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Peterson JK, Clarke S, Gelb BD, Kasparian NA, Kazazian V, Pieciak K, Pike NA, Setty SP, Uveges MK, Rudd NA. Trisomy 21 and Congenital Heart Disease: Impact on Health and Functional Outcomes From Birth Through Adolescence: A Scientific Statement From the American Heart Association. J Am Heart Assoc 2024:e036214. [PMID: 39263820 DOI: 10.1161/jaha.124.036214] [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: 04/24/2024] [Accepted: 04/24/2024] [Indexed: 09/13/2024]
Abstract
Due to improvements in recognition and management of their multisystem disease, the long-term survival of infants, children, and adolescents with trisomy 21 and congenital heart disease now matches children with congenital heart disease and no genetic condition in many scenarios. Although this improved survival is a triumph, individuals with trisomy 21 and congenital heart disease have unique and complex care needs in the domains of physical, developmental, and psychosocial health, which affect functional status and quality of life. Pulmonary hypertension and single ventricle heart disease are 2 known cardiovascular conditions that reduce life expectancy in individuals with trisomy 21. Multisystem involvement with respiratory, endocrine, gastrointestinal, hematological, neurological, and sensory systems can interact with cardiovascular health concerns to amplify adverse effects. Neurodevelopmental, psychological, and functional challenges can also affect quality of life. A highly coordinated interdisciplinary care team model, or medical home, can help address these complex and interactive conditions from infancy through the transition to adult care settings. The purpose of this Scientific Statement is to identify ongoing cardiovascular and multisystem, developmental, and psychosocial health concerns for children with trisomy 21 and congenital heart disease from birth through adolescence and to provide a framework for monitoring and management to optimize quality of life and functional status.
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Constantine A, Ferrero P, Gribaudo E, Mitropoulou P, Krishnathasan K, Costola G, Lwin MT, Fitzsimmons S, Brida M, Montanaro C, Kempny A, Heng EL, Chessa M, Dimopoulos K, Rafiq I. Morbidity and mortality in adults with a Fontan circulation beyond the fourth decade of life. Eur J Prev Cardiol 2024; 31:1316-1323. [PMID: 38306409 DOI: 10.1093/eurjpc/zwae031] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/05/2023] [Revised: 01/02/2024] [Accepted: 01/15/2024] [Indexed: 02/04/2024]
Abstract
AIMS To evaluate the late outcomes of adults (above 35 years) with a Fontan-type circulation, for whom current data on morbidity and mortality are lacking. METHODS AND RESULTS Data were collected retrospectively on consecutive patients with Fontan circulation above the age of 35 years followed in three European specialist centres. Overall, 115 Fontan patients were included [median age 35 (range 35-48) years, 47.8% female]. The most common underlying congenital heart disease diagnosis was tricuspid atresia (n = 58, 50.4%), and the age at first Fontan completion was 9.1 (interquartile range 5.0-15.8) years. Almost two-thirds (61.7%) of patients had undergone an atriopulmonary Fontan, and 23.5% had received a total cavopulmonary connection. One-third required repeat surgery or intervention. Most patients (55.9%) were in New York Heart Association functional class II or class I (30.6%), 76 (66.1%) patients had experienced at least one arrhythmia, and eight (7.0%) protein-losing enteropathy. At a median follow-up of 5.0 (2.4-10.3) years, 15 (13.0%) patients were referred for transplantation assessment and 19 (16.5%) patients died, mainly from heart failure (84.2%). Univariable predictors of death or transplantation included lower serum albumin level [hazard ratio (HR) 1.09 per g/L decrease, 95% confidence interval (CI): 1.04-1.15, P = 0.0009], prior heart failure admission (HR 4.28, 95% CI:1.75-10.44, P = 0.001), prior atrial tachycardia or flutter (HR 3.02, 95% CI: 1.23-7.38, P = 0.02), and baseline pulmonary vasodilator therapy (HR 8.59, 95% CI:1.05-70.13, P = 0.04). Lower serum albumin and prior atrial tachycardia or flutter remained significant on bivariable analysis. CONCLUSION Our study highlights the significant morbidity and mortality in older adults with a Fontan-type circulation, emphasizing the need for lifelong specialist surveillance with frequent risk stratification, close monitoring, and early consideration for transplantation assessment.
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Affiliation(s)
- Andrew Constantine
- Adult Congenital Heart Centre and Centre for Pulmonary Hypertension, Royal Brompton Hospital, Royal Brompton & Harefield Hospitals, Guy's and St Thomas' NHS Foundation Trust, Sydney Street, SW3 6NP London, UK
- National Heart and Lung Institute, Imperial College London, Guy Scadding Building, Dovehouse Street, SW3 6LY London, UK
| | - Paolo Ferrero
- ACHD Unit, IRCCS-Policlinico San Donato, San Donato Milanese, Milan, Italy
| | - Elena Gribaudo
- Adult Congenital Heart Centre and Centre for Pulmonary Hypertension, Royal Brompton Hospital, Royal Brompton & Harefield Hospitals, Guy's and St Thomas' NHS Foundation Trust, Sydney Street, SW3 6NP London, UK
| | - Panagiota Mitropoulou
- Congenital Cardiac Centre, Southampton General Hospital, University Hospital Southampton NHS Foundation Trust, Southampton, UK
| | - Kaushiga Krishnathasan
- Adult Congenital Heart Centre and Centre for Pulmonary Hypertension, Royal Brompton Hospital, Royal Brompton & Harefield Hospitals, Guy's and St Thomas' NHS Foundation Trust, Sydney Street, SW3 6NP London, UK
- National Heart and Lung Institute, Imperial College London, Guy Scadding Building, Dovehouse Street, SW3 6LY London, UK
| | - Giulia Costola
- Adult Congenital Heart Centre and Centre for Pulmonary Hypertension, Royal Brompton Hospital, Royal Brompton & Harefield Hospitals, Guy's and St Thomas' NHS Foundation Trust, Sydney Street, SW3 6NP London, UK
| | - Myo T Lwin
- Congenital Cardiac Centre, Southampton General Hospital, University Hospital Southampton NHS Foundation Trust, Southampton, UK
| | - Samantha Fitzsimmons
- Congenital Cardiac Centre, Southampton General Hospital, University Hospital Southampton NHS Foundation Trust, Southampton, UK
| | - Margarita Brida
- Adult Congenital Heart Centre and Centre for Pulmonary Hypertension, Royal Brompton Hospital, Royal Brompton & Harefield Hospitals, Guy's and St Thomas' NHS Foundation Trust, Sydney Street, SW3 6NP London, UK
- National Heart and Lung Institute, Imperial College London, Guy Scadding Building, Dovehouse Street, SW3 6LY London, UK
- Department of Medical Rehabilitation, Medical Faculty University of Rijeka, Rijeka, Croatia
| | - Claudia Montanaro
- Adult Congenital Heart Centre and Centre for Pulmonary Hypertension, Royal Brompton Hospital, Royal Brompton & Harefield Hospitals, Guy's and St Thomas' NHS Foundation Trust, Sydney Street, SW3 6NP London, UK
- National Heart and Lung Institute, Imperial College London, Guy Scadding Building, Dovehouse Street, SW3 6LY London, UK
| | - Aleksander Kempny
- Adult Congenital Heart Centre and Centre for Pulmonary Hypertension, Royal Brompton Hospital, Royal Brompton & Harefield Hospitals, Guy's and St Thomas' NHS Foundation Trust, Sydney Street, SW3 6NP London, UK
- National Heart and Lung Institute, Imperial College London, Guy Scadding Building, Dovehouse Street, SW3 6LY London, UK
| | - Ee Ling Heng
- Adult Congenital Heart Centre and Centre for Pulmonary Hypertension, Royal Brompton Hospital, Royal Brompton & Harefield Hospitals, Guy's and St Thomas' NHS Foundation Trust, Sydney Street, SW3 6NP London, UK
- National Heart and Lung Institute, Imperial College London, Guy Scadding Building, Dovehouse Street, SW3 6LY London, UK
| | - Massimo Chessa
- ACHD Unit, IRCCS-Policlinico San Donato, San Donato Milanese, Milan, Italy
- UniSR - Vita Salute Sal Raffaele University, Milan, Italy
| | - Konstantinos Dimopoulos
- Adult Congenital Heart Centre and Centre for Pulmonary Hypertension, Royal Brompton Hospital, Royal Brompton & Harefield Hospitals, Guy's and St Thomas' NHS Foundation Trust, Sydney Street, SW3 6NP London, UK
- National Heart and Lung Institute, Imperial College London, Guy Scadding Building, Dovehouse Street, SW3 6LY London, UK
| | - Isma Rafiq
- Adult Congenital Heart Centre and Centre for Pulmonary Hypertension, Royal Brompton Hospital, Royal Brompton & Harefield Hospitals, Guy's and St Thomas' NHS Foundation Trust, Sydney Street, SW3 6NP London, UK
- National Heart and Lung Institute, Imperial College London, Guy Scadding Building, Dovehouse Street, SW3 6LY London, UK
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Lee S, Rathod RH, Valente AM, Davey BT, Wu F, Drucker N, Lombardi K, St Clair N, Azcue N, Toro-Salazar OH, Elder RW. Life and Death: A Multicenter Study Evaluating Cardiologists' Approach to Difficult Conversations with Fontan Patients and Families. Pediatr Cardiol 2024:10.1007/s00246-024-03631-5. [PMID: 39164409 DOI: 10.1007/s00246-024-03631-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/07/2024] [Accepted: 08/14/2024] [Indexed: 08/22/2024]
Abstract
Outpatient cardiologists provide longitudinal care for Fontan patients. As these patients age, they face mounting morbidities, necessitating challenging conversations about prognosis and goals of care. We created a novel survey to evaluate cardiologists' attitudes surrounding risk counseling for patients/caregivers. Cardiologists were recruited during concomitant outpatient enrollment of individuals with Fontan operation > age 10. Physician demographic data, expectations of timing in discussing adverse event risk, and perceived barriers were collected. Barriers were analyzed using a thematic approach. 40 cardiologists (9 institutions) responded regarding 155 patients (mean age 21.2 years, SD 7.7). Physicians were mostly male (58%) with mean practice of 21 years post-fellowship (SD 12). Most felt the time was right to have a conversation with patient (55%) and family (62%), and majority thought patient (53%) and family (75%) were ready for such a conversation. Most had previously discussed prognosis with patient (72%) and family (75%). Providers were inclined to discuss risk with caregivers earlier (mean patient age 9 years, SD 11) than patients (mean patient age 17 years, SD 6.4). Nevertheless, 42% of physicians perceived significant barriers and provided 58 narrative comments categorized into 4 major themes: (1) Patient-related (53.4%), including cognitive limitations and mental health; (2) Provider-related (16.4%), including lack of familiarity, preservation of happiness, and discomfort; (3) Family related (12.3%), including protection/denial and psychosocial stressors; (4) Other (26%), including social barriers. Experienced cardiologists are willing to have difficult conversations; nearly half reported largely patient-related barriers. Facilitating these conversations is critical for the adolescent/young adult with Fontan physiology.
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Affiliation(s)
- Seohyuk Lee
- Department of Pediatrics and Internal Medicine (Cardiology), Yale University School of Medicine, New Haven, CT, USA
- Department of Medicine, Beth Israel Deaconess Medical Center, Boston, MA, USA
| | - Rahul H Rathod
- Department of Cardiology, Harvard Medical School, Boston Children's Hospital, Boston, MA, USA
| | - Anne Marie Valente
- Department of Cardiology, Harvard Medical School, Boston Children's Hospital, Boston, MA, USA
- Division of Cardiology, Department of Medicine, Harvard Medical School, Brigham and Women's Hospital, Boston, MA, USA
| | - Brooke T Davey
- Division of Cardiology, Connecticut Children's, Hartford, CT, USA
| | - Fred Wu
- Department of Cardiology, Harvard Medical School, Boston Children's Hospital, Boston, MA, USA
- Division of Cardiology, Department of Medicine, Harvard Medical School, Brigham and Women's Hospital, Boston, MA, USA
| | - Nancy Drucker
- Division of Pediatric Cardiology, The University of Vermont Children's Hospital, Burlington, VT, USA
| | - Kristin Lombardi
- Department of Pediatrics, Warren Alpert Medical School of Brown University, Providence, RI, USA
| | - Nicole St Clair
- Department of Cardiology, Harvard Medical School, Boston Children's Hospital, Boston, MA, USA
| | - Nina Azcue
- Department of Cardiology, Harvard Medical School, Boston Children's Hospital, Boston, MA, USA
| | | | - Robert W Elder
- Department of Pediatrics and Internal Medicine (Cardiology), Yale University School of Medicine, New Haven, CT, USA.
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Maisat W, Yuki K. The Fontan Circulation in Pregnancy: Hemodynamic Challenges and Anesthetic Considerations. J Cardiothorac Vasc Anesth 2024:S1053-0770(24)00458-0. [PMID: 39097487 DOI: 10.1053/j.jvca.2024.07.021] [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: 03/08/2024] [Revised: 06/14/2024] [Accepted: 07/08/2024] [Indexed: 08/05/2024]
Abstract
Pregnancy in patients with Fontan physiology presents unique challenges due to altered cardiovascular dynamics inherent to both conditions. The Fontan procedure reroutes venous blood directly to the pulmonary arteries, bypassing the heart, and necessitating precise regulation of pulmonary venous resistance and systemic venous pressure to maintain effective cardiac output. The significant cardiovascular adaptations required during pregnancy to meet the metabolic demands of the mother and fetus can overburden the limited preload capacity and venous compliance in Fontan patients, predisposing them to a spectrum of potential complications, including arrhythmias, heart failure, thromboembolism, and obstetric and fetal risks. This review delineates the essential physiological adaptations during pregnancy and the challenges faced by Fontan patients, advocating for a comprehensive care approach involving multidisciplinary collaboration, vigilant monitoring, tailored anesthetic management, and postpartum care. Understanding the complex dynamics between Fontan physiology and pregnancy is crucial for anesthesiologists to develop and execute individualized management strategies to minimize risks and optimize outcomes for this high-risk population.
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Affiliation(s)
- Wiriya Maisat
- Department of Anesthesiology, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Koichi Yuki
- Cardiac Anesthesia Division, Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children's Hospital, Boston, MA; Department of Anaesthesia, Harvard Medical School, Boston, MA.
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Kulshrestha K, Greenberg JW, Kennedy JT, Hogue S, Winlaw DS, Ashfaq A, Zafar F, Morales DLS. The majority of pediatric Fontan patients have excellent post-transplant survival. J Thorac Cardiovasc Surg 2024; 167:2193-2203. [PMID: 37774778 PMCID: PMC10965507 DOI: 10.1016/j.jtcvs.2023.09.044] [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: 05/05/2023] [Revised: 08/20/2023] [Accepted: 09/17/2023] [Indexed: 10/01/2023]
Abstract
OBJECTIVE Many pediatric Fontan patients require heart transplant, but this cohort is understudied given the difficulty in identifying these patients in national registries. We sought to characterize survival post-transplant in a large cohort of pediatric patients undergoing the Fontan. METHODS The United Network for Organ Sharing and Pediatric Health Information System were used to identify Fontan heart transplant recipients aged less than 18 years (n = 241) between 2005 and 2022. Decompensation was defined as the presence of extracorporeal membrane oxygenation, ventilation, hepatic/renal dysfunction, paralytics, or total parenteral nutrition at transplant. RESULTS Median age at transplant was 9 (interquartile range, 5-12) years. Median waitlist time was 107 (37-229) days. Median volume across 32 center was 8 (3-11) cases. Approximately half (n = 107, 45%) of recipients had 1A/1 initial listing status. Sixty-four patients (28%) were functionally impaired at transplant, 10 patients (4%) were ventilated, and 18 patients (8%) had ventricular assist device support. Fifty-nine patients (25%) had hepatic dysfunction, and 15 patients (6%) had renal dysfunction. Twenty-one patients (9%) were dependent on total parenteral nutrition. Median postoperative stay was 24 (14-46) days, and in-hospital mortality was 7%. Kaplan-Meier analysis showed 1- and 5-year survivals of 89% (95% CI, 85-94) and 74% (95% CI, 81-86), respectively. Kaplan-Meier of Fontan patients without decompensation (n = 154) at transplant demonstrated 1- and 5-year survivals of 93% (95% CI, 88-97) and 88% (95% CI, 82-94), respectively. In-hospital mortality was higher in decompensated patients (11% vs 4%, P = .023). Multivariable analysis showed that decompensation predicted worse post-transplant survival (hazard ratio, 2.47; 95% CI, 1.16-5.22; P = .018), whereas older age at transplant predicted superior post-transplant survival (hazard ratio, 0.89/year; 95% CI, 0.80-0.98; P = .019). CONCLUSIONS Pediatric Fontan post-transplant outcomes are promising, although early mortality remains high. For nondecompensated pediatric patients at transplant without end-organ disease (>63% of cohort), early mortality is circumvented and post-transplant survival is excellent and similar to all pediatric transplantation.
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Affiliation(s)
- Kevin Kulshrestha
- Division of Cardiothoracic Surgery, Cincinnati Children's Hospital Medical Center, Heart Institute, University of Cincinnati College of Medicine, Cincinnati, Ohio.
| | - Jason W Greenberg
- Division of Cardiothoracic Surgery, Cincinnati Children's Hospital Medical Center, Heart Institute, University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - John T Kennedy
- Division of Cardiothoracic Surgery, Cincinnati Children's Hospital Medical Center, Heart Institute, University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - Spencer Hogue
- Division of Cardiothoracic Surgery, Cincinnati Children's Hospital Medical Center, Heart Institute, University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - David S Winlaw
- Division of Cardiothoracic Surgery, Cincinnati Children's Hospital Medical Center, Heart Institute, University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - Awais Ashfaq
- Division of Cardiothoracic Surgery, Cincinnati Children's Hospital Medical Center, Heart Institute, University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - Farhan Zafar
- Division of Cardiothoracic Surgery, Cincinnati Children's Hospital Medical Center, Heart Institute, University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - David L S Morales
- Division of Cardiothoracic Surgery, Cincinnati Children's Hospital Medical Center, Heart Institute, University of Cincinnati College of Medicine, Cincinnati, Ohio
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Di Mambro C, Yammine ML, Tamborrino PP, Giordano U, Righi D, Unolt M, Cantarutti N, Maiolo S, Albanese S, Carotti A, Amodeo A, Galletti L, Drago F. Long-term incidence of arrhythmias in extracardiac conduit Fontan and comparison between systemic left and right ventricle. Europace 2024; 26:euae097. [PMID: 38650062 PMCID: PMC11089577 DOI: 10.1093/europace/euae097] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2024] [Accepted: 02/16/2024] [Indexed: 04/25/2024] Open
Abstract
AIMS The extracardiac conduit-Fontan (ECC) has become the preferred technique for univentricular heart palliation, but there are currently no data on the incidence of long-term arrhythmias. This study investigated the incidence of arrhythmias and relation to single ventricle morphology in the long-term follow-up (FU) in ECC. METHODS AND RESULTS All patients with ECC performed in our Centre between 1987 and 2017 were included (minimum FU 5 years). Of 353 consecutive patients, 303 [57.8% males, aging 8-50 (median 20) years at last FU] were considered and divided into two groups depending on left (194 in Group 1) or right (109 in Group 2) ventricular morphology. Eighty-five (28%) experienced ≥1 arrhythmic complications, with early and late arrhythmias in 17 (5.6%) and 73 (24.1%) patients, respectively. Notably, late bradyarrhythmias occurred after 6 years in 21 (11%) patients in Group 1, and in 15 (13.8%) in Group 2 [P = 0.48]. Late tachyarrhythmias occurred in 55 (18.2%) patients after 12 years: 33 (17%) in Group 1 and 22 (20.2%) patients in Group 2 [P = 0.5]. Ventricular tachycardias (VT) were documented after 12.5 years in 14 (7.2%) patients of Group 1 and 15 (13.8%) of Group 2 [P = 0.06] with a higher incidence in Group 2 during the FU [P = 0.005]. CONCLUSION Extracardiac conduit is related to a significant arrhythmic risk in the long-term FU, higher than previously reported. Bradyarrhythmias occur earlier but are less frequent than tachyarrhythmias. Interestingly, patients with systemic right ventricle have a significantly higher incidence of VT, especially in a very long FU.
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Affiliation(s)
- Corrado Di Mambro
- Pediatric Cardiology and Cardiac Arrhythmias Complex Unit, Neonatal and Cardiological Area, Bambino Gesù Children’s Hospital IRCCS (European Reference Network for Rare and Low Prevalence Complex Disease of the Heart-ERN GUARD-Heart), Via Torre di Palidoro, 00050 Rome, Italy
| | - Marie Laure Yammine
- Pediatric Cardiology and Cardiac Arrhythmias Complex Unit, Neonatal and Cardiological Area, Bambino Gesù Children’s Hospital IRCCS (European Reference Network for Rare and Low Prevalence Complex Disease of the Heart-ERN GUARD-Heart), Via Torre di Palidoro, 00050 Rome, Italy
| | - Pietro Paolo Tamborrino
- Pediatric Cardiology and Cardiac Arrhythmias Complex Unit, Neonatal and Cardiological Area, Bambino Gesù Children’s Hospital IRCCS (European Reference Network for Rare and Low Prevalence Complex Disease of the Heart-ERN GUARD-Heart), Via Torre di Palidoro, 00050 Rome, Italy
| | - Ugo Giordano
- Sports Medicine Unit, Neonatal and Cardiological Area, Bambino Gesù Children’s Hospital IRCCS, Rome, Italy
| | - Daniela Righi
- Pediatric Cardiology and Cardiac Arrhythmias Complex Unit, Neonatal and Cardiological Area, Bambino Gesù Children’s Hospital IRCCS (European Reference Network for Rare and Low Prevalence Complex Disease of the Heart-ERN GUARD-Heart), Via Torre di Palidoro, 00050 Rome, Italy
| | - Marta Unolt
- Pediatric Cardiology and Cardiac Arrhythmias Complex Unit, Neonatal and Cardiological Area, Bambino Gesù Children’s Hospital IRCCS (European Reference Network for Rare and Low Prevalence Complex Disease of the Heart-ERN GUARD-Heart), Via Torre di Palidoro, 00050 Rome, Italy
| | - Nicoletta Cantarutti
- Pediatric Cardiology and Cardiac Arrhythmias Complex Unit, Neonatal and Cardiological Area, Bambino Gesù Children’s Hospital IRCCS (European Reference Network for Rare and Low Prevalence Complex Disease of the Heart-ERN GUARD-Heart), Via Torre di Palidoro, 00050 Rome, Italy
| | - Stella Maiolo
- Pediatric Cardiology and Cardiac Arrhythmias Complex Unit, Neonatal and Cardiological Area, Bambino Gesù Children’s Hospital IRCCS (European Reference Network for Rare and Low Prevalence Complex Disease of the Heart-ERN GUARD-Heart), Via Torre di Palidoro, 00050 Rome, Italy
| | - Sonia Albanese
- Cardiac Surgery Unit, Neonatal and Cardiological Area, Bambino Gesù Children’s Hospital IRCCS, Rome, Italy
| | - Adriano Carotti
- Cardiac Surgery Unit, Neonatal and Cardiological Area, Bambino Gesù Children’s Hospital IRCCS, Rome, Italy
| | - Antonio Amodeo
- Heart Failure, Transplant and Mechanical Assist Device, Neonatal and Cardiological Area, Bambino Gesù Children’s Hospital IRCCS, Rome, Italy
| | - Lorenzo Galletti
- Cardiac Surgery Unit, Neonatal and Cardiological Area, Bambino Gesù Children’s Hospital IRCCS, Rome, Italy
| | - Fabrizio Drago
- Pediatric Cardiology and Cardiac Arrhythmias Complex Unit, Neonatal and Cardiological Area, Bambino Gesù Children’s Hospital IRCCS (European Reference Network for Rare and Low Prevalence Complex Disease of the Heart-ERN GUARD-Heart), Via Torre di Palidoro, 00050 Rome, Italy
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Miyazaki A. Pacemaker Therapy for the Optimization of Fontan Circulation. Circ J 2024; 88:649-651. [PMID: 38267034 DOI: 10.1253/circj.cj-23-0963] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/26/2024]
Affiliation(s)
- Aya Miyazaki
- Department of Adult Congenital Heart Disease, Seirei Hamamatsu General Hospital
- Department of Pediatric Cardiology, Seirei Hamamatsu General Hospital
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Heering G, Lebovics N, Agarwal R, Frishman WH, Lebovics E. Fontan-Associated Liver Disease: A Review. Cardiol Rev 2024:00045415-990000000-00231. [PMID: 38477576 DOI: 10.1097/crd.0000000000000684] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/14/2024]
Abstract
Fontan-associated liver disease (FALD) is a chronic complication of the Fontan procedure, a palliative surgery for patients with congenital heart disease that results in a single-ventricle circulation. The success of the Fontan procedure has led to a growing population of post-Fontan patients living well into adulthood. For this population, FALD is a major cause of morbidity and mortality. It encompasses a spectrum of hepatic abnormalities, ranging from mild fibrosis to cirrhosis and hepatocellular carcinoma. The pathophysiology of FALD is multifactorial, involving hemodynamic and inflammatory factors. The diagnosis and monitoring of FALD present many challenges. Conventional noninvasive tests that use liver stiffness as a surrogate marker of fibrosis are unreliable in FALD, where liver stiffness is also a result of congestion due to the Fontan circulation. Even invasive tissue sampling is inconsistent due to the patchy distribution of fibrosis. FALD is also associated with both benign and malignant liver lesions, which may exhibit similar imaging features. There is therefore a need for validated diagnostic and surveillance protocols to address these challenges. The definitive treatment of end-stage FALD is also a subject of controversy. Both isolated heart transplantation and combined heart-liver transplantation have been employed, with the latter becoming increasingly preferred in the US. This article reviews the current literature on the epidemiology, pathophysiology, diagnosis, and management of FALD, and highlights knowledge gaps that require further research.
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Affiliation(s)
- Gabriel Heering
- From the Department of Medicine, Westchester Medical Center/New York Medical College, Valhalla, NY
| | - Nachum Lebovics
- From the Department of Medicine, Westchester Medical Center/New York Medical College, Valhalla, NY
- Albert Einstein College of Medicine, Bronx, NY
| | - Raksheeth Agarwal
- From the Department of Medicine, Westchester Medical Center/New York Medical College, Valhalla, NY
- Internal Medicine at Jacobi Medical Center/Albert Einstein College of Medicine, Bronx, NY
| | - William H Frishman
- From the Department of Medicine, Westchester Medical Center/New York Medical College, Valhalla, NY
| | - Edward Lebovics
- From the Department of Medicine, Westchester Medical Center/New York Medical College, Valhalla, NY
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Schaffner D, Perez MH, Duran R, Pretre R, Di Bernardo S. Case Report: Transcatheter interventional procedure to innominate vein turn-down procedure for failing fontan circulation. Front Pediatr 2024; 12:1341443. [PMID: 38379912 PMCID: PMC10876887 DOI: 10.3389/fped.2024.1341443] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/20/2023] [Accepted: 01/17/2024] [Indexed: 02/22/2024] Open
Abstract
Fontan physiology creates a chronic state of decreased cardiac output and systemic venous congestion, leading to liver cirrhosis/malignancy, protein-losing enteropathy, chylothorax, or plastic bronchitis. Creating a fenestration improves cardiac output and relieves some venous congestion. The anatomic connection of the thoracic duct to the subclavian-jugular vein junction exposes the lymphatic system to systemic venous hypertension and could induce plastic bronchitis. To address this complication, two techniques have been developed. A surgical method that decompresses the thoracic duct by diverting the innominate vein to the atrium, and a percutaneous endovascular procedure that uses a covered stent to create an extravascular connection between the innominate vein and the left atrium. We report a novel variant transcatheter intervention of the innominate vein turn-down procedure without creating an extravascular connection in a 39-month-old patient with failing Fontan circulation complicated by plastic bronchitis and a 2-year post-intervention follow-up.
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Affiliation(s)
- Damien Schaffner
- Pediatric Cardiology Unit, Women Mother and Child Department, Lausanne University Hospital, Lausanne, Switzerland
| | - Maria-Helena Perez
- Pediatric Intensive Care Unit, Women Mother and Child Department, Lausanne University Hospital, Lausanne, Switzerland
| | - Rafael Duran
- Department of Radiology and Interventional Radiology, Lausanne University Hospital, Lausanne, Switzerland
| | - René Pretre
- Department of Cardiac Surgery, Lausanne University Hospital, Lausanne, Switzerland
| | - Stefano Di Bernardo
- Pediatric Cardiology Unit, Women Mother and Child Department, Lausanne University Hospital, Lausanne, Switzerland
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10
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Yao T, St. Clair N, Miller GF, Dorfman AL, Fogel MA, Ghelani S, Krishnamurthy R, Lam CZ, Quail M, Robinson JD, Schidlow D, Slesnick TC, Weigand J, Steeden JA, Rathod RH, Muthurangu V. A Deep Learning Pipeline for Assessing Ventricular Volumes from a Cardiac MRI Registry of Patients with Single Ventricle Physiology. Radiol Artif Intell 2024; 6:e230132. [PMID: 38166332 PMCID: PMC10831511 DOI: 10.1148/ryai.230132] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2023] [Revised: 10/05/2023] [Accepted: 10/30/2023] [Indexed: 01/04/2024]
Abstract
Purpose To develop an end-to-end deep learning (DL) pipeline for automated ventricular segmentation of cardiac MRI data from a multicenter registry of patients with Fontan circulation (Fontan Outcomes Registry Using CMR Examinations [FORCE]). Materials and Methods This retrospective study used 250 cardiac MRI examinations (November 2007-December 2022) from 13 institutions for training, validation, and testing. The pipeline contained three DL models: a classifier to identify short-axis cine stacks and two U-Net 3+ models for image cropping and segmentation. The automated segmentations were evaluated on the test set (n = 50) by using the Dice score. Volumetric and functional metrics derived from DL and ground truth manual segmentations were compared using Bland-Altman and intraclass correlation analysis. The pipeline was further qualitatively evaluated on 475 unseen examinations. Results There were acceptable limits of agreement (LOA) and minimal biases between the ground truth and DL end-diastolic volume (EDV) (bias: -0.6 mL/m2, LOA: -20.6 to 19.5 mL/m2) and end-systolic volume (ESV) (bias: -1.1 mL/m2, LOA: -18.1 to 15.9 mL/m2), with high intraclass correlation coefficients (ICCs > 0.97) and Dice scores (EDV, 0.91 and ESV, 0.86). There was moderate agreement for ventricular mass (bias: -1.9 g/m2, LOA: -17.3 to 13.5 g/m2) and an ICC of 0.94. There was also acceptable agreement for stroke volume (bias: 0.6 mL/m2, LOA: -17.2 to 18.3 mL/m2) and ejection fraction (bias: 0.6%, LOA: -12.2% to 13.4%), with high ICCs (>0.81). The pipeline achieved satisfactory segmentation in 68% of the 475 unseen examinations, while 26% needed minor adjustments, 5% needed major adjustments, and in 0.4%, the cropping model failed. Conclusion The DL pipeline can provide fast standardized segmentation for patients with single ventricle physiology across multiple centers. This pipeline can be applied to all cardiac MRI examinations in the FORCE registry. Keywords: Cardiac, Adults and Pediatrics, MR Imaging, Congenital, Volume Analysis, Segmentation, Quantification Supplemental material is available for this article. © RSNA, 2023.
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Affiliation(s)
| | | | - Gabriel F. Miller
- From the Institutes of Health Informatics (T.Y.) and Cardiovascular Science (M.Q., J.A.S., V.M.), University College London, 20c Guilford Street, London WC1N 1DZ, England; Department of Cardiology, Boston Children's Hospital, Boston, Mass (N.S.C., G.F.M., S.G., D.S., R.H.R.); Department of Pediatrics, University of Michigan, Ann Arbor, Mich (A.L.D.); Division of Cardiology, The Children's Hospital of Philadelphia, Philadelphia, Pa (M.A.F.); Department of Radiology, Nationwide Children's Hospital, Columbus, Ohio (R.K.); Department of Diagnostic Imaging, Hospital for Sick Children, Toronto, Canada (C.Z.L.); Department of Pediatrics, Ann and Robert H Lurie Children's Hospital of Chicago, Chicago, Ill (J.D.R.); Department of Pediatric Cardiology, Emory University School of Medicine, Atlanta, Ga (T.C.S.); and Department of Cardiology, Texas Children's Hospital, Houston, Tex (J.W.)
| | - Adam L. Dorfman
- From the Institutes of Health Informatics (T.Y.) and Cardiovascular Science (M.Q., J.A.S., V.M.), University College London, 20c Guilford Street, London WC1N 1DZ, England; Department of Cardiology, Boston Children's Hospital, Boston, Mass (N.S.C., G.F.M., S.G., D.S., R.H.R.); Department of Pediatrics, University of Michigan, Ann Arbor, Mich (A.L.D.); Division of Cardiology, The Children's Hospital of Philadelphia, Philadelphia, Pa (M.A.F.); Department of Radiology, Nationwide Children's Hospital, Columbus, Ohio (R.K.); Department of Diagnostic Imaging, Hospital for Sick Children, Toronto, Canada (C.Z.L.); Department of Pediatrics, Ann and Robert H Lurie Children's Hospital of Chicago, Chicago, Ill (J.D.R.); Department of Pediatric Cardiology, Emory University School of Medicine, Atlanta, Ga (T.C.S.); and Department of Cardiology, Texas Children's Hospital, Houston, Tex (J.W.)
| | - Mark A. Fogel
- From the Institutes of Health Informatics (T.Y.) and Cardiovascular Science (M.Q., J.A.S., V.M.), University College London, 20c Guilford Street, London WC1N 1DZ, England; Department of Cardiology, Boston Children's Hospital, Boston, Mass (N.S.C., G.F.M., S.G., D.S., R.H.R.); Department of Pediatrics, University of Michigan, Ann Arbor, Mich (A.L.D.); Division of Cardiology, The Children's Hospital of Philadelphia, Philadelphia, Pa (M.A.F.); Department of Radiology, Nationwide Children's Hospital, Columbus, Ohio (R.K.); Department of Diagnostic Imaging, Hospital for Sick Children, Toronto, Canada (C.Z.L.); Department of Pediatrics, Ann and Robert H Lurie Children's Hospital of Chicago, Chicago, Ill (J.D.R.); Department of Pediatric Cardiology, Emory University School of Medicine, Atlanta, Ga (T.C.S.); and Department of Cardiology, Texas Children's Hospital, Houston, Tex (J.W.)
| | - Sunil Ghelani
- From the Institutes of Health Informatics (T.Y.) and Cardiovascular Science (M.Q., J.A.S., V.M.), University College London, 20c Guilford Street, London WC1N 1DZ, England; Department of Cardiology, Boston Children's Hospital, Boston, Mass (N.S.C., G.F.M., S.G., D.S., R.H.R.); Department of Pediatrics, University of Michigan, Ann Arbor, Mich (A.L.D.); Division of Cardiology, The Children's Hospital of Philadelphia, Philadelphia, Pa (M.A.F.); Department of Radiology, Nationwide Children's Hospital, Columbus, Ohio (R.K.); Department of Diagnostic Imaging, Hospital for Sick Children, Toronto, Canada (C.Z.L.); Department of Pediatrics, Ann and Robert H Lurie Children's Hospital of Chicago, Chicago, Ill (J.D.R.); Department of Pediatric Cardiology, Emory University School of Medicine, Atlanta, Ga (T.C.S.); and Department of Cardiology, Texas Children's Hospital, Houston, Tex (J.W.)
| | - Rajesh Krishnamurthy
- From the Institutes of Health Informatics (T.Y.) and Cardiovascular Science (M.Q., J.A.S., V.M.), University College London, 20c Guilford Street, London WC1N 1DZ, England; Department of Cardiology, Boston Children's Hospital, Boston, Mass (N.S.C., G.F.M., S.G., D.S., R.H.R.); Department of Pediatrics, University of Michigan, Ann Arbor, Mich (A.L.D.); Division of Cardiology, The Children's Hospital of Philadelphia, Philadelphia, Pa (M.A.F.); Department of Radiology, Nationwide Children's Hospital, Columbus, Ohio (R.K.); Department of Diagnostic Imaging, Hospital for Sick Children, Toronto, Canada (C.Z.L.); Department of Pediatrics, Ann and Robert H Lurie Children's Hospital of Chicago, Chicago, Ill (J.D.R.); Department of Pediatric Cardiology, Emory University School of Medicine, Atlanta, Ga (T.C.S.); and Department of Cardiology, Texas Children's Hospital, Houston, Tex (J.W.)
| | - Christopher Z. Lam
- From the Institutes of Health Informatics (T.Y.) and Cardiovascular Science (M.Q., J.A.S., V.M.), University College London, 20c Guilford Street, London WC1N 1DZ, England; Department of Cardiology, Boston Children's Hospital, Boston, Mass (N.S.C., G.F.M., S.G., D.S., R.H.R.); Department of Pediatrics, University of Michigan, Ann Arbor, Mich (A.L.D.); Division of Cardiology, The Children's Hospital of Philadelphia, Philadelphia, Pa (M.A.F.); Department of Radiology, Nationwide Children's Hospital, Columbus, Ohio (R.K.); Department of Diagnostic Imaging, Hospital for Sick Children, Toronto, Canada (C.Z.L.); Department of Pediatrics, Ann and Robert H Lurie Children's Hospital of Chicago, Chicago, Ill (J.D.R.); Department of Pediatric Cardiology, Emory University School of Medicine, Atlanta, Ga (T.C.S.); and Department of Cardiology, Texas Children's Hospital, Houston, Tex (J.W.)
| | - Michael Quail
- From the Institutes of Health Informatics (T.Y.) and Cardiovascular Science (M.Q., J.A.S., V.M.), University College London, 20c Guilford Street, London WC1N 1DZ, England; Department of Cardiology, Boston Children's Hospital, Boston, Mass (N.S.C., G.F.M., S.G., D.S., R.H.R.); Department of Pediatrics, University of Michigan, Ann Arbor, Mich (A.L.D.); Division of Cardiology, The Children's Hospital of Philadelphia, Philadelphia, Pa (M.A.F.); Department of Radiology, Nationwide Children's Hospital, Columbus, Ohio (R.K.); Department of Diagnostic Imaging, Hospital for Sick Children, Toronto, Canada (C.Z.L.); Department of Pediatrics, Ann and Robert H Lurie Children's Hospital of Chicago, Chicago, Ill (J.D.R.); Department of Pediatric Cardiology, Emory University School of Medicine, Atlanta, Ga (T.C.S.); and Department of Cardiology, Texas Children's Hospital, Houston, Tex (J.W.)
| | - Joshua D. Robinson
- From the Institutes of Health Informatics (T.Y.) and Cardiovascular Science (M.Q., J.A.S., V.M.), University College London, 20c Guilford Street, London WC1N 1DZ, England; Department of Cardiology, Boston Children's Hospital, Boston, Mass (N.S.C., G.F.M., S.G., D.S., R.H.R.); Department of Pediatrics, University of Michigan, Ann Arbor, Mich (A.L.D.); Division of Cardiology, The Children's Hospital of Philadelphia, Philadelphia, Pa (M.A.F.); Department of Radiology, Nationwide Children's Hospital, Columbus, Ohio (R.K.); Department of Diagnostic Imaging, Hospital for Sick Children, Toronto, Canada (C.Z.L.); Department of Pediatrics, Ann and Robert H Lurie Children's Hospital of Chicago, Chicago, Ill (J.D.R.); Department of Pediatric Cardiology, Emory University School of Medicine, Atlanta, Ga (T.C.S.); and Department of Cardiology, Texas Children's Hospital, Houston, Tex (J.W.)
| | - David Schidlow
- From the Institutes of Health Informatics (T.Y.) and Cardiovascular Science (M.Q., J.A.S., V.M.), University College London, 20c Guilford Street, London WC1N 1DZ, England; Department of Cardiology, Boston Children's Hospital, Boston, Mass (N.S.C., G.F.M., S.G., D.S., R.H.R.); Department of Pediatrics, University of Michigan, Ann Arbor, Mich (A.L.D.); Division of Cardiology, The Children's Hospital of Philadelphia, Philadelphia, Pa (M.A.F.); Department of Radiology, Nationwide Children's Hospital, Columbus, Ohio (R.K.); Department of Diagnostic Imaging, Hospital for Sick Children, Toronto, Canada (C.Z.L.); Department of Pediatrics, Ann and Robert H Lurie Children's Hospital of Chicago, Chicago, Ill (J.D.R.); Department of Pediatric Cardiology, Emory University School of Medicine, Atlanta, Ga (T.C.S.); and Department of Cardiology, Texas Children's Hospital, Houston, Tex (J.W.)
| | - Timothy C. Slesnick
- From the Institutes of Health Informatics (T.Y.) and Cardiovascular Science (M.Q., J.A.S., V.M.), University College London, 20c Guilford Street, London WC1N 1DZ, England; Department of Cardiology, Boston Children's Hospital, Boston, Mass (N.S.C., G.F.M., S.G., D.S., R.H.R.); Department of Pediatrics, University of Michigan, Ann Arbor, Mich (A.L.D.); Division of Cardiology, The Children's Hospital of Philadelphia, Philadelphia, Pa (M.A.F.); Department of Radiology, Nationwide Children's Hospital, Columbus, Ohio (R.K.); Department of Diagnostic Imaging, Hospital for Sick Children, Toronto, Canada (C.Z.L.); Department of Pediatrics, Ann and Robert H Lurie Children's Hospital of Chicago, Chicago, Ill (J.D.R.); Department of Pediatric Cardiology, Emory University School of Medicine, Atlanta, Ga (T.C.S.); and Department of Cardiology, Texas Children's Hospital, Houston, Tex (J.W.)
| | - Justin Weigand
- From the Institutes of Health Informatics (T.Y.) and Cardiovascular Science (M.Q., J.A.S., V.M.), University College London, 20c Guilford Street, London WC1N 1DZ, England; Department of Cardiology, Boston Children's Hospital, Boston, Mass (N.S.C., G.F.M., S.G., D.S., R.H.R.); Department of Pediatrics, University of Michigan, Ann Arbor, Mich (A.L.D.); Division of Cardiology, The Children's Hospital of Philadelphia, Philadelphia, Pa (M.A.F.); Department of Radiology, Nationwide Children's Hospital, Columbus, Ohio (R.K.); Department of Diagnostic Imaging, Hospital for Sick Children, Toronto, Canada (C.Z.L.); Department of Pediatrics, Ann and Robert H Lurie Children's Hospital of Chicago, Chicago, Ill (J.D.R.); Department of Pediatric Cardiology, Emory University School of Medicine, Atlanta, Ga (T.C.S.); and Department of Cardiology, Texas Children's Hospital, Houston, Tex (J.W.)
| | - Jennifer A. Steeden
- From the Institutes of Health Informatics (T.Y.) and Cardiovascular Science (M.Q., J.A.S., V.M.), University College London, 20c Guilford Street, London WC1N 1DZ, England; Department of Cardiology, Boston Children's Hospital, Boston, Mass (N.S.C., G.F.M., S.G., D.S., R.H.R.); Department of Pediatrics, University of Michigan, Ann Arbor, Mich (A.L.D.); Division of Cardiology, The Children's Hospital of Philadelphia, Philadelphia, Pa (M.A.F.); Department of Radiology, Nationwide Children's Hospital, Columbus, Ohio (R.K.); Department of Diagnostic Imaging, Hospital for Sick Children, Toronto, Canada (C.Z.L.); Department of Pediatrics, Ann and Robert H Lurie Children's Hospital of Chicago, Chicago, Ill (J.D.R.); Department of Pediatric Cardiology, Emory University School of Medicine, Atlanta, Ga (T.C.S.); and Department of Cardiology, Texas Children's Hospital, Houston, Tex (J.W.)
| | - Rahul H. Rathod
- From the Institutes of Health Informatics (T.Y.) and Cardiovascular Science (M.Q., J.A.S., V.M.), University College London, 20c Guilford Street, London WC1N 1DZ, England; Department of Cardiology, Boston Children's Hospital, Boston, Mass (N.S.C., G.F.M., S.G., D.S., R.H.R.); Department of Pediatrics, University of Michigan, Ann Arbor, Mich (A.L.D.); Division of Cardiology, The Children's Hospital of Philadelphia, Philadelphia, Pa (M.A.F.); Department of Radiology, Nationwide Children's Hospital, Columbus, Ohio (R.K.); Department of Diagnostic Imaging, Hospital for Sick Children, Toronto, Canada (C.Z.L.); Department of Pediatrics, Ann and Robert H Lurie Children's Hospital of Chicago, Chicago, Ill (J.D.R.); Department of Pediatric Cardiology, Emory University School of Medicine, Atlanta, Ga (T.C.S.); and Department of Cardiology, Texas Children's Hospital, Houston, Tex (J.W.)
| | - Vivek Muthurangu
- From the Institutes of Health Informatics (T.Y.) and Cardiovascular Science (M.Q., J.A.S., V.M.), University College London, 20c Guilford Street, London WC1N 1DZ, England; Department of Cardiology, Boston Children's Hospital, Boston, Mass (N.S.C., G.F.M., S.G., D.S., R.H.R.); Department of Pediatrics, University of Michigan, Ann Arbor, Mich (A.L.D.); Division of Cardiology, The Children's Hospital of Philadelphia, Philadelphia, Pa (M.A.F.); Department of Radiology, Nationwide Children's Hospital, Columbus, Ohio (R.K.); Department of Diagnostic Imaging, Hospital for Sick Children, Toronto, Canada (C.Z.L.); Department of Pediatrics, Ann and Robert H Lurie Children's Hospital of Chicago, Chicago, Ill (J.D.R.); Department of Pediatric Cardiology, Emory University School of Medicine, Atlanta, Ga (T.C.S.); and Department of Cardiology, Texas Children's Hospital, Houston, Tex (J.W.)
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11
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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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12
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Gill M, Mudaliar S, Prince D, Than NN, Cordina R, Majumdar A. Poor correlation of 2D shear wave elastography and transient elastography in Fontan-associated liver disease: A head-to-head comparison. JGH Open 2023; 7:690-697. [PMID: 37908293 PMCID: PMC10615175 DOI: 10.1002/jgh3.12967] [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: 03/19/2023] [Revised: 08/10/2023] [Accepted: 08/31/2023] [Indexed: 11/02/2023]
Abstract
Background and Aims Fontan-associated liver disease (FALD) is a long-term complication of the Fontan procedure. Guidelines recommend elastography, but the utility of transient elastography (TE) and two-dimensional shear wave elastography (2D SWE) is unknown. We aimed to evaluate the relationship between TE and 2D SWE in FALD. Methods This prospective cohort study included 25 patients managed in a specialist clinic between January 2018 and August 2021. Trained clinicians performed 2D SWE (GE Logiq-E9) and TE (FibroScan 503 Touch) on the same day under the same conditions. Laboratory, echocardiography, and imaging data were collected. The atrioventricular systolic-to-diastolic duration (AVV S/D ratio) was calculated as a measure of cardiac diastolic function. Results We analyzed 40 paired measurements. Median age was 22 years. Median liver stiffness measurement (LSM) was 15.4 kPa (12.1-19.6) by TE and 8.0 kPa (7.0-10.3) (P = 0.001) by 2D SWE. There was weak correlation between the modalities (r = 0.41, P = 0.004). There was no correlation between time since Fontan and LSM by TE (r = 0.15, P = 0.19) or 2D SWE (r = 0.19, P = 0.13). There was no difference in LSM irrespective of whether sonographic cirrhosis was present or absent by TE (17.4 kPa [15.9-23.6] vs. 14.9 kPa [12.0-19.4], respectively, P = 0.6) or 2D SWE (9.0 kPa [2.8-10.5] vs. 8.0 kPa [6.7-10.1], P = 0.46). There was no correlation between AVV S/D ratio and LSM by TE (r = 0.16, P = 0.18) or 2D SWE (r = 0.02, P = 0.45). Conclusions In FALD, TE and 2D SWE are poorly correlated. LSM by either modality was not associated with known risk factors for liver fibrosis or Fontan function. Based on these data, the role of elastography in FALD is uncertain.
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Affiliation(s)
- Madeleine Gill
- Australian National Liver Transplant UnitRoyal Prince Alfred HospitalSydneyNew South WalesAustralia
- Faculty of Medicine and HealthThe University of SydneySydneyNew South WalesAustralia
- Centenary Institute of Cancer Medicine and Cell BiologySydneyNew South WalesAustralia
| | - Sanjivan Mudaliar
- Australian National Liver Transplant UnitRoyal Prince Alfred HospitalSydneyNew South WalesAustralia
| | - David Prince
- Australian National Liver Transplant UnitRoyal Prince Alfred HospitalSydneyNew South WalesAustralia
- Centenary Institute of Cancer Medicine and Cell BiologySydneyNew South WalesAustralia
| | - Nwe Ni Than
- Department of Gastroenterology and HepatologyUniversity Hospital CoventryCoventryUK
| | - Rachel Cordina
- Faculty of Medicine and HealthThe University of SydneySydneyNew South WalesAustralia
- Department of CardiologyRoyal Prince Alfred HospitalSydneyNew South WalesAustralia
| | - Avik Majumdar
- Faculty of Medicine and HealthThe University of SydneySydneyNew South WalesAustralia
- Victorian Liver Transplant Unit, Austin HospitalHeidelbergVictoriaAustralia
- Division of Medicine, Dentistry and Health ScienceThe University of MelbourneMelbourneVictoriaAustralia
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13
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Payno E, Juez LD, Nuñez J, Lopez Buenadicha A, Nuño J. Surgical treatment of hepatocarcinoma after Fontan surgery. Cir Esp 2023; 101:724-727. [PMID: 36265770 DOI: 10.1016/j.cireng.2022.10.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2021] [Revised: 07/28/2022] [Accepted: 08/08/2022] [Indexed: 06/16/2023]
Affiliation(s)
- Elena Payno
- Servicio de Cirugía General del Hospital Universitario Ramón y Cajal, Madrid, Spain.
| | - Luz Divina Juez
- Servicio de Cirugía General del Hospital Universitario Ramón y Cajal, Madrid, Spain
| | - Jordi Nuñez
- Servicio de Cirugía General del Hospital Universitario Ramón y Cajal, Madrid, Spain
| | | | - Javier Nuño
- Servicio de Cirugía General del Hospital Universitario Ramón y Cajal, Madrid, Spain
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O'Byrne ML, Song L, Huang J, Lemley B, Goldberg D, Gardner MM, Ravishankar C, Rome JJ, Glatz AC. Attributable mortality benefit of digoxin treatment in hypoplastic left heart syndrome after the Norwood operation: An instrumental variable-based analysis using data from the Pediatric Health Information Systems Database. Am Heart J 2023; 263:35-45. [PMID: 37169122 DOI: 10.1016/j.ahj.2023.05.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/11/2023] [Revised: 05/01/2023] [Accepted: 05/04/2023] [Indexed: 05/13/2023]
Abstract
BACKGROUND Observational studies have demonstrated an association between the use of digoxin and reduced interstage mortality after Norwood operation for hypoplastic left heart syndrome (HLHS). Digoxin use has increased significantly but remains variable between different hospitals, independent of case-mix. Instrumental variable analyses have the potential to overcome unmeasured confounding, the major limitation of previous observational studies and to generate an estimate of the attributable benefit of treatment with digoxin. METHODS A cohort of neonates with HLHS born from January 1, 2007 to December 31, 2021 who underwent Norwood operation at Pediatric Health Information Systems Database hospitals and survived >14 days after operation were studied. Using hospital-specific, 6-month likelihood of administering digoxin as an instrumental variable, analyses adjusting for both unmeasured confounding (using the instrumental variable) and measured confounders with multivariable logistic regression were performed. RESULTS The study population included 5,148 subjects treated at 47 hospitals of which 63% were male and 46% non-Hispanic white. Of these, 44% (n = 2,184) were prescribed digoxin. Treatment with digoxin was associated with superior 1-year transplant-free survival in unadjusted analyses (85% vs 82%, P = .02). This survival benefit persisted in an instrumental-variable analysis (OR: 0.71, 95% CI: 0.54-0.94, P = .01), which can be converted to an absolute risk reduction of 5% (number needed to treat of 20). CONCLUSIONS In this observational study of patients with HLHS after Norwood using instrumental variable techniques, a significant benefit in 1-year transplant-free survival attributable to digoxin was demonstrated. In the absence of clinical trial data, this should encourage the use of digoxin in this vulnerable population.
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Affiliation(s)
- Michael L O'Byrne
- Division of Cardiology, The Children's Hospital of Philadelphia, Department of Pediatrics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA; Center For Pediatric Clinical Effectiveness, Department of Pediatrics, The Children's Hospital of Philadelphia, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA; Leonard Davis Institute and Center for Cardiovascular Outcomes, Quality, and Evaluative Research, Perelman School of Medicine, University of Pennsylvania, Philadelphia PA.
| | - Lihai Song
- Department of Biomedical and Health Informatics, Data Science and Biostatistics Unit, The Children's Hospital of Philadelphia, Philadelphia, PA
| | - Jing Huang
- Division of Cardiology, The Children's Hospital of Philadelphia, Department of Pediatrics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA; Department of Biomedical and Health Informatics, Data Science and Biostatistics Unit, The Children's Hospital of Philadelphia, Philadelphia, PA; Department of Biostatistics, Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Bethan Lemley
- Division of Cardiology, Department of Pediatrics, Lurie Children's Hospital, Feinberg School of Medicine Northwestern University, Chicago, IL
| | - David Goldberg
- Division of Cardiology, The Children's Hospital of Philadelphia, Department of Pediatrics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Monique M Gardner
- Division of Cardiac Critical Care, The Children's Hospital of Philadelphia, Department of Anesthesia and Critical Care, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Chitra Ravishankar
- Division of Cardiology, The Children's Hospital of Philadelphia, Department of Pediatrics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Jonathan J Rome
- Division of Cardiology, The Children's Hospital of Philadelphia, Department of Pediatrics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Andrew C Glatz
- Division of Cardiology St. Louis Children's Hospital and Department of Pediatrics Washington University Medical School, St. Louis, MO
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Hanser A, Hofbeck M, Hofmeister M, Martirosian P, Hornung A, Esser M, Schick F, Kaulitz R, Michel J, Nikolaou K, Schäfer J, Schlensak C, Sieverding L. Thoracic lymphatic anomalies in patients with univentricular hearts: correlation of morphologic findings in isotropic T2-weighted MRI with the outcome after fontan palliation. Front Cardiovasc Med 2023; 10:1145613. [PMID: 37229222 PMCID: PMC10203211 DOI: 10.3389/fcvm.2023.1145613] [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: 01/16/2023] [Accepted: 04/19/2023] [Indexed: 05/27/2023] Open
Abstract
Objectives In this study we examined the correlation between the extent of thoracic lymphatic anomalies in patients after surgical palliation by total cavopulmonary connection (TCPC) and their outcome in terms of clinical and laboratory parameters. Materials and methods We prospectively examined 33 patients after TCPC with an isotropic heavily T2-weighted MRI sequence on a 3.0 T scanner. Examinations were performed after a solid meal, slice thickness of 0.6 mm, TR of 2400 ms, TE of 692 ms, FoV of 460 mm, covering thoracic and abdominal regions. Findings of the lymphatic system were correlated with clinical and laboratory parameters obtained at the annual routine check-up. Results Eight patients (group 1) showed type 4 lymphatic abnormalities. Twentyfive patients (group 2) presented less severe anomalies (type 1-3). In the treadmill CPET, group 2 reached step 7.0;6.0/8.0 vs. 6.0;3.5/6.8 in group 1 (p = 0.006*) and a distance of 775;638/854 m vs. 513;315/661 m (p = 0.006*). In the laboratory examinations, group 2 showed significantly lower levels of AST, ALT and stool calprotectin as compared to group 1. There were no significant differences in NT-pro-BNP, total protein, IgG, lymphocytes or platelets, but trends. A history of ascites showed 5/8 patients in group 1 vs. 4/25 patients in group 2 (p = 0.02*), PLE occurred in 4/8 patient in group 1 vs. 1/25 patients in group 2 (p = 0.008*). Conclusion In the long-term follow-up after TCPC, patients with severe thoracic and cervical lymphatic abnormalities showed restrictions in exercise capacity, higher liver enzymes and an increased rate of symptoms of imminent Fontan-failure such as ascites and PLE.
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Affiliation(s)
- Anja Hanser
- Department of Pediatric Cardiology, University Children's Hospital, University of Tübingen, Tübingen, Germany
| | - Michael Hofbeck
- Department of Pediatric Cardiology, University Children's Hospital, University of Tübingen, Tübingen, Germany
| | - Melanie Hofmeister
- Department of Pediatric Cardiology, University Children's Hospital, University of Tübingen, Tübingen, Germany
| | - Petros Martirosian
- Section on Experimental Radiology, University Hospital of Tübingen, Tübingen, Germany
| | - Andreas Hornung
- Department of Pediatric Cardiology, University Children's Hospital, University of Tübingen, Tübingen, Germany
| | - Michael Esser
- Department of Diagnostic and Interventional Radiology, University Hospital of Tübingen, Tübingen, Germany
| | - Fritz Schick
- Section on Experimental Radiology, University Hospital of Tübingen, Tübingen, Germany
| | - Renate Kaulitz
- Department of Pediatric Cardiology, University Children's Hospital, University of Tübingen, Tübingen, Germany
| | - Jörg Michel
- Department of Pediatric Cardiology, University Children's Hospital, University of Tübingen, Tübingen, Germany
| | - Konstantin Nikolaou
- Department of Diagnostic and Interventional Radiology, University Hospital of Tübingen, Tübingen, Germany
| | - Jürgen Schäfer
- Department of Diagnostic and Interventional Radiology, University Hospital of Tübingen, Tübingen, Germany
| | - Christian Schlensak
- Department of Cardiothoracic and Vascular Surgery, University Hospital of Tübingen, Tübingen, Germany
| | - Ludger Sieverding
- Department of Pediatric Cardiology, University Children's Hospital, University of Tübingen, Tübingen, Germany
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Spentzou G, Taylor L, Zhang Y, D'Udekem Y, Zannino D, Davis A, Pflaumer A. Long-term outcomes of pacemaker implantation in children with univentricular versus complex biventricular surgical repair. J Arrhythm 2023; 39:207-216. [PMID: 37021029 PMCID: PMC10068957 DOI: 10.1002/joa3.12832] [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: 08/21/2022] [Revised: 01/17/2023] [Accepted: 02/05/2023] [Indexed: 02/15/2023] Open
Abstract
Objective Pacing in a univentricular circulation has been associated with worsened outcomes. We investigated the long-term outcomes of pacing in children with a univentricular circulation compared to a complex biventricular circulation. We also identified predictors of adverse outcomes. Methods A retrospective study of all children with major congenital heart disease who underwent pacemaker implantation under the age of 18 years between November 1994 and October 2017. Results Eighty-nine patients were included; 19 with a univentricular and 70 with a complex biventricular circulation. A total of 96% of pacemaker systems were epicardial. Median follow up was 8.3 years. The incidence of adverse outcome was similar between the two groups. Five (5.6%) patients died and two (2.2%) underwent heart transplantation. Most adverse events occurred within the first 8 years after pacemaker implantation. Univariate analysis identified five predictors of adverse outcomes in the patients in the biventricular but none in the univentricular group. The predictors of adverse outcome in the biventricular circulation were a right morphologic ventricle as the systemic ventricle, age at first congenital heart disease (CHD) operation, number of CHD operations, and female gender. The nonapical lead position was associated with a much higher risk of an adverse outcome. Conclusions Children with a pacemaker and a complex biventricular circulation have similar survival to the ones with a pacemaker and a univentricular circulation. The only modifiable predictor was the epicardial lead position on the paced ventricle, emphasizing the importance of apical placement of the ventricular lead.
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Affiliation(s)
- Georgia Spentzou
- Department of CardiologyRoyal Children's Hospital MelbourneParkvilleVictoriaAustralia
| | - Luke Taylor
- Department of CardiologyRoyal Children's Hospital MelbourneParkvilleVictoriaAustralia
| | - Yiyan Zhang
- Department of PaediatricsUniversity of MelbourneParkvilleVictoriaAustralia
| | - Yves D'Udekem
- Department of Cardiac SurgeryRoyal Children's Hospital MelbourneParkvilleVictoriaAustralia
- Murdoch Children's Research Institute MelbourneRoyal Children's Hospital MelbourneParkvilleVictoriaAustralia
| | - Diana Zannino
- Murdoch Children's Research Institute MelbourneRoyal Children's Hospital MelbourneParkvilleVictoriaAustralia
| | - Andrew Davis
- Department of CardiologyRoyal Children's Hospital MelbourneParkvilleVictoriaAustralia
- Department of PaediatricsUniversity of MelbourneParkvilleVictoriaAustralia
- Murdoch Children's Research Institute MelbourneRoyal Children's Hospital MelbourneParkvilleVictoriaAustralia
| | - Andreas Pflaumer
- Department of CardiologyRoyal Children's Hospital MelbourneParkvilleVictoriaAustralia
- Department of PaediatricsUniversity of MelbourneParkvilleVictoriaAustralia
- Murdoch Children's Research Institute MelbourneRoyal Children's Hospital MelbourneParkvilleVictoriaAustralia
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17
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Tricuspid Valve Regurgitation in Hypoplastic Left Heart Syndrome: Current Insights and Future Perspectives. J Cardiovasc Dev Dis 2023; 10:jcdd10030111. [PMID: 36975875 PMCID: PMC10051129 DOI: 10.3390/jcdd10030111] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2023] [Revised: 02/24/2023] [Accepted: 03/01/2023] [Indexed: 03/09/2023] Open
Abstract
Hypoplastic Left Heart Syndrome (HLHS) is a congenital heart defect that requires a three-stage surgical palliation to create a single ventricle system in the right side of the heart. Of patients undergoing this cardiac palliation series, 25% will develop tricuspid regurgitation (TR), which is associated with an increased mortality risk. Valvular regurgitation in this population has been extensively studied to understand indicators and mechanisms of comorbidity. In this article, we review the current state of research on TR in HLHS, including identified valvular anomalies and geometric properties as the main reasons for the poor prognosis. After this review, we present some suggestions for future TR-related studies to answer the central question: What are the predictors of TR onset during the three palliation stages? These studies involve (i) the use of engineering-based metrics to evaluate valve leaflet strains and predict tissue material properties, (ii) perform multivariate analyses to identify TR predictors, and (iii) develop predictive models, particularly using longitudinally tracked patient cohorts to foretell patient-specific trajectories. Regarded together, these ongoing and future efforts will result in the development of innovative tools that can aid in surgical timing decisions, in prophylactic surgical valve repair, and in the refinement of current intervention techniques.
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18
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Keaney JF, Simmons MA, Elder RW, Beach CM. Fontan-related morbidity and paced QRS duration: A case series. PROGRESS IN PEDIATRIC CARDIOLOGY 2023. [DOI: 10.1016/j.ppedcard.2023.101641] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/03/2023]
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19
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Dal Sasso E, Schöndorf T, Schlüter KJ, Miera O, De Rita F, Menon AK. A Novel Strategy for the Mechanical Subpulmonary Support in Failing Fontan Patients. Thorac Cardiovasc Surg 2022; 70:e34-e41. [DOI: 10.1055/s-0042-1757916] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
Abstract
Background The number of single ventricle patients undergoing Fontan palliation and surviving to adulthood worldwide has steadily increased in recent years. Nevertheless, the Fontan circulation is destined to fail. Ultimately, heart transplantation (HTx) remains the definitive treatment option. Due a shortage of organs, mechanical circulatory support in the form of ventricular assist devices (VADs) is widely used to bridge heart failure patients to HTx, but these devices have been mainly developed to address the needs of normal anatomies. A novel venous cannula has been developed as part of the EXCOR® VAD to provide subpulmonary support in these patients. Its clinical application is investigated in the “Registry to Assess the Safety and Feasibility of the Subpulmonary Support with the Novel Venous Cannula in Patients with Failing/Absence of the Right Heart” (RegiVe study, NCT04782232).
Methods RegiVe is a multicenter, international, observational, prospective, non-randomized registry aiming to collect the routine clinical data of up to 20 patients. The primary endpoints address device performance and safety, while the secondary endpoints target organ status and overall safety (according to the Interagency Registry for Mechanically Assisted Circulatory Support – INTERMACS – definitions). Data analysis will be performed by means of descriptive statistics.
Results RegiVe has received the favorable opinion of an independent ethics committee and enrollment has recently started.
Conclusion RegiVe is the first study evaluating the use of a medical device specifically developed for subpulmonary support of failing Fontan patients. The study will provide important insight and further information on this cohort and help to improve a dedicated VAD strategy.
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Affiliation(s)
| | | | | | - Oliver Miera
- Department of Congenital Heart Disease – Pediatric Cardiology, German Heart Center Berlin (DHZB), Berlin, Germany
| | - Fabrizio De Rita
- Adult Congenital and Paediatric Heart Unit, Freeman Hospital, Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, United Kingdom
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20
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Alhabdan MS, Alzayer EA, Alawami MH, Khouqeer FA. Social life in adult patients after Fontan procedure. THE CARDIOTHORACIC SURGEON 2022. [DOI: 10.1186/s43057-022-00087-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022] Open
Abstract
Abstract
Background
Little is known about the social life in adult patients after Fontan palliation. The study aimed to assess the long-term social life of patients after Fontan surgery, including school achievement, employment, and marital status.
Results
We conducted a cross-sectional study on patients aged 18 years or above who had a Fontan operation for a single ventricle pathology. Our outcomes were the academic performance and marital and employment status of adult Fontan patients. Patients or their families were interviewed directly or by phone, and a set of questions were asked to address their educational level, employment, and marital status. Ninety-nine patients were included in the study. Their median age was 21 years (min–max: 18–41), and 60% were females (n= 59). The most common diagnoses were double inlet left ventricle (n= 24, 24%), tricuspid atresia (n= 21, 21%), and the unbalanced atrioventricular canal (n= 21, 21%). Fourteen patients (14%) were married, and 6 of them had children (two were females). Eleven percent were college graduates (either diploma or bachelor’s degree), and 47% were high school graduates.
Conclusions
Fontan operation could negatively affect the social life of the patients. It may affect employment patterns, educational levels, and marital status.
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21
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Chubb H, Bulic A, Mah D, Moore JP, Janousek J, Fumanelli J, Asaki SY, Pflaumer A, Hill AC, Escudero C, Kwok SY, Mangat J, Ochoa Nunez LA, Balaji S, Rosenthal E, Regan W, Horndasch M, Asakai H, Tanel R, Czosek RJ, Young ML, Bradley DJ, Paul T, Fischbach P, Malloy-Walton L, McElhinney DB, Dubin AM. Impact and Modifiers of Ventricular Pacing in Patients With Single Ventricle Circulation. J Am Coll Cardiol 2022; 80:902-914. [PMID: 36007989 DOI: 10.1016/j.jacc.2022.05.053] [Citation(s) in RCA: 15] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/10/2022] [Revised: 05/04/2022] [Accepted: 05/23/2022] [Indexed: 10/15/2022]
Abstract
BACKGROUND Palliation of the single ventricle (SV) circulation is associated with a burden of lifelong complications. Previous studies have identified that the need for a permanent ventricular pacing system (PPMv) may be associated with additional adverse long-term outcomes. OBJECTIVES The goal of this study was to quantify the attributable risk of PPMv in patients with SV, and to identify modifiable risk factors. METHODS This international study was sponsored by the Pediatric and Congenital Electrophysiology Society. Centers contributed baseline and longitudinal data for functionally SV patients with PPMv. Enrollment was at implantation. Controls were matched 1:1 to PPMv subjects by ventricular morphology and sex, identified within center, and enrolled at matched age. Primary outcome was transplantation or death. RESULTS In total, 236 PPMv subjects and 213 matched controls were identified (22 centers, 9 countries). Median age at enrollment was 5.3 years (quartiles: 1.5-13.2 years), follow-up 6.9 years (3.4-11.6 years). Median percent ventricular pacing (Vp) was 90.8% (25th-75th percentile: 4.3%-100%) in the PPMv cohort. Across 213 matched pairs, multivariable HR for death/transplant associated with PPMv was 3.8 (95% CI 1.9-7.6; P < 0.001). Within the PPMv population, higher Vp (HR: 1.009 per %; P = 0.009), higher QRS z-score (HR: 1.19; P = 0.009) and nonapical lead position (HR: 2.17; P = 0.042) were all associated with death/transplantation. CONCLUSIONS PPMv in patients with SV is associated with increased risk of heart transplantation and death, despite controlling for increased associated morbidity of the PPMv cohort. Increased Vp, higher QRS z-score, and nonapical ventricular lead position are all associated with higher risk of adverse outcome and may be modifiable risk factors.
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Affiliation(s)
- Henry Chubb
- Division of Pediatric Cardiology, Department of Pediatrics, Stanford University, Stanford, California, USA; Division of Pediatric Cardiothoracic Surgery, Department of Cardiothoracic Surgery, Stanford University, Stanford, California, USA.
| | - Anica Bulic
- Labatt Family Heart Centre, The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
| | - Douglas Mah
- Department of Cardiology, Boston Children's Hospital, Boston, Massachusetts, USA; Department of Pediatrics, Harvard Medical School, Boston, Massachusetts, USA
| | - Jeremy P Moore
- Division of Cardiology, Department of Pediatrics, UCLA Health System, Los Angeles, California, USA; Division of Cardiology, Department of Medicine, Ahmanson/UCLA Adult Congenital Heart Disease Center, Los Angeles, California, USA; UCLA Cardiac Arrhythmia Center, UCLA Health System, Los Angeles, California, USA
| | - Jan Janousek
- Children's Heart Centre, Second Faculty of Medicine, Charles University in Prague and Motol University Hospital, Prague, Czech Republic
| | - Jennifer Fumanelli
- Children's Heart Centre, Second Faculty of Medicine, Charles University in Prague and Motol University Hospital, Prague, Czech Republic; Pediatric Cardiology Unit, Department of Women's and Child's Health, University of Padova, Padova, Italy
| | - S Yukiko Asaki
- Primary Children's Hospital, University of Utah, Salt Lake City, Utah, USA
| | - Andreas Pflaumer
- The Royal Children's Hospital, MCRI and University of Melbourne, Melbourne, Victoria, Australia
| | - Allison C Hill
- Division of Cardiology, Children's Hospital Los Angeles, Los Angeles, California, USA; Keck School of Medicine, University of Southern California, Los Angeles, California, USA
| | - Carolina Escudero
- Department of Pediatrics, Division of Pediatric Cardiology, University of Alberta, Stollery Children's Hospital, Edmonton, Alberta, Canada
| | - Sit Yee Kwok
- Cardiology Centre, Department of Paediatrics and Adolescent Medicine, Hong Kong Children's Hospital, Hong Kong SAR, China
| | - Jasveer Mangat
- Paediatric Cardiology, Great Ormond Street, London, United Kingdom
| | | | - Seshadri Balaji
- Department of Pediatrics, Division of Cardiology, Oregon Health & Science University, Portland, Oregon, USA
| | - Eric Rosenthal
- Paediatric Cardiology, Evelina London Children's Hospital, London, United Kingdom
| | - William Regan
- Paediatric Cardiology, Evelina London Children's Hospital, London, United Kingdom
| | - Michaela Horndasch
- Department of Congenital Heart Diseases and Pediatric Cardiology, German Heart Center Munich, Munich, Germany
| | - Hiroko Asakai
- Department of Paediatrics, University of Tokyo Hospital, Tokyo, Japan
| | - Ronn Tanel
- Division of Pediatric Cardiology, Department of Pediatrics, UCSF School of Medicine, San Francisco, California, USA
| | - Richard J Czosek
- The Heart Institute, Cincinnati Children's Hospital Medical Center, Ohio, USA
| | - Ming-Lon Young
- Joe DiMaggio Children's Hospital, Hollywood, Florida, USA
| | - David J Bradley
- University of Michigan, CS Mott Children's Hospital, Ann Arbor, Michigan, USA
| | - Thomas Paul
- Department of Pediatric Cardiology, Georg-August-University Medical Center, Göttingen, Germany
| | | | | | - Doff B McElhinney
- Division of Pediatric Cardiology, Department of Pediatrics, Stanford University, Stanford, California, USA; Division of Pediatric Cardiothoracic Surgery, Department of Cardiothoracic Surgery, Stanford University, Stanford, California, USA
| | - Anne M Dubin
- Division of Pediatric Cardiology, Department of Pediatrics, Stanford University, Stanford, California, USA
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Determinants of oxygen uptake and prognostic factors in cardiopulmonary exercise test in patients with Fontan surgery. Cardiol Young 2022; 32:1285-1288. [PMID: 34602111 DOI: 10.1017/s1047951121004054] [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: 11/07/2022]
Abstract
INTRODUCTION Cardiopulmonary exercise test (CPET) allows quantification of functional capacity of patients with Fontan. The objective of this study was to determine the role of CPET parameters in predicting a higher maximum oxygen consumption (VO2 max) and to analyse the role of CPET parameters in predicting an unfavourable outcome. METHODS A retrospective, cross-sectional, descriptive study was carried out on 57 patients with Fontan, who had undergone incremental CPET with cycloergometer between 2010 and 2020. Determinants of VO2 max and determinants of clinical deterioration were analysed. RESULTS In the univariate analysis, the variables significantly related to VO2 max were: age, sex, body mass index (BMI), years of Fontan evolution, intracardiac Fontan, oxygen consumption at anaerobic threshold (VO2AT), CO2 equivalents at anaerobic threshold (VE/VCO2) and chronotropic insufficiency. The multiple linear regression model that best fitted the relationship between VO2 max and independent variables (correlation coefficient 0.73) included sex (correlation index 3.35; p = 0.02), BMI (-0.27; p = 0.02), chronotropic failure (-2.79; p = 0.01) and VO2AT (0.92; p < 0.0001). In the univariate analysis of the prognostic CPET variables related to an unfavourable clinical situation, significance was only obtained with chronotropic insufficiency (p = 0.003). In multivariate analysis, chronotropic insufficiency maintains its association [p= 0.017, OR = 4.65 (1.3-16.5)]. CONCLUSIONS In conclusion, together with the anthropometric parameters universally related to VO2 max, chronotropic insufficiency and VO2AT are the main determinants of functional capacity in patients with Fontan. Moreover, chronotropic insufficiency is closely related to unfavourable clinical evolution. Our data would support the intensive treatment of chronotropic insufficiency in order to improve the quality of life and the clinical situation of patients with Fontan.
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O'Byrne ML, McHugh KE, Huang J, Song L, Griffis H, Anderson BR, Bucholz EM, Chanani NK, Elhoff JJ, Handler SS, Jacobs JP, Li JS, Lewis AB, McCrindle BW, Pinto NM, Sassalos P, Spar DS, Pasquali SK, Glatz AC. Cumulative In-Hospital Costs Associated With Single-Ventricle Palliation. JACC. ADVANCES 2022; 1:100029. [PMID: 38939312 PMCID: PMC11198056 DOI: 10.1016/j.jacadv.2022.100029] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/16/2022] [Revised: 04/20/2022] [Accepted: 04/22/2022] [Indexed: 06/29/2024]
Abstract
Background In the SVR (Single Ventricle Reconstruction) Trial, 1-year survival in recipients of right ventricle to pulmonary artery shunts (RVPAS) was superior to that in those receiving modified Blalock-Taussig-Thomas shunts (MBTTS), but not in subsequent follow-up. Cost analysis is an expedient means of evaluating value and morbidity. Objectives The purpose of this study was to evaluate differences in cumulative hospital costs between RVPAS and MBTTS. Methods Clinical data from SVR and costs from Pediatric Health Information Systems database were combined. Cumulative hospital costs and cost-per-day-alive were compared serially at 1, 3, and 5 years between RVPAS and MBTTS. Potential associations between patient-level factors and cost were explored with multivariable models. Results In total, 303 participants (55% of the SVR cohort) from 9 of 15 sites were studied (48% MBTTS). Observed total costs at 1 year were lower for MBTTS ($701,260 ± 442,081) than those for RVPAS ($804,062 ± 615,068), a difference that was not statistically significant (P = 0.10). Total costs were also not significantly different at 3 and 5 years (P = 0.21 and 0.32). Similarly, cost-per-day-alive did not differ significantly for either group at 1, 3, and 5 years (all P > 0.05). In analyses of transplant-free survivors, total costs and cost-per-day-alive were higher for RVPAS at 1 year (P = 0.05 for both) but not at 3 and 5 years (P > 0.05 for all). In multivariable models, aortic atresia and prematurity were associated with increased cost-per-day-alive across follow-up (P < 0.05). Conclusions Total costs do not differ significantly between MBTTS and RVPAS. The magnitude of longitudinal costs underscores the importance of efforts to improve outcomes in this vulnerable population.
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Affiliation(s)
- Michael L. O'Byrne
- Division of Cardiology, The Children's Hospital of Philadelphia and Department of Pediatrics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, USA
- Center for Pediatric Clinical Effectiveness, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
- Leonard Davis Institute of Health Economics and Cardiovascular Outcomes, Quality, and Evaluative Research Center, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Kimberly E. McHugh
- Division of Cardiology, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Jing Huang
- Division of Cardiology, The Children's Hospital of Philadelphia and Department of Pediatrics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, USA
- Department of Biostatistics, Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine, Philadelphia, Pennsylvania, USA
| | - Lihai Song
- Data Science and Biostatistics Unit, Department of Biomedical and Health Informatics, The Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Heather Griffis
- Data Science and Biostatistics Unit, Department of Biomedical and Health Informatics, The Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Brett R. Anderson
- Division of Cardiology, New York-Presbyterian Morgan-Stanley Children’s Hospital/Columbia University Irving Medical Center, New York, New York, USA
| | - Emily M. Bucholz
- Department of Cardiology, Children’s Hospital Boston and Harvard University Medical School, Boston, Massachusetts, USA
| | - Nikhil K. Chanani
- Children’s Healthcare of Atlanta, Sibley Heart Center and Emory University School of Medicine, Atlanta, Georgia, USA
| | - Justin J. Elhoff
- Sections of Critical Care and Cardiology, Texas Children’s Hospital and Baylor College of Medicine, Houston, Texas, USA
| | | | - Jeffery P. Jacobs
- Division of Cardiothoracic Surgery, Departments of Surgery and Pediatrics, Congenital Heart Center, University of Florida, Gainesville, Florida, USA
| | - Jennifer S. Li
- Division of Pediatric Cardiology, Duke University School of Medicine, Durham, North Carolina, USA
| | - Alan B. Lewis
- Division of Cardiology, Department of Pediatrics, Children’s Hospital of Los Angeles, Keck School of Medicine of University of Southern California, Los Angeles, California, USA
| | - Brian W. McCrindle
- Department of Pediatrics, Labatt Family Heart Centre, The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
| | - Nelangi M. Pinto
- Division of Cardiology, Primary Children’s Hospital and University of Utah School of Medicine, Salt Lake City, Utah, USA
| | - Peter Sassalos
- Division of Pediatric Cardiothoracic Surgery, C.S. Mott Children’s Hospital and University of Michigan School of Medicine, Ann Arbor, Michigan, USA
| | - David S. Spar
- The Heart Institute, Cincinnati Children’s Hospital Medical Center and Department of Pediatrics, University of Cincinnati School of Medicine, Cincinnati, Ohio, USA
| | - Sara K. Pasquali
- Division of Cardiology, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio, USA
| | - Andrew C. Glatz
- Division of Cardiology, The Children's Hospital of Philadelphia and Department of Pediatrics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, USA
- Center for Pediatric Clinical Effectiveness, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
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A pilot investigation of the tricuspid valve annulus in newborns with hypoplastic left heart syndrome. JTCVS OPEN 2022; 10:324-339. [PMID: 35937182 PMCID: PMC9354836 DOI: 10.1016/j.xjon.2022.02.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Objective Hypoplastic left heart syndrome (HLHS) is a congenital disease characterized by an underdevelopment of the anatomical components inside the left heart. Approximately 30% of newborns with HLHS will develop tricuspid regurgitation, and it is currently unknown how the valve annulus mechanics and geometry are associated with regurgitation. Thus, we present an engineering mechanics-based analysis approach to quantify the mechanics and geometry of the HLHS-afflicted tricuspid valve (TV), using 4-dimensional echocardiograms. Methods Infants born with HLHS (n = 8) and healthy newborns (n = 4) had their TVs imaged, and the data were imported to 3D Slicer. The annular curves were defined at 5 points in the cardiac cycle. The geometry and deformation (strain) of the TV annulus were calculated to elucidate the mechanics of this critical structure and to compare them between neonates with and without HLHS. Results For the annular geometry, HLHS-afflicted newborns had significantly larger annular circumferences (20%-30%) and anteroposterior diameters (35%-45%) than the healthy patients. From a biomechanics' perspective, the HLHS patients had significantly smaller strains in the anterior segments (–0.1 ± 2.6%) during end-diastolic and end-isovolumetric relaxation (1.7 ± 3.0%) compared with the healthy counterparts (–13.3 ± 2.9% and 6.8 ± 0.9%, respectively). Conclusions The image-based analysis presented in this study may provide novel insights into the geometric and mechanistic differences in the TV annulus between the healthy and HLHS newborns. Future longitudinal studies of the biomechanics of TV annulus and other subvalvular structures may inform our understanding of the initiation and development of tricuspid regurgitation and the design of optimal repairs in this challenging population.
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Black AK, Alsoufi B. Invited Commentary: Computational Flow Dynamics: The Future of Fontan Conduit Selection and Operative Planning? World J Pediatr Congenit Heart Surg 2022; 13:302-303. [PMID: 35446216 DOI: 10.1177/21501351221091341] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Affiliation(s)
- Allison K Black
- Departments of Pediatrics, University of Louisville School of Medicine, Norton Children's Hospital, Louisville, KY, USA
| | - Bahaaldin Alsoufi
- Cardiovascular and Thoracic Surgery, University of Louisville School of Medicine, Norton Children's Hospital, Louisville, KY, USA
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Kramer P, Schleiger A, Schafstedde M, Danne F, Nordmeyer J, Berger F, Ovroutski S. A Multimodal Score Accurately Classifies Fontan Failure and Late Mortality in Adult Fontan Patients. Front Cardiovasc Med 2022; 9:767503. [PMID: 35360016 PMCID: PMC8960137 DOI: 10.3389/fcvm.2022.767503] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2021] [Accepted: 02/02/2022] [Indexed: 11/23/2022] Open
Abstract
Objectives Despite the outstanding success of the Fontan operation, it is a palliative procedure and a substantial number of patients experience late failure of the Fontan circulation. Clinical presentation and hemodynamic phenotypes of Fontan failure are considerably variable. While various parameters have been identified as risk factors for late Fontan failure, a feasible score to classify Fontan failure and possibly allow timely risk stratification is lacking. Here, we explored the possibility of developing a score based on hemodynamic, clinical and laboratory parameters to classify Fontan failure and mortality. Methods We performed a retrospective study in our cohort of adult Fontan patients from two institutions [n = 198, median follow-up after Fontan 20.3 (IQR 15.6–24.3) years], identifying those patients with clinical Fontan failure (n = 52, 26.3%). Various hemodynamic, echocardiographic, laboratory and clinical data were recorded and differences between patients with and without Fontan failure were analyzed. We composed a Fontan Failure Score containing 15 parameters associated with Fontan failure and/or mortality and assessed its accuracy to discriminate between patients with and without late Fontan failure as well as late mortality and survival. Results Late failure occurred at a median of 18.2 (IQR 9.1–21.1) years after Fontan completion. Mortality associated with Fontan failure was substantial (25/52, 48.1%) with freedom of death/transplantation/take-down of 64% at 5 years and 36% at 10 years after onset of Fontan failure, respectively. Patients with Fontan failure had a significantly higher median Fontan Failure Score compared to non-failing Fontan patients [8 points (IQR 5–10) vs. 2 points (IQR 1-5), p < 0.001]. The score accurately classifies Fontan failure as well as mortality as assessed with receiver operating characteristic analysis. Area under the curve of the Fontan Failure Score was 0.963 (95% CI 0.921; 0.985, p < 0.001) to discriminate failure and 0.916 (95% CI 0.873; 0.959, p < 0.001) to classify mortality. Conclusion We have developed an uncomplex yet remarkably accurate score to classify Fontan failure and late mortality in adult Fontan patients. Prospective validation and most likely refinement and calibration of the score in larger and preferably multi-institutional cohorts is required to assess its potential to predict the risk of Fontan failure and late mortality.
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Affiliation(s)
- Peter Kramer
- Department of Congenital Heart Disease/Pediatric Cardiology, German Heart Centre Berlin, Berlin, Germany
- *Correspondence: Peter Kramer
| | - Anastasia Schleiger
- Department of Congenital Heart Disease/Pediatric Cardiology, German Heart Centre Berlin, Berlin, Germany
| | - Marie Schafstedde
- Department of Congenital Heart Disease/Pediatric Cardiology, German Heart Centre Berlin, Berlin, Germany
- Institute for Cardiovascular Computer-Assisted Medicine, Charité - Universitätsmedizin Berlin, Berlin, Germany
- Berlin Institute of Health, Berlin, Germany
| | - Friederike Danne
- Department of Congenital Heart Disease/Pediatric Cardiology, German Heart Centre Berlin, Berlin, Germany
| | - Johannes Nordmeyer
- Department of Congenital Heart Disease/Pediatric Cardiology, German Heart Centre Berlin, Berlin, Germany
| | - Felix Berger
- Department of Congenital Heart Disease/Pediatric Cardiology, German Heart Centre Berlin, Berlin, Germany
- Department of Pediatric Cardiology, Charité - Universitätsmedizin Berlin, Campus Virchow-Klinikum, Berlin, Germany
- German Centre for Cardiovascular Research (DZHK), Partner Site Berlin, Berlin, Germany
| | - Stanislav Ovroutski
- Department of Congenital Heart Disease/Pediatric Cardiology, German Heart Centre Berlin, Berlin, Germany
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Stephens EH. Commentary: Fontan candidacy in which all roads do not lead to Rome. JTCVS OPEN 2022; 9:235-236. [PMID: 36003457 PMCID: PMC9390596 DOI: 10.1016/j.xjon.2021.08.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/01/2021] [Revised: 08/01/2021] [Accepted: 08/03/2021] [Indexed: 11/30/2022]
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Venna A, Cetta F, d'Udekem Y. Fontan candidacy, optimizing Fontan circulation, and beyond. JTCVS OPEN 2022; 9:227-232. [PMID: 36003486 PMCID: PMC9390390 DOI: 10.1016/j.xjon.2021.07.042] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/02/2020] [Indexed: 10/24/2022]
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Classic pattern dyssynchrony is associated with outcome in patients with Fontan circulation. J Am Soc Echocardiogr 2022; 35:513-522. [DOI: 10.1016/j.echo.2022.01.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/06/2021] [Revised: 01/08/2022] [Accepted: 01/21/2022] [Indexed: 11/24/2022]
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Reid CS, Kaiser HA, Heinisch PP, Bruelisauer T, Michel S, Siepe M. Ventricular assist device for Fontan: who, when and why? Curr Opin Anaesthesiol 2022; 35:12-17. [PMID: 34812751 DOI: 10.1097/aco.0000000000001078] [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] [Indexed: 12/17/2022]
Abstract
PURPOSE OF REVIEW Since the advent of the Fontan palliation, survival of patients with univentricular congenital heart disease has increased significantly. These patients will, however, ultimately develop heart failure requiring advanced therapies such as heart transplantation. As wait times are long, mechanical circulatory support (MCS) is an attractive therapy, both for bridge to transplantation and destination therapy in patients not suitable for transplantation. This review aims to summarize current thinking about how to determine which patients would benefit from a ventricular assist device (VAD), the optimal time for implantation and which device should be considered. RECENT FINDINGS VAD implantation in end-stage Fontan is still in its infancy; however, case reports and research interest have increased extensively in the past few years. Mortality is significantly higher than in noncongenital heart disease patients. Implantation in patients with primarily systolic dysfunction is indicated, whereas patients with increased transpulmonary gradient may not benefit from a single-VAD solution. When possible, implantation should occur prior to clinical decompensation with evidence of end-organ damage, as outcomes at this point are worse. SUMMARY Fontan patients demonstrating signs of heart failure should be evaluated early and often for feasibility and optimal timing of VAD implantation. The frequency of this procedure will likely increase significantly in the future.
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Affiliation(s)
- Catherine S Reid
- Department of Anaesthesiology and Pain Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Heiko A Kaiser
- Department of Anaesthesiology and Pain Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
- Centre for Anaesthesiology and Intensive Care Medicine, Hirslanden Klinik Aarau, Hirslanden Group, Aarau, Switzerland
| | - Paul Philipp Heinisch
- Department of Congenital and Pediatric Heart Surgery, German Heart Center Munich, Technische Universität München, Germany
- Division of Congenital and Pediatric Heart Surgery, University Hospital of Munich, Ludwig-Maximilians-Universität, Munich, Germany
| | - Thomas Bruelisauer
- German Heart Center Berlin, Department of Cardiac Anesthesiology and Intensive Care Medicine, Berlin, Germany
| | - Sebastian Michel
- Department of Congenital and Pediatric Heart Surgery, German Heart Center Munich, Technische Universität München, Germany
- Division of Congenital and Pediatric Heart Surgery, University Hospital of Munich, Ludwig-Maximilians-Universität, Munich, Germany
| | - Matthias Siepe
- Department of Cardiovascular Surgery, Heart Center University Freiburg - Bad Krozingen, Bad Krozingen, Germany
- Faculty of Medicine, University of Freiburg, Freiburg, Germany
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Psychological functioning in paediatric patients with single ventricle heart disease: a systematic review. Cardiol Young 2022; 32:173-184. [PMID: 35045915 DOI: 10.1017/s1047951122000063] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
BACKGROUND Patients with single ventricle heart disease are living into adulthood due to medical and surgical advancements but have significant physical comorbidities and an increased risk for psychological comorbidities compared to healthy subjects or those with other CHD diagnoses. This study aimed to systematically review psychological functioning in paediatric single ventricle heart disease. METHODS Literature was searched using PubMed, Embase, PsycInfo, CINAHL Complete and Scopus. Peer-reviewed articles that included patients ages 0-25 years with single ventricle heart disease, and quantitative measures of psychological outcomes were included. Meta-analysis using a fixed-effect model was conducted for internalising and externalising t-scores, utilised by the Achenbach Child Behavior Checklist. RESULTS Twenty-nine records met the criteria for inclusion. 13/24 studies demonstrated increased risk for internalising disorders, such as anxiety/depression; 16/22 studies demonstrated risk for externalising disorders, such as attention or behavioural problems. Meta-analysis of four studies revealed that paediatric single ventricle heart disease patients had no significant difference in internalising and externalising t-scores compared to normative values. CONCLUSIONS The current review demonstrates the need for further studies to better understand psychological functioning in patients with single ventricle heart disease, with a majority of studies showing increased risk for psychological problems despite no difference seen in a small meta-analysis. This summary of the literature underscores the need for regular psychological screening, earlier intervention and integrated mental health therapies in paediatric single ventricle heart disease.
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Hedlund E, Lundell B. Endurance training may improve exercise capacity, lung function and quality of life in Fontan patients. Acta Paediatr 2022; 111:17-23. [PMID: 34554597 DOI: 10.1111/apa.16121] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/30/2021] [Revised: 08/31/2021] [Accepted: 09/22/2021] [Indexed: 12/17/2022]
Abstract
Children born with univentricular hearts undergo staged surgical procedures to a Fontan circulation. Long-term experience with Fontan palliation has shown dramatically improved survival but also of a life-long burden of an abnormal circulation with significant morbidity. Many Fontan patients have reduced exercise capacity, oxygen uptake, lung function and quality of life. Endurance training may improve submaximal, but not maximal, exercise capacity, lung function and quality of life. Physical activity and endurance training is also positively correlated with sleep quality. Reviewing the literature and from our single-centre experience, we believe there is enough evidence to support structured individualised endurance training in most young Fontan patients.
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Affiliation(s)
- Eva Hedlund
- Department of Women’s and Children’s Health Karolinska Institutet Stockholm Sweden
| | - Bo Lundell
- Department of Women’s and Children’s Health Karolinska Institutet Stockholm Sweden
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Hedlund E, Lundell B. Fontan circulation has improved life expectancy for infants born with complex heart disease over the last 50 years but has also resulted in significant morbidity. Acta Paediatr 2022; 111:11-16. [PMID: 34235784 DOI: 10.1111/apa.16023] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/22/2021] [Revised: 06/22/2021] [Accepted: 07/06/2021] [Indexed: 12/17/2022]
Abstract
The prognosis for infants born with complex heart disease improved dramatically with the introduction of the Fontan circulation 50 years ago. With today's carefully designed and staged operations to a Fontan circulation, life expectancy has increased and most children will survive into adult life. The Fontan circulation entails an unphysiological circulation with high risk for multiple organ system dysfunction. Neurodevelopmental disabilities with adverse psychosocial effects are prevalent. The Fontan circulation may eventually fail and necessitate heart transplantation. CONCLUSION: Fifty years development of the Fontan circulation to today's staged surgical procedures has improved survival but also revealed the burden of a high morbidity for a growing number of patients.
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Affiliation(s)
- Eva Hedlund
- Department of Women's and Children's Health Karolinska Institutet Stockholm Sweden
| | - Bo Lundell
- Department of Women's and Children's Health Karolinska Institutet Stockholm Sweden
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Driesen BW, Voskuil M, Grotenhuis HB. Current Treatment Options for the Failing Fontan Circulation. Curr Cardiol Rev 2022; 18:e060122200067. [PMID: 34994331 PMCID: PMC9893132 DOI: 10.2174/1573403x18666220106114518] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/21/2020] [Revised: 10/22/2021] [Accepted: 11/16/2021] [Indexed: 11/22/2022] Open
Abstract
The Fontan operation was introduced in 1968. For congenital malformations, where biventricular repair is unsuitable, the Fontan procedure has provided a long-term palliation strategy with improved outcomes compared to the initially developed procedures. Despite these improvements, several complications merely due to a failing Fontan circulation, including myocardial dysfunction, arrhythmias, increased pulmonary vascular resistance, protein-losing enteropathy, hepatic dysfunction, plastic bronchitis, and thrombo-embolism, may occur, thereby limiting the life-expectancy in this patient cohort. This review provides an overview of the most common complications of Fontan circulation and the currently available treatment options.
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Affiliation(s)
- Bart W. Driesen
- Department of Pediatric Cardiology, Wilhelmina Children’s Hospital, University Medical Center, Utrecht, Utrecht, The Netherlands
- Department of Cardiology, University Medical Center Utrecht, Utrecht, The Netherlands
- Department of Cardiology, Laurentius Ziekenhuis, Roermond, The Netherlands
| | - Michiel Voskuil
- Department of Cardiology, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Heynric B. Grotenhuis
- Department of Pediatric Cardiology, Wilhelmina Children’s Hospital, University Medical Center, Utrecht, Utrecht, The Netherlands
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Kim JL, Vaikunth SS, Haeffele C, MacArthur JW. Extracorporeal Membrane Oxygenator as a Bridge to Heart-Liver en bloc Transplant in a Fontan Patient. JTCVS Tech 2022; 12:171-174. [PMID: 35403048 PMCID: PMC8987382 DOI: 10.1016/j.xjtc.2022.01.018] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2021] [Accepted: 01/12/2022] [Indexed: 11/28/2022] Open
Affiliation(s)
- Jennifer Lynn Kim
- Department of Cardiothoracic Surgery, Stanford University School of Medicine, Stanford, Calif
| | - Sumeet S. Vaikunth
- Division of Cardiovascular Medicine, Department of Medicine, Stanford University School of Medicine, Stanford, Calif
| | - Christiane Haeffele
- Division of Cardiovascular Medicine, Department of Medicine, Stanford University School of Medicine, Stanford, Calif
| | - John W. MacArthur
- Department of Cardiothoracic Surgery, Stanford University School of Medicine, Stanford, Calif
- Address for reprints: John W. MacArthur, MD, Cardiothoracic Surgery, Stanford University Hospital, Stanford Hospital and Clinics, 870 Quarry Rd Ext, Palo Alto, CA 94304.
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Sallmon H, Ovroutski S, Schleiger A, Photiadis J, Weber SC, Nordmeyer J, Berger F, Kramer P. Late Fontan failure in adult patients is predominantly associated with deteriorating ventricular function. Int J Cardiol 2021; 344:87-94. [PMID: 34563595 DOI: 10.1016/j.ijcard.2021.09.042] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/21/2021] [Revised: 08/19/2021] [Accepted: 09/20/2021] [Indexed: 12/24/2022]
Abstract
BACKGROUND The Fontan operation is a palliative procedure and a substantial number of patients eventually experiences late Fontan circulation failure. Previous concepts of Fontan failure implicate increasing pulmonary vascular resistance (PVR) as a key contributor to late circulatory failure. However, data to support this assumption are sparse. We sought to characterize longitudinal hemodynamic and echocardiographic findings in adult failing Fontan patients. METHODS We performed a retrospective cohort study in adult Fontan patients, identifying patients with Fontan failure. Hemodynamic, echocardiographic and clinical data were recorded. RESULTS Of 173 adult patients (median follow-up after Fontan 20.2 years [IQR 15.7-24.3]), 48 (28%) showed signs of clinical Fontan failure. Thirty-seven patients (77.1%) exhibited ventricular dysfunction (systolic dysfunction defined by ejection fraction ≤45%, n = 22, or diastolic dysfunction defined by systemic ventricular end-diastolic pressure (SVEDP) ≥12 mmHg, n = 15). Elevated indexed PVR (≥2.5 WU*m2) was only observed in 9 (18.8%) patients. Ejection fraction declined from 60% [IQR 55-65] to 47% [IQR 35-55] during follow-up (p < 0.001). Mean pulmonary artery pressure and SVEDP increased from 11 mmHg [IQR 9-15] to 15 mmHg [IQR 12-18] and from 7 mmHg [IQR 4-10] to 11 mmHg [IQR 8-15] (both p < 0.001), respectively, while indexed PVR did not change significantly (2.1 [IQR 1.1-2.4] vs. 1.7 [IQR 1.1-2.5] WU*m2, p = 0.949). Fontan failure-associated mortality during follow-up was substantial (23/48; 48%). CONCLUSIONS Systolic and diastolic ventricular dysfunction are frequent features in late Fontan failure in adults, while increases in PVR were rarely observed. The intricate interplay between hemodynamic compromises in Fontan failure deserves further research to optimize treatment strategies and outcome.
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Affiliation(s)
- Hannes Sallmon
- Department of Pediatric Cardiology, Charité - Universitätsmedizin Berlin, Germany; Department of Congenital Heart Disease/Pediatric Cardiology, German Heart Center Berlin, Germany
| | - Stanislav Ovroutski
- Department of Congenital Heart Disease/Pediatric Cardiology, German Heart Center Berlin, Germany
| | - Anastasia Schleiger
- Department of Congenital Heart Disease/Pediatric Cardiology, German Heart Center Berlin, Germany
| | - Joachim Photiadis
- Department of Congenital Heart Surgery, German Heart Center Berlin, Germany
| | - Sven C Weber
- Department of Pediatric Cardiology, Charité - Universitätsmedizin Berlin, Germany
| | - Johannes Nordmeyer
- Department of Congenital Heart Disease/Pediatric Cardiology, German Heart Center Berlin, Germany
| | - Felix Berger
- Department of Pediatric Cardiology, Charité - Universitätsmedizin Berlin, Germany; Department of Congenital Heart Disease/Pediatric Cardiology, German Heart Center Berlin, Germany; DZHK (German Center for Cardiovascular Research), Partner Site Berlin, Germany
| | - Peter Kramer
- Department of Congenital Heart Disease/Pediatric Cardiology, German Heart Center Berlin, Germany.
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Predictors of Poor Functional Status in Adult Fontan Patients Living at Moderate Altitude. Pediatr Cardiol 2021; 42:1757-1765. [PMID: 34143227 DOI: 10.1007/s00246-021-02660-8] [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: 03/28/2021] [Accepted: 06/08/2021] [Indexed: 10/21/2022]
Abstract
Patients who have undergone Fontan palliation have reduced exercise tolerance measured by maximal oxygen consumption (VO2 max). Declining exercise capacity is associated with increased morbidity and mortality. The impact of hemodynamics and other variables on this population's functional status is not well understood. This study sought to identify variables that predict low VO2 max in Fontan patients living at moderate altitude (5,000-8,000 feet). We performed a retrospective cohort study of 44 adult Fontan patients living at moderate altitude who had undergone cardiopulmonary exercise testing (CPET) and cardiac catheterization. We evaluated hemodynamic parameters measured during catheterization, imaging results, and laboratory studies for correlation with VO2 max measured during CPET. Our study cohort (median age 30 years, 52% female) had exercise impairment with mean VO2 max of 21.6 mL/kg/min. Higher trans-pulmonary gradient (TPG) (p < 0.001) and mean pulmonary artery (PA) pressure (p = 0.013) were predictors of lower maximal and submaximal VO2. Higher BNP values correlated with lower VO2 max (p = 0.01). Platelet count, GGT, albumin, and pulmonary vasodilator therapy did not correlate with VO2 max. None of the studied variables were associated with higher minute ventilation to peak carbon dioxide production (VE/VCO2 slope) or change in VO2 max over time. In conclusion, higher TPG and mean PA pressure predicted lower exercise tolerance amongst our cohort of adult Fontan patients living at moderate altitude. Future studies are needed to determine if these clinical variables represent viable therapeutic targets that could result in improved exercise tolerance and outcomes in patients with Fontan circulation.
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Hanser A, Martirosian P, Hornung A, Hofbeck M, Grosse U, Esser M, Schick F, Schäfer J, Nikolaou K, Sieverding L. T2-Weighted High-Resolution Isotropic Magnetic Resonance Lymphangiography of the Thoracic and Abdominal Lymphatic Vessels with and without Previous High-Fat Meal. Acad Radiol 2021; 28 Suppl 1:S218-S224. [PMID: 33183951 DOI: 10.1016/j.acra.2020.10.008] [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: 08/12/2020] [Revised: 09/29/2020] [Accepted: 10/01/2020] [Indexed: 10/23/2022]
Abstract
RATIONALE AND OBJECTIVES The aim of this study was to assess the potential benefit of a high-fat meal for preparation of patients before lymphangiography of the thoracic and abdominal lymphatic vessels by a heavily T2-weighted 3D magnetic resonance sequence at 3T. MATERIALS AND METHODS A heavily T2-weighted 3D Fast-Spin-Echo sequence was applied twice for lymphangiography in 15 healthy volunteers. One examination was performed following overnight fasting and the second examination was conducted 3 hours after a drinking of 200 ml of cream and a solid meal. The effect of a high-fat meal on the visualization of different segments of the thoracic and abdominal lymphatic vessels was analyzed by scoring of the image quality. RESULTS Evaluation of the summarized score of all four segments of the thoracic duct showed significantly improved general visualization of the lymphatic system in the postprandial examination when compared to the results obtained after overnight fasting (mean ± SD: 4.5 ± 1.7 vs. 5.9 ± 1.8, p = 0.007*). Regarding different segments of the lymphatic system significant differences between pre and post cream lymphangiographies were found in the cervical segment (p = 0.012*), the inferior thoracic segment (p = 0.003*) and the abdominal segment (p = 0.035*). In contrast, the visualization of the superior thoracic segment was not significantly improved by high fat meal preparation of the subjects (p = 0.388). CONCLUSION A high-fat meal 3 hours prior to T2-weighted MR-lymphangiography improves the visualization of the main lymphatic thoracic and abdominal vessels, particularly the abdominal and cervical part as well as the inferior segment of the thoracic duct.
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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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Hadjicosta E, Franklin R, Seale A, Stumper O, Tsang V, Anderson DR, Pagel C, Crowe S, Espuny Pujol F, Ridout D, Brown KL. Cohort study of intervened functionally univentricular heart in England and Wales (2000-2018). Heart 2021; 108:1046-1054. [PMID: 34706904 PMCID: PMC9209673 DOI: 10.1136/heartjnl-2021-319677] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/11/2021] [Accepted: 09/17/2021] [Indexed: 11/21/2022] Open
Abstract
Objective Given the paucity of long-term outcome data for complex congenital heart disease (CHD), we aimed to describe the treatment pathways and survival for patients who started interventions for functionally univentricular heart (FUH) conditions, excluding hypoplastic left heart syndrome. Methods We performed a retrospective cohort study using all procedure records from the National Congenital Heart Diseases Audit for children born in 2000–2018. The primary outcome was mortality, ascertained from the Office for National Statistics in 2020. Results Of 53 615 patients, 1557 had FUH: 55.9% were boys and 67.4% were of White ethnic groups. The largest diagnostic categories were tricuspid atresia (28.9%), double inlet left ventricle (21.0%) and unbalanced atrioventricular septal defect (AVSD) (15.2%). The ages at staged surgery were: initial palliation 11.5 (IQR 5.5–43.5) days, cavopulmonary shunt 9.2 (IQR 6.0–17.1) months and Fontan 56.2 (IQR 45.5–70.3) months. The median follow-up time was 10.8 (IQR 7.0–14.9) years and the 1, 5 and 10-year survival rates after initial palliation were 83.6% (95% CI 81.7% to 85.4%), 79.4% (95% CI 77.3% to 81.4%) and 77.2% (95% CI 75.0% to 79.2%), respectively. Higher hazards were present for unbalanced AVSD HR 2.75 (95% CI 1.82 to 4.17), atrial isomerism HR 1.75 (95% CI 1.14 to 2.70) and low weight HR 1.65 (95% CI 1.13 to 2.41), critical illness HR 2.30 (95% CI 1.67 to 3.18) or acquired comorbidities HR 2.71 (95% CI 1.82 to 4.04) at initial palliation. Conclusion Although treatment pathways for FUH are complex and variable, nearly 8 out of 10 children survived to 10 years. Longer-term analyses of outcome based on diagnosis (rather than procedure) can inform parents, patients and clinicians, driving practice improvements for complex CHD.
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Affiliation(s)
- Elena Hadjicosta
- Clinical Operational Research Unit, Department of Mathematics, University College London, London, UK
| | - Rodney Franklin
- Paediatric Cardiology, Royal Brompton and Harefield NHS Trust, London, UK
| | - Anna Seale
- Paediatric Cardiology, Birmingham Children's Hospital, Birmingham, UK
| | - Oliver Stumper
- Paediatric Cardiology, Birmingham Children's Hospital, Birmingham, UK
| | - Victor Tsang
- Heart and Lung Division, Great Ormond Street Hospital, London, UK.,Institute of Cardiovascular Science, University College London, London, UK
| | - David R Anderson
- Paediatric Cardiac Surgery, Evelina London Children's Healthcare, London, UK
| | - Christina Pagel
- Clinical Operational Research Unit, Department of Mathematics, University College London, London, UK
| | - Sonya Crowe
- Clinical Operational Research Unit, Department of Mathematics, University College London, London, UK
| | - Ferran Espuny Pujol
- Clinical Operational Research Unit, Department of Mathematics, University College London, London, UK
| | - Deborah Ridout
- University College London Institute of Child Health, London, UK
| | - Kate L Brown
- Institute of Cardiovascular Science, University College London, London, UK .,NIHR Great Ormond Street Hospital Biomedical Research Centre, London, UK
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Padalino MA, Ponzoni M, Castaldi B, Leoni L, Chemello L, Toscano G, Gerosa G, Di Salvo G, Vida VL. Surgical management of failing Fontan circulation: results from 30 cases with 285 patient-years follow-up. Eur J Cardiothorac Surg 2021; 61:338-345. [PMID: 34687535 DOI: 10.1093/ejcts/ezab450] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/29/2021] [Revised: 09/15/2021] [Accepted: 09/16/2021] [Indexed: 01/01/2023] Open
Abstract
OBJECTIVES Fontan patients are known to suffer from clinical attrition over the years, which has been characterized as Fontan failure. We sought to evaluate the clinical outcomes of such Fontan patients undergoing surgical management in a 25-year, single-centre experience. METHODS A retrospective single-centre analysis of patients undergoing surgical treatment for failing Fontan between 1995 and 2020, including any reoperations when ventricular function was preserved, or a heart transplant (HTx), when ventricular contractility was impaired. We analysed survival, indications for surgery and early and late complication rates. RESULTS We collected 30 patients (mean age 24.7 years) who required surgery after a mean time of 19.3 years from the original Fontan procedure: Fontan conversion in 21 (70%, extracardiac conduit in 19, lateral tunnel in 2), a HTx in 4 (13.3%) and other reoperations in 5 (16.7%). The most common indications for surgery were tachyarrhythmias (63.3%) and severe right atrial dilatation (63.3%). Overall survival at the 1-, 5-, 10- and 20-year follow-up examinations were 75.9% [95% confidence interval (CI): 91.4-60.4%], 75.9% (95% CI: 91.4-60.4%), 70% (95% CI: 78-52%) and 70% (95% CI: 78-52%), respectively. The most frequent complications were postoperative tachyarrhythmias (50%) and late Fontan-associated liver disease (56.5%). HTx and Fontan conversion provided comparably good outcomes compared to other reoperations (P = 0.022). CONCLUSIONS Surgery for failing Fontan can be performed effectively with overall good long-term survival. However, early and late morbidities are still a significant burden. Because other reoperations performed when patients presented with contraindications for a HTx have carried high mortality, close clinical follow-up is mandatory, and an earlier indication for Fontan conversion or a HTx is advisable to optimize outcomes.
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Affiliation(s)
- Massimo A Padalino
- Pediatric and Congenital Cardiac Surgery Unit, Department of Cardiac, Thoracic, Vascular Sciences and Public Health, University of Padova Medical School, Padova, Italy
| | - Matteo Ponzoni
- Pediatric and Congenital Cardiac Surgery Unit, Department of Cardiac, Thoracic, Vascular Sciences and Public Health, University of Padova Medical School, Padova, Italy
| | - Biagio Castaldi
- Pediatric Cardiology Unit, Department of Woman and Child's Health, University of Padova Medical School, Padova, Italy
| | - Loira Leoni
- Cardiology Clinic, Department of Cardiac, Thoracic, Vascular Sciences and Public Health, University of Padova Medical School, Padova, Italy
| | - Liliana Chemello
- Department of Internal Medicine-DIMED, University of Padova Medical School, Padova, Italy
| | - Giuseppe Toscano
- Cardiac Surgery and Heart Transplant Unit, Department of Cardiac, Thoracic, Vascular Sciences and Public Health, University of Padova Medical School, Padova, Italy
| | - Gino Gerosa
- Cardiac Surgery and Heart Transplant Unit, Department of Cardiac, Thoracic, Vascular Sciences and Public Health, University of Padova Medical School, Padova, Italy
| | - Giovanni Di Salvo
- Pediatric Cardiology Unit, Department of Woman and Child's Health, University of Padova Medical School, Padova, Italy
| | - Vladimiro L Vida
- Pediatric and Congenital Cardiac Surgery Unit, Department of Cardiac, Thoracic, Vascular Sciences and Public Health, University of Padova Medical School, Padova, Italy
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Gasparini M, Cox N. Role of cardiac magnetic resonance strain analysis in patients with hypoplastic left heart syndrome in evaluating right ventricular (dys)function: a systematic review. Eur J Cardiothorac Surg 2021; 60:497-505. [PMID: 34331061 DOI: 10.1093/ejcts/ezab105] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/13/2020] [Revised: 12/08/2020] [Accepted: 01/07/2021] [Indexed: 11/14/2022] Open
Abstract
OBJECTIVES Right ventricular dysfunction predicts death in patients with hypoplastic left heart syndrome (HLHS), but differences in morphology and loading conditions make calculation of the ejection fraction (EF), a challenging measure of its function. Our goal was to evaluate how strain measurements with cardiac magnetic resonance feature tracking could be used to evaluate right ventricular function in patients with HLHS. METHODS A systematic search of the literature was performed by 2 independent researchers using the terms 'population', 'intervention', 'comparison', 'outcome' and 'time criteria'. PubMed and the Ovid database were searched according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. RESULTS Our review included 8 studies with 608 participants with ventricular strain values obtained using cardiac magnetic resonance feature tracking. After stage I palliation, global strain was reduced in patients after a hybrid procedure and a right ventricle-to-pulmonary artery conduit compared with a modified Blalock-Taussig shunt despite similar EFs. Global longitudinal strain did not differ between stage II and stage III (Fontan) palliation. Fontan patients had significantly impaired global longitudinal and circumferential strain compared to the left ventricular strain of the controls. Studies of Fontan patients that included patients with HLHS who were part of a cohort with a single right ventricle showed impaired global circumferential strain compared with the cohort with a single left ventricle, with controls, and over time. In this group, impaired global circumferential strain was associated with major adverse cardiac events. CONCLUSIONS Cardiac magnetic resonance feature tracking can be used in patients with HLHS to evaluate RV strain and demonstrate differences between surgical strategies, over time and compared with controls. It could be used alongside clinical symptoms and EF values to detect ventricular dysfunction.
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Affiliation(s)
- Marisa Gasparini
- Department of Surgery, Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - Natasha Cox
- Department of Medicine, Guy's and St Thomas' NHS Foundation Trust, London, UK
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Ten Harkel ADJ, Van der Hulst AE. Atrial strain: an important addition to the armamentarium of non-invasively assessing Fontan function? Int J Cardiovasc Imaging 2021; 37:2661-2662. [PMID: 34245394 DOI: 10.1007/s10554-021-02329-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Affiliation(s)
- Arend D J Ten Harkel
- Department of Pediatric Cardiology, Willem Alexander Children's Hospital, Leiden University Medical Center, Leiden, The Netherlands.
| | - Annelies E Van der Hulst
- Department of Pediatric Cardiology, Emma Children's Hospital, Amsterdam University Medical Center, Amsterdam, The Netherlands
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Poh CL, Cordina RL, Iyengar AJ, Zannino D, Grigg LE, Wheaton GR, Bullock A, Ayer J, Alphonso N, Gentles TL, Celermajer DS, d'Udekem Y. Pre- and Post-operative determinants of transplantation-free survival after Fontan. The Australia and New Zealand experience. IJC HEART & VASCULATURE 2021; 35:100825. [PMID: 34286062 PMCID: PMC8273214 DOI: 10.1016/j.ijcha.2021.100825] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2021] [Revised: 05/01/2021] [Accepted: 06/09/2021] [Indexed: 12/02/2022]
Abstract
Background This review identifies the predictors of late mortality and heart transplantation that remain relevant in the contemporary population of patients with a Fontan circulation, focusing on the potential impact of post-Fontan morbidities on the late outlook of these patients. Methods and Results A total of 1561 patients who had survived the Fontan operation in Australia or New Zealand from 1975 to 2018 were included in this review. Over a median duration of 11.4 years, there was a total of 117 deaths (7%) and 32 heart transplantations (2%). Freedom from death and heart transplantation at 10, 20 and 35 years post Fontan surgery were 94% (95% CI 93–95%), 87% (95 %CI 85–90%) and 66% (95 %CI 57–78%) respectively. Being male, having an atriopulmonary Fontan, pre-Fontan atrioventricular valve intervention, or prolonged pleural effusions post Fontan were predictive of late death or heart transplantation. However, time-dependent variables such as the development of atrial arrhythmia, protein/losing enteropathy or late ventricular dysfunction were stronger predictors of the same outcome. Patients who developed a time-dependent risk factor had a freedom from death and heart transplantation rate of 54% (95 %CI 43–66) at 15 years and 44% (95 %CI 33–57) at 25 years post Fontan. However, 95% (95 %CI 91–99) of patients without any of the identified risk factors were free from death or heart transplantation rate at 25 years post Fontan. Conclusion In conclusion, the occurrence of post-operative complications such as PLE, arrhythmia and ventricular dysfunction will likely precede the late demise of these patients.
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Affiliation(s)
- Chin L Poh
- Heart Research Group, Murdoch Children's Research Institute, Melbourne, Australia.,Department of Paediatrics, Faculty of Medicine, The University of Melbourne, Victoria, Australia.,Department of Cardiac Surgery, Royal Children's Hospital, Melbourne, Victoria, Australia
| | - Rachael L Cordina
- Sydney Medical School, University of Sydney, Sydney, Australia.,Department of Cardiology, Royal Prince Alfred Hospital, Sydney, Australia
| | - Ajay J Iyengar
- Heart Research Group, Murdoch Children's Research Institute, Melbourne, Australia.,Department of Paediatrics, Faculty of Medicine, The University of Melbourne, Victoria, Australia.,Department of Cardiac Surgery, Royal Children's Hospital, Melbourne, Victoria, Australia
| | - Diana Zannino
- Heart Research Group, Murdoch Children's Research Institute, Melbourne, Australia
| | - Leeanne E Grigg
- Department of Cardiology, The Royal Melbourne Hospital, Melbourne, Vic, Australia
| | - Gavin R Wheaton
- Department of Cardiology, Women's and Children's Hospital, Adelaide, South Australia, Australia
| | - Andrew Bullock
- Department of Cardiology, Perth Children's Hospital, Perth, Western Australia, Australia
| | - Julian Ayer
- Heart Centre for Children, The Children's Hospital at Westmead, Sydney, New South Wales, Australia.,Discipline of Paediatrics and Child Health, The University of Sydney, Sydney, New South Wales, Australia
| | - Nelson Alphonso
- Department of Cardiac Surgery, Queensland Children's Hospital, Brisbane, Australia
| | - Thomas L Gentles
- Greenlane Paediatric and Congenital Cardiac Service, Starship Children's Hospital, Auckland, New Zealand
| | - David S Celermajer
- Department of Medicine, The University of Sydney, Sydney, New South Wales, Australia.,Department of Cardiology, Royal Prince Alfred Hospital, Sydney, New South Wales, Australia
| | - Yves d'Udekem
- Heart Research Group, Murdoch Children's Research Institute, Melbourne, Australia.,Department of Paediatrics, Faculty of Medicine, The University of Melbourne, Victoria, Australia.,Department of Cardiac Surgery, Royal Children's Hospital, Melbourne, Victoria, Australia
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Rao PS. Single Ventricle-A Comprehensive Review. CHILDREN (BASEL, SWITZERLAND) 2021; 8:441. [PMID: 34073809 PMCID: PMC8225092 DOI: 10.3390/children8060441] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/28/2021] [Revised: 05/20/2021] [Accepted: 05/21/2021] [Indexed: 02/06/2023]
Abstract
In this paper, the author enumerates cardiac defects with a functionally single ventricle, summarizes single ventricle physiology, presents a summary of management strategies to address the single ventricle defects, goes over the steps of staged total cavo-pulmonary connection, cites the prevalence of inter-stage mortality, names the causes of inter-stage mortality, discusses strategies to address the inter-stage mortality, reviews post-Fontan issues, and introduces alternative approaches to Fontan circulation.
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Affiliation(s)
- P Syamasundar Rao
- McGovern Medical School, University of Texas-Houston, Children's Memorial Hermann Hospital, 6410 Fannin Street, UTPB Suite # 425, Houston, TX 77030, USA
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46
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Arrigoni SC, IJsselhof R, Postmus D, Vonk JM, François K, Bové T, Hazekamp MG, Rijnberg FM, Meyns B, van Puyvelde J, Poncelet AJ, de Beco G, van de Woestijne PC, Bogers AJJC, Schoof PH, Ebels T. Long-term outcomes of atrioventricular septal defect and single ventricle: A multicenter study. J Thorac Cardiovasc Surg 2021; 163:1166-1175. [PMID: 34099273 DOI: 10.1016/j.jtcvs.2021.05.015] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/21/2021] [Revised: 04/12/2021] [Accepted: 05/01/2021] [Indexed: 11/29/2022]
Abstract
OBJECTIVE The study objective was to analyze survival and incidence of Fontan completion of patients with single-ventricle and concomitant unbalanced atrioventricular septal defect. METHODS Data from 4 Dutch and 3 Belgian institutional databases were retrospectively collected. A total of 151 patients with single-ventricle atrioventricular septal defect were selected; 36 patients underwent an atrioventricular valve procedure (valve surgery group). End points were survival, incidence of Fontan completion, and freedom from atrioventricular valve reoperation. RESULTS Median follow-up was 13.4 years. Cumulative survival was 71.2%, 70%, and 68.5% at 10, 15, and 20 years, respectively. An atrioventricular valve procedure was not a risk factor for mortality. Patients with moderate-severe or severe atrioventricular valve regurgitation at echocardiographic follow-up had a significantly worse 15-year survival (58.3%) compared with patients with no or mild regurgitation (89.2%) and patients with moderate regurgitation (88.6%) (P = .033). Cumulative incidence of Fontan completion was 56.5%, 71%, and 77.6% at 5, 10, and 15 years, respectively. An atrioventricular valve procedure was not associated with the incidence of Fontan completion. In the valve surgery group, freedom from atrioventricular valve reoperation was 85.7% at 1 year and 52.6% at 5 years. CONCLUSIONS The long-term survival and incidence of Fontan completion in our study were better than previously described for patients with single-ventricle atrioventricular septal defect. A concomitant atrioventricular valve procedure did not increase the mortality rate or decrease the incidence of Fontan completion, whereas patients with moderate-severe or severe valve regurgitation at follow-up had a worse survival. Therefore, in patients with single-ventricle atrioventricular septal defect when atrioventricular valve regurgitation exceeds a moderate degree, the atrioventricular valve should be repaired.
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Affiliation(s)
- Sara C Arrigoni
- Department of Cardiothoracic Surgery, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands.
| | - Rinske IJsselhof
- Department of Pediatric Cardiac Surgery, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Douwe Postmus
- Department of Epidemiology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Judith M Vonk
- Department of Epidemiology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Katrien François
- Department of Cardiac Surgery, University Hospital of Gent, Gent, Belgium
| | - Thierry Bové
- Department of Cardiac Surgery, University Hospital of Gent, Gent, Belgium
| | - Mark G Hazekamp
- Department of Pediatric Cardiac Surgery, University Medical Center Leiden, Leiden, The Netherlands
| | - Friso M Rijnberg
- Department of Pediatric Cardiac Surgery, University Medical Center Leiden, Leiden, The Netherlands
| | - Bart Meyns
- Department of Cardiac Surgery, University Hospital of Leuven, Leuven, Belgium
| | - Joeri van Puyvelde
- Department of Cardiac Surgery, University Hospital of Leuven, Leuven, Belgium
| | - Alain J Poncelet
- Department of Cardiac Surgery, University Hospital of Louvain, Bruxelles, Belgium
| | - Geoffroy de Beco
- Department of Cardiac Surgery, University Hospital of Louvain, Bruxelles, Belgium
| | - Pieter C van de Woestijne
- Department of Cardiothoracic Surgery, University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Ad J J C Bogers
- Department of Cardiothoracic Surgery, University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Paul H Schoof
- Department of Pediatric Cardiac Surgery, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Tjark Ebels
- Department of Cardiothoracic Surgery, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
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47
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Systemic ventricular assist device support in Fontan patients: A report by ACTION. J Heart Lung Transplant 2021; 40:368-376. [DOI: 10.1016/j.healun.2021.01.011] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2020] [Revised: 01/03/2021] [Accepted: 01/13/2021] [Indexed: 12/31/2022] Open
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O’Byrne ML, Song L, Huang J, Goldberg D, Gardner MM, Ravishankar C, Rome JJ, Glatz AC. Trends in Discharge Prescription of Digoxin After Norwood Operation: An Analysis of Data from the Pediatric Health Information System (PHIS) Database. Pediatr Cardiol 2021; 42:793-803. [PMID: 33528619 PMCID: PMC8113119 DOI: 10.1007/s00246-021-02543-y] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/29/2020] [Accepted: 01/05/2021] [Indexed: 10/22/2022]
Abstract
Quality improvement efforts have focused on reducing interstage mortality for infants with hypoplastic left heart syndrome (HLHS). In 1/2016, two publications reported that use of digoxin was associated with reduced interstage mortality. The degree to which these findings have affected real world practice has not been evaluated. The discharge medications of neonates with HLHS undergoing Norwood operation between 1/2007 and 12/2018 at Pediatric Health Information Systems Database hospitals were studied. Mixed effects models were calculated to evaluate the hypothesis that the likelihood of digoxin prescription increased after 1/2016, adjusting for measurable confounders with furosemide and aspirin prescription measured as falsification tests. Interhospital practice variation was measured using the median odds ratio. Over the study period, 6091 subjects from 45 hospitals were included. After adjusting for measurable covariates, discharge after 1/2016 was associated with increased odds of receiving digoxin (OR 3.9, p < 0.001). No association was seen between date of discharge and furosemide (p = 0.26) or aspirin (p = 0.12). Prior to 1/2016, the likelihood of receiving digoxin was decreasing (OR 0.9 per year, p < 0.001), while after 1/2016 the rate has increased (OR 1.4 per year, p < 0.001). However, there remains significant interhospital variation in the likelihood of receiving digoxin even after adjusting for known confounders (median odds ratio = 3.5, p < 0.0001). Following publication of studies describing an association between digoxin and improved interstage survival, the likelihood of receiving digoxin at discharge increased without similar changes for furosemide or aspirin. Despite concerted efforts to standardize interstage care, interhospital variation in pharmacotherapy in this vulnerable population persists.
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Affiliation(s)
- Michael L O’Byrne
- Division of Cardiology, The Children’s Hospital of Philadelphia and Department of Pediatrics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA,Center For Pediatric Clinical Effectiveness, The Children’s Hospital of Philadelphia and Department of Pediatrics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA,Leonard Davis Institute and Center for Cardiovascular Outcomes, Quality, and Evaluative Research, Perelman School of Medicine at the University of Pennsylvania, Philadelphia PA
| | - Lihai Song
- Department of Biomedical and Health Informatics, Data Science and Biostatistics Unit, The Children’s Hospital of Philadelphia, Philadelphia, PA
| | - Jing Huang
- Division of Cardiology, The Children’s Hospital of Philadelphia and Department of Pediatrics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA,Department of Biomedical and Health Informatics, Data Science and Biostatistics Unit, The Children’s Hospital of Philadelphia, Philadelphia, PA,Department of Biostatistics, Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA
| | - David Goldberg
- Division of Cardiology, The Children’s Hospital of Philadelphia and Department of Pediatrics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA
| | - Monique M Gardner
- Division of Cardiac Critical Care, The Children’s Hospital of Philadelphia and Department of Pediatrics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA
| | - Chitra Ravishankar
- Division of Cardiology, The Children’s Hospital of Philadelphia and Department of Pediatrics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA
| | - Jonathan J Rome
- Division of Cardiology, The Children’s Hospital of Philadelphia and Department of Pediatrics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA
| | - Andrew C Glatz
- Division of Cardiology, The Children’s Hospital of Philadelphia and Department of Pediatrics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA,Center For Pediatric Clinical Effectiveness, The Children’s Hospital of Philadelphia and Department of Pediatrics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA
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Strodka F, Logoteta J, Schuwerk R, Salehi Ravesh M, Gabbert DD, Uebing AS, Krupickova S, Voges I. Myocardial deformation in patients with a single left ventricle using 2D cardiovascular magnetic resonance feature tracking: a case-control study. Int J Cardiovasc Imaging 2021; 37:2549-2559. [PMID: 33788063 PMCID: PMC8302517 DOI: 10.1007/s10554-021-02230-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/15/2021] [Accepted: 03/23/2021] [Indexed: 11/30/2022]
Abstract
Ventricular dysfunction is a well-known complication in single ventricle patients in Fontan circulation. As studies exclusively examining patients with a single left ventricle (SLV) are sparse, we assessed left ventricular (LV) function in SLV patients by using 2D-cardiovascular magnetic resonance (CMR) feature tracking (2D-CMR-FT) and 2D-speckle tracking echocardiography (2D-STE). 54 SLV patients (11.4, 3.1–38.1 years) and 35 age-matched controls (12.3, 6.3–25.8 years) were included. LV global longitudinal, circumferential and radial strain (GLS, GCS, GRS) and strain rate (GLSR, GCSR, GRSR) were measured using 2D-CMR-FT. LV volumes, ejection fraction (LVEF) and mass were determined from short axis images. 2D-STE was applied in patients to measure peak systolic GLS and GLSR. In a subgroup analysis, we compared double inlet left ventricle (DILV) with tricuspid atresia (TA) patients. The population consisted of 19 DILV patients, 24 TA patients and 11 patients with diverse diagnoses. 52 patients were in NYHA class I and 2 patients were in class II. Most SLV patients had a normal systolic function but median LVEF in patients was lower compared to controls (55.6% vs. 61.2%, p = 0.0001). 2D-CMR-FT demonstrated reduced GLS, GCS and GCSR values in patients compared to controls. LVEF correlated with GS values in patients (p < 0.05). There was no significant difference between GLS values from 2D-CMR-FT and 2D-STE in the patient group. LVEF, LV volumes, GS and GSR (from 2D-CMR-FT) were not significantly different between DILV and TA patients. Although most SLV patients had a preserved EF derived by CMR, our results suggest that, LV deformation and function may behave differently in SLV patients compared to healthy subjects.
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Affiliation(s)
- Fabian Strodka
- Department of Congenital Heart Disease and Paediatric Cardiology, University Hospital Schleswig-Holstein, Campus Kiel, Arnold-Heller-Str. 3, 24105, Kiel, Germany
| | - Jana Logoteta
- Department of Paediatric Cardiology, Children's Hospital of Zurich, Zurich, Switzerland
| | - Roman Schuwerk
- Department of Congenital Heart Disease and Paediatric Cardiology, University Hospital Schleswig-Holstein, Campus Kiel, Arnold-Heller-Str. 3, 24105, Kiel, Germany
| | - Mona Salehi Ravesh
- Department of Radiology and Neuroradiology, University Hospital Schleswig-Holstein, Kiel, Germany
| | - Dominik Daniel Gabbert
- Department of Congenital Heart Disease and Paediatric Cardiology, University Hospital Schleswig-Holstein, Campus Kiel, Arnold-Heller-Str. 3, 24105, Kiel, Germany
| | - Anselm Sebastian Uebing
- Department of Congenital Heart Disease and Paediatric Cardiology, University Hospital Schleswig-Holstein, Campus Kiel, Arnold-Heller-Str. 3, 24105, Kiel, Germany
| | | | - Inga Voges
- Department of Congenital Heart Disease and Paediatric Cardiology, University Hospital Schleswig-Holstein, Campus Kiel, Arnold-Heller-Str. 3, 24105, Kiel, Germany.
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50
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Marathe SP, Iyengar AJ, Betts KS, du Plessis K, Salve GG, Justo RN, Venugopal P, Winlaw DS, d'Udekem Y, Alphonso N. Long-term outcomes following Fontan takedown in Australia and New Zealand. J Thorac Cardiovasc Surg 2021; 161:1126-1135. [DOI: 10.1016/j.jtcvs.2020.09.074] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/09/2020] [Revised: 08/28/2020] [Accepted: 09/19/2020] [Indexed: 11/26/2022]
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