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Hoashi T, Shimada M, Imai K, Komori M, Kurosaki K, Ohuchi H, Ichikawa H. Long-term therapeutic effect of Fontan conversion with an extracardiac conduit. Eur J Cardiothorac Surg 2020; 57:951-957. [PMID: 31883324 DOI: 10.1093/ejcts/ezz355] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/30/2019] [Revised: 11/08/2019] [Accepted: 11/29/2019] [Indexed: 11/14/2022] Open
Abstract
OBJECTIVES The aim of this study was to identify the long-term therapeutic effect of total cavopulmonary connection (TCPC) conversion with an extracardiac conduit. METHODS Between 1991 and 2014, 36 patients underwent TCPC conversion with an extracardiac conduit. Half of these patients were diagnosed with tricuspid atresia or its variant. The left ventricle was dominant in 26 patients (72.2%). Median age at conversion and interval from initial Fontan operation to conversion were 24.1 years (interquartile range 18.9-29.2) and 17.8 years (15.4-20.9), respectively. Surgical cryoablation was concomitantly performed in 32 patients (88.9%). Cardiac catheter examination was performed preoperatively (36 patients, 100%) and at 1 year (31 patients, 86%), 5 years (25 patients, 69%) and 10 years (13 patients, 36%) after TCPC conversion. Symptom-limited treadmill exercise with expired gas analysis was performed preoperatively (32 patients, 88.9%) and at 1 year (27 patients, 75.0%), 5 years (20 patients, 55.6%) and 10 years (12 patients, 33.3%) after conversion. RESULTS All patients received follow-up; the mean follow-up period was 8.2 ± 4.8 years. Actuarial survival rate, protein-losing enteropathy-free survival rate and rate of survival with sinus rhythm maintenance at 10 years were 79.2%, 67.8% and 48.5%, respectively. The survival curve declined steeply when the duration of Fontan circulation exceeded 25 years. New cases of protein-losing enteropathy developed postoperatively in 2 patients. Permanent pacemakers were implanted in 12 patients (33%), but atrial tachyarrhythmia was not sustained in any of the remaining patients. Pulmonary arterial pressure (11.0 ± 3.1 to 9.5 ± 3.6 mmHg, P = 0.003), pulmonary vascular resistance (2.1 ± 0.7 to 1.3 ± 0.5 WU/m2, P < 0.0001) and cardiac index (2.0 ± 0.3 to 2.9 ± 0.6 l/min/m2, P < 0.0001) significantly improved from preoperative evaluation to 1 year after the conversion, and these improvements were maintained during the entire follow-up period. Peak oxygen uptake remained unchanged from the preoperative evaluation (49.7 ± 11.5% predicted) to 1 year (52.5 ± 12.0%), 5 years (56.2 ± 9.6%) and 10 years (51.2 ± 9.4%) after conversion (P = 0.19). CONCLUSIONS Owing to its anti-arrhythmic effect and Fontan pathway recruitment effect, TCPC conversion with an extracardiac conduit prevented the natural decline of exercise tolerance that is seen in classic Fontan patients.
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Affiliation(s)
- Takaya Hoashi
- Department of Pediatric Cardiovascular Surgery, National Cerebral and Cardiovascular Center, Suita, Osaka, Japan
| | - Masatoshi Shimada
- Department of Pediatric Cardiovascular Surgery, National Cerebral and Cardiovascular Center, Suita, Osaka, Japan
| | - Kenta Imai
- Department of Pediatric Cardiovascular Surgery, National Cerebral and Cardiovascular Center, Suita, Osaka, Japan
| | - Motoki Komori
- Department of Pediatric Cardiovascular Surgery, National Cerebral and Cardiovascular Center, Suita, Osaka, Japan
| | - Kenichi Kurosaki
- Department of Pediatric Cardiology, National Cerebral and Cardiovascular Center, Suita, Osaka, Japan
| | - Hideo Ohuchi
- Department of Pediatric Cardiology, National Cerebral and Cardiovascular Center, Suita, Osaka, Japan
| | - Hajime Ichikawa
- Department of Pediatric Cardiovascular Surgery, National Cerebral and Cardiovascular Center, Suita, Osaka, Japan
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Higashida A, Hoashi T, Kagisaki K, Shimada M, Ohuchi H, Shiraishi I, Ichikawa H. Can Fontan Conversion for Patients Without Late Fontan Complications be Justified? Ann Thorac Surg 2017; 103:1963-1968. [DOI: 10.1016/j.athoracsur.2016.11.062] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/20/2016] [Revised: 11/19/2016] [Accepted: 11/21/2016] [Indexed: 02/05/2023]
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Brida M, Baumgartner H, Gatzoulis MA, Diller GP. Early mortality and concomitant procedures related to Fontan conversion: Quantitative analysis. Int J Cardiol 2017; 236:132-137. [DOI: 10.1016/j.ijcard.2017.01.111] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/16/2016] [Accepted: 01/22/2017] [Indexed: 11/16/2022]
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Sughimoto K, Okauchi K, Zannino D, Brizard CP, Liang F, Sugawara M, Liu H, Tsubota KI. Total Cavopulmonary Connection is Superior to Atriopulmonary Connection Fontan in Preventing Thrombus Formation: Computer Simulation of Flow-Related Blood Coagulation. Pediatr Cardiol 2015; 36:1436-41. [PMID: 26024646 DOI: 10.1007/s00246-015-1180-y] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/14/2014] [Accepted: 04/29/2015] [Indexed: 01/19/2023]
Abstract
The classical Fontan route, namely the atriopulmonary connection (APC), continues to be associated with a risk of thrombus formation in the atrium. A conversion to a total cavopulmonary connection (TCPC) from the APC can ameliorate hemodynamics for the failed Fontan; however, the impact of these surgical operations on thrombus formation remains elusive. This study elucidates the underlying mechanism of thrombus formation in the Fontan route by using a two-dimensional computer hemodynamic simulation based on a simple blood coagulation rule. Hemodynamics in the Fontan route was simulated with Navier-Stokes equations. The blood coagulation and the hemodynamics were combined using a particle method. Three models were created: APC with a square atrium, APC with a round atrium, and TCPC. To examine the effects of the venous blood flow velocity, the velocity at rest and during exercise (0.5 and 1.0 W/kg) was measured. The total area of the thrombi increased over time. The APC square model showed the highest incidence for thrombus formation, followed by the APC round, whereas no thrombus was formed in the TCPC model. Slower blood flow at rest was associated with a higher incidence of thrombus formation. The TCPC was superior to the classical APC in terms of preventing thrombus formation, due to significant blood flow stagnation in the atrium of the APC. Thus, local hemodynamic behavior associated with the complex channel geometry plays a major role in thrombus formation in the Fontan route.
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Affiliation(s)
- Koichi Sughimoto
- Department of Cardiac Surgery, The Royal Children's Hospital, Melbourne, Australia
| | - Kazuki Okauchi
- Department of Mechanical Engineering, Graduate School of Engineering, Chiba University, Chiba, Japan.,Hitachi Construction Machinery, Tokyo, Japan
| | - Diana Zannino
- Murdoch Childrens Research Institute, Melbourne, Australia
| | - Christian P Brizard
- Department of Cardiac Surgery, The Royal Children's Hospital, Melbourne, Australia.,Murdoch Childrens Research Institute, Melbourne, Australia
| | - Fuyou Liang
- School of Naval Architecture, Ocean and Civil Engineering (NAOCE), Shanghai Jiao Tong University, Shanghai, China.,Shanghai Jiao Tong University and Chiba University International Cooperative Research Centre (SJTU-CU ICRC), Shanghai Jiao Tong University, Shanghai, China
| | - Michiko Sugawara
- Department of Mechanical Engineering, Graduate School of Engineering, Chiba University, Chiba, Japan
| | - Hao Liu
- Department of Mechanical Engineering, Graduate School of Engineering, Chiba University, Chiba, Japan.,Shanghai Jiao Tong University and Chiba University International Cooperative Research Centre (SJTU-CU ICRC), Shanghai Jiao Tong University, Shanghai, China
| | - Ken-Ichi Tsubota
- Department of Mechanical Engineering, Graduate School of Engineering, Chiba University, Chiba, Japan.
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Jang WS, Kim WH, Choi K, Nam J, Choi ES, Lee JR, Kim YJ, Kwon BS, Kim GB, Bae EJ. The mid-term surgical results of Fontan conversion with antiarrhythmia surgery. Eur J Cardiothorac Surg 2014; 45:922-927. [DOI: 10.1093/ejcts/ezt511] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 08/30/2023] Open
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Atrial and ventricular mechanics in patients after Fontan-type procedures: atriopulmonary connection versus extracardiac conduit. J Am Soc Echocardiogr 2014; 27:666-74. [PMID: 24637059 DOI: 10.1016/j.echo.2014.01.027] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/11/2013] [Indexed: 11/20/2022]
Abstract
BACKGROUND Differences in systemic venous flow dynamics and energy losses exist in various Fontan-type procedures, which may affect atrial and ventricular filling. The aim of this study was to test the hypothesis that atrial and ventricular mechanics differ between two types of Fontan procedures, atriopulmonary connection (APC) and extracardiac conduit, which have distinctly different systemic venous hemodynamics. METHODS This was a cross-sectional, case-control study of 28 Fontan patients (13 with APC, 15 with extracardiac conduit) aged 19.8 ± 6.5 years and 26 healthy controls. Atrial and systemic ventricular myocardial deformation was determined using speckle-tracking echocardiography, while ventricular volumes and systolic dyssynchrony index were assessed using three-dimensional echocardiography. RESULTS Compared with controls, patients had significantly lower values of global ventricular longitudinal, circumferential, and radial systolic strain in all three directions, reduced systolic and early diastolic strain rates (SRs) in more than one dimension, lower ejection fractions, and worse ventricular dyssynchrony. For atrial deformation, patients had lower global and positive strain and conduit and reservoir SRs and delayed electromechanical coupling. Among patients, those with APC had significantly lower ventricular longitudinal strain and early diastolic SRs, worse ventricular dyssynchrony, and reduced atrial positive and negative strain and conduit and active contractile SRs. Atrial global strain (r = 0.60, P = .001) and conduit SR (r = 0.49, P = .008) correlated positively with systemic ventricular early diastolic SR. CONCLUSIONS Atrial and ventricular mechanics are impaired in patients after Fontan-type operation, which is worse with APC than extracardiac conduit.
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Heart Failure in Adults who had the Fontan Procedure: Natural History, Evaluation, and Management. CURRENT TREATMENT OPTIONS IN CARDIOVASCULAR MEDICINE 2013; 15:587-601. [DOI: 10.1007/s11936-013-0257-2] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
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Dinardo JA. Heart failure associated with adult congenital heart disease. Semin Cardiothorac Vasc Anesth 2012; 17:44-54. [PMID: 23264549 DOI: 10.1177/1089253212469841] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
The population of adults with congenital heart disease (ACHD) now exceeds that of children with congenital heart disease. Within this relatively young population of adults in their third decade of life exist a population of patients with heart failure (HF) who, in functional status, closely resemble patients in their fifth and sixth decades of life with HF caused by coronary artery disease and myocardial ischemia. The ACHD patients currently at greatest risk for HF are those with single-ventricle physiology, those with a 2-ventricle circulation with the right ventricle as the systemic ventricle, and those with repaired tetralogy of Fallot and pulmonary valve insufficiency. This article will review the demographics, diagnosis, functional capacity, and treatment of HF in the ACHD population.
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Angeli E, Pace Napoleone C, Balducci A, Formigari R, Lovato L, Candini L, Oppido G, Gargiulo G. Natural and modified history of single-ventricle physiology in adult patients. Eur J Cardiothorac Surg 2012; 42:996-1002. [DOI: 10.1093/ejcts/ezs202] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
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McCrindle BW, Zak V, Sleeper LA, Paridon SM, Colan SD, Geva T, Mahony L, Li JS, Breitbart RE, Margossian R, Williams RV, Gersony WM, Atz AM. Laboratory measures of exercise capacity and ventricular characteristics and function are weakly associated with functional health status after Fontan procedure. Circulation 2009; 121:34-42. [PMID: 20026781 DOI: 10.1161/circulationaha.109.869396] [Citation(s) in RCA: 37] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Patients after the Fontan procedure are at risk for suboptimal functional health status, and associations with laboratory measures are important for planning interventions and outcome measures for clinical trials. METHODS AND RESULTS Parents completed the generic Child Health Questionnaire for 511 Fontan Cross-Sectional Study patients 6 to 18 years of age (61% male). Associations of Child Health Questionnaire Physical and Psychosocial Functioning Summary Scores (FSS) with standardized measurements from prospective exercise testing, echocardiography, magnetic resonance imaging, and measurement of brain natriuretic peptide were determined by regression analyses. For exercise variables for maximal effort patients only, the final model showed that higher Physical FSS was associated only with higher maximum work rate, accounting for 9% of variation in Physical FSS. For echocardiography, lower Tei index (particularly for patients with extracardiac lateral tunnel connections), lower indexed end-systolic volume, and the absence of atrioventricular valve regurgitation for patients having Fontan procedure at age <2 years were associated with higher Physical FSS, accounting for 14% of variation in Physical FSS. For magnetic resonance imaging, ratio of lower mass to end-diastolic volume and midquartiles of indexed end-systolic volume (nonlinear) were associated with higher Physical FSS, accounting for 11% of variation. Lower brain natriuretic peptide was significantly but weakly associated with higher Physical FSS (1% of variation). Significant associations for Psychosocial FSS with laboratory measures were fewer and weaker than for Physical FSS. CONCLUSIONS In relatively healthy Fontan patients, laboratory measures account for a small proportion of the variation in functional health status and therefore may not be optimal surrogate end points for trials of therapeutic interventions.
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Affiliation(s)
- Brian W McCrindle
- Hospital for Sick Children, 555 University Ave, Toronto, Ontario, Canada M5G 1X8.
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Holmgren D, Strömvall-Larsson E, Lundberg PA, Eriksson BO, Wåhlander H. Brain natriuretic peptide assessed at long-term follow-up before and after maximal exercise in surgically palliated patients with functionally univentricular hearts. Cardiol Young 2007; 17:505-11. [PMID: 17588281 DOI: 10.1017/s1047951107000686] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
We evaluated the concentrations of brain natriuretic peptide in the plasma as a marker of systolic ventricular function before and after maximal exercise in 15 surgically palliated patients with functionally univentricular hearts, with apparently good ventricular function. Of the patients, 6 with median age of 14.6 years, and a range from 12.5 to 17.9 years, had been palliated by construction of a total cavopulmonary connection, while the other 9 patients, with a median age of 32.1 years, and a range from 15.6 to 54.2 years, had undergone the classical Fontan procedure. We used 8 healthy individuals, with a median age of 13.9 years, and a range from 12.8 to 14.2 years, as a control group for the measurements of brain natriuretic peptide. The values of the peptide were significantly higher in those with the classical Fontan procedure, both before, when the median value was 131.8 nanogram per litre, with a range from 0.5 to 296.4, and after maximal exercise, when the median value was 108.1, with a range from 0.1 to 235.9. The comparable values in those with a total cavopulmonary connection were a median of 12.8, and a range from 0.5 to 39.1 before, and a median of 9.7, with a range from 2.7 to 26.2 after maximal exercise. The median value for the control group was 13.1, with a range from 2.6 to 38.7 before exercise (p = 0.016), and a median of 24.1, with a range from 5.8 to 66.7 after maximal exercise (p = 0.03), respectively. In the control subjects, the level of the peptide increased by a median of 9.7 nanograms per litre, with a range from 1.2 to 28.0 after maximal exercise (p = 0.008). The level was unchanged after maximal exercise in those with classical Fontan procedures and total cavopulmonary connections, with a difference between levels before and after exercise of a median of 5.9 nanogram per litre, and a range from -23.7 to 31.0 (p = 0.96), and a median of -1.0 nanogram per litre, with a range from -12.0 to 3.9 (p > 0.99), respectively. We conclude that maximal exercise did not increase the level of brain natriuretic peptide level in those patients with the classical Fontan procedure, nor those with a total cavopulmonary connection, findings which may indicate that systolic ventricular dysfunction is not the major cause of the decreased working capacity observed in patients with well functioning palliated functionally univentricular hearts.
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Affiliation(s)
- Daniel Holmgren
- The Department of Paediatrics, Division of Cardiology, The Queen Silvia Children's Hospital, Göteborg, Sweden.
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