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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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Polat AB, Ertürk M, Uzunhan O, Karademir N, Öztarhan K. 27 years of experience with the Fontan procedure: characteristics and clinical outcomes of children in a tertiary referral hospital. J Cardiothorac Surg 2023; 18:38. [PMID: 36653817 PMCID: PMC9850550 DOI: 10.1186/s13019-023-02148-x] [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: 08/03/2022] [Accepted: 01/10/2023] [Indexed: 01/19/2023] Open
Abstract
BACKGROUND The Fontan operation has improved the survival of children born with congenital heart disease with single ventricle physiology. The most widely adopted variations of the Fontan procedure are the extracardiac conduit, the lateral tunnel ve the intra/extracardiac conduit with fenestration. Despite advances in the treatment and prevention of early and late complications that may develop after Fontan surgery, morbidity still remains an important problem. METHODS 304 patients who underwent Fontan surgery in our center between 1995 and 2022 were included in our study. The complications that developed in patients who underwent primary Fontan or lateral tunnel surgery and extracardiac conduit Fontan application were compared. RESULTS Classic Fontan surgery and lateral tunnel surgery were performed in 26 of the patients, and extracardiac Fontan surgery was performed in 278 patients. 218 of 304 cases were patients with single ventricular pathology. 86 cases were patients with two ventricular morphologies but complex cardiac pathology. Fenestration was performed in only 6 patients, other patients did not require fenestration. The mean follow-up period of our patients was 12 years (3 months-27 years). When the complications between Fontan procedures were compared in our study, it was found that the length of hospital stay and mortality were statistically significantly reduced in patients who underwent extracardiac Fontan surgery. There was no significant difference in terms of complications that can be seen after Fontan surgery and the length of stay in the intensive care unit. CONCLUSION Fontan complex is a palliative surgery for children with complex heart disease. Palliative surgical operations aimed at the preparation of the Fontan circulation lead to the preparation of the pulmonary vascular bed and the preservation of ventricular function. The techniques applied in Fontan surgery affect the early and long-term complications and the survival of the patients. In our study, when we examined the patients who extracardiac conduit Fontan procedure for the non-cardiac route, we found that mortality and morbidity were minimal.
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Affiliation(s)
- Ahmet Bülent Polat
- grid.414934.f0000 0004 0644 9503Department of Cardiovascular Surgery, Florence Nightingale Hospital, T.C. Demiroglu Bilim University, İzzetpaşa Mah, Abide-I Hürriyet Cad, No:166, Sisli, 34394 Istanbul, Turkey
| | - Murat Ertürk
- grid.414934.f0000 0004 0644 9503Department of Cardiovascular Surgery, Florence Nightingale Hospital, T.C. Demiroglu Bilim University, İzzetpaşa Mah, Abide-I Hürriyet Cad, No:166, Sisli, 34394 Istanbul, Turkey
| | - Ozan Uzunhan
- grid.414934.f0000 0004 0644 9503Department of Newborn, Florence Nightingale Hospital, T.C. Demiroglu Bilim University, İzzetpaşa Mah, Abide-I Hürriyet Cad, No:166, Sisli, 34394 Istanbul, Turkey
| | - Nur Karademir
- grid.414934.f0000 0004 0644 9503Florence Nightingale Hospital, T.C. Demiroglu Bilim University, İzzetpaşa Mah, Abide-I Hürriyet Cad, No:166, Sisli, 34394 Istanbul, Turkey
| | - Kazım Öztarhan
- grid.414934.f0000 0004 0644 9503Department of Pediatric Cardiology, Florence Nightingale Hospital, T.C. Demiroglu Bilim University, İzzetpaşa Mah, Abide-I Hürriyet Cad, No:166, Sisli, 34394 Istanbul, Turkey
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Okólska M, Karkowski G, Kuniewicz M, Bednarek J, Pająk J, Róg B, Łach J, Legutko J, Tomkiewicz-Pająk L. Prevalence of Arrhythmia in Adults after Fontan Operation. J Clin Med 2022; 11:jcm11071968. [PMID: 35407577 PMCID: PMC9000042 DOI: 10.3390/jcm11071968] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2022] [Revised: 03/25/2022] [Accepted: 03/28/2022] [Indexed: 11/16/2022] Open
Abstract
Structural, hemodynamic, and morphological cardiac changes following Fontan operation (FO) can contribute to the development of arrhythmias and conduction disorders. Sinus node dysfunction, junction rhythms, tachyarrhythmias, and ventricular arrhythmias (VAs) are some of the commonly reported arrhythmias. Only a few studies have analyzed this condition in adults after FO. This study aimed to determine the type and prevalence of arrhythmias and conduction disorders among patients who underwent FO and were under the medical surveillance of the John Paul II Hospital in Krakow. Data for the study were obtained from 50 FO patients (mean age 24 ± 5.7 years; 28 men (56%)). The median follow-up time was 4 (2–9) years. Each patient received a physical examination, an echocardiographic assessment, and a 24 h electrocardiogram assessment. Bradyarrhythmia was diagnosed in 22 patients (44%), supraventricular tachyarrhythmias in 14 patients (28%), and VAs in 6 patients (12%). Six patients required pacemaker implantation, and three required radiofrequency catheter ablation (6%). Arrythmias is a widespread clinical problem in adults after FO. It can lead to serious haemodynamic impairment, and therefore requires early diagnosis and effective treatment with the use of modern approaches, including electrotherapy methods.
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Affiliation(s)
- Magdalena Okólska
- Cardiological Outpatient Clinic, Department of Cardiovascular Diseases, John Paul II Hospital, 31-202 Krakow, Poland; (M.O.); (B.R.)
| | - Grzegorz Karkowski
- Department of Electrocardiology, Institute of Cardiology, Faculty of Medicine, Jagiellonian University Medical College, John Paul II Hospital, 31-202 Krakow, Poland; (G.K.); (M.K.); (J.B.)
| | - Marcin Kuniewicz
- Department of Electrocardiology, Institute of Cardiology, Faculty of Medicine, Jagiellonian University Medical College, John Paul II Hospital, 31-202 Krakow, Poland; (G.K.); (M.K.); (J.B.)
- Department of Anatomy, Jagiellonian University Medical College, 31-008 Krakow, Poland
| | - Jacek Bednarek
- Department of Electrocardiology, Institute of Cardiology, Faculty of Medicine, Jagiellonian University Medical College, John Paul II Hospital, 31-202 Krakow, Poland; (G.K.); (M.K.); (J.B.)
| | - Jacek Pająk
- Institute of Medical Sciences, Department of Surgery, Medical College of Rzeszow University, 35-959 Rzeszow, Poland;
| | - Beata Róg
- Cardiological Outpatient Clinic, Department of Cardiovascular Diseases, John Paul II Hospital, 31-202 Krakow, Poland; (M.O.); (B.R.)
| | - Jacek Łach
- Department of Cardiac and Vascular Diseases, Institute of Cardiology, Jagiellonian University Medical College, John Paul II Hospital, 31-202 Krakow, Poland;
| | - Jacek Legutko
- Clinical Department of Interventional Cardiology, John Paul II Hospital, 31-202 Krakow, Poland;
- Department of Interventional Cardiology, Faculty of Medicine, Institute of Cardiology, Jagiellonian University Medical College, 31-008 Krakow, Poland
| | - Lidia Tomkiewicz-Pająk
- Department of Cardiac and Vascular Diseases, Institute of Cardiology, Jagiellonian University Medical College, John Paul II Hospital, 31-202 Krakow, Poland;
- Correspondence: ; Tel.: +48-12-614-35-15
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Kamp AN, Nair K, Fish FA, Khairy P. Catheter ablation of atrial arrhythmias in patients post-Fontan. Can J Cardiol 2022; 38:1036-1047. [PMID: 35240252 DOI: 10.1016/j.cjca.2022.02.023] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2021] [Revised: 02/18/2022] [Accepted: 02/20/2022] [Indexed: 12/25/2022] Open
Abstract
Atrial arrhythmias are highly prevalent in the aging Fontan population and contribute importantly to morbidity and mortality. Although the most common arrhythmia is scar-based intra-atrial re-entrant tachycardia, various other arrhythmias may occur including focal atrial tachycardia, atrioventricular node-dependent tachycardias, and atrial fibrillation. The type and prevalence of atrial arrhythmia is determined, in part, by the underlying congenital defect and variant of Fontan surgery. While the cumulative incidence of atrial tachyarrhythmias has decreased substantially from the atriopulmonary anastomosis to the more recent total cavopulmonary connection Fontan, the burden of atrial arrhythmias remains substantial. Management is often multi-faceted and can include anticoagulation, anti-arrhythmic drug therapy, pacing, and cardioversion. Catheter ablation plays a key role in arrhythmia control. Risks and benefits must be carefully weighed. Among the important considerations are the clinical burden of arrhythmia, ventricular function, hemodynamic stability in tachycardia, suspected arrhythmia mechanisms, risks associated with anaesthesia, venous access, approaches to reaching the pulmonary venous atrium, and accompanying co-morbidities. Careful review of surgical notes, electrocardiographic tracings, and advanced imaging is paramount, with particular attention to anatomic abnormalities such as venous obstructions and displaced conduction systems. Despite numerous challenges, ablation of atrial arrhythmias is effective in improving clinical status. Nevertheless, onset of new arrhythmias is common during long-term follow-up. Advanced technologies such as high-density mapping catheters and remote magnetic guided ablation carry the potential to further improve outcomes. Fontan patients with atrial arrhythmias should be referred to centers with dedicated expertise in congenital heart disease including catheter ablation, anaesthesia support, and advanced imaging.
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Affiliation(s)
- Anna N Kamp
- Nationwide Children's Hospital, Ohio State University, Columbus, OH, USA
| | - Krishnakumar Nair
- University Health Network, Toronto General Hospital, Toronto, Canada
| | - Frank A Fish
- Vanderbilt University Medical Center, Nashville, TN, USA; and
| | - Paul Khairy
- Montreal Heart Institute, Université de Montréal, Montreal, Quebec, Canada.
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Cao JY, Marathe SP, Zannino D, Celermajer DS, Justo RN, Alphonso N, d'Udekem Y, Winlaw DS. Fontan operation at less than 3 years of age is not a risk factor for long-term failure. Eur J Cardiothorac Surg 2021; 61:497-504. [PMID: 34355744 DOI: 10.1093/ejcts/ezab355] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/27/2021] [Revised: 06/14/2021] [Accepted: 06/17/2021] [Indexed: 11/13/2022] Open
Abstract
OBJECTIVES The age at which the Fontan operation is performed varies globally. Over the last decade, the median age of patients having the Fontan in Australia and New Zealand has been 4.6 years, including 6% of patients younger than 3 years. Long-term outcomes of an early Fontan operation are unclear and are described in this study. METHODS Patients from the Australian and New Zealand Fontan Registry were grouped by age at Fontan. A Fontan before 3 years (early Fontan) was compared to the combined second and third quartiles by age at surgery in the Registry (3.6-6.1 years; control). Outcomes included Fontan failure (death, transplant, New York Heart Association functional group III/IV heart failure, Fontan takedown or conversion, protein losing enteropathy and plastic bronchitis), arrhythmias, thromboembolism and reinterventions. RESULTS A total of 191 patients who had early Fontan operations were compared to 781 controls. Profound or progressive cyanosis was noted more frequently in the early than in the control group (63% vs 23%; P < 0.001). The early group was followed up for a median 22.1 years. The incidence of long-term failure was similar between the 2 groups (early, 1.08 failures per 100 patient-years of follow-up vs control, 0.99; log-rank P = 0.79). Adjusted for risk factors, early age at Fontan was not a risk factor for long-term failure [hazard ratio (HR) 1.16, 95% confidence interval (CI) 0.77-1.76; P = 0.48], new-onset arrhythmia (HR 0.93, 95% CI 0.63-1.39; P = 0.73), thromboembolism (HR 0.50, 95% CI 0.28-0.91; P = 0.024) or reintervention (HR 1.08, 95% CI 0.80-1.45; P = 0.62). CONCLUSIONS Having the Fontan operation at an early age was not a risk factor for short- or long-term adverse outcomes in our cohort.
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Affiliation(s)
- Jacob Y Cao
- Sydney Medical School, University of Sydney, Sydney, Australia.,Department of Cardiology, Royal Prince Alfred Hospital, Sydney, Australia
| | - Supreet P Marathe
- Queensland Children's Hospital, Brisbane, Australia.,University of Queensland, Brisbane, Australia
| | - Diana Zannino
- Murdoch Children's Research Institute, Melbourne, Australia
| | - David S Celermajer
- Sydney Medical School, University of Sydney, Sydney, Australia.,Department of Cardiology, Royal Prince Alfred Hospital, Sydney, Australia
| | - Robert N Justo
- Queensland Children's Hospital, Brisbane, Australia.,University of Queensland, Brisbane, Australia
| | - Nelson Alphonso
- Queensland Children's Hospital, Brisbane, Australia.,University of Queensland, Brisbane, Australia
| | - Yves d'Udekem
- Murdoch Children's Research Institute, Melbourne, Australia.,Royal Children's Hospital, Melbourne, Australia
| | - David S Winlaw
- Heart Centre for Children, The Children's Hospital at Westmead, Sydney, Australia.,Heart Institute, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
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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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Cardiovascular complications in patients with total cavopulmonary connection: A nationwide cohort study. Int J Cardiol 2020; 305:120-126. [PMID: 32001036 DOI: 10.1016/j.ijcard.2019.12.062] [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: 09/22/2019] [Revised: 12/16/2019] [Accepted: 12/29/2019] [Indexed: 11/24/2022]
Abstract
BACKGROUND Long-term outcomes are not well established at the population level after completion of the total cavopulmonary connection (TCPC) among patients with functional univentricular hearts. PURPOSE To evaluate the incidence of cardiovascular events after TCPC completion. METHODS From a validated population-based cohort, we identified 178 patients with TCPC circulation completed after January 1, 1995. We established a comparison cohort by frequency-matching patients 1:200 on sex, and month and year of birth to the general Danish population (n = 35,600 population controls). We started follow-up at date of TCPC completion for cases and, for controls, at the index date of their matched case. The risks of cardiovascular events were assessed using cumulative incidence rates and Poisson regression models adjusted for age, sex, and calendar year. RESULTS The median age at TCPC completion was 3.3 years (interquartile range 2.6 to 5.3 years). Over a median follow-up of 12.5 years, 10 (5.6%) TCPC patients died and 7 (4.5%) had a heart transplantation compared with a 0.2% mortality in the matched population. In TCPC patients, 15.7% had an arrhythmia (11.8% supraventricular tachycardia), 3.4% had a stroke (all ischemic), and 21.4% of TCPC patients initiated a combination of a diuretic and a renin-angiotensin system (RAS)-inhibitor. These rates were >50-fold higher than in the comparison cohort: 0.2% arrhythmia, 0.06% stroke, and 0.04% starting a diuretic and a RAS-inhibitor. CONCLUSIONS Patients with TCPC circulation face a high risk of cardiovascular events during intermediate term follow-up.
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Udholm S, Aldweib N, Hjortdal VE, Veldtman GR. Prognostic power of cardiopulmonary exercise testing in Fontan patients: a systematic review. Open Heart 2018; 5:e000812. [PMID: 30057765 PMCID: PMC6059270 DOI: 10.1136/openhrt-2018-000812] [Citation(s) in RCA: 43] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/23/2018] [Revised: 04/03/2018] [Accepted: 04/24/2018] [Indexed: 11/04/2022] Open
Abstract
Objective Exercise impairment is common in Fontan patients. Our aim is to systematically review previous literature to determine the prognostic value of exercise capacity in older adolescent and adult Fontan patients with respect to late outcome. Additionally, we reviewed the determinants of exercise capacity in Fontan patients and changes in exercise capacity over time. Methods PubMed, CINAHL, Embase, The Cochrane Library and Scopus were searched systematically for studies reporting exercise capacity and late outcome such as mortality, cardiac transplantation and hospitalisation. Studies were eligible for inclusion if more than 30 patients were included and mean age was ≥16 years. Results Four thousand and seven hundred and twenty-two studies were identified by the systematic search. Seven studies fulfilled the inclusion and exclusion criteria. The total number of patients was 1664 adult Fontan patients. There were 149 deaths and 35 heart transplantations. All eligible studies were retrospective cohort studies. The correlation between exercise capacity and late outcome was identified, and HRs were reported. Conclusion In Fontan patients, the best predictors of death and transplantation were a decline in peak VO2, heart rate variables and exercise oscillatory ventilation. Peak VO2 was not strongly predictive of mortality or hospitalisation in Fontan patients. Several variables were strong and independent predictors of hospitalisation and morbidity.
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Affiliation(s)
- Sebastian Udholm
- Department of Cardiothoracic and Vascular Surgery, Aarhus University Hospital, Aarhus, Denmark
| | - Nael Aldweib
- Cardiovascular Medicine Department, Allegheny General Hospital, Pittsburgh, Pennsylvania, USA
| | | | - Gruschen R Veldtman
- Adult Congenital Heart Disease Program, Heart Institute, Cincinnati Children's Hospital Medical Centre, Cincinnati, Ohio, USA
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9
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Smaś-Suska M, Róg B, Weryński P, Płazak W, Komar M, Olszowska M, Podolec P, Tomkiewicz-Pająk L. Long-Term Effects of Percutaneous Fenestration Following the Fontan Procedure in Adult Patients with Congenital Univentricular Heart. Med Sci Monit 2018; 24:3506-3513. [PMID: 29802801 PMCID: PMC5996839 DOI: 10.12659/msm.905786] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
Abstract
Background The Fontan procedure, performed for univentricular heart, may also include the technique of percutaneous fenestration to create a small atrial septal defect (ASD) and a right-to-left shunt. The aim of this study was to evaluate the long-term effects of fenestration in adult patients who had a Fontan procedure for univentricular heart. Material/Methods Fontan surgery was performed in 39 patients, including 19 (49%) patients with fenestration (Group I), and 20 (51%) patients without the fenestration procedure (Group II). Laboratory tests in both groups included echocardiography, plethysmography, cardiopulmonary exercise testing, and 24-hour Holter monitoring. Results Compared with patients in Group I, patients in Group II had a significantly increased level of N-terminal pro-brain natriuretic peptide (NT-proBNP) (p=0.04), alkaline phosphatase (ALP) (p=0.01) and a significant increase in frequency of atrial fibrillation (p=0.04). Patients in Group I had a significantly increased systemic ventricular ejection fraction (SVEF) (p=0.05) and increased heart rate (HR) (p=0.006), heart rate reserve (HRR) (p=0.02), ventilatory equivalent (VE) (p=0.01), and VO2 peak (p=0.05) on cardiopulmonary exercise testing (CPET). Renal, hematologic, and ventilatory parameters, and incidence of thromboembolism showed no significant differences between the groups. Conclusions Long-term follow-up of patients who underwent Fontan procedures with percutaneous fenestration had improved single ventricular function, lower NT-proBNP levels, improved exercise capacity, and reduced ALP levels. These findings indicate that percutaneous fenestration closure should be considered for adult patients who have undergone Fontan procedure for univentricular heart.
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Affiliation(s)
- Monika Smaś-Suska
- Departament of Cardiac and Vascular Diseases, Institute of Cardiology, Jagiellonian University Medical College, Cracow, Poland
| | - Beata Róg
- Outpatient Department of Cardiology and Cardiac Surgery, Institute of Cardiology, Jagiellonian University Medical College, Cracow, Poland
| | - Piotr Weryński
- Department of Pediatric Cardiology, Polish-American Institute of Pediatrics (PAIP), Jagiellonian University, Medical College, Cracow, Poland
| | - Wojciech Płazak
- Departament of Cardiac and Vascular Diseases, Institute of Cardiology, Jagiellonian University Medical College, Cracow, Poland
| | - Monika Komar
- Departament of Cardiac and Vascular Diseases, Institute of Cardiology, Jagiellonian University Medical College, Cracow, Poland
| | - Maria Olszowska
- Departament of Cardiac and Vascular Diseases, Institute of Cardiology, Jagiellonian University Medical College, Cracow, Poland
| | - Piotr Podolec
- Departament of Cardiac and Vascular Diseases, Institute of Cardiology, Jagiellonian University Medical College, Cracow, Poland
| | - Lidia Tomkiewicz-Pająk
- Departament of Cardiac and Vascular Diseases, Institute of Cardiology, Jagiellonian University Medical College, Cracow, Poland
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10
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Schwartz I, McCracken CE, Petit CJ, Sachdeva R. Late outcomes after the Fontan procedure in patients with single ventricle: a meta-analysis. Heart 2018. [PMID: 29535229 DOI: 10.1136/heartjnl-2017-312807] [Citation(s) in RCA: 46] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/22/2022] Open
Abstract
OBJECTIVE More patients with Fontan physiology are reaching adulthood. The purpose of this meta-analysis was to evaluate the late outcomes of patients palliated with Fontan procedure and to assess the risk factors for mortality. METHODS PubMed, Embase and Web of Science were queried to retrieve observational studies of survival in patients following the Fontan procedure with ≥5 years of follow-up. A random-effects model was used to determine pooled survival estimates at 5, 10 and 15 years. Meta-regression was used to assess potential moderators for death. RESULTS Nineteen articles with a total of 5859 patients were included. The weighted mean follow-up time was 8.94±2.64 years with overall 8.3% deaths and 1.5% transplants. Pooled survival estimates at 5, 10 and 15 years were 90.7%, 87.2% and 87.5%, respectively; and 88.4%, 85.7% and 84.1%, respectively, for studies that included all three time intervals (n=4). Earliest surgical year included in the study, proportion of atriopulmonary connections versus extracardiac conduit or lateral tunnel, and older age at Fontan were associated with higher rates of death, but ventricular morphology was not. Protein-losing enteropathy, reoperation and pacemaker insertion were reported in 2.1%, 5.6% and 6.8% patients, respectively. CONCLUSIONS Survival following the Fontan procedure has improved with time and is influenced by Fontan type and age at the time of Fontan. At a mean follow-up of 8.9 years, there was no significant association between survival and ventricular morphology, not taking into account the mortality prior to Fontan.
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Affiliation(s)
- Ilana Schwartz
- School of Medicine, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Courtney E McCracken
- Department of Pediatrics, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Christopher J Petit
- Department of Pediatrics, Emory University School of Medicine, Atlanta, Georgia, USA.,Children's Healthcare of Atlanta, Sibley Heart Center Cardiology, Atlanta, Georgia, USA
| | - Ritu Sachdeva
- Department of Pediatrics, Emory University School of Medicine, Atlanta, Georgia, USA.,Children's Healthcare of Atlanta, Sibley Heart Center Cardiology, Atlanta, Georgia, USA
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11
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Kverneland LS, Kramer P, Ovroutski S. Five decades of the Fontan operation: A systematic review of international reports on outcomes after univentricular palliation. CONGENIT HEART DIS 2018; 13:181-193. [DOI: 10.1111/chd.12570] [Citation(s) in RCA: 61] [Impact Index Per Article: 10.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/28/2017] [Revised: 11/08/2017] [Accepted: 12/08/2017] [Indexed: 11/28/2022]
Affiliation(s)
- Laura S. Kverneland
- Department of Internal Medicine; Herlev Hospital; Copenhagen Denmark
- Department of Congenital Heart Disease/Pediatric Cardiology; German Heart Center Berlin; Berlin Germany
| | - Peter Kramer
- Department of Congenital Heart Disease/Pediatric Cardiology; German Heart Center Berlin; Berlin Germany
| | - Stanislav Ovroutski
- Department of Congenital Heart Disease/Pediatric Cardiology; German Heart Center Berlin; Berlin Germany
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12
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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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13
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Ohye RG, Schranz D, D'Udekem Y. Current Therapy for Hypoplastic Left Heart Syndrome and Related Single Ventricle Lesions. Circulation 2017; 134:1265-1279. [PMID: 27777296 DOI: 10.1161/circulationaha.116.022816] [Citation(s) in RCA: 126] [Impact Index Per Article: 18.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
Universally fatal only 4 decades ago, the progress in the 3-stage palliation of hypoplastic left heart syndrome and related single right ventricular lesions has drastically improved the outlook for these patients. Although the stage II operation (hemi-Fontan or bidirectional Glenn) and stage III Fontan procedure have evolved into relatively low-risk operations, the stage I Norwood procedure remains one of the highest-risk and costliest common operations performed in congenital heart surgery. Yet, despite this fact, experienced centers now report hospital survivals of >90% for the Norwood procedure. This traditional 3-stage surgical palliation has seen several innovations in the past decade aimed at improving outcomes, particularly for the Norwood procedure. One significant change is a renewed interest in the right ventricle-to-pulmonary artery shunt as the source of pulmonary blood flow, rather than the modified Blalock-Taussig shunt for the Norwood. The multi-institutional Single Ventricle Reconstruction trial randomly assigned 555 patients to one or the other shunt, and these subjects continue to be followed closely as they now approach 10 years postrandomization. In addition to modifications to the Norwood procedure, the hybrid procedure, a combined catheter-based and surgical approach, avoids the Norwood procedure in the newborn period entirely. The initial hybrid procedure is then followed by a comprehensive stage II, which combines components of both the Norwood and the traditional stage II, and later completion of the Fontan. Proponents of this approach hope to improve not only short-term survival, but also potentially longer-term outcomes, such as neurodevelopment, as well. Regardless of the approach, traditional surgical staged palliation or the hybrid procedure, survivals have vastly improved, and large numbers of these patients are surviving not only through their Fontan in early childhood, but also into adolescence and young adulthood. As this population grows, it becomes increasingly important to understand the longer-term outcomes of these Fontan patients, not only in terms of survival, but also in terms of the burden of disease, neurodevelopmental outcomes, psychosocial development, and quality of life.
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Affiliation(s)
- Richard G Ohye
- From University of Michigan C. S. Mott Children's Hospital, Ann Arbor (R.G.O.); Pediatric Heart Center, Justus Liebig University Giessen, Germany (D.S.); and Department of Cardiac Surgery, Royal Children's Hospital, Melbourne, Australia (Y.D'U.).
| | - Dietmar Schranz
- From University of Michigan C. S. Mott Children's Hospital, Ann Arbor (R.G.O.); Pediatric Heart Center, Justus Liebig University Giessen, Germany (D.S.); and Department of Cardiac Surgery, Royal Children's Hospital, Melbourne, Australia (Y.D'U.)
| | - Yves D'Udekem
- From University of Michigan C. S. Mott Children's Hospital, Ann Arbor (R.G.O.); Pediatric Heart Center, Justus Liebig University Giessen, Germany (D.S.); and Department of Cardiac Surgery, Royal Children's Hospital, Melbourne, Australia (Y.D'U.)
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14
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Alsaied T, Bokma JP, Engel ME, Kuijpers JM, Hanke SP, Zuhlke L, Zhang B, Veldtman GR. Factors associated with long-term mortality after Fontan procedures: a systematic review. Heart 2016; 103:104-110. [DOI: 10.1136/heartjnl-2016-310108] [Citation(s) in RCA: 91] [Impact Index Per Article: 11.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/05/2016] [Revised: 10/13/2016] [Accepted: 10/18/2016] [Indexed: 12/16/2022] Open
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15
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Carins TA, Shi WY, Iyengar AJ, Nisbet A, Forsdick V, Zannino D, Gentles T, Radford DJ, Justo R, Celermajer DS, Bullock A, Winlaw D, Wheaton G, Grigg L, d'Udekem Y. Long-term outcomes after first-onset arrhythmia in Fontan physiology. J Thorac Cardiovasc Surg 2016; 152:1355-1363.e1. [PMID: 27751239 DOI: 10.1016/j.jtcvs.2016.07.073] [Citation(s) in RCA: 49] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/26/2015] [Revised: 07/26/2016] [Accepted: 07/26/2016] [Indexed: 11/17/2022]
Abstract
OBJECTIVES Patients living with a Fontan circulation are prone to develop arrhythmias. However, their prognostic impact has been seldom studied. As such, we aimed to determine the incidence and predictors of arrhythmias after the Fontan procedure and the long-term outcomes after the first onset of arrhythmias. METHODS Of the 1034 patients who have undergone a Fontan procedure as recorded in the Australian and New Zealand Fontan Registry, we identified those in whom a tachyarrhythmia or bradyarrhythmia developed. We evaluated the incidence and predictors of developing arrhythmias and their prognostic impact on late outcomes. RESULTS Arrhythmia developed in 195 patients. Tachyarrhythmia was present in 162 patients, bradyarrhythmia was present in 74 patients, and both forms were present in 41 patients. At 20 years, freedom from any arrhythmia, tachyarrhythmia, and bradyarrhythmia was 66% (95% confidence interval [CI], 59-72), 69% (95% CI, 62-75), and 85% (95% CI, 80-90), respectively. On multivariable analyses, patients with an extracardiac Fontan (hazard ratio [HR], 0.23; 95% CI, 0.10-0.51; P < .001) were less likely to develop an arrhythmia, whereas those with left atrial (HR, 3.18; 95% CI, 1.45-6.95; P = .004) and right atrial (HR, 4.00; 95% CI, 2.41-6.61; P < .001) isomerism were more likely to have an arrhythmia. After onset of any arrhythmia (tachyarrhythmia or bradyarrhythmia), 10- and 15-year survivals were 74% (65%-83%) and 70% (60%-80%), respectively, and freedom from Fontan failure was 55% (44%-64%) and 44% (32%-56%), respectively. The development of any arrhythmia (HR, 2.20; 95% CI, 1-44-3.34; P < .001), tachyarrhythmia (HR, 2.56; 95% CI, 1.60-4.11; P < .001), and bradyarrhythmia (HR, 1.85; 95% CI, 1.16-2.95; P = .01) were all independent predictors of late Fontan failure on multivariable analyses. CONCLUSIONS The development of an arrhythmia is associated with a heightened risk of subsequent failure of the Fontan circulation.
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Affiliation(s)
- Thomas A Carins
- Department of Cardiac Surgery, The Royal Children's Hospital, Melbourne, Australia
| | - William Y Shi
- Department of Cardiac Surgery, The Royal Children's Hospital, Melbourne, Australia; Department of Paediatrics, University of Melbourne, Melbourne, Australia; The Murdoch Childrens Research Institute, Melbourne, Australia
| | - Ajay J Iyengar
- Department of Cardiac Surgery, The Royal Children's Hospital, Melbourne, Australia; Department of Paediatrics, University of Melbourne, Melbourne, Australia; The Murdoch Childrens Research Institute, Melbourne, Australia
| | - Ashley Nisbet
- Department of Cardiology, The Prince Charles Hospital, Brisbane, Australia
| | - Victoria Forsdick
- Department of Medicine, The University of Notre Dame, Sydney, Australia
| | - Diana Zannino
- The Murdoch Childrens Research Institute, Melbourne, Australia
| | - Thomas Gentles
- Green Lane Congenital Cardiac Service, Starship Children's Hospital, Auckland, New Zealand
| | - Dorothy J Radford
- Department of Cardiology, The Prince Charles Hospital, Brisbane, Australia
| | - Robert Justo
- Queensland Paediatric Cardiac Service, Lady Cilento Hospital, Brisbane, Queensland, Australia
| | - David S Celermajer
- Department of Cardiology, Royal Prince Alfred Hospital, Sydney, Australia
| | - Andrew Bullock
- Paediatric Cardiology, Princess Margaret Hospital for Children, Perth, Australia
| | - David Winlaw
- The Heart Centre for Children, The Children's Hospital at Westmead, Sydney, Australia
| | - Gavin Wheaton
- Department of Cardiology, Women's and Children's Hospital, Adelaide, Australia
| | - Leeanne Grigg
- Department of Cardiology, Royal Melbourne Hospital, Melbourne, Australia
| | - Yves d'Udekem
- Department of Cardiac Surgery, The Royal Children's Hospital, Melbourne, Australia; Department of Paediatrics, University of Melbourne, Melbourne, Australia; The Murdoch Childrens Research Institute, Melbourne, Australia.
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16
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Cauldwell M, Von Klemperer K, Uebing A, Swan L, Steer PJ, Babu-Narayan SV, Gatzoulis MA, Johnson MR. A cohort study of women with a Fontan circulation undergoing preconception counselling. Heart 2016; 102:534-40. [DOI: 10.1136/heartjnl-2015-308788] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/05/2015] [Accepted: 12/15/2015] [Indexed: 11/04/2022] Open
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17
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Bordin G, Padalino MA, Perentaler S, Castaldi B, Maschietto N, Michieli P, Crepaz R, Frigo AC, Vida VL, Milanesi O. Clinical Profile and Quality of Life of Adult Patients After the Fontan Procedure. Pediatr Cardiol 2015; 36:1261-9. [PMID: 25828147 DOI: 10.1007/s00246-015-1156-y] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/23/2014] [Accepted: 03/24/2015] [Indexed: 11/29/2022]
Abstract
Increasingly, more patients with univentricular heart reach adulthood. Therefore, long-term psychological features are an important concern. The aim of this study was to evaluate the clinical and psychological profile of post-Fontan adult patients and to identify the most significant determinants of quality of life. In this retrospective cross-sectional study, we reviewed the surgical and medical history of post-Fontan adult patients. Patients underwent a 24-h electrocardiogram, echocardiography and exercise testing. Self-report questionnaires were used to assess the Work Ability Index, quality of life (Satisfaction with Life Scale), perceived health status (SF-36 questionnaire), coping strategies (Brief Cope questionnaire) and presence of mood disorders (Hospital Anxiety and Depression Scale). Thirty-nine patients aged between 18 and 48 years (mean 27.5 years) were enrolled. The mean follow-up was 21.5 years. Most patients were unmarried (82.9 %), had a high school diploma (62.9 %) and were employed (62.9 %). Twenty-nine patients (82.3 %) had at least one long-term complication. The median single ventricle ejection fraction was 57 %, and the median maximal oxygen consumption was 26.8 ml/min/kg. This population tended to be anxious and to use adaptive coping strategies. Quality of life was perceived as excellent or good in 57.2 % of cases and was not related to either cardiac function or exercise capacity. Both quality of life and SF-36 domains were related to the Work Ability Index. This cohort of post-Fontan adult patients enjoyed a good quality of life irrespective of disease severity.
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Affiliation(s)
- Giulia Bordin
- Pediatric Cardiology Unit, Department of Women's and Children's Health, University of Padua, Via Giustiniani 3, 35128, Padua, Italy,
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18
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Hebert A, Mikkelsen UR, Thilen U, Idorn L, Jensen AS, Nagy E, Hanseus K, Sørensen KE, Søndergaard L. Bosentan Improves Exercise Capacity in Adolescents and Adults After Fontan Operation. Circulation 2014; 130:2021-30. [DOI: 10.1161/circulationaha.113.008441] [Citation(s) in RCA: 159] [Impact Index Per Article: 15.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background—
The Fontan procedure has improved survival in children with functionally univentricular hearts. With time, however, complications such as reduced exercise capacity are seen more frequently. Exercise intolerance is multifactorial, but pulmonary vascular resistance probably plays a crucial role. Elevated pulmonary vascular resistance has been associated with raised levels of endothelin-1, which are common both before and after Fontan operations. Treatment with endothelin-1 receptor antagonists could theoretically improve cardiopulmonary hemodynamics and exercise capacity. The aim of this study was therefore to examine the efficacy and safety of bosentan in Fontan patients.
Methods and Results—
Seventy-five adolescents and adults were randomized 1:1 to 14 weeks of treatment with bosentan or placebo. Cardiopulmonary exercise test, functional class, blood samples, and quality-of-life questionnaires were evaluated at baseline and at the end of treatment. Sixty-nine patients (92%) completed the study. Peak oxygen consumption increased 2.0 mL·kg
−1
·min
−1
(from 28.7 to 30.7 mL·kg
−1
·min
−1
) in the bosentan group compared with 0.6 mL·kg
−1
·min
−1
(from 28.4 to 29.0 mL·kg
−1
·min
−1
) in the placebo group (
P
=0.02). Cardiopulmonary exercise test time increased by 0.48 minute (from 6.79 to 7.27 minutes) versus 0.08 minute (from 6.94 to 7.02 minutes;
P
=0.04). Nine bosentan-treated patients improved 1 functional class, whereas none improved in the placebo group (
P
=0.0085). Side effects were mild and occurred equally in both groups. No serious adverse effects were seen, and no patients had liver enzyme levels above the 3-fold upper limit.
Conclusions—
Bosentan improves exercise capacity, exercise time, and functional class in Fontan patients without serious adverse events or hepatotoxicity.
Clinical Trial Registration—
URL:
http://www.clinicaltrials.gov
. Unique identifier: NCT01292551.
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Affiliation(s)
- Anders Hebert
- From the Department of Cardiology, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark (A.H., L.I., A.S.J., L.S.); Institute of Sports Medicine, Department of Orthopedic Surgery, Bispebjerg Hospital and Center for Healthy Ageing, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark (U.R.M.); Departments of Cardiology (U.T.) and Pediatric Cardiology (K.H.), Lund University Hospital, Lund, Sweden; Department of Cardiology/Department of Medicine,
| | - Ulla R. Mikkelsen
- From the Department of Cardiology, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark (A.H., L.I., A.S.J., L.S.); Institute of Sports Medicine, Department of Orthopedic Surgery, Bispebjerg Hospital and Center for Healthy Ageing, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark (U.R.M.); Departments of Cardiology (U.T.) and Pediatric Cardiology (K.H.), Lund University Hospital, Lund, Sweden; Department of Cardiology/Department of Medicine,
| | - Ulf Thilen
- From the Department of Cardiology, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark (A.H., L.I., A.S.J., L.S.); Institute of Sports Medicine, Department of Orthopedic Surgery, Bispebjerg Hospital and Center for Healthy Ageing, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark (U.R.M.); Departments of Cardiology (U.T.) and Pediatric Cardiology (K.H.), Lund University Hospital, Lund, Sweden; Department of Cardiology/Department of Medicine,
| | - Lars Idorn
- From the Department of Cardiology, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark (A.H., L.I., A.S.J., L.S.); Institute of Sports Medicine, Department of Orthopedic Surgery, Bispebjerg Hospital and Center for Healthy Ageing, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark (U.R.M.); Departments of Cardiology (U.T.) and Pediatric Cardiology (K.H.), Lund University Hospital, Lund, Sweden; Department of Cardiology/Department of Medicine,
| | - Annette S. Jensen
- From the Department of Cardiology, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark (A.H., L.I., A.S.J., L.S.); Institute of Sports Medicine, Department of Orthopedic Surgery, Bispebjerg Hospital and Center for Healthy Ageing, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark (U.R.M.); Departments of Cardiology (U.T.) and Pediatric Cardiology (K.H.), Lund University Hospital, Lund, Sweden; Department of Cardiology/Department of Medicine,
| | - Edit Nagy
- From the Department of Cardiology, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark (A.H., L.I., A.S.J., L.S.); Institute of Sports Medicine, Department of Orthopedic Surgery, Bispebjerg Hospital and Center for Healthy Ageing, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark (U.R.M.); Departments of Cardiology (U.T.) and Pediatric Cardiology (K.H.), Lund University Hospital, Lund, Sweden; Department of Cardiology/Department of Medicine,
| | - Katarina Hanseus
- From the Department of Cardiology, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark (A.H., L.I., A.S.J., L.S.); Institute of Sports Medicine, Department of Orthopedic Surgery, Bispebjerg Hospital and Center for Healthy Ageing, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark (U.R.M.); Departments of Cardiology (U.T.) and Pediatric Cardiology (K.H.), Lund University Hospital, Lund, Sweden; Department of Cardiology/Department of Medicine,
| | - Keld E. Sørensen
- From the Department of Cardiology, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark (A.H., L.I., A.S.J., L.S.); Institute of Sports Medicine, Department of Orthopedic Surgery, Bispebjerg Hospital and Center for Healthy Ageing, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark (U.R.M.); Departments of Cardiology (U.T.) and Pediatric Cardiology (K.H.), Lund University Hospital, Lund, Sweden; Department of Cardiology/Department of Medicine,
| | - Lars Søndergaard
- From the Department of Cardiology, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark (A.H., L.I., A.S.J., L.S.); Institute of Sports Medicine, Department of Orthopedic Surgery, Bispebjerg Hospital and Center for Healthy Ageing, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark (U.R.M.); Departments of Cardiology (U.T.) and Pediatric Cardiology (K.H.), Lund University Hospital, Lund, Sweden; Department of Cardiology/Department of Medicine,
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19
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Hemodynamic causes of exercise intolerance in Fontan patients. Int J Cardiol 2014; 175:478-83. [DOI: 10.1016/j.ijcard.2014.06.015] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/08/2014] [Revised: 06/11/2014] [Accepted: 06/20/2014] [Indexed: 11/18/2022]
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20
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Factors influencing adaptation and performance at physical exercise in complex congenital heart diseases after surgical repair. BIOMED RESEARCH INTERNATIONAL 2014; 2014:862372. [PMID: 24822218 PMCID: PMC4009320 DOI: 10.1155/2014/862372] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 10/24/2013] [Accepted: 03/27/2014] [Indexed: 01/02/2023]
Abstract
In the last thirty years, steady progress in the diagnostic tools and care of subjects affected by congenital heart diseases (CHD) has resulted in a significant increase in their survival to adulthood, even for those affected by complex CHD. Based on these premises, a number of teenagers and adults affected by corrected (surgically or through interventional techniques) CHD ask to be allowed to undertake sporting activities, both at a recreational and competitive level. The purpose of this review is to examine the mechanisms influencing the adaption at physical exercise of patients suffering from complex CHD. The conclusion is that even if there are some modest risks with exercise, they should be seen in perspective, and the life-long benefits of regular exercise on general health, mood, and well-being should be emphasized.
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21
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Wallihan DB, Podberesky DJ, Marino BS, Sticka JS, Serai S. Relationship of MR elastography determined liver stiffness with cardiac function after Fontan palliation. J Magn Reson Imaging 2013; 40:1328-35. [PMID: 24408379 DOI: 10.1002/jmri.24496] [Citation(s) in RCA: 40] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2013] [Accepted: 09/28/2013] [Indexed: 01/15/2023] Open
Abstract
PURPOSE To use MR elastography to assess liver stiffness in patients with congenital heart disease palliated with the Fontan procedure and correlate findings with cardiac index and other functional parameters obtained during cardiac MRI. MATERIALS AND METHODS We performed a retrospective study of 14 patients (15 examinations) with Fontan circulation who underwent both cardiac MRI and liver MR elastography (MRE) on the same day. Liver stiffness was determined by calculating the mean liver stiffness from four slice locations. The cardiac index and other flow measurements were calculated from phase contrast MR imaging. RESULTS The MRE was abnormal on all examinations with a median liver stiffness of 4.0 kPa (range, 3.4-6.2 kPa; normal adult liver stiffness is < 2.51 kPa). The cardiac index decreased as the duration of Fontan circulation (Fontan duration) increased (P = 0.005). We found a statistically significant inverse correlation between liver stiffness and cardiac index (P = 0.02), as well as the ejection fraction (P = 0.002). Patients with long Fontan durations (≥ 20 years) had greater liver stiffness compared with those having a shorter duration (P = 0.02). CONCLUSION MRE shows promise as a monitoring tool in the Fontan population, demonstrating an elevated liver stiffness in all patients, which inversely correlated with the MR determined cardiac index.
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Affiliation(s)
- Daniel B Wallihan
- Cincinnati Children's Hospital Medical Center, Department of Radiology, Cincinnati, Ohio, USA
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