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Jayadeva PS, Peters S, Tee SL, Burchill LJ, Marasco SF, Grigg L, Leet A, McGiffin D, Zentner D. Characteristics and Outcomes of a Single-Centre Cohort of Adult Congenital Heart Disease Patients Referred for Heart Transplant. Heart Lung Circ 2024; 33:1184-1192. [PMID: 38609798 DOI: 10.1016/j.hlc.2024.02.019] [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: 08/16/2023] [Revised: 02/08/2024] [Accepted: 02/26/2024] [Indexed: 04/14/2024]
Abstract
BACKGROUND Adult congenital heart disease (ACHD) services increasingly encounter heart failure (HF) in the ageing ACHD population. Optimal timing of referral for heart transplant (HTx) evaluation in this heterogeneous population is complex and ill-defined. We aim to outline the characteristics and outcomes of ACHD patients referred for HTx from a large Australian ACHD centre. METHOD Retrospective review of ACHD patients referred for HTx from a primary ACHD centre (1992-2021). Database analysis of patient demographics, characteristics, wait-listing, and transplantation outcomes was performed. RESULTS A total of 45 patients (mean age 37±9.9 years old; 69% male) were referred for HTx with a mean follow-up of 5.9±6.3 years. Of these, 22 of 45 (49%) were listed and transplanted, including one heart-lung transplant. The commonest diagnosis was dextro-transposition of the great arteries (13/45, 29%). Most patients, 33 of 45 (73.3%) had undergone at least one cardiac surgery in childhood. Indications for HTx referral included HF in 34 of 45 (75%), followed by pulmonary hypertension in 7 of 45 (11%). Median transplant wait-list time was 145 days (interquartile range, 112-256). Of the 23 patients not wait-listed, the reasons included clinical stability in 13 of 45 (29%), psychosocial factors in 2 of 45 (4.4%) and prohibitive surgical risk, including multiorgan dysfunction, in 8 of 45 (17.7%). Transplant was of a single organ in most, 21 of 22 (95.5%). Overall mortality was 5 of 22 (22.7%) in those after HTx, and 14 of 23 (60.9%) in those not listed (p=0.0156). CONCLUSIONS Increasingly, ACHD patients demonstrate the need for advanced HF treatments. HTx decision-making is complex, and increased mortality is seen in those not wait-listed. Ultimately, the referral of ACHD patients for HTx is underpinned by local decision-making and experience, wait-list times and outcomes.
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Affiliation(s)
- Pavithra S Jayadeva
- Department of Cardiology, Royal Melbourne Hospital, Melbourne, Vic, Australia.
| | - Stacey Peters
- Department of Cardiology, Royal Melbourne Hospital, Melbourne, Vic, Australia
| | - Su Ling Tee
- Department of Cardiology and Cardiothoracic Surgery, Alfred Hospital, Vic, Australia
| | | | - Silvana F Marasco
- Department of Cardiology and Cardiothoracic Surgery, Alfred Hospital, Vic, Australia
| | - Leeanne Grigg
- Department of Cardiology, Royal Melbourne Hospital, Melbourne, Vic, Australia
| | - Angeline Leet
- Department of Cardiology and Cardiothoracic Surgery, Alfred Hospital, Vic, Australia
| | - David McGiffin
- Department of Cardiology and Cardiothoracic Surgery, Alfred Hospital, Vic, Australia
| | - Dominica Zentner
- Department of Cardiology, Royal Melbourne Hospital, Melbourne, Vic, Australia
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Herrick N, Urey M, Alshawabkeh L. Adults with Congenital Heart Disease and Transplant: Challenges, Opportunities, and Policy. Heart Fail Clin 2024; 20:167-174. [PMID: 38462321 DOI: 10.1016/j.hfc.2023.12.009] [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: 03/12/2024]
Abstract
The rate of heart transplantation in adults with congenital heart disease (ACHD) is rising, but the 1-year mortality posttransplantation remains higher than non-ACHD patients. A robust pretransplant assessment and operative and postoperative planning can mitigate much of the perioperative risk. Importantly, ACHD patients who survive the first year have significantly better 10-year survival compared with non-ACHD patients. The current allocation system gives ACHD patients a relatively high priority, but providers must use the prespecified exception requests for higher status, especially for patients with the Fontan circulation. It is vital that ACHD patients with end-stage heart failure are cared for at centers with ACHD subspecialty care.
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Affiliation(s)
- Nicole Herrick
- Division of Cardiovascular Medicine, Department of Medicine, University of Calilfornia San Francisco, 505 Parnassus Avenue, San Francisco, CA 94143, USA
| | - Marcus Urey
- Division of Cardiovascular Medicine, Department of Medicine, University of Calilfornia San Francisco, 505 Parnassus Avenue, San Francisco, CA 94143, USA
| | - Laith Alshawabkeh
- Adult Congenital Heart Disease Program, Division of Cardiovascular Medicine, Department of Medicine, University of California, San Diego, 9452 Med Center Drive, ACTRI-3E, Mail 7411, La Jolla, CA 92037, USA.
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3
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Téllez L, Payancé A, Tjwa E, Del Cerro MJ, Idorn L, Ovroutski S, De Bruyne R, Verkade HJ, De Rita F, de Lange C, Angelini A, Paradis V, Rautou PE, García-Pagán JC. EASL-ERN position paper on liver involvement in patients with Fontan-type circulation. J Hepatol 2023; 79:1270-1301. [PMID: 37863545 DOI: 10.1016/j.jhep.2023.07.013] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/06/2023] [Accepted: 07/06/2023] [Indexed: 10/22/2023]
Abstract
Fontan-type surgery is the final step in the sequential palliative surgical treatment of infants born with a univentricular heart. The resulting long-term haemodynamic changes promote liver damage, leading to Fontan-associated liver disease (FALD), in virtually all patients with Fontan circulation. Owing to the lack of a uniform definition of FALD and the competitive risk of other complications developed by Fontan patients, the impact of FALD on the prognosis of these patients is currently debatable. However, based on the increasing number of adult Fontan patients and recent research interest, the European Association for The Study of the Liver and the European Reference Network on Rare Liver Diseases thought a position paper timely. The aims of the current paper are: (1) to provide a clear definition and description of FALD, including clinical, analytical, radiological, haemodynamic, and histological features; (2) to facilitate guidance for staging the liver disease; and (3) to provide evidence- and experience-based recommendations for the management of different clinical scenarios.
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Affiliation(s)
- Luis Téllez
- Gastroenterology and Hepatology Department, Hospital Universitario Ramón y Cajal, Madrid, Spain; Instituto Ramón y Cajal de Investigación Sanitaria (IRYCIS), CIBEREHD (Centro de Investigación Biomédica en Red Enfermedades Hepáticas y Digestivas), University of Alcalá, Madrid, Spain
| | - Audrey Payancé
- DHU Unity, Pôle des Maladies de l'Appareil Digestif, Service d'Hépatologie, Hôpital Beaujon, AP-HP, Clichy, France; Université Denis Diderot-Paris 7, Sorbonne Paris Cité, Paris, France
| | - Eric Tjwa
- Department of Gastroenterology and Hepatology, Radboud University Medical Center, Nijmegen, The Netherlands
| | - María Jesús Del Cerro
- Pediatric Cardiology Department, Hospital Universitario Ramón y Cajal, Madrid, Spain; Instituto Ramón y Cajal de Investigación Sanitaria (IRYCIS), University of Alcalá, Madrid, Spain
| | - Lars Idorn
- Department of Pediatrics, Section of Pediatric Cardiology, Rigshospitalet, Copenhagen, Denmark
| | - Stanislav Ovroutski
- Department of Congenital Heart Disease/Pediatric Cardiology, Deutsches Herzzentrum Berlin, Berlin, Germany
| | - Ruth De Bruyne
- Department of Pediatric Gastroenterology, Hepatology and Nutrition, Ghent University Hospital, Belgium
| | - Henkjan J Verkade
- Department of Pediatrics, Beatrix Children's Hospital/University Medical Center Groningen, The Netherlands
| | - Fabrizio De Rita
- Adult Congenital and Paediatric Heart Unit, Freeman Hospital, Newcastle Upon Tyne Hospitals NHS Foundation Trust, Newcastle Upon Tyne, UK
| | - Charlotte de Lange
- Department of Pediatric Radiology, Queen Silvia Childrens' Hospital, Sahlgrenska University Hospital, Behandlingsvagen 7, 41650 Göteborg, Sweden
| | - Annalisa Angelini
- Pathology of Cardiac Transplantation and Regenerative Medicine Unit, Department of Cardiac, Thoracic and Vascular Sciences and Public Health, University of Padua, Padua, Italy
| | - Valérie Paradis
- Centre de recherche sur l'inflammation, INSERM1149, Université Paris Cité, Paris, France; Pathology Department, Beaujon Hospital, APHP.Nord, Clichy, France
| | - Pierre Emmanuel Rautou
- AP-HP, Service d'Hépatologie, Hôpital Beaujon, DMU DIGEST, Centre de Référence des Maladies Vasculaires du Foie, FILFOIE, Clichy, France; Université Paris-Cité, Inserm, Centre de recherche sur l'inflammation, UMR 1149, Paris, France
| | - Juan Carlos García-Pagán
- Barcelona Hepatic Hemodynamic Laboratory, Liver Unit, Hospital Clínic, Institut de Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Departament de Medicina i Ciències de la Salut, University of Barcelona, Barcelona, Spain; CIBEREHD (Centro de Investigación Biomédica en Red Enfermedades Hepáticas y Digestivas), Health Care Provider of the European Reference Network on Rare Liver Disorders (ERN-Liver), Spain.
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4
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Márquez-González H, Hernández-Vásquez JG, Del Valle-Lom M, Yáñez-Gutiérrez L, Klünder-Klünder M, Almeida-Gutiérrez E, Koretzky SG. Failures of the Fontan System in Univentricular Hearts and Mortality Risk in Heart Transplantation: A Systematic Review and Meta-Analysis. Life (Basel) 2021; 11:1363. [PMID: 34947894 PMCID: PMC8709145 DOI: 10.3390/life11121363] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2021] [Revised: 11/12/2021] [Accepted: 11/13/2021] [Indexed: 02/07/2023] Open
Abstract
The Fontan procedure (FP) is the standard surgical treatment for Univentricular heart diseases. Over time, the Fontan system fails, leading to pathologies such as protein-losing enteropathy (PLE), plastic bronchitis (PB), and heart failure (HF). FP should be considered as a transitional step to the final treatment: heart transplantation (HT). This systematic review and meta-analysis aims to establish the risk of death following HT according to the presence of FP complications. There was a total of 691 transplanted patients in the 18 articles, immediate survival 88% (n = 448), survival from 1 to 5 years of 78% (n = 427) and survival from 5.1 to 10 years of 69% (n = 208), >10 years 61% (n = 109). The relative risk (RR) was 1.12 for PLE (95% confidence interval [CI] = 0.89-1.40, p = 0.34), 1.03 for HF (0.7-1.51, p = 0.88), 0.70 for Arrhythmias (0.39-1.24, p = 0.22), 0.46 for PB (0.08-2.72, p = 0.39), and 5.81 for CKD (1.70-19.88, p = 0.005). In patients with two or more failures, the RR was 1.94 (0.99-3.81, p = 0.05). After FP, the risk of death after HT is associated with CKD and with the presence of two or more failures.
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Affiliation(s)
- Horacio Márquez-González
- Department of Clinical Research, Federico Gómez Children’s Hospital, Mexico City 06720, Mexico; (H.M.-G.); (J.G.H.-V.); (M.D.V.-L.); (M.K.-K.)
- Centro Médico Nacional Siglo XXI, IMSS, Department Congenital Heart Diseases, Mexico City 06720, Mexico; (L.Y.-G.); (E.A.-G.)
| | - Jose Gustavo Hernández-Vásquez
- Department of Clinical Research, Federico Gómez Children’s Hospital, Mexico City 06720, Mexico; (H.M.-G.); (J.G.H.-V.); (M.D.V.-L.); (M.K.-K.)
| | - Montserrat Del Valle-Lom
- Department of Clinical Research, Federico Gómez Children’s Hospital, Mexico City 06720, Mexico; (H.M.-G.); (J.G.H.-V.); (M.D.V.-L.); (M.K.-K.)
| | - Lucelli Yáñez-Gutiérrez
- Centro Médico Nacional Siglo XXI, IMSS, Department Congenital Heart Diseases, Mexico City 06720, Mexico; (L.Y.-G.); (E.A.-G.)
| | - Miguel Klünder-Klünder
- Department of Clinical Research, Federico Gómez Children’s Hospital, Mexico City 06720, Mexico; (H.M.-G.); (J.G.H.-V.); (M.D.V.-L.); (M.K.-K.)
| | - Eduardo Almeida-Gutiérrez
- Centro Médico Nacional Siglo XXI, IMSS, Department Congenital Heart Diseases, Mexico City 06720, Mexico; (L.Y.-G.); (E.A.-G.)
| | - Solange Gabriela Koretzky
- Department of Clinical Research, Nacional de Cardiología “Ignacio Chávez”, Mexico City 14080, Mexico
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5
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Téllez L, Rodríguez de Santiago E, Albillos A. Fontan-Associated Liver Disease: Pathophysiology, Staging, and Management. Semin Liver Dis 2021; 41:538-550. [PMID: 34399435 DOI: 10.1055/s-0041-1732355] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
Fontan-associated liver disease is the term used to encompass the disorders arising from abnormal hemodynamic alterations and systemic venous congestion after the Fontan procedure. The histological changes produced in the liver are similar but not equivalent to those seen in other forms of cardiac liver disease. While the natural history of this form of liver disease is poorly established, many Fontan patients ultimately develop portal hypertension-related complications such as ascites, esophageal varices, malnutrition, and encephalopathy. Fontan survivors also show an elevated risk of hepatocellular carcinoma. Adequate staging of the liver damage is essential to anticipate screening strategies and improve global management.
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Affiliation(s)
- Luis Téllez
- Department of Gastroenterology and Hepatology, Hospital Universitario Ramón y Cajal, Instituto Ramón y Cajal de Investigación Sanitaria (IRYCIS), Centro de Investigación Biomédica en Red (CIBEREHD), Universidad de Alcalá, Madrid, Spain
| | - Enrique Rodríguez de Santiago
- Department of Gastroenterology and Hepatology, Hospital Universitario Ramón y Cajal, Instituto Ramón y Cajal de Investigación Sanitaria (IRYCIS), Centro de Investigación Biomédica en Red (CIBEREHD), Universidad de Alcalá, Madrid, Spain
| | - Agustín Albillos
- Department of Gastroenterology and Hepatology, Hospital Universitario Ramón y Cajal, Instituto Ramón y Cajal de Investigación Sanitaria (IRYCIS), Centro de Investigación Biomédica en Red (CIBEREHD), Universidad de Alcalá, Madrid, Spain
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6
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Heart Transplantation in Adult Congenital Heart Disease with the Organ Care System Use: A 4-Year Single-Center Experience. ASAIO J 2021; 67:862-868. [PMID: 34039886 DOI: 10.1097/mat.0000000000001482] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
Recent advances in the management of patients with adult congenital heart disease (ACHD) have led to an increased number of patients who may develop heart failure and require heart transplantation (HTx). The purpose of this study was to evaluate early and mid-term postoperative outcomes after HTx with the use of Organ Care System (OCS) in a cohort of ACHD patients transplanted at our tertiary center. All consecutive HTx performed from January 2015 to January 2019 at our institution were analyzed. Donor and recipient preoperative characteristics, intraoperative course, and perioperative clinical outcomes were evaluated. Nine patients with median age of 44 years (range 17-61 years) underwent isolated HTx for end-stage ACHD during the study period. Mean cold ischemic time was 84 ± 17 minutes. Postoperatively, four patients (44%) needed venoarterial extracorporeal membrane oxygenation (1-7 days). One patient (11%) required surgical re-exploration for bleeding. Thirty-day and 1-year mortality were 11% and 22%, respectively. In our experience, despite the challenges of transplantation in ACHD, these patients can be successfully transplanted with the use of the OCS in a highly specialized center. Careful donor and recipient selection are of paramount importance.
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7
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McNamara JR, McMahon A, Griffin M. Perioperative Management of the Fontan Patient for Cardiac and Noncardiac Surgery. J Cardiothorac Vasc Anesth 2021; 36:275-285. [PMID: 34023201 DOI: 10.1053/j.jvca.2021.04.021] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/29/2020] [Revised: 04/05/2021] [Accepted: 04/12/2021] [Indexed: 11/11/2022]
Abstract
The Fontan circulation is the single-ventricle approach to surgical palliation of complex congenital heart disease wherein biventricular separation and function cannot be safely achieved. Incremental improvements in this surgical technique, along with improvements in the long-term medical management of these patients, have led to greater survival of these patients and a remarkably steady increase in the number of adults living with this unusual circulation and physiology. This has implications for healthcare providers who now have a greater chance of encountering Fontan patients during the course of their practice. This has particularly important implications for anesthesiologists because the effects of their interventions on the finely balanced Fontan circulation may be profound. The American Heart Association and American College of Cardiology recommend that, when possible, elective surgery should be performed in an adult congenital heart disease center, although this may not be feasible in the provision of true emergency care. This review article summarizes the pathophysiology pertinent to the provision of anesthesia in this complex patient group and describes important modifications to anesthetic technique and perioperative management.
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Affiliation(s)
- John Richard McNamara
- Department of Anaesthesiology and Intensive Care Medicine, Mater Misericordiae University Hospital, Dublin, Ireland.
| | - Aisling McMahon
- Department of Anaesthesiology and Intensive Care Medicine, Mater Misericordiae University Hospital, Dublin, Ireland
| | - Michael Griffin
- Department of Anaesthesiology and Intensive Care Medicine, Mater Misericordiae University Hospital, Dublin, Ireland
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8
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Kainuma A, Ning Y, Kurlansky PA, Axsom K, Farr M, Sayer G, Uriel N, Lewis MJ, Rosenbaum MS, Kalfa D, LaPar DJ, Bacha EA, Takayama H, Naka Y, Takeda K. Cardiac transplantation in adult congenital heart disease with prior sternotomy. Clin Transplant 2021; 35:e14229. [PMID: 33476438 DOI: 10.1111/ctr.14229] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2020] [Revised: 01/10/2021] [Accepted: 01/12/2021] [Indexed: 12/17/2022]
Abstract
BACKGROUND Adult congenital heart disease (ACHD) patients who require orthotopic heart transplantation are surgically complex due to anatomical abnormalities and multiple prior surgeries. In this study, we investigated these patients' outcomes using our institutional database. METHODS ACHD patients who had prior intracardiac repair and subsequent heart transplant were included (2008-2018). Adult patients without ACHD were extracted as a control. A comparison of patients with functional single ventricular (SV) and biventricular (BV) hearts was performed. RESULTS There were 9 SV and 24 BV patients. The SV group had higher central venous pressure/pulmonary capillary wedge pressure (P = .028), hemoglobin concentration (P = .010), alkaline phosphatase (P = .022), and were more likely to have liver congestion (P = .006). Major complications included infection in 16 (48.5%), temporary dialysis in 12 (36.4%), and graft dysfunction requiring perioperative mechanical support in 7 (21.2%). Overall in-hospital mortality was 15.2%. Kaplan-Meier analysis showed a higher, but not statistically significant, survival after 10 years between the ACHD and control groups (ACHD 84.9% vs. control 67.5%, P = .429). There was no significant difference in 10-year survival between SV and BV groups (78% vs. 88%, P = .467). CONCLUSIONS Complex ACHD cardiac transplant recipients have a high incidence of early morbidities after transplantation. However, long-term outcomes were acceptable.
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Affiliation(s)
- Atsushi Kainuma
- Department of Cardiovascular Surgery, Columbia University Medical Center, New York, NY, USA
| | - Yuming Ning
- Center for Innovation and Outcomes Research, Columbia University Medical Center, New York, NY, USA
| | - Paul A Kurlansky
- Department of Surgery CT, Columbia University Medical Center, New York, NY, USA
| | - Kelly Axsom
- Department of Medicine Cardiology, Columbia University Medical Center, New York, NY, USA
| | - Maryjane Farr
- Department of Medicine Cardiology, Columbia University Medical Center, New York, NY, USA
| | - Gabriel Sayer
- Department of Medicine, The University of Chicago Medicine, Chicago, IL, USA
| | - Nir Uriel
- Department of Medicine Cardiology, Columbia University Medical Center, New York, NY, USA
| | - Matthew J Lewis
- Department of Medicine Cardiology, Columbia University Medical Center, New York, NY, USA
| | - Marlon S Rosenbaum
- Department of Medicine Cardiology, Columbia University Medical Center, New York, NY, USA
| | - David Kalfa
- Pediatric Cardiac Surgery, Columbia University Medical Center, Morgan Stanley Children's Hospital, New York, NY, USA
| | - Damien J LaPar
- Department of Surgery CT, Columbia University Medical Center, New York, NY, USA
| | - Emile A Bacha
- Pediatric Cardiac Surgery, Columbia University Medical Center, Morgan Stanley Children's Hospital, New York, NY, USA
| | - Hiroo Takayama
- Department of Cardiovascular Surgery, Columbia University Medical Center, New York, NY, USA
| | - Yoshifumi Naka
- Department of Cardiovascular Surgery, Columbia University Medical Center, New York, NY, USA
| | - Koji Takeda
- Department of Cardiovascular Surgery, Columbia University Medical Center, New York, NY, USA
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Chih S, McDonald M, Dipchand A, Kim D, Ducharme A, Kaan A, Abbey S, Toma M, Anderson K, Davey R, Mielniczuk L, Campbell P, Zieroth S, Bourgault C, Badiwala M, Clarke B, Belanger E, Carrier M, Conway J, Doucette K, Giannetti N, Isaac D, MacArthur R, Senechal M. Canadian Cardiovascular Society/Canadian Cardiac Transplant Network Position Statement on Heart Transplantation: Patient Eligibility, Selection, and Post-Transplantation Care. Can J Cardiol 2020; 36:335-356. [PMID: 32145863 DOI: 10.1016/j.cjca.2019.12.025] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2019] [Revised: 12/16/2019] [Accepted: 12/17/2019] [Indexed: 12/17/2022] Open
Abstract
Significant practice-changing developments have occurred in the care of heart transplantation candidates and recipients over the past decade. This Canadian Cardiovascular Society/Canadian Cardiac Transplant Network Position Statement provides evidence-based, expert panel recommendations with values and preferences, and practical tips on: (1) patient selection criteria; (2) selected patient populations; and (3) post transplantation surveillance. The recommendations were developed through systematic review of the literature and using the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) system. The evolving areas of importance addressed include transplant recipient age, frailty assessment, pulmonary hypertension evaluation, cannabis use, combined heart and other solid organ transplantation, adult congenital heart disease, cardiac amyloidosis, high sensitization, and post-transplantation management of antibodies to human leukocyte antigen, rejection, cardiac allograft vasculopathy, and long-term noncardiac care. Attention is also given to Canadian-specific management strategies including the prioritization of highly sensitized transplant candidates (status 4S) and heart organ allocation algorithms. The focus topics in this position statement highlight the increased complexity of patients who undergo evaluation for heart transplantation as well as improved patient selection, and advances in post-transplantation management and surveillance that have led to better long-term outcomes for heart transplant recipients.
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Affiliation(s)
- Sharon Chih
- University of Ottawa Heart Institute, Ottawa, Ontario, Canada.
| | - Michael McDonald
- Peter Munk Cardiac Centre, University Health Network, Toronto, Ontario, Canada
| | - Anne Dipchand
- Labatt Family Heart Centre, Hospital for Sick Children, Department of Paediatrics, University of Toronto, Toronto, Ontario, Canada
| | - Daniel Kim
- University of Alberta, Edmonton, Alberta, Canada
| | - Anique Ducharme
- Institut de Cardiologie de Montréal, Université de Montréal, Montréal, Québec, Canada
| | | | - Susan Abbey
- Centre for Mental Health, University Health Network and Department of Psychiatry, University of Toronto, Toronto, Ontario, Canada
| | - Mustafa Toma
- University of British Columbia, Vancouver, British Columbia, Canada
| | - Kim Anderson
- Halifax Infirmary, Department of Medicine-Cardiology, Dalhousie University, Halifax, Nova Scotia, Canada
| | - Ryan Davey
- University of Western Ontario, London, Ontario, Canada
| | - Lisa Mielniczuk
- University of Ottawa Heart Institute, Ottawa, Ontario, Canada
| | | | | | - Christine Bourgault
- Institut Universitaire de Cardiologie et de Pneumologie de Québec, Québec, Québec
| | - Mitesh Badiwala
- Peter Munk Cardiac Centre, University Health Network and Department of Surgery, University of Toronto, Toronto, Ontario, Canada
| | | | | | - Michel Carrier
- Department of Surgery, Montreal Heart Institute, Université de Montréal, Montreal, Quebec, Canada
| | - Jennifer Conway
- Stollery Children's Hospital, University of Alberta, Edmonton, Alberta, Canada
| | | | | | - Debra Isaac
- University of Calgary, Calgary, Alberta, Canada
| | | | - Mario Senechal
- Institut Universitaire de Cardiologie et de Pneumologie de Québec (IUCPQ), Université Laval, Laval, Québec, Canada
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10
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McMahon A, McNamara J, Griffin M. A Review of Heart Transplantation for Adults With Congenital Heart Disease. J Cardiothorac Vasc Anesth 2020; 35:752-762. [PMID: 32839039 DOI: 10.1053/j.jvca.2020.07.027] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/19/2019] [Revised: 06/30/2020] [Accepted: 07/05/2020] [Indexed: 12/16/2022]
Abstract
As techniques for corrective and palliative surgery in congenital heart disease improve, the number of patients surviving to become adults with congenital heart disease (ACHD) has increased. A significant proportion of these patients will progress to develop advanced heart failure, the symptoms of which vary, complicating prediction of life expectancy. Unlike acquired heart failure, there is a lack of evidence-based treatments with which to relieve symptoms and prolong survival. As a result, a number of ACHD patients will proceed to heart transplantation. Referral for transplantation should be considered early, given the difficulties with prognostication, and should take place in a center with surgical and medical expertise in the management of ACHD patients and transplantation. In addition to assessing contraindications to heart transplantation for the general population, factors specific to ACHD should be considered. These include pulmonary hypertension, cyanosis, liver disease, previous surgeries, and the degree of allosensitization. Once listed for transplantation, ACHD patients spend longer on the waitlist, and are more likely to die or be delisted than their non-ACHD counterparts. Mechanical circulatory support is used less commonly as a bridge to transplantation given the difficulties with implantation and unfamiliarity of use. Recent evidence suggests that with increased experience and early consideration, mechanical circulatory support can be used successfully as a bridging therapy. Despite a higher early mortality, long-term survival is greater for ACHD patients after transplant due to younger age and relative lack of comorbidities. With early referral, careful assessment of each individual's unique anatomy and physiology, and care in a center experienced with ACHD patients and transplantation, outcomes will continue to improve.
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Affiliation(s)
- Aisling McMahon
- Department of Anaesthesiology and Intensive Care Medicine, Mater Misericordiae University Hospital, Dublin, Ireland.
| | - John McNamara
- Department of Anaesthesiology and Intensive Care Medicine, Mater Misericordiae University Hospital, Dublin, Ireland
| | - Michael Griffin
- Department of Anaesthesiology and Intensive Care Medicine, Mater Misericordiae University Hospital, Dublin, Ireland
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11
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Hernandez GA, Lemor A, Clark D, Blumer V, Burstein D, Byrne R, Fowler R, Frischhertz B, Sandhaus E, Schlendorf K, Zalawadiya S, Lindenfeld J, Menachem JN. Heart transplantation and in‐hospital outcomes in adult congenital heart disease patients with Fontan: A decade nationwide analysis from 2004 to 2014. J Card Surg 2020; 35:603-608. [DOI: 10.1111/jocs.14430] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Affiliation(s)
- Gabriel A. Hernandez
- Cardiovascular Division, Department of MedicineUniversity of Mississippi Medical Center Jackson Mississippi
| | - Alejandro Lemor
- Cardiovascular Division, Department of MedicineHenry Ford Hospital Detroit Michigan
| | - Daniel Clark
- Cardiovascular Division, Department of MedicineVanderbilt University Medical Center Nashville Tennessee
| | - Vanessa Blumer
- Cardiovascular Division, Department of MedicineDuke University Durham North Carolina
| | - Danielle Burstein
- Cardiology DivisionChildren's Hospital of Philadelphia Philadelphia Pennsylvania
| | - Ryan Byrne
- Department of MedicineVanderbilt University Medical Cente Nashville Tennessee
| | - Rachel Fowler
- Cardiovascular Division, Department of MedicineVanderbilt University Medical Center Nashville Tennessee
| | - Benjamin Frischhertz
- Cardiovascular Division, Department of MedicineVanderbilt University Medical Center Nashville Tennessee
| | - Emily Sandhaus
- Cardiovascular Division, Department of MedicineVanderbilt University Medical Center Nashville Tennessee
| | - Kelly Schlendorf
- Cardiovascular Division, Department of MedicineVanderbilt University Medical Center Nashville Tennessee
| | - Sandip Zalawadiya
- Cardiovascular Division, Department of MedicineVanderbilt University Medical Center Nashville Tennessee
| | - JoAnn Lindenfeld
- Cardiovascular Division, Department of MedicineVanderbilt University Medical Center Nashville Tennessee
| | - Jonathan N. Menachem
- Cardiovascular Division, Department of MedicineVanderbilt University Medical Center Nashville Tennessee
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12
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Konno R, Tatebe S, Sugimura K, Satoh K, Aoki T, Miura M, Suzuki H, Yamamoto S, Sato H, Terui Y, Miyata S, Adachi O, Kimura M, Saiki Y, Shimokawa H. Prognostic value of the model for end-stage liver disease excluding INR score (MELD-XI) in patients with adult congenital heart disease. PLoS One 2019; 14:e0225403. [PMID: 31743362 PMCID: PMC6863541 DOI: 10.1371/journal.pone.0225403] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2019] [Accepted: 11/04/2019] [Indexed: 12/14/2022] Open
Abstract
Patients with adult congenital heart disease (ACHD) are at increased risk of developing late cardiovascular complication. However, little is known about the predictive factors for long-term outcome. The Model for End-Stage Liver Disease eXcluding INR (MELD-XI) score was originally developed to assess cirrhotic patients and has the prognostic value for heart failure (HF) patients. In the present study, we examined whether the score also has the prognostic value in this population. We retrospectively examined 637 ACHD patients (mean age 31.0 years) who visited our Tohoku University hospital from 1995 to 2015. MELD-XI score was calculated as follows; 11.76 x ln(serum creatinine) + 5.11 x ln(serum total bilirubin) + 9.44. We compared the long-term outcomes between the high (≥10.4) and the low (<10.4) score groups. The cutoff value of MELD-XI score was determined based on the survival classification and regression tree (CART) analysis. The major adverse cardiac event (MACE) was defined as a composite of cardiac death, HF hospitalization, and lethal ventricular arrhythmias. During a mean follow-up period of 8.6 years (interquartile range 4.4–11.4 years), MACE was noted in 51 patients, including HF hospitalization in 37, cardiac death in 8, and lethal ventricular arrhythmias in 6. In Kaplan-Meier analysis, the high score group had significantly worse MACE-free survival compared with the low score group (log-rank, P<0.001). Multivariable Cox regression analysis showed that the MELD-XI score remained a significant predictor of MACE (hazard ratio 1.36, confidence interval 1.17–1.58, P<0.001) even after adjusting for patient characteristics, such as sex, functional status, estimated glomerular filtration rate, and cardiac function. Furthermore, CART analysis revealed that the MELD-XI score was the most important variable for predicting MACE. These results demonstrate that the MELD-XI score can effectively predict MACE in ACHD patients, indicating that ACHD patients with high MELD-XI score need to be closely followed.
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Affiliation(s)
- Ryo Konno
- Department of Cardiovascular Medicine, Tohoku University Graduate School of Medicine, Sendai, Japan
| | - Shunsuke Tatebe
- Department of Cardiovascular Medicine, Tohoku University Graduate School of Medicine, Sendai, Japan
| | - Koichiro Sugimura
- Department of Cardiovascular Medicine, Tohoku University Graduate School of Medicine, Sendai, Japan
| | - Kimio Satoh
- Department of Cardiovascular Medicine, Tohoku University Graduate School of Medicine, Sendai, Japan
| | - Tatsuo Aoki
- Department of Cardiovascular Medicine, Tohoku University Graduate School of Medicine, Sendai, Japan
| | - Masanobu Miura
- Department of Cardiovascular Medicine, Tohoku University Graduate School of Medicine, Sendai, Japan
| | - Hideaki Suzuki
- Department of Cardiovascular Medicine, Tohoku University Graduate School of Medicine, Sendai, Japan
| | - Saori Yamamoto
- Department of Cardiovascular Medicine, Tohoku University Graduate School of Medicine, Sendai, Japan
| | - Haruka Sato
- Department of Cardiovascular Medicine, Tohoku University Graduate School of Medicine, Sendai, Japan
| | - Yosuke Terui
- Department of Cardiovascular Medicine, Tohoku University Graduate School of Medicine, Sendai, Japan
| | - Satoshi Miyata
- Department of Evidence-Based Cardiovascular Medicine, Tohoku University Graduate School of Medicine, Sendai, Japan
| | - Osamu Adachi
- Department of Cardiovascular Surgery, Tohoku University Graduate School of Medicine, Sendai, Japan
| | - Masato Kimura
- Department of Pediatrics, Tohoku University Graduate School of Medicine, Sendai, Japan
| | - Yoshikatsu Saiki
- Department of Cardiovascular Surgery, Tohoku University Graduate School of Medicine, Sendai, Japan
| | - Hiroaki Shimokawa
- Department of Cardiovascular Medicine, Tohoku University Graduate School of Medicine, Sendai, Japan
- Department of Evidence-Based Cardiovascular Medicine, Tohoku University Graduate School of Medicine, Sendai, Japan
- * E-mail:
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13
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Lebray P, Varnous S. Combined heart and liver transplantation: State of knowledge and outlooks. Clin Res Hepatol Gastroenterol 2019; 43:123-130. [PMID: 30635235 DOI: 10.1016/j.clinre.2018.08.009] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/20/2018] [Revised: 08/05/2018] [Accepted: 08/15/2018] [Indexed: 02/08/2023]
Abstract
Various types of liver impairment have been described in patients with end-stage heart failure who are awaiting heart transplantation. The liver impairment may be severe, characterized by a high model for end-stage liver disease (MELD) Score and/or the presence of ascites, both of which are associated with a high risk of failure after single heart transplantation. A liver function assessment is therefore necessary before registration on the heart transplant list, moreover in case of long-developing heart failure, such as with congenital heart disease or in the presence of risk factors for chronic liver disease including excessive alcohol consumption, metabolic syndrome or chronic viral hepatitis B or C. In these instances, screening for cirrhosis with liver biopsy and for hepatocellular carcinoma through imaging must be systematic and when present, the indication for combined heart-liver transplantation must be considered. Its benefits, however, in case of liver failure with a high MELD score or multi-organ failure remains to be demonstrated. An exception in which the liver shows no morphological or functional alteration is with familial amyloid neuropathy, during which moderate to severe heart failure implies surgical treatment consisting of a liver or even heart-liver transplantation. These must be done early and are mainly contraindicated according to the level of neurological damage.
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Affiliation(s)
- Pascal Lebray
- Hepato-gastroenterology department, hôpital de la Pitié-Salpêtrière (AP-HP), 47-83, boulevard de l'Hôpital, 75013 Paris, France.
| | - Shaida Varnous
- Cardio-thoracic surgery department, hôpital de la Pitié-Salpêtrière (AP-HP), 47-83, boulevard de l'Hôpital, 75013 Paris, France
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14
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Abstract
Heart failure remains the most common cause of morbidity and mortality in adults with congenital heart disease (CHD). Although gender-specific outcomes are not robust, it seems that women with CHD may be more affected by late heart failure (HF) than men. A specialized and experienced adult CHD team is required to care for these women as they age, including assessment for reversible causes of HF and in the management of pregnancy, labor, and delivery.
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15
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Adams ED, Jackson NJ, Young T, DePasquale EC, Reardon LC. Prognostic utility of MELD-XI in adult congenital heart disease patients undergoing cardiac transplantation. Clin Transplant 2018; 32:e13257. [PMID: 29660764 DOI: 10.1111/ctr.13257] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/01/2018] [Indexed: 11/29/2022]
Abstract
BACKGROUND Model of End-Stage Liver Disease eXcluding INR (MELD-XI) at cardiac transplant has demonstrated prognostic survival utility, but has not been specifically validated in adult congenital heart disease (ACHD) in a registry study. METHODS Adults undergoing first-time orthotopic heart transplant from 2005 to 2015 in the United Network for Organ Sharing (UNOS) registry were examined in parallel: ACHD (n = 543), ischemic-dilated cardiomyopathy (IDCM, n = 6954) and valvular heart disease (VHD, n = 355). Our primary endpoint was a composite of death, graft failure, and retransplantation assessed at 3 months (early), and those with freedom from early endpoint were reassessed at 5 years (late). Interactions between hepatorenal indices and waitlist time were examined. Secondary outcomes relating to long-term morbidity were assessed at late endpoint. Freedom from endpoint analysis in ACHD at clinically relevant endpoints was also conducted. RESULTS Model of End-Stage Liver Disease eXcluding INR score at transplant associated with an increased risk of early endpoint in all cohorts. At late endpoint, bilirubin level associated with increased risk uniquely in ACHD. CONCLUSIONS Model of End-Stage Liver Disease eXcluding INR holds prognostic application to ACHD in early time points and demonstrates unique waitlist interactions. Transplant bilirubin level may hold significance in long-term risk stratification of the ACHD population. Time on waitlist is an important consideration to contextualize these values.
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Affiliation(s)
- Evan D Adams
- David Geffen School of Medicine, UCLA, Los Angeles, CA, USA
| | | | - Tim Young
- Department of Internal Medicine, UCLA, Los Angeles, CA, USA
| | - Eugene C DePasquale
- Division of Cardiology, UCLA Advanced Heart Failure, Heart Transplantation and Mechanical Circulatory Support Program, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA
| | - Leigh C Reardon
- Division of Cardiology, Ahmanson/UCLA Adult Congenital Heart Disease Center, David Geffen School of Medicine, Los Angeles, CA, USA.,Division of Pediatric Cardiology, Mattel Children's Hospital UCLA, David Geffen School of Medicine, Los Angeles, CA, USA
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16
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Transplantation and Mechanical Circulatory Support in Adult Congenital Heart Disease-Related Advanced Heart Failure. HEART FAILURE IN ADULT CONGENITAL HEART DISEASE 2018. [DOI: 10.1007/978-3-319-77803-7_13] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
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17
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Van De Bruaene A, Meier L, Droogne W, De Meester P, Troost E, Gewillig M, Budts W. Management of acute heart failure in adult patients with congenital heart disease. Heart Fail Rev 2017; 23:1-14. [DOI: 10.1007/s10741-017-9664-x] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
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18
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Daniels CJ, Bradley EA, Landzberg MJ, Aboulhosn J, Beekman RH, Book W, Gurvitz M, John A, John B, Marelli A, Marino BS, Minich LL, Poterucha JJ, Rand EB, Veldtman GR. Fontan-Associated Liver Disease. J Am Coll Cardiol 2017; 70:3173-3194. [DOI: 10.1016/j.jacc.2017.10.045] [Citation(s) in RCA: 110] [Impact Index Per Article: 15.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
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Abstract
PURPOSE OF REVIEW Hypoplastic left heart syndrome (HLHS) is characterized by underdevelopment of the mitral valve, left ventricle, and aorta and is ultimately palliated with a single-ventricle repair. Universally fatal in infancy prior to the advent of modern surgical techniques, the majority of HLHS patients will now reach adulthood. However, despite improvements in early survival, the HLHS population continues to face significant morbidity and early mortality. This review delineates common sources of patient morbidity and highlights areas in need of additional research for this growing segment of the adult congenital heart disease population. RECENT FINDINGS It has become increasingly clear that palliated adult single ventricle patients, like those with HLHS, face significant life-long morbidity from elevated systemic venous pressures as a consequence of the Fontan procedure. Downstream organ dysfunction secondary to elevated Fontan pressures has the potential to significantly impact long-term management decisions, including strategies of organ allocation. Because of the presence of a morphologic systemic right ventricle, HLHS patients may be at even higher risk than other adult patients with a Fontan. Because the adult HLHS population continues to grow, recognition of common sources of patient morbidity and mortality is becoming increasingly important. A coordinated effort between patients and providers is necessary to address the many remaining areas of clinical uncertainty to help ensure continued improvement in patient prognosis and quality of life.
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Matsuda H, Ichikawa H, Ueno T, Sawa Y. Heart transplantation for adults with congenital heart disease: current status and future prospects. Gen Thorac Cardiovasc Surg 2017; 65:309-320. [PMID: 28439697 DOI: 10.1007/s11748-017-0777-x] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2017] [Accepted: 04/10/2017] [Indexed: 02/07/2023]
Abstract
Increased survival rates after corrective or palliative surgery for complex congenital heart disease (CHD) in infancy and childhood are now being coupled with increased numbers of patients who survive to adulthood with various residual lesions or sequelae. These patients are likely to deteriorate in cardiac function or end-organ function, eventually requiring lifesaving treatment including heart transplantation. Although early and late outcomes of heart transplantation have been improving for adult survivors of CHD, outcomes and pretransplant management could still be improved. Survivors of Fontan procedures are a vulnerable cohort, particularly when single ventricle physiology fails, mostly with protein-losing enteropathy and hepatic dysfunction. Therefore, we reviewed single-institution and larger database analyses of adults who underwent heart transplantation for CHD, to enable risk stratification by identifying the indications and outcomes. As the results, despite relatively high early mortality, long-term results were encouraging after heart transplantation. However, further investigations are needed to improve the indication criteria for complex CHD, especially for failed Fontan. In addition, the current system of status criteria and donor heart allocation system in heart transplantation should be arranged as suitable for adults with complex CHD. Furthermore, there is a strong need to develop ventricular assist devices as a bridge to transplantation or destination therapy, especially where right-sided circulatory support is needed.
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Affiliation(s)
- Hikaru Matsuda
- Professor Emeritus Osaka University, Cardiovascular Surgery, Higashi-Takarazuka Satoh Hospital, Nagao-cho 2-1, Takarazuka, Hyogo, Japan.
| | - Hajime Ichikawa
- Division of Pediatric Cardiac Sergey, National Cerebral and Cardiovascular Center, Suita, Osaka, Japan
| | - Takayoshi Ueno
- Department of Cardiovascular Surgery, Graduate School of Medicine, Osaka University, Suita, Osaka, Japan
| | - Yoshiki Sawa
- Department of Cardiovascular Surgery, Graduate School of Medicine, Osaka University, Suita, Osaka, Japan
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21
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Subramaniam K, Nazarnia S. Noteworthy Literature Published in 2016 for Thoracic Organ Transplantation Anesthesiologists. Semin Cardiothorac Vasc Anesth 2017; 21:45-57. [DOI: 10.1177/1089253216688537] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
This article is first in the series to review the published literature on perioperative issues in patients undergoing thoracic solid organ transplantations. We present recent literature from 2016 on preoperative considerations, organ preservation, intraoperative anesthesia management, surgical techniques, postoperative complications, and the impact of perioperative management on short- and long-term outcomes that are pertinent to thoracic transplantation anesthesiologists.
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22
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Burchill LJ. Heart transplantation in adult congenital heart disease. Heart 2016; 102:1871-1877. [DOI: 10.1136/heartjnl-2015-309074] [Citation(s) in RCA: 35] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/19/2016] [Revised: 06/15/2016] [Accepted: 06/29/2016] [Indexed: 11/04/2022] Open
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