Congenital Heart Disease and Pediatric Cardiology, University Hospital of Schleswig-Holstein, Campus Kiel, Kiel, Germany
| | - Anselm Uebing
- Department of Congenital Heart Disease and Pediatric Cardiology, University Hospital of Schleswig-Holstein, Campus Kiel, Kiel, Germany.,DZHK (German Center for Cardiovascular Research), Partner Site Hamburg/Kiel/Lübeck, Germany
| | - Jan Hinnerk Hansen
- Department of Congenital Heart Disease and Pediatric Cardiology, University Hospital of Schleswig-Holstein, Campus Kiel, Kiel, Germany.,DZHK (German Center for Cardiovascular Research), Partner Site Hamburg/Kiel/Lübeck, Germany
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20
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Well A, Stewart E, Mery CM. Long-term outcomes after Fontan palliation-the many shades of blue. Eur J Cardiothorac Surg 2021; 61:62-63. [PMID: 34279026 DOI: 10.1093/ejcts/ezab331] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Affiliation(s)
- Andrew Well
- Texas Center for Pediatric and Congenital Heart Disease, UT Health Austin/Dell Children's Medical Center, Austin, TX, USA.,Department of Surgery and Perioperative Care, The University of Texas at Austin Dell Medical School, Austin, TX, USA
| | - Eileen Stewart
- Texas Center for Pediatric and Congenital Heart Disease, UT Health Austin/Dell Children's Medical Center, Austin, TX, USA.,Department of Pediatrics, The University of Texas at Austin Dell Medical School, Austin, TX, USA
| | - Carlos M Mery
- Texas Center for Pediatric and Congenital Heart Disease, UT Health Austin/Dell Children's Medical Center, Austin, TX, USA.,Department of Surgery and Perioperative Care, The University of Texas at Austin Dell Medical School, Austin, TX, USA
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21
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Schafstedde M, Nordmeyer S, Schleiger A, Nordmeyer J, Berger F, Kramer P, Ovroutski S. Persisting and reoccurring cyanosis after Fontan operation is associated with increased late mortality. Eur J Cardiothorac Surg 2021; 61:54-61. [PMID: 34195822 DOI: 10.1093/ejcts/ezab298] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/24/2020] [Revised: 04/22/2021] [Accepted: 05/13/2021] [Indexed: 12/23/2022] Open
Abstract
OBJECTIVES The Fontan operation aims at reducing cyanosis and cardiac volume overload in patients with complex univentricular heart malformations. However, persisting or reoccurring cyanosis is frequently observed. We sought to systematically determine the prevalence and clinical consequences of persisting and secondary cyanosis after Fontan operation. METHODS A total of 331 Fontan patients, operated between 1984 and 2016 with a median postoperative follow-up of 7.9 (interquartile range 2.6-15.8) years, were studied retrospectively. Cyanosis was defined as transcutaneous oxygen saturation ≤93% at rest measured by pulse oximetry. Prevalence of cyanosis was analysed at 3 different time points (t1 = post-Fontan operation, t2 = post-Fontan cardiac catheterization, t3 = last follow-up) and the association of cyanosis with mortality was examined. RESULTS Prevalence of cyanosis was 50% at t1 and 39% at t3. Fenestration was patent in 71% and 33% of all cyanotic patients at t1 and t3, respectively. In patients with clinical indication for catheterization (t2; n = 178/331), prevalence of cyanosis was 72%. At t2, patent fenestration (33%), veno-venous collaterals (24%) or both (32%) were present. Thirty-six (11%) patients died during follow-up. In a time-varying multivariable Cox regression analysis, cyanosis was the strongest predictor for late mortality (P < 0.001, hazard ratio 12.2, 95% confidence interval 3.7-40.5). CONCLUSIONS Prevalence of cyanosis was considerable during long-term follow-up after Fontan operation and-as a surrogate parameter for unfavourable Fontan haemodynamics-is associated with increased late mortality. Accordingly, particular attention should be directed towards the persistence or reoccurrence of cyanosis during follow-up since it may indicate haemodynamic attrition and development of Fontan failure.
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Affiliation(s)
- Marie Schafstedde
- Department of Congenital Heart Disease/Paediatric Cardiology, German Heart Center Berlin, Berlin, Germany.,Institute for Cardiovascular Computer-Assisted Medicine, Charité Universitätsmedizin Berlin, Berlin, Germany.,Berlin Institute of Health, Berlin, Germany.,DZHK (German Center for Cardiovascular Research), Partner Site Berlin, Germany
| | - Sarah Nordmeyer
- Department of Congenital Heart Disease/Paediatric Cardiology, German Heart Center Berlin, Berlin, Germany.,Institute for Cardiovascular Computer-Assisted Medicine, Charité Universitätsmedizin Berlin, Berlin, Germany
| | - Anastasia Schleiger
- Department of Congenital Heart Disease/Paediatric Cardiology, German Heart Center Berlin, Berlin, Germany
| | - Johannes Nordmeyer
- Department of Congenital Heart Disease/Paediatric Cardiology, German Heart Center Berlin, Berlin, Germany
| | - Felix Berger
- Department of Congenital Heart Disease/Paediatric Cardiology, German Heart Center Berlin, Berlin, Germany.,DZHK (German Center for Cardiovascular Research), Partner Site Berlin, Germany.,Department of Paediatric Cardiology, Charité Universitätsmedizin Berlin, Berlin, Germany
| | - Peter Kramer
- Department of Congenital Heart Disease/Paediatric Cardiology, German Heart Center Berlin, Berlin, Germany
| | - Stanislav Ovroutski
- Department of Congenital Heart Disease/Paediatric Cardiology, German Heart Center Berlin, Berlin, Germany
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22
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Villa CR, Lorts A, Morales DLS. Ventricular Assist Device Therapy in the Fontan Circulation. Semin Thorac Cardiovasc Surg Pediatr Card Surg Annu 2021; 24:19-25. [PMID: 34116777 DOI: 10.1053/j.pcsu.2021.01.001] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2020] [Revised: 01/04/2021] [Accepted: 01/14/2021] [Indexed: 12/25/2022]
Abstract
The number of Fontan patients with circulatory failure and systolic dysfunction is growing rapidly. The last decade has demonstrated that ventricular assist device (VAD) is an effective therapy in properly selected patients. Herein, we discuss the current approach to patient selection, implantation, and patient management.
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Affiliation(s)
- Chet R Villa
- The Heart Institute, Cincinnati Children's Hospital Medical Center, University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - Angela Lorts
- The Heart Institute, Cincinnati Children's Hospital Medical Center, University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - David L S Morales
- The Heart Institute, Cincinnati Children's Hospital Medical Center, University of Cincinnati College of Medicine, Cincinnati, Ohio.
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23
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Abstract
A Fontan circulation requires a series of three-staged operations aimed to palliate patients with single-ventricle CHD. Currently, the most frequent technique is the extracardiac total cavopulmonary connection, an external conduit connecting the IVC and right pulmonary artery, bypassing the right side of the heart. Fontan candidates must meet strict criteria; they are assessed utilising both cardiac catheterisation and cardiac magnetic resonance. Postoperatively, treatment protocols prioritise antibiotic prophylaxis, diuretics, angiotensin-converting enzyme inhibitors, anticoagulation, and oxygen therapy with fluid restriction and a low-fat diet. These measures aim to reduce length of stay in the ICU and hospital by preventing acute complications such as infection, venous thromboembolism, low cardiac output, pleural effusion, and acute kidney injury. Late complications of a Fontan procedure include circulation failure, protein-losing enteropathy, plastic bronchitis, and Fontan-associated liver disease. The definitive management is cardiac transplantation, with promising innovations in selective embolisation of lymphatic vessels and Fontan-specific ventricular assist devices. Further research assessing current protocols in the perioperative management of Fontan patients would be beneficial for standardising current practice and improving outcomes.
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24
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25
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Özyüksel A, Şimşek B, Özden Ö, Demiroluk Ş, Saygı M, Bilal MS. Fontan procedure in patients with preoperative mean pulmonary artery pressure over 15 mmHg. J Card Surg 2021; 36:941-949. [PMID: 33415747 DOI: 10.1111/jocs.15293] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2020] [Accepted: 11/09/2020] [Indexed: 11/29/2022]
Abstract
BACKGROUND Several factors affect the long-term outcome of Fontan procedure, but a high pulmonary artery pressure is still one of the most important limitation for proceeding to a Fontan circulation. Herein, we present our experience in Fontan patients with high preoperative pulmonary artery pressures. METHODS A retrospective analysis was performed to evaluate Fontan patients with a preoperative pulmonary artery pressure >15 mmHg between 2009 and 2020. Sixteen patients were operated on with a mean preoperative pulmonary artery pressure of 17.5 ± 2.1 mmHg. RESULTS Mean age at the time of Fontan procedure was 7.8 ± 5.6 years. All the patients had stage 2 cavopulmonary anastomosis before Fontan completion, with a mean interstage period of 4 ± 2.6 years. Fontan completion was achieved with a polytetrafluorethylene tubular conduit, two of which were intra-extracardiac. Fenestration was performed in five (31%) cases. Postoperative pulmonary artery pressures and arterial oxygen saturation levels were 11.2 ± 2.8 and 97.8 ± 2 mmHg, respectively. Mean duration of pleural drainage was 3.9 ± 5.3 days. Any morbidity and mortality were not encountered during a mean follow-up period of 4.8 ± 7.7 years. CONCLUSIONS The midterm results of stage 3 Fontan completion in patients with pulmonary artery >15 mmHg are encouraging. Not only the mean pulmonary artery pressure but also the pulmonary vascular resistance may be helpful in order to identify the high risk patients before Fontan completion.
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Affiliation(s)
- Arda Özyüksel
- Department of Cardiovascular Surgery, Biruni University, Istanbul, Turkey.,Department of Cardiovascular Surgery, Medicana International Hospital, Istanbul, Turkey
| | - Baran Şimşek
- Department of Cardiovascular Surgery, Medicana International Hospital, Istanbul, Turkey
| | - Ömer Özden
- Department of Cardiovascular Surgery, Medicana International Hospital, Istanbul, Turkey
| | - Şener Demiroluk
- Department of Anesthesiology, Medicana International Hospital, Istanbul, Turkey
| | - Murat Saygı
- Department of Pediatric Cardiology, Medicana International Hospital, Istanbul, Turkey
| | - Mehmet Salih Bilal
- Department of Cardiovascular Surgery, Medicana International Hospital, Istanbul, Turkey
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26
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Thrombosis and thromboprophylactic strategies in the adult with Fontan circulation. INTERNATIONAL JOURNAL OF CARDIOLOGY CONGENITAL HEART DISEASE 2020. [DOI: 10.1016/j.ijcchd.2020.100054] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022] Open
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27
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Ergün S, Yıldız O, Ayyıldız P, Çilsal E, Öztürk E, Onan İS, Güzeltaş A, Haydin S. Parameters affecting pleural drainage and management strategy after Fontan operation. J Card Surg 2020; 35:1556-1562. [DOI: 10.1111/jocs.14691] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Affiliation(s)
- Servet Ergün
- Department of Pediatric Cardiovascular Surgery Istanbul Mehmet Akif Ersoy Thoracic and Cardiovascular Surgery Education and Research Hospital Istanbul Turkey
- Vocational School of Health Services Istanbul Aydın Universty Istanbul Turkey
| | - Okan Yıldız
- Department of Pediatric Cardiovascular Surgery Istanbul Mehmet Akif Ersoy Thoracic and Cardiovascular Surgery Education and Research Hospital Istanbul Turkey
| | - Pelin Ayyıldız
- Department of Pediatric Cardiology Istanbul Mehmet Akif Ersoy Thoracic and Cardiovascular Surgery Education and Research Hospital Istanbul Turkey
| | - Erman Çilsal
- Department of Pediatric Cardiology Istanbul Mehmet Akif Ersoy Thoracic and Cardiovascular Surgery Education and Research Hospital Istanbul Turkey
| | - Erkut Öztürk
- Department of Pediatric Cardiology Istanbul Mehmet Akif Ersoy Thoracic and Cardiovascular Surgery Education and Research Hospital Istanbul Turkey
| | - İsmihan Selen Onan
- Department of Pediatric Cardiovascular Surgery Istanbul Mehmet Akif Ersoy Thoracic and Cardiovascular Surgery Education and Research Hospital Istanbul Turkey
| | - Alper Güzeltaş
- Department of Pediatric Cardiology Istanbul Mehmet Akif Ersoy Thoracic and Cardiovascular Surgery Education and Research Hospital Istanbul Turkey
| | - Sertaç Haydin
- Department of Pediatric Cardiovascular Surgery Istanbul Mehmet Akif Ersoy Thoracic and Cardiovascular Surgery Education and Research Hospital Istanbul Turkey
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