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Kazerouninia A, Georgekutty J, Kendsersky P, Byrne RD, Seto B, Chu PY, Wang Y, Rodriguez FH, Smith C, Saraf A, Lloyd MS, Frischhertz BP, Parekh DR, Ermis PR, Franklin WJ, Lam WW. A Multisite Retrospective Review of Direct Oral Anticoagulants Compared to Warfarin in Adult Fontan Patients. Cardiovasc Drugs Ther 2023; 37:519-527. [PMID: 35022950 PMCID: PMC11040449 DOI: 10.1007/s10557-021-07298-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 11/29/2021] [Indexed: 11/25/2022]
Abstract
PURPOSE Direct oral anticoagulants (DOACs) are not recommended in adult Fontan patients (Level of Evidence C). We hypothesized that DOACs are comparable to warfarin and do not increase thrombotic and embolic complications (TEs) or clinically significant bleeds. METHODS We reviewed the medical records of adult Fontan patients on DOACs or warfarin at three major medical centers. We identified 130 patients: 48 on DOACs and 107 on warfarin. In total, they were treated for 810 months on DOACs and 5637 months on warfarin. RESULTS The incidence of TEs in patients on DOACs compared to those on warfarin was not increased in a statistically significant way (hazard ratio [HR] 1.7 and p value 0.431). Similarly, the incidence of nonmajor and major bleeds in patients on DOACs compared to those on warfarin was also not increased in a statistically significant way (HR for nonmajor bleeds in DOAC patients was 2.8 with a p value of 0.167 and the HR for major bleeds was 2.0 with a p value 0.267). In multivariate analysis, congestive heart failure (CHF) was a risk factor for TEs across both groups (odds ratio [OR] = 4.8, 95% confidence interval [CI] = 1.3-17.6) and bleed history was a risk factor for clinically significant bleeds (OR = 6.8, 95% CI = 2.7-17.2). CONCLUSION In this small, retrospective multicenter study, the use of DOACs did not increase the risk of TEs or clinically significant bleeds compared to warfarin in a statistically significant way.
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Affiliation(s)
- Amir Kazerouninia
- Departments of Internal Medicine and Pediatrics, Baylor College of Medicine, Houston, TX, USA.
| | - Justin Georgekutty
- Division of Pediatric Cardiology, Cohen Children's Medical Center/Northwell Health, New Hyde Park, NY, USA
| | - Payton Kendsersky
- Department of Medicine, Duke University School of Medicine, Durham, NC, USA
| | - Ryan D Byrne
- Departments of Internal Medicine and Pediatrics, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Brendan Seto
- University of Hawaii, John A. Burns School of Medicine, Honolulu, HI, USA
| | - Patricia Y Chu
- Departments of Internal Medicine and Pediatrics, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Yunfei Wang
- Division of Pediatric Cardiology, Texas Children's Hospital/Baylor College of Medicine, Houston, TX, USA
| | - Fred H Rodriguez
- Departments of Pediatrics and Internal Medicine, Division of Cardiology, Emory University, Atlanta, GA, USA
- Sibley Heart Center Cardiology, Atlanta, GA, USA
| | - Clayton Smith
- Departments of Pediatrics and Internal Medicine, Division of Cardiology, Emory University, Atlanta, GA, USA
- Sibley Heart Center Cardiology, Atlanta, GA, USA
| | - Anita Saraf
- Departments of Pediatrics and Internal Medicine, Division of Cardiology, Emory University, Atlanta, GA, USA
- Sibley Heart Center Cardiology, Atlanta, GA, USA
| | - Michael S Lloyd
- Department of Internal Medicine, Division of Cardiology, Emory University, Atlanta, GA, USA
| | - Benjamin P Frischhertz
- Vanderbilt Heart and Vascular Institute, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Dhaval R Parekh
- Division of Adult Congenital Cardiology, Texas Children's Hospital/Baylor College of Medicine, Houston, TX, USA
| | - Peter R Ermis
- Division of Adult Congenital Cardiology, Texas Children's Hospital/Baylor College of Medicine, Houston, TX, USA
| | - Wayne J Franklin
- Division of Adult Congenital Cardiology, Texas Children's Hospital/Baylor College of Medicine, Houston, TX, USA
| | - Wilson W Lam
- Division of Adult Congenital Cardiology, Texas Children's Hospital/Baylor College of Medicine, Houston, TX, USA
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Skubera M, Gołąb A, Sternalski T, Trojnarska O, Plicner D, Smaś-Suska M, Mazurek-Kula A, Bartczak-Rutkowska A, Pająk J, Podolec P, Tomkiewicz-Pająk L. Thromboembolic Complications in Adult Patients Following Fontan Procedure-A Multicenter Study. J Clin Med 2023; 12:jcm12103465. [PMID: 37240571 DOI: 10.3390/jcm12103465] [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: 02/20/2023] [Revised: 04/20/2023] [Accepted: 05/12/2023] [Indexed: 05/28/2023] Open
Abstract
BACKGROUND Morbidity and mortality following Fontan (FO) surgery are primarily thromboembolic in nature. However, follow-up data regarding thromboembolic complications (TECs) in adult patients after FO procedure are inconsistent. In this multicenter study, we investigated the incidence of TECs in FO patients. METHODS We studied 91 patients who underwent FO procedure. Clinical data, laboratory, and imaging investigations were collected prospectively during the scheduled medical appointments in 3 Adult Congenital Heart Disease Departments in Poland. TECs were recorded during a median follow-up of 31 months. RESULTS Four patients (4.4%) were lost to follow-up. The mean age of patients was 25.3 (±6.0) years at enrollment, and the mean time between FO operation and investigation was 22.1 (±5.1) years. A total of 21 out of 91 patients (23.1%) had a history of 24 TECs since an FO procedure, mainly pulmonary embolism (PE; n = 12, 13.2%), including 4 (33.3%) silent PE. The mean time since FO operation to the first TEC was 17.8 (±5.1) years. During follow-up, we documented 9 TECs in 7 (8.0%) patients, mainly PE (n = 5, 5.5%). Most patients with TEC had a left type of systemic ventricle (57.1%). Three patients (42.9%) were treated with aspirin, 3 (3.4%) with Vitamin K antagonists or novel oral anticoagulants, and 1 patient had no antithrombotic treatment at the time of TEC occurrence. Supraventricular tachyarrhythmias were present in 3 patients (42.9%). CONCLUSIONS This prospective study shows that TECs are common in FO patients, and a significant number of these events occur during adolescence and young adulthood. We also indicated how much TECs are underestimated in the growing adult FO population. The complexity of the problem requires more studies, especially to standardize the prevention of TECs in the whole FO population.
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Affiliation(s)
- Maciej Skubera
- Department of Cardiac and Vascular Diseases, John Paul II Hospital, 31-202 Krakow, Poland
| | - Aleksandra Gołąb
- Faculty of Medicine and Dentistry, Pomeranian Medical University in Szczecin, 70-204 Szczecin, Poland
- Center for Research and Innovative Technology, John Paul II Hospital, 31-202 Krakow, Poland
| | - Tomasz Sternalski
- Faculty of Medicine, Collegium Medicum Jagiellonian University, 31-008 Krakow, Poland
| | - Olga Trojnarska
- 1st Department of Cardiology, Poznan University of Medical Sciences, 61-701 Poznan, Poland
| | - Dariusz Plicner
- Department of Cardiovascular Surgery and Transplantation, John Paul II Hospital, 31-202 Krakow, Poland
- Unit of Experimental Cardiology and Cardiac Surgery, Faculty of Medicine and Health Sciences, Andrzej Frycz Modrzewski Krakow University, 30-705 Krakow, Poland
| | - Monika Smaś-Suska
- Department of Liver Diseases, John Paul II Hospital, 31-202 Krakow, Poland
| | - Anna Mazurek-Kula
- Department of Cardiology, Polish Mother's Memorial Hospital, Research Institute, 93-338 Lodz, Poland
| | | | - Jacek Pająk
- Institute of Medical Sciences, Department of Surgery, Medical College of Rzeszow University, 35-025 Rzeszow, Poland
| | - Piotr Podolec
- Department of Cardiac and Vascular Diseases, John Paul II Hospital, 31-202 Krakow, Poland
- Institute of Cardiology, Jagiellonian University Medical College, 31-008 Krakow, Poland
| | - Lidia Tomkiewicz-Pająk
- Department of Cardiac and Vascular Diseases, John Paul II Hospital, 31-202 Krakow, Poland
- Department of Liver Diseases, John Paul II Hospital, 31-202 Krakow, Poland
- Institute of Cardiology, Jagiellonian University Medical College, 31-008 Krakow, Poland
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3
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Minaev AV, Gushchin DK, Kovalev DV, Mwela BM. Hemostasis assessment in Fontan patients using the new thrombodynamics test. Egypt Heart J 2023; 75:39. [PMID: 37150775 PMCID: PMC10164663 DOI: 10.1186/s43044-023-00365-2] [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: 02/15/2023] [Accepted: 05/04/2023] [Indexed: 05/09/2023] Open
Abstract
BACKGROUND Thromboembolic events are a well-known risk for Fontan patients and often lead to morbidity and mortality in cyanotic patients and patients with a single ventricle. Coagulopathy and thrombophilia, in addition to disturbed Fontan blood flow and endothelial injury, are major contributors to thromboembolic complications. However, there is currently no consensus regarding the optimal medication to prevent or treat these events. Identification of coagulation disorders is therefore crucial for selecting appropriate management strategies and evaluating long-term outcomes in these patients. CASE PRESENTATION We present the case of a 35-year-old male who underwent the Fontan procedure with a total cavopulmonary modification during childhood due to tricuspid atresia. He was admitted with complaints of headaches and visual disturbances, but no clear cardiovascular cause was identified. Standard coagulation test parameters were normal, but the thrombodynamics test indicated severe hypercoagulation and spontaneous clot formation. Anticoagulation therapy was initiated, and a subsequent thrombodynamics assay showed normalization of the coagulation parameters. The patient remained asymptomatic during the six-month follow-up period. CONCLUSIONS The thrombodynamics test is a valuable tool for the diagnosis of coagulation disorders, as it can assess coagulation parameters and clot growth in vitro. This method can also aid in the optimization of antithrombotic therapy. The presented clinical case highlights the potential use of the thrombodynamics test in Fontan patients to diagnose coagulation disorders and improve long-term outcomes.
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Affiliation(s)
- Anton V Minaev
- Congenital Heart Diseases Department, A.N. Bakoulev National Medical Research Center of Cardiovascular Surgery, Moscow, Russia.
| | - Dmitry K Gushchin
- Congenital Heart Diseases Department, A.N. Bakoulev National Medical Research Center of Cardiovascular Surgery, Moscow, Russia
| | - Dmitry V Kovalev
- Congenital Heart Diseases Department, A.N. Bakoulev National Medical Research Center of Cardiovascular Surgery, Moscow, Russia
| | - Bupe M Mwela
- Peoples' Friendship University of Russia, Moscow, Russia
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Van den Eynde J, Possner M, Alahdab F, Veldtman G, Goldstein BH, Rathod RH, Hoskoppal AK, Saraf A, Feingold B, Alsaied T. Thromboprophylaxis in Patients With Fontan Circulation. J Am Coll Cardiol 2023; 81:374-389. [PMID: 36697138 PMCID: PMC11040452 DOI: 10.1016/j.jacc.2022.10.037] [Citation(s) in RCA: 9] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/20/2022] [Revised: 10/24/2022] [Accepted: 10/26/2022] [Indexed: 01/24/2023]
Abstract
BACKGROUND The optimal strategy for thromboprophylaxis in patients with a Fontan circulation is unknown. OBJECTIVES The aim of this study was to compare the efficacy and safety of aspirin, warfarin, and nonvitamin K oral anticoagulants (NOACs) in a network meta-analysis. METHODS Relevant studies published by February 2022 were included. The primary efficacy outcome was thromboembolic events; major bleeding was a secondary safety outcome. Frequentist network meta-analyses were conducted to estimate the incidence rate ratios (IRRs) of both outcomes. Ranking of treatments was performed based on probability (P) score. RESULTS A total of 21 studies were included (26,546 patient-years). When compared with no thromboprophylaxis, NOAC (IRR: 0.11; 95% CI: 0.03-0.40), warfarin (IRR: 0.23; 95% CI: 0.14-0.37), and aspirin (IRR: 0.24; 95% CI: 0.15-0.39) were all associated with significantly lower rates of thromboembolic events. However, the network meta-analysis revealed no significant differences in the rates of major bleeding (NOAC: IRR: 1.45 [95% CI: 0.28-7.43]; warfarin: IRR: 1.38 [95% CI: 0.41-4.69]; and aspirin: IRR: 0.72 [95% CI: 0.20-2.58]). Rankings, which simultaneously analyze competing interventions, suggested that NOACs have the highest P score to prevent thromboembolic events (P score 0.921), followed by warfarin (P score 0.582), aspirin (P score 0.498), and no thromboprophylaxis (P score 0.001). Aspirin tended to have the most favorable overall profile. CONCLUSIONS Aspirin, warfarin, and NOAC are associated with lower risk of thromboembolic events. Recognizing the limited number of patients and heterogeneity of studies using NOACs, the results support the safety and efficacy of NOACs in patients with a Fontan circulation.
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Affiliation(s)
- Jef Van den Eynde
- Helen B. Taussig Heart Center, The Johns Hopkins Hospital and School of Medicine, Baltimore, Maryland, USA; Department of Cardiovascular Diseases, University Hospitals Leuven and Department of Cardiovascular Sciences, KU Leuven, Leuven, Belgium. https://twitter.com/JefVandenEynde
| | - Mathias Possner
- Cardiology Department, Cantonal Hospital St Gallen, St Gallen, Switzerland; University Heart Center Zurich, Department of Cardiology, University of Zurich, Zurich, Switzerland. https://twitter.com/m_possner
| | - Fares Alahdab
- Houston Methodist Research Institute, Houston Methodist Hospital, Houston, Texas, USA
| | - Gruschen Veldtman
- Scottish Adult Congenital Cardiac Service, Golden Jubilee Hospital, Glasgow, Scotland, United Kingdom
| | - Bryan H Goldstein
- The Heart and Vascular Institute, UPMC Children's Hospital of Pittsburgh, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Rahul H Rathod
- Department of Cardiology, Department of Pediatrics, Harvard Medical School, Boston, Massachusetts, USA
| | - Arvind K Hoskoppal
- The Heart and Vascular Institute, UPMC Children's Hospital of Pittsburgh, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Anita Saraf
- The Heart and Vascular Institute, UPMC Children's Hospital of Pittsburgh, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Brian Feingold
- The Heart and Vascular Institute, UPMC Children's Hospital of Pittsburgh, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Tarek Alsaied
- The Heart and Vascular Institute, UPMC Children's Hospital of Pittsburgh, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA.
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5
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Basmaji S, Samuel M, Shohoudi A, Hamilton RM, Aboulhosn J, Broberg CS, Chaix MA, Cohen S, Cook S, Dore A, Fernandes SM, Fortier A, Fournier A, Guertin MC, Kay J, Mondésert B, Mongeon FP, Opotowsky AR, Proietti A, Ting J, Zaidi A, Khairy P. Time in Therapeutic Range With Vitamin K Antagonists in Congenital Heart Disease: A Multicentre Study. Can J Cardiol 2022; 38:1751-1758. [PMID: 35964887 DOI: 10.1016/j.cjca.2022.08.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2022] [Revised: 08/01/2022] [Accepted: 08/03/2022] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Vitamin K antagonists (VKAs) are frequently prescribed to patients with congenital heart disease (CHD) for atrial arrhythmias or Fontan palliation, but there is a paucity of data regarding time spent in the therapeutic range (TTR). We sought to determine the TTR in patients with CHD and atrial arrhythmias or Fontan palliation prescribed VKAs and explore associations with thromboembolic and bleeding events. METHODS A multicentre North American cohort study was conducted on patients with CHD who received VKAs for sustained atrial arrhythmia or Fontan palliation. TTR was calculated using the Rosendaal linear interpolation method. Generalized estimating equations were used to explore factors associated with time outside the therapeutic range. RESULTS A total of 567 patients, aged 33 ± 17 years, 56% female, received VKAs for 11.5 ± 8.4 years for atrial arrhythmias (63.0%) or Fontan palliation (58.0%). CHD was simple, moderate, and complex in 10.8%, 20.3%, and 69.0%, respectively. Site investigators perceived good control over international normalized ratio (INR) levels in most patients (75.3%), with no or minor compliance or adherence issues (85.6%). The mean TTR was 41.9% (95% confidence interval [CI], 39.0%-44.8%). Forty-seven (8.3%) and 34 (6.0%) patients had thromboembolic and bleeding events, respectively. Thromboembolic events were associated with a higher proportion of time below the therapeutic range (31.3% vs 19.1%, P = 0.003) and bleeding complications with a higher proportion of time above the therapeutic range (32.5% vs 19.5%, P = 0.006). CONCLUSIONS Patients with CHD who receive VKAs spend < 42% of their time with INR levels in the therapeutic range, with repercussions regarding thromboembolic and bleeding complications.
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Affiliation(s)
- Samir Basmaji
- Montreal Heart Institute, Université de Montréal, Montréal, Québec, Canada
| | - Michelle Samuel
- Montreal Heart Institute, Université de Montréal, Montréal, Québec, Canada
| | - Azadeh Shohoudi
- Montreal Heart Institute, Université de Montréal, Montréal, Québec, Canada
| | - Robert M Hamilton
- The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
| | | | | | - Marie-A Chaix
- Montreal Heart Institute, Université de Montréal, Montréal, Québec, Canada
| | - Scott Cohen
- The Wisconsin Adult Congenital Heart (WAtCH) Program, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | - Stephen Cook
- Children's Hospital of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Annie Dore
- Montreal Heart Institute, Université de Montréal, Montréal, Québec, Canada
| | | | - Annik Fortier
- Montreal Heart Institute, Université de Montréal, Montréal, Québec, Canada
| | - Anne Fournier
- Hôpital Sainte-Justine, Université de Montréal, Montréal, Québec, Canada
| | | | - Joseph Kay
- University of Colorado Denver, Aurora, Colorado, USA
| | - Blandine Mondésert
- Montreal Heart Institute, Université de Montréal, Montréal, Québec, Canada
| | | | - Alexander R Opotowsky
- Boston Adult Congenital Heart Service, Boston Children's Hospital and Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Anna Proietti
- Montreal Heart Institute, Université de Montréal, Montréal, Québec, Canada
| | - Jennifer Ting
- Milton S. Hershey Medical Center, Pennsylvania State University, Hershey, Pennsylvania, USA
| | - Ali Zaidi
- Nationwide Children's Hospital, Ohio State University, Columbus, Ohio, USA
| | - Paul Khairy
- Montreal Heart Institute, Université de Montréal, Montréal, Québec, Canada.
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Ohuchi H, Kawata M, Uemura H, Akagi T, Yao A, Senzaki H, Kasahara S, Ichikawa H, Motoki H, Syoda M, Sugiyama H, Tsutsui H, Inai K, Suzuki T, Sakamoto K, Tatebe S, Ishizu T, Shiina Y, Tateno S, Miyazaki A, Toh N, Sakamoto I, Izumi C, Mizuno Y, Kato A, Sagawa K, Ochiai R, Ichida F, Kimura T, Matsuda H, Niwa K. JCS 2022 Guideline on Management and Re-Interventional Therapy in Patients With Congenital Heart Disease Long-Term After Initial Repair. Circ J 2022; 86:1591-1690. [DOI: 10.1253/circj.cj-22-0134] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Affiliation(s)
- Hideo Ohuchi
- Department of Pediatric Cardiology and Adult Congenital Heart Disease, National Cerebral and Cardiovascular Center
| | - Masaaki Kawata
- Division of Pediatric and Congenital Cardiovascular Surgery, Jichi Children’s Medical Center Tochigi
| | - Hideki Uemura
- Congenital Heart Disease Center, Nara Medical University
| | - Teiji Akagi
- Department of Cardiovascular Medicine, Okayama University Graduate School of Medicine Dentistry and Pharmaceutical Sciences
| | - Atsushi Yao
- Division for Health Service Promotion, University of Tokyo
| | - Hideaki Senzaki
- Department of Pediatrics, International University of Health and Welfare
| | - Shingo Kasahara
- Department of Cardiovascular Surgery, Okayama University Graduate School of Medicine Dentistry and Pharmaceutical Sciences
| | - Hajime Ichikawa
- Department of Pediatric Cardiovascular Surgery, National Cerebral and Cardiovascular Center
| | - Hirohiko Motoki
- Department of Cardiovascular Medicine, Shinshu University School of Medicine
| | - Morio Syoda
- Department of Cardiology, Tokyo Women’s Medical University
| | - Hisashi Sugiyama
- Department of Pediatric Cardiology, Seirei Hamamatsu General Hospital
| | - Hiroyuki Tsutsui
- Department of Cardiovascular Medicine, Kyushu University Graduate School of Medical Sciences
| | - Kei Inai
- Department of Pediatric Cardiology and Adult Congenital Cardiology, Tokyo Women’s Medical University
| | - Takaaki Suzuki
- Department of Pediatric Cardiac Surgery, Saitama Medical University
| | | | - Syunsuke Tatebe
- Department of Cardiovascular Medicine, Tohoku University Graduate School of Medicine
| | - Tomoko Ishizu
- Cardiovascular Division, Faculty of Medicine, University of Tsukuba
| | - Yumi Shiina
- Cardiovascular Center, St. Luke’s International Hospital
| | - Shigeru Tateno
- Department of Pediatrics, Chiba Kaihin Municipal Hospital
| | - Aya Miyazaki
- Division of Congenital Heart Disease, Department of Transition Medicine, Shizuoka General Hospital
| | - Norihisa Toh
- Department of Cardiovascular Medicine, Okayama University Graduate School of Medicine Dentistry and Pharmaceutical Sciences
| | - Ichiro Sakamoto
- Department of Cardiovascular Medicine, Kyushu University Graduate School of Medical Sciences
| | - Chisato Izumi
- Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center
| | - Yoshiko Mizuno
- Faculty of Nursing, Tokyo University of Information Sciences
| | - Atsuko Kato
- Department of Pediatric Cardiology, National Cerebral and Cardiovascular Center
| | - Koichi Sagawa
- Department of Pediatric Cardiology, Fukuoka Children’s Hospital
| | - Ryota Ochiai
- Department of Adult Nursing, Yokohama City University
| | - Fukiko Ichida
- Department of Pediatrics, International University of Health and Welfare
| | - Takeshi Kimura
- Department of Cardiovascular Medicine, Kyoto University Graduate School of Medicine
| | | | - Koichiro Niwa
- Department of Cardiology, St. Luke’s International Hospital
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Boucher AA, Heneghan JA, Jang S, Spillane KA, Abarbanell AM, Steiner ME, Meyer AD. A Narrative Review of Postoperative Anticoagulation Therapy for Congenital Cardiac Disease. Front Surg 2022; 9:907782. [PMID: 35774388 PMCID: PMC9237365 DOI: 10.3389/fsurg.2022.907782] [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: 03/30/2022] [Accepted: 05/26/2022] [Indexed: 11/18/2022] Open
Abstract
Congenital heart disease encompasses a range of cardiac birth defects. Some defects require early and complex surgical intervention and post-operative thromboprophylaxis primarily for valve, conduit, and shunt patency. Antiplatelet and anticoagulant management strategies vary considerably and may or may not align with recognized consensus practice guidelines. In addition, newer anticoagulant agents are being increasingly used in children, but these medications are not addressed in most consensus statements. This narrative review evaluated the literature from 2011 through 2021 on the topic of postoperative thromboprophylaxis after congenital heart disease operations. The search was focused on the descriptions and results of pediatric studies for replacement and/or repair of heart valves, shunts, conduits, and other congenital heart disease operations. Wide variability in practice exists and, as was true a decade ago, few randomized controlled trials have been conducted. Aspirin, warfarin, and perioperative heparin remain the most commonly used agents with varying dosing, duration, and monitoring strategies, making comparisons difficult. Only recently have data on direct oral anticoagulants been published in children, suggesting evolving paradigms of care. Our findings highlight the need for more research to strengthen the evidence for standardized thromboprophylaxis strategies.
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Affiliation(s)
- Alexander A. Boucher
- Division of Pediatric Hematology and Oncology, Department of Pediatrics, University of Minnesota Masonic Children’s Hospital, Minneapolis, MN, United States
- Correspondence: Alexander A. Boucher Julia A. Heneghan
| | - Julia A. Heneghan
- Division of Critical Care, Department of Pediatrics, University of Minnesota Masonic Children’s Hospital, Minneapolis, MN, United States
- Correspondence: Alexander A. Boucher Julia A. Heneghan
| | - Subin Jang
- Division of Pediatric Cardiac Surgery, Department of Surgery, University of Minnesota Masonic Children’s Hospital, Minneapolis, MN, United States
| | - Kaitlyn A. Spillane
- Division of Critical Care, Department of Pediatrics, Long School of Medicine, University of Texas Health Science Center, San Antonio, TX, United States
| | - Aaron M. Abarbanell
- Division of Congenital Cardiac Surgery, Department of Cardiothoracic Surgery, Long School of Medicine, University of Texas Health Science Center, San Antonio, TX, United States
| | - Marie E. Steiner
- Division of Pediatric Hematology and Oncology, Department of Pediatrics, University of Minnesota Masonic Children’s Hospital, Minneapolis, MN, United States
- Division of Critical Care, Department of Pediatrics, University of Minnesota Masonic Children’s Hospital, Minneapolis, MN, United States
| | - Andrew D. Meyer
- Division of Critical Care, Department of Pediatrics, Long School of Medicine, University of Texas Health Science Center, San Antonio, TX, United States
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8
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Westhoff-Bleck M, Klages C, Zwadlo C, Sonnenschein K, Sieweke JT, Bauersachs J, Bertram H, Grosse U. Thromboembolic characteristics and role of anticoagulation in long-standing Fontan circulation. INTERNATIONAL JOURNAL OF CARDIOLOGY CONGENITAL HEART DISEASE 2022. [DOI: 10.1016/j.ijcchd.2022.100328] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
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9
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Singh D, Jerrom T, Issitt R, Saxena R. Early thromboembolic complications after total cavopulmonary connection/Fontan operation in children: A five year single centre review. PROGRESS IN PEDIATRIC CARDIOLOGY 2021. [DOI: 10.1016/j.ppedcard.2021.101344] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
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10
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Low-molecular-weight heparin administered by subcutaneous catheter is a safe and effective anti-coagulation regimen in selected inpatient infants and children with complex congenital heart disease. Cardiol Young 2021; 31:1439-1444. [PMID: 33588972 DOI: 10.1017/s1047951121000317] [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] [Indexed: 11/07/2022]
Abstract
BACKGROUND/HYPOTHESIS Disadvantages of intravenous therapeutic unfractionated heparin, the first-line anti-coagulant agent in children with complex congenital heart disease, include unpredictable pharmacokinetics requiring frequent phlebotomies and the need for continuous intravenous access. OBJECTIVE To compare efficacy and safety of low-molecular-weight heparin administered by a subcutaneous indwelling catheter with intravenous unfractionated heparin. MATERIALS AND METHODS Clinical data from 31 inpatients prospectively enrolled to receive subcutaneous low-molecular-weight heparin were compared with those from a historical group of 44 inpatients receiving intravenous unfractionated heparin. Investigation of parents' satisfaction by telephone survey. RESULTS The percentage of anti-factor Xa levels outside therapeutic range was lower in the subcutaneous low-molecular-weight heparin group compared with the percentage of activated partial thromboplastin times outside therapeutic range in the intravenous unfractionated heparin group (40% versus 90%, p < 0.001). Neither group had a major complication. Transient local reactions occurred in 19% of patients of the subcutaneous low-molecular-weight heparin group. The number of needle punctures and that of placement of indwelling catheters were significantly lower in the subcutaneous low-molecular-weight heparin compared with the intravenous unfractionated heparin group (p < 0.001). In total, 84.2% of parents in the subcutaneous low-molecular-weight heparin group reported a positive experience when asked about comparison with prior intravenous unfractionated heparin treatment. CONCLUSION Subcutaneous low-molecular-weight heparin offers a safe anti-coagulation regimen for children with complex congenital heart disease providing more efficient therapeutic anti-coagulation and a reduction in needle punctures, thus causing less pain and anxiety in this children.
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11
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A unique case of embolic myocardial infarction in a 22-year-old woman with Fontan circulation. COR ET VASA 2021. [DOI: 10.33678/cor.2020.116] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
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12
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McNamara JR, McMahon A, Griffin M. Perioperative Management of the Fontan Patient for Cardiac and Noncardiac Surgery. J Cardiothorac Vasc Anesth 2021; 36:275-285. [PMID: 34023201 DOI: 10.1053/j.jvca.2021.04.021] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/29/2020] [Revised: 04/05/2021] [Accepted: 04/12/2021] [Indexed: 11/11/2022]
Abstract
The Fontan circulation is the single-ventricle approach to surgical palliation of complex congenital heart disease wherein biventricular separation and function cannot be safely achieved. Incremental improvements in this surgical technique, along with improvements in the long-term medical management of these patients, have led to greater survival of these patients and a remarkably steady increase in the number of adults living with this unusual circulation and physiology. This has implications for healthcare providers who now have a greater chance of encountering Fontan patients during the course of their practice. This has particularly important implications for anesthesiologists because the effects of their interventions on the finely balanced Fontan circulation may be profound. The American Heart Association and American College of Cardiology recommend that, when possible, elective surgery should be performed in an adult congenital heart disease center, although this may not be feasible in the provision of true emergency care. This review article summarizes the pathophysiology pertinent to the provision of anesthesia in this complex patient group and describes important modifications to anesthetic technique and perioperative management.
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Affiliation(s)
- John Richard McNamara
- Department of Anaesthesiology and Intensive Care Medicine, Mater Misericordiae University Hospital, Dublin, Ireland.
| | - Aisling McMahon
- Department of Anaesthesiology and Intensive Care Medicine, Mater Misericordiae University Hospital, Dublin, Ireland
| | - Michael Griffin
- Department of Anaesthesiology and Intensive Care Medicine, Mater Misericordiae University Hospital, Dublin, Ireland
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13
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Kakiuchi T, Kumamoto T, Koji A, Matsuo M. Low-dose aspirin-induced gastric mucosal injury after Fontan surgery in an adolescent. Clin Case Rep 2021; 9:2460-2464. [PMID: 33936713 PMCID: PMC8077239 DOI: 10.1002/ccr3.4070] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2021] [Revised: 03/08/2021] [Accepted: 03/08/2021] [Indexed: 11/10/2022] Open
Abstract
Low-dose aspirin (LDA)-induced gastric mucosal injury always requires rigorous follow-up while taking LDA, even in adolescents, and after a long time from the start of LDA.
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Affiliation(s)
| | - Takashi Kumamoto
- Department of PediatricsFaculty of MedicineSaga UniversitySagaJapan
| | - Azusa Koji
- Department of PediatricsFaculty of MedicineSaga UniversitySagaJapan
| | - Muneaki Matsuo
- Department of PediatricsFaculty of MedicineSaga UniversitySagaJapan
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14
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de Miguel IM, Ávila P. Atrial Fibrillation in Congenital Heart Disease. Eur Cardiol 2021; 16:e06. [PMID: 33737960 PMCID: PMC7967824 DOI: 10.15420/ecr.2020.41] [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: 10/20/2020] [Accepted: 12/08/2020] [Indexed: 01/25/2023] Open
Abstract
The increasing prevalence of AF in a growing population of adults with congenital heart disease (CHD) poses new challenges to clinicians involved in the management of these patients. Distinctive underlying anatomies, unique physiological aspects, a high diversity of corrective surgeries and associated comorbidities can complicate clinical decision-making. In this review, the authors provide an overview of the current knowledge on epidemiology and pathophysiology, with a special focus on the differences to the non-CHD population and the clinical impact of AF in adults with CHD. Acute and long-term management strategies are summarised, including the use of antiarrhythmic drugs, catheter or surgical ablation and prophylaxis of thromboembolism. Finally, gaps of knowledge and potential areas of future research are highlighted.
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Affiliation(s)
- Irene Martín de Miguel
- Cardiology Department, Hospital General Universitario Gregorio Marañón Madrid, Spain.,Instituto de Investigación Sanitaria Gregorio Marañón Madrid, Spain.,Faculty of Medicine, Universidad Complutense and CIBERCV Madrid, Spain
| | - Pablo Ávila
- Cardiology Department, Hospital General Universitario Gregorio Marañón Madrid, Spain.,Instituto de Investigación Sanitaria Gregorio Marañón Madrid, Spain.,Faculty of Medicine, Universidad Complutense and CIBERCV Madrid, Spain
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15
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Lubert AM, Redington AN. Commentary: Aspirin versus warfarin in patients with a Fontan circulation-the clot thickens. J Thorac Cardiovasc Surg 2021; 162:1231-1233. [PMID: 33593610 DOI: 10.1016/j.jtcvs.2021.01.019] [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: 01/05/2021] [Revised: 01/05/2021] [Accepted: 01/06/2021] [Indexed: 12/01/2022]
Affiliation(s)
- Adam M Lubert
- Cincinnati Children's Hospital Heart Institute, Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio; Cincinnati Adult Congenital Heart Disease Program, Cincinnati, Ohio.
| | - Andrew N Redington
- Cincinnati Children's Hospital Heart Institute, Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio
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16
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Kawamatsu N, Ishizu T, Machino-Ohtsuka T, Masuda K, Horigome H, Takechi F, Tateno S, Fukuda T, Kijima Y, Shiina Y, Komiyama N, Niwa K, Hiramatsu Y, Ieda M. Direct oral anticoagulant use and outcomes in adult patients with Fontan circulation: A multicenter retrospective cohort study. Int J Cardiol 2020; 327:74-79. [PMID: 33220361 DOI: 10.1016/j.ijcard.2020.11.024] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/03/2020] [Revised: 11/07/2020] [Accepted: 11/12/2020] [Indexed: 12/25/2022]
Abstract
BACKGROUND Many adult patients with Fontan circulation are treated with antithrombotic agents, including direct oral anticoagulants (DOACs). However, few studies have investigated the efficacy, feasibility, and safety of DOACs in adult patients with Fontan circulation. METHODS AND RESULTS In this retrospective cohort study, clinical records of 139 adult patients with Fontan circulation (70 females, 50.4%) from April 2015 to March 2018 were reviewed and classified into five groups according to the therapeutic agents used: DOAC (n = 36), vitamin K antagonist (VKA; n = 41), antiplatelet drug (n = 43), combination of an antiplatelet and anticoagulant (n = 14), and no-antithrombotic prophylaxis (n = 5). In a 1114-patient-year follow-up, 28 major events occurred, including 10 thrombotic and 18 bleeding events; 11 of 18 (61%) female patients had severe menorrhagia. The incidence (% patient-years) of major events was 0.6, 1.42, 3.74, and 5.13 in the DOAC, antiplatelet, VKA, combination, and no-antithrombotic groups, respectively. The Cox proportional hazards analysis revealed that the DOAC group had a lower rate of primary endpoints than the VKA group in males. CONCLUSIONS DOAC may be a safe antithrombotic agent for use in adult patients with Fontan circulation, particularly in males. However, these findings should be confirmed in multi-institutional prospective studies.
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Affiliation(s)
- Naoto Kawamatsu
- Department of Cardiology, Faculty of Medicine, University of Tsukuba, Tsukuba, Japan
| | - Tomoko Ishizu
- Department of Cardiology, Faculty of Medicine, University of Tsukuba, Tsukuba, Japan.
| | | | - Keita Masuda
- Department of Cardiology, Faculty of Medicine, University of Tsukuba, Tsukuba, Japan
| | - Hitoshi Horigome
- Department of Child Health, University of Tsukuba, Tsukuba, Japan
| | - Fumie Takechi
- Department of Adult Congenital Heart Disease, Chiba Cerebral and Cardiovascular Center, Chiba, Japan
| | - Shigeru Tateno
- Department of Adult Congenital Heart Disease, Chiba Cerebral and Cardiovascular Center, Chiba, Japan
| | - Terunobu Fukuda
- Department of Cardiovascular Medicine, St. Luke's International Hospital, Tokyo, Japan
| | - Yasufumi Kijima
- Department of Cardiovascular Medicine, St. Luke's International Hospital, Tokyo, Japan
| | - Yumi Shiina
- Department of Cardiovascular Medicine, St. Luke's International Hospital, Tokyo, Japan
| | - Nobuyuki Komiyama
- Department of Cardiovascular Medicine, St. Luke's International Hospital, Tokyo, Japan
| | - Koichiro Niwa
- Department of Cardiovascular Medicine, St. Luke's International Hospital, Tokyo, Japan
| | - Yuji Hiramatsu
- Division of Cardiovascular Surgery, University of Tsukuba, Tsukuba, Japan
| | - Masaki Ieda
- Department of Cardiology, Faculty of Medicine, University of Tsukuba, Tsukuba, Japan
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17
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Thrombosis and thromboprophylactic strategies in the adult with Fontan circulation. INTERNATIONAL JOURNAL OF CARDIOLOGY CONGENITAL HEART DISEASE 2020. [DOI: 10.1016/j.ijcchd.2020.100054] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022] Open
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18
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Ing RJ, Mclennan D, Twite MD, DiMaria M. Anesthetic Considerations for Fontan-Associated Liver Disease and the Failing Fontan Circuit. J Cardiothorac Vasc Anesth 2020; 34:2224-2233. [PMID: 32249074 DOI: 10.1053/j.jvca.2020.02.040] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/16/2018] [Revised: 02/19/2020] [Accepted: 02/23/2020] [Indexed: 12/13/2022]
Affiliation(s)
- Richard J Ing
- Department of Anesthesiology, Children's Hospital Colorado, Anschutz Medical Campus, Aurora, CO; School of Medicine, University of Colorado, Aurora, CO.
| | - Daniel Mclennan
- Stead Family Children's Hospital, University of Iowa, Iowa City, IA
| | - Mark D Twite
- Department of Anesthesiology, Children's Hospital Colorado, Anschutz Medical Campus, Aurora, CO; School of Medicine, University of Colorado, Aurora, CO
| | - Michael DiMaria
- Department of Anesthesiology, Children's Hospital Colorado, Anschutz Medical Campus, Aurora, CO; School of Medicine, University of Colorado, Aurora, CO
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Luo Q, Su Z, Jia Y, Liu Y, Wang H, Zhang L, Li Y, Wu X, Liu Q, Yan F. Risk Factors for Prolonged Mechanical Ventilation After Total Cavopulmonary Connection Surgery: 8 Years of Experience at Fuwai Hospital. J Cardiothorac Vasc Anesth 2020; 34:940-948. [DOI: 10.1053/j.jvca.2019.10.043] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/27/2019] [Revised: 10/21/2019] [Accepted: 10/26/2019] [Indexed: 02/07/2023]
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20
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NOACs in adult congenital heart disease – Still limited experience. Int J Cardiol 2020; 300:143-144. [DOI: 10.1016/j.ijcard.2019.11.117] [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: 10/31/2019] [Accepted: 11/15/2019] [Indexed: 11/17/2022]
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21
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Stout KK, Daniels CJ, Aboulhosn JA, Bozkurt B, Broberg CS, Colman JM, Crumb SR, Dearani JA, Fuller S, Gurvitz M, Khairy P, Landzberg MJ, Saidi A, Valente AM, Van Hare GF. 2018 AHA/ACC Guideline for the Management of Adults With Congenital Heart Disease: Executive Summary: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines. Circulation 2020; 139:e637-e697. [PMID: 30586768 DOI: 10.1161/cir.0000000000000602] [Citation(s) in RCA: 132] [Impact Index Per Article: 33.0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Affiliation(s)
- Karen K Stout
- Writing committee members are required to recuse themselves from voting on sections to which their specific relationships with industry may apply; see Appendix 1 for recusal information. †ACC/AHA Representative. ‡International Society for Adult Congenital Heart Disease Representative. §Society for Cardiovascular Angiography and Interventions Representative. ‖ACC/AHA Task Force on Clinical Practice Guidelines Liaison. ¶Society of Thoracic Surgeons Representative. #American Association for Thoracic Surgery Representative. **ACC/AHA Task Force on Performance Measures Liaison. ††American Society of Echocardiography Representative. ‡‡Heart Rhythm Society Representative. §§Former Task Force member; current member during the writing effort
| | - Curt J Daniels
- Writing committee members are required to recuse themselves from voting on sections to which their specific relationships with industry may apply; see Appendix 1 for recusal information. †ACC/AHA Representative. ‡International Society for Adult Congenital Heart Disease Representative. §Society for Cardiovascular Angiography and Interventions Representative. ‖ACC/AHA Task Force on Clinical Practice Guidelines Liaison. ¶Society of Thoracic Surgeons Representative. #American Association for Thoracic Surgery Representative. **ACC/AHA Task Force on Performance Measures Liaison. ††American Society of Echocardiography Representative. ‡‡Heart Rhythm Society Representative. §§Former Task Force member; current member during the writing effort
| | - Jamil A Aboulhosn
- Writing committee members are required to recuse themselves from voting on sections to which their specific relationships with industry may apply; see Appendix 1 for recusal information. †ACC/AHA Representative. ‡International Society for Adult Congenital Heart Disease Representative. §Society for Cardiovascular Angiography and Interventions Representative. ‖ACC/AHA Task Force on Clinical Practice Guidelines Liaison. ¶Society of Thoracic Surgeons Representative. #American Association for Thoracic Surgery Representative. **ACC/AHA Task Force on Performance Measures Liaison. ††American Society of Echocardiography Representative. ‡‡Heart Rhythm Society Representative. §§Former Task Force member; current member during the writing effort
| | - Biykem Bozkurt
- Writing committee members are required to recuse themselves from voting on sections to which their specific relationships with industry may apply; see Appendix 1 for recusal information. †ACC/AHA Representative. ‡International Society for Adult Congenital Heart Disease Representative. §Society for Cardiovascular Angiography and Interventions Representative. ‖ACC/AHA Task Force on Clinical Practice Guidelines Liaison. ¶Society of Thoracic Surgeons Representative. #American Association for Thoracic Surgery Representative. **ACC/AHA Task Force on Performance Measures Liaison. ††American Society of Echocardiography Representative. ‡‡Heart Rhythm Society Representative. §§Former Task Force member; current member during the writing effort
| | - Craig S Broberg
- Writing committee members are required to recuse themselves from voting on sections to which their specific relationships with industry may apply; see Appendix 1 for recusal information. †ACC/AHA Representative. ‡International Society for Adult Congenital Heart Disease Representative. §Society for Cardiovascular Angiography and Interventions Representative. ‖ACC/AHA Task Force on Clinical Practice Guidelines Liaison. ¶Society of Thoracic Surgeons Representative. #American Association for Thoracic Surgery Representative. **ACC/AHA Task Force on Performance Measures Liaison. ††American Society of Echocardiography Representative. ‡‡Heart Rhythm Society Representative. §§Former Task Force member; current member during the writing effort
| | - Jack M Colman
- Writing committee members are required to recuse themselves from voting on sections to which their specific relationships with industry may apply; see Appendix 1 for recusal information. †ACC/AHA Representative. ‡International Society for Adult Congenital Heart Disease Representative. §Society for Cardiovascular Angiography and Interventions Representative. ‖ACC/AHA Task Force on Clinical Practice Guidelines Liaison. ¶Society of Thoracic Surgeons Representative. #American Association for Thoracic Surgery Representative. **ACC/AHA Task Force on Performance Measures Liaison. ††American Society of Echocardiography Representative. ‡‡Heart Rhythm Society Representative. §§Former Task Force member; current member during the writing effort
| | - Stephen R Crumb
- Writing committee members are required to recuse themselves from voting on sections to which their specific relationships with industry may apply; see Appendix 1 for recusal information. †ACC/AHA Representative. ‡International Society for Adult Congenital Heart Disease Representative. §Society for Cardiovascular Angiography and Interventions Representative. ‖ACC/AHA Task Force on Clinical Practice Guidelines Liaison. ¶Society of Thoracic Surgeons Representative. #American Association for Thoracic Surgery Representative. **ACC/AHA Task Force on Performance Measures Liaison. ††American Society of Echocardiography Representative. ‡‡Heart Rhythm Society Representative. §§Former Task Force member; current member during the writing effort
| | - Joseph A Dearani
- Writing committee members are required to recuse themselves from voting on sections to which their specific relationships with industry may apply; see Appendix 1 for recusal information. †ACC/AHA Representative. ‡International Society for Adult Congenital Heart Disease Representative. §Society for Cardiovascular Angiography and Interventions Representative. ‖ACC/AHA Task Force on Clinical Practice Guidelines Liaison. ¶Society of Thoracic Surgeons Representative. #American Association for Thoracic Surgery Representative. **ACC/AHA Task Force on Performance Measures Liaison. ††American Society of Echocardiography Representative. ‡‡Heart Rhythm Society Representative. §§Former Task Force member; current member during the writing effort
| | - Stephanie Fuller
- Writing committee members are required to recuse themselves from voting on sections to which their specific relationships with industry may apply; see Appendix 1 for recusal information. †ACC/AHA Representative. ‡International Society for Adult Congenital Heart Disease Representative. §Society for Cardiovascular Angiography and Interventions Representative. ‖ACC/AHA Task Force on Clinical Practice Guidelines Liaison. ¶Society of Thoracic Surgeons Representative. #American Association for Thoracic Surgery Representative. **ACC/AHA Task Force on Performance Measures Liaison. ††American Society of Echocardiography Representative. ‡‡Heart Rhythm Society Representative. §§Former Task Force member; current member during the writing effort
| | - Michelle Gurvitz
- Writing committee members are required to recuse themselves from voting on sections to which their specific relationships with industry may apply; see Appendix 1 for recusal information. †ACC/AHA Representative. ‡International Society for Adult Congenital Heart Disease Representative. §Society for Cardiovascular Angiography and Interventions Representative. ‖ACC/AHA Task Force on Clinical Practice Guidelines Liaison. ¶Society of Thoracic Surgeons Representative. #American Association for Thoracic Surgery Representative. **ACC/AHA Task Force on Performance Measures Liaison. ††American Society of Echocardiography Representative. ‡‡Heart Rhythm Society Representative. §§Former Task Force member; current member during the writing effort
| | - Paul Khairy
- Writing committee members are required to recuse themselves from voting on sections to which their specific relationships with industry may apply; see Appendix 1 for recusal information. †ACC/AHA Representative. ‡International Society for Adult Congenital Heart Disease Representative. §Society for Cardiovascular Angiography and Interventions Representative. ‖ACC/AHA Task Force on Clinical Practice Guidelines Liaison. ¶Society of Thoracic Surgeons Representative. #American Association for Thoracic Surgery Representative. **ACC/AHA Task Force on Performance Measures Liaison. ††American Society of Echocardiography Representative. ‡‡Heart Rhythm Society Representative. §§Former Task Force member; current member during the writing effort
| | - Michael J Landzberg
- Writing committee members are required to recuse themselves from voting on sections to which their specific relationships with industry may apply; see Appendix 1 for recusal information. †ACC/AHA Representative. ‡International Society for Adult Congenital Heart Disease Representative. §Society for Cardiovascular Angiography and Interventions Representative. ‖ACC/AHA Task Force on Clinical Practice Guidelines Liaison. ¶Society of Thoracic Surgeons Representative. #American Association for Thoracic Surgery Representative. **ACC/AHA Task Force on Performance Measures Liaison. ††American Society of Echocardiography Representative. ‡‡Heart Rhythm Society Representative. §§Former Task Force member; current member during the writing effort
| | - Arwa Saidi
- Writing committee members are required to recuse themselves from voting on sections to which their specific relationships with industry may apply; see Appendix 1 for recusal information. †ACC/AHA Representative. ‡International Society for Adult Congenital Heart Disease Representative. §Society for Cardiovascular Angiography and Interventions Representative. ‖ACC/AHA Task Force on Clinical Practice Guidelines Liaison. ¶Society of Thoracic Surgeons Representative. #American Association for Thoracic Surgery Representative. **ACC/AHA Task Force on Performance Measures Liaison. ††American Society of Echocardiography Representative. ‡‡Heart Rhythm Society Representative. §§Former Task Force member; current member during the writing effort
| | - Anne Marie Valente
- Writing committee members are required to recuse themselves from voting on sections to which their specific relationships with industry may apply; see Appendix 1 for recusal information. †ACC/AHA Representative. ‡International Society for Adult Congenital Heart Disease Representative. §Society for Cardiovascular Angiography and Interventions Representative. ‖ACC/AHA Task Force on Clinical Practice Guidelines Liaison. ¶Society of Thoracic Surgeons Representative. #American Association for Thoracic Surgery Representative. **ACC/AHA Task Force on Performance Measures Liaison. ††American Society of Echocardiography Representative. ‡‡Heart Rhythm Society Representative. §§Former Task Force member; current member during the writing effort
| | - George F Van Hare
- Writing committee members are required to recuse themselves from voting on sections to which their specific relationships with industry may apply; see Appendix 1 for recusal information. †ACC/AHA Representative. ‡International Society for Adult Congenital Heart Disease Representative. §Society for Cardiovascular Angiography and Interventions Representative. ‖ACC/AHA Task Force on Clinical Practice Guidelines Liaison. ¶Society of Thoracic Surgeons Representative. #American Association for Thoracic Surgery Representative. **ACC/AHA Task Force on Performance Measures Liaison. ††American Society of Echocardiography Representative. ‡‡Heart Rhythm Society Representative. §§Former Task Force member; current member during the writing effort
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22
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Stout KK, Daniels CJ, Aboulhosn JA, Bozkurt B, Broberg CS, Colman JM, Crumb SR, Dearani JA, Fuller S, Gurvitz M, Khairy P, Landzberg MJ, Saidi A, Valente AM, Van Hare GF. 2018 AHA/ACC Guideline for the Management of Adults With Congenital Heart Disease: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines. Circulation 2020; 139:e698-e800. [PMID: 30586767 DOI: 10.1161/cir.0000000000000603] [Citation(s) in RCA: 230] [Impact Index Per Article: 57.5] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Affiliation(s)
- Karen K Stout
- Writing committee members are required to recuse themselves from voting on sections to which their specific relationships with industry may apply; see Appendix 1 for recusal information. †ACC/AHA Representative. ‡International Society for Adult Congenital Heart Disease Representative. §Society for Cardiovascular Angiography and Interventions Representative. ‖ACC/AHA Task Force on Clinical Practice Guidelines Liaison. ¶Society of Thoracic Surgeons Representative. #American Association for Thoracic Surgery Representative. **ACC/AHA Task Force on Performance Measures Liaison. ††American Society of Echocardiography Representative. ‡‡Heart Rhythm Society Representative
| | - Curt J Daniels
- Writing committee members are required to recuse themselves from voting on sections to which their specific relationships with industry may apply; see Appendix 1 for recusal information. †ACC/AHA Representative. ‡International Society for Adult Congenital Heart Disease Representative. §Society for Cardiovascular Angiography and Interventions Representative. ‖ACC/AHA Task Force on Clinical Practice Guidelines Liaison. ¶Society of Thoracic Surgeons Representative. #American Association for Thoracic Surgery Representative. **ACC/AHA Task Force on Performance Measures Liaison. ††American Society of Echocardiography Representative. ‡‡Heart Rhythm Society Representative
| | - Jamil A Aboulhosn
- Writing committee members are required to recuse themselves from voting on sections to which their specific relationships with industry may apply; see Appendix 1 for recusal information. †ACC/AHA Representative. ‡International Society for Adult Congenital Heart Disease Representative. §Society for Cardiovascular Angiography and Interventions Representative. ‖ACC/AHA Task Force on Clinical Practice Guidelines Liaison. ¶Society of Thoracic Surgeons Representative. #American Association for Thoracic Surgery Representative. **ACC/AHA Task Force on Performance Measures Liaison. ††American Society of Echocardiography Representative. ‡‡Heart Rhythm Society Representative
| | - Biykem Bozkurt
- Writing committee members are required to recuse themselves from voting on sections to which their specific relationships with industry may apply; see Appendix 1 for recusal information. †ACC/AHA Representative. ‡International Society for Adult Congenital Heart Disease Representative. §Society for Cardiovascular Angiography and Interventions Representative. ‖ACC/AHA Task Force on Clinical Practice Guidelines Liaison. ¶Society of Thoracic Surgeons Representative. #American Association for Thoracic Surgery Representative. **ACC/AHA Task Force on Performance Measures Liaison. ††American Society of Echocardiography Representative. ‡‡Heart Rhythm Society Representative
| | - Craig S Broberg
- Writing committee members are required to recuse themselves from voting on sections to which their specific relationships with industry may apply; see Appendix 1 for recusal information. †ACC/AHA Representative. ‡International Society for Adult Congenital Heart Disease Representative. §Society for Cardiovascular Angiography and Interventions Representative. ‖ACC/AHA Task Force on Clinical Practice Guidelines Liaison. ¶Society of Thoracic Surgeons Representative. #American Association for Thoracic Surgery Representative. **ACC/AHA Task Force on Performance Measures Liaison. ††American Society of Echocardiography Representative. ‡‡Heart Rhythm Society Representative
| | - Jack M Colman
- Writing committee members are required to recuse themselves from voting on sections to which their specific relationships with industry may apply; see Appendix 1 for recusal information. †ACC/AHA Representative. ‡International Society for Adult Congenital Heart Disease Representative. §Society for Cardiovascular Angiography and Interventions Representative. ‖ACC/AHA Task Force on Clinical Practice Guidelines Liaison. ¶Society of Thoracic Surgeons Representative. #American Association for Thoracic Surgery Representative. **ACC/AHA Task Force on Performance Measures Liaison. ††American Society of Echocardiography Representative. ‡‡Heart Rhythm Society Representative
| | - Stephen R Crumb
- Writing committee members are required to recuse themselves from voting on sections to which their specific relationships with industry may apply; see Appendix 1 for recusal information. †ACC/AHA Representative. ‡International Society for Adult Congenital Heart Disease Representative. §Society for Cardiovascular Angiography and Interventions Representative. ‖ACC/AHA Task Force on Clinical Practice Guidelines Liaison. ¶Society of Thoracic Surgeons Representative. #American Association for Thoracic Surgery Representative. **ACC/AHA Task Force on Performance Measures Liaison. ††American Society of Echocardiography Representative. ‡‡Heart Rhythm Society Representative
| | - Joseph A Dearani
- Writing committee members are required to recuse themselves from voting on sections to which their specific relationships with industry may apply; see Appendix 1 for recusal information. †ACC/AHA Representative. ‡International Society for Adult Congenital Heart Disease Representative. §Society for Cardiovascular Angiography and Interventions Representative. ‖ACC/AHA Task Force on Clinical Practice Guidelines Liaison. ¶Society of Thoracic Surgeons Representative. #American Association for Thoracic Surgery Representative. **ACC/AHA Task Force on Performance Measures Liaison. ††American Society of Echocardiography Representative. ‡‡Heart Rhythm Society Representative
| | - Stephanie Fuller
- Writing committee members are required to recuse themselves from voting on sections to which their specific relationships with industry may apply; see Appendix 1 for recusal information. †ACC/AHA Representative. ‡International Society for Adult Congenital Heart Disease Representative. §Society for Cardiovascular Angiography and Interventions Representative. ‖ACC/AHA Task Force on Clinical Practice Guidelines Liaison. ¶Society of Thoracic Surgeons Representative. #American Association for Thoracic Surgery Representative. **ACC/AHA Task Force on Performance Measures Liaison. ††American Society of Echocardiography Representative. ‡‡Heart Rhythm Society Representative
| | - Michelle Gurvitz
- Writing committee members are required to recuse themselves from voting on sections to which their specific relationships with industry may apply; see Appendix 1 for recusal information. †ACC/AHA Representative. ‡International Society for Adult Congenital Heart Disease Representative. §Society for Cardiovascular Angiography and Interventions Representative. ‖ACC/AHA Task Force on Clinical Practice Guidelines Liaison. ¶Society of Thoracic Surgeons Representative. #American Association for Thoracic Surgery Representative. **ACC/AHA Task Force on Performance Measures Liaison. ††American Society of Echocardiography Representative. ‡‡Heart Rhythm Society Representative
| | - Paul Khairy
- Writing committee members are required to recuse themselves from voting on sections to which their specific relationships with industry may apply; see Appendix 1 for recusal information. †ACC/AHA Representative. ‡International Society for Adult Congenital Heart Disease Representative. §Society for Cardiovascular Angiography and Interventions Representative. ‖ACC/AHA Task Force on Clinical Practice Guidelines Liaison. ¶Society of Thoracic Surgeons Representative. #American Association for Thoracic Surgery Representative. **ACC/AHA Task Force on Performance Measures Liaison. ††American Society of Echocardiography Representative. ‡‡Heart Rhythm Society Representative
| | - Michael J Landzberg
- Writing committee members are required to recuse themselves from voting on sections to which their specific relationships with industry may apply; see Appendix 1 for recusal information. †ACC/AHA Representative. ‡International Society for Adult Congenital Heart Disease Representative. §Society for Cardiovascular Angiography and Interventions Representative. ‖ACC/AHA Task Force on Clinical Practice Guidelines Liaison. ¶Society of Thoracic Surgeons Representative. #American Association for Thoracic Surgery Representative. **ACC/AHA Task Force on Performance Measures Liaison. ††American Society of Echocardiography Representative. ‡‡Heart Rhythm Society Representative
| | - Arwa Saidi
- Writing committee members are required to recuse themselves from voting on sections to which their specific relationships with industry may apply; see Appendix 1 for recusal information. †ACC/AHA Representative. ‡International Society for Adult Congenital Heart Disease Representative. §Society for Cardiovascular Angiography and Interventions Representative. ‖ACC/AHA Task Force on Clinical Practice Guidelines Liaison. ¶Society of Thoracic Surgeons Representative. #American Association for Thoracic Surgery Representative. **ACC/AHA Task Force on Performance Measures Liaison. ††American Society of Echocardiography Representative. ‡‡Heart Rhythm Society Representative
| | - Anne Marie Valente
- Writing committee members are required to recuse themselves from voting on sections to which their specific relationships with industry may apply; see Appendix 1 for recusal information. †ACC/AHA Representative. ‡International Society for Adult Congenital Heart Disease Representative. §Society for Cardiovascular Angiography and Interventions Representative. ‖ACC/AHA Task Force on Clinical Practice Guidelines Liaison. ¶Society of Thoracic Surgeons Representative. #American Association for Thoracic Surgery Representative. **ACC/AHA Task Force on Performance Measures Liaison. ††American Society of Echocardiography Representative. ‡‡Heart Rhythm Society Representative
| | - George F Van Hare
- Writing committee members are required to recuse themselves from voting on sections to which their specific relationships with industry may apply; see Appendix 1 for recusal information. †ACC/AHA Representative. ‡International Society for Adult Congenital Heart Disease Representative. §Society for Cardiovascular Angiography and Interventions Representative. ‖ACC/AHA Task Force on Clinical Practice Guidelines Liaison. ¶Society of Thoracic Surgeons Representative. #American Association for Thoracic Surgery Representative. **ACC/AHA Task Force on Performance Measures Liaison. ††American Society of Echocardiography Representative. ‡‡Heart Rhythm Society Representative
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Saraf A, Book WM, Nelson TJ, Xu C. Hypoplastic left heart syndrome: From bedside to bench and back. J Mol Cell Cardiol 2019; 135:109-118. [PMID: 31419439 PMCID: PMC10831616 DOI: 10.1016/j.yjmcc.2019.08.005] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/23/2019] [Revised: 08/07/2019] [Accepted: 08/12/2019] [Indexed: 02/09/2023]
Abstract
Hypoplastic Left Heart Syndrome (HLHS) is a complex Congenital Heart Disease (CHD) that was almost universally fatal until the advent of the Norwood operation in 1981. Children with HLHS who largely succumbed to the disease within the first year of life, are now surviving to adulthood. However, this survival is associated with multiple comorbidities and HLHS infants have a higher mortality rate as compared to other non-HLHS single ventricle patients. In this review we (a) discuss current clinical challenges associated in the care of HLHS patients, (b) explore the use of systems biology in understanding the molecular framework of this disease, (c) evaluate induced pluripotent stem cells as a translational model to understand molecular mechanisms and manipulate them to improve outcomes, and (d) investigate cell therapy, gene therapy, and tissue engineering as a potential tool to regenerate hypoplastic cardiac structures and improve outcomes.
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Affiliation(s)
- Anita Saraf
- Division of Cardiology, Emory University School of Medicine, Atlanta, GA 30322, USA.
| | - Wendy M Book
- Division of Cardiology, Emory University School of Medicine, Atlanta, GA 30322, USA
| | - Timothy J Nelson
- Division of General Internal Medicine, Center for Regenerative Medicine, Pediatric Cardiothoracic Surgery, Division of Cardiovascular Diseases, Transplant Center, Division of Biomedical Statistics and Informatics, Division of Pediatric Cardiology, Department of Molecular Pharmacology and Experimental Therapeutics, Mayo Clinic, Rochester, MN 55905, USA
| | - Chunhui Xu
- Division of Pediatric Cardiology, Department of Pediatrics, Emory University School of Medicine and Children's Healthcare of Atlanta, Atlanta, GA 30322, USA; Wallace H. Coulter Department of Biomedical Engineering, Georgia Institute of Technology and Emory University, Atlanta, GA 30322, USA
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24
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Sathananthan G, Johal N, Verma T, Sandhu S, Chakrabarti S, Riahi M, Human D, Leipsic J, Grewal J. Clinical Importance of Fontan Circuit Thrombus in the Adult Population: Significant Association With Increased Risk of Cardiovascular Events. Can J Cardiol 2019; 35:1807-1814. [PMID: 31813509 DOI: 10.1016/j.cjca.2019.08.038] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2019] [Revised: 08/30/2019] [Accepted: 08/30/2019] [Indexed: 10/26/2022] Open
Abstract
BACKGROUND The impact of Fontan circuit thrombus is poorly understood. The objectives of this study were to determine (1) the incidence of Fontan circuit thrombus and proportion of silent thrombus; (2) any association between Fontan circuit thrombus and markers of Fontan circulatory dysfunction; and (3) the association of Fontan circuit thrombus with adverse cardiac outcomes. METHODS We conducted a retrospective review of adult patients who underwent the Fontan procedure (aged > 18 years) followed at St. Paul's Hospital who underwent cardiac computed tomography or magnetic resonance imaging assessment (n = 67). Fontan circulatory dysfunction markers included clinical heart failure, N-terminal pro-brain natriuretic peptide, ventricular dysfunction, atrioventricular valvular regurgitation, refractory arrhythmias, declining exercise capacity, and hepatic/renal dysfunction. Adverse cardiac outcomes were death, heart transplantation, or surgery for Fontan revision or atrioventricular valve replacement. RESULTS Fontan circuit thrombus was present in 15 of 67 patients (22%): 41% (7/17) classic/modified Fontan and 16% (8/50) total cavopulmonary connection. Incidence was 36% among those suspected to have Fontan circuit thrombus; 14% in those with no clinical/echocardiographic suspicion; and clinically silent in 40% diagnosed with Fontan thrombus. The time from Fontan surgery to Fontan circuit thrombus diagnosis was 22 ± 6 years in the classic/modified group vs 14 ± 8 years in the total cavopulmonary connection group (P = 0.03. Fontan circuit thrombus was associated with adverse cardiac outcomes (27% [4/15] vs 8% [4/52], P = 0.02), but there was no difference in Fontan circulatory dysfunction markers. CONCLUSION Given the incidence of Fontan circuit thrombus and association with adverse cardiac outcomes, routine surveillance of the Fontan circuit should strongly be considered. The identification of thrombus should lead to anticoagulation implementation/optimization, along with screening/intervention for reversible Fontan circulatory issues in an attempt to prevent adverse cardiac outcomes.
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Affiliation(s)
- Gnalini Sathananthan
- University of British Columbia, Division of Cardiology, St Paul's Hospital, Vancouver, British Columbia, Canada
| | - Niall Johal
- University of British Columbia, Division of Cardiology, St Paul's Hospital, Vancouver, British Columbia, Canada
| | - Tony Verma
- University of British Columbia, Division of Cardiology, St Paul's Hospital, Vancouver, British Columbia, Canada
| | - Sherry Sandhu
- University of British Columbia, Division of Cardiology, St Paul's Hospital, Vancouver, British Columbia, Canada
| | - Shantabanu Chakrabarti
- University of British Columbia, Division of Cardiology, St Paul's Hospital, Vancouver, British Columbia, Canada
| | - Mounir Riahi
- University of British Columbia, Division of Cardiology, St Paul's Hospital, Vancouver, British Columbia, Canada
| | - Derek Human
- University of British Columbia, Division of Cardiology, St Paul's Hospital, Vancouver, British Columbia, Canada
| | - Jonathon Leipsic
- University of British Columbia, Department of Radiology, St Paul's Hospital, Vancouver, British Columbia, Canada
| | - Jasmine Grewal
- University of British Columbia, Division of Cardiology, St Paul's Hospital, Vancouver, British Columbia, Canada.
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Deshaies C, Hamilton RM, Shohoudi A, Trottier H, Poirier N, Aboulhosn J, Broberg CS, Cohen S, Cook S, Dore A, Fernandes SM, Fournier A, Kay J, Mondésert B, Mongeon FP, Opotowsky AR, Proietti A, Ting J, Zaidi A, Khairy P. Thromboembolic Risk After Atriopulmonary, Lateral Tunnel, and Extracardiac Conduit Fontan Surgery. J Am Coll Cardiol 2019; 74:1071-1081. [DOI: 10.1016/j.jacc.2019.06.051] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/11/2018] [Revised: 05/24/2019] [Accepted: 06/12/2019] [Indexed: 10/26/2022]
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Arrhythmias in Adults With Congenital Heart Disease: What the Practicing Cardiologist Needs to Know. Can J Cardiol 2019; 35:1698-1707. [PMID: 31703824 DOI: 10.1016/j.cjca.2019.07.009] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2019] [Revised: 07/05/2019] [Accepted: 07/07/2019] [Indexed: 12/19/2022] Open
Abstract
The expanding population of adults with congenital heart disease (CHD) combined with the pervasiveness of arrhythmias has resulted in the rapid growth of a dedicated sector of cardiology at the intersection between 2 subspecialties: electrophysiology and adult CHD. Herein, practical considerations are offered regarding urgent referral for catheter ablation of atrial arrhythmias, anticoagulation, and primary prevention implantable cardioverter-defibrillators (ICDs). Patients with Ebstein anomaly and ventricular pre-excitation should be referred promptly due to the high prevalence of multiple accessory pathways and increased incidence of atrial tachyarrhythmias, which may be poorly tolerated. In patients with transposition of the great arteries and atrial switch surgery, atrial arrhythmias should be managed without delay because they could provoke ventricular arrhythmias and sudden death. Other settings in which atrial arrhythmias can be poorly tolerated include single ventricle physiology and Eisenmenger syndrome. Long-term anticoagulation is generally indicated in patients with sustained intra-atrial reentrant tachycardia or atrial fibrillation and a mechanical valve, moderate or severe systemic atrioventricular valve stenosis, traditional risk factors for stroke, and/or moderate or complex CHD. The only class I indication for a primary prevention ICD is a systemic left ventricular ejection fraction ≤ 35%, with biventricular physiology, and New York Heart Association class II or III symptoms. ICD therapy is reasonable in selected adults with tetralogy of Fallot and multiple risk factors for sudden death identified by observational studies. Indications for ICDs in patients with systemic right ventricles and univentricular hearts are less well established, underscoring the need for future research to inform risk stratification.
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Thromboprophylaxis strategies for children with single-ventricle circulations (superior or total cavo-pulmonary connections) after stent implantation. Cardiol Young 2019; 29:877-884. [PMID: 31208476 DOI: 10.1017/s1047951119000969] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
OBJECTIVE To define optimal thromboprophylaxis strategy after stent implantation in superior or total cavopulmonary connections. BACKGROUND Stent thrombosis is a rare complication of intravascular stenting, with a perceived higher risk in single-ventricle patients. METHODS All patients who underwent stent implantation within superior or total cavopulmonary connections (caval vein, innominate vein, Fontan, or branch pulmonary arteries) were included. Cohort was divided into aspirin therapy alone versus advanced anticoagulation, including warfarin, enoxaparin, heparin, or clopidogrel. Primary endpoint was in-stent or downstream thrombus, and secondary endpoints included bleeding complications. RESULTS A total of 58 patients with single-ventricle circulation underwent 72 stent implantations. Of them 14 stents (19%) were implanted post-superior cavopulmonary connection and 58 (81%) post-total cavopulmonary connection. Indications for stenting included vessel/conduit stenosis (67%), external compression (18%), and thrombotic occlusion (15%). Advanced anticoagulation was prescribed for 32 (44%) patients and aspirin for 40 (56%) patients. Median follow up was 1.1 (25th-75th percentile, 0.5-2.6) years. Echocardiograms were available in 71 patients (99%), and advanced imaging in 44 patients (61%). Thrombosis was present in two patients on advanced anticoagulation (6.3%) and none noted in patients on aspirin (p = 0.187). Both patients with in-stent thrombus underwent initial stenting due to occlusive left pulmonary artery thrombus acutely post-superior cavopulmonary connection. There were seven (22%) significant bleeding complications for advanced anticoagulation and none for aspirin (p < 0.001). CONCLUSIONS Antithrombotic strategy does not appear to affect rates of in-stent thrombus in single-ventricle circulations. Aspirin alone may be sufficient for most patients undergoing stent implantation, while pre-existing thrombus may warrant advanced anticoagulation.
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Pina LM, Dong X, Zhang L, Samtani MN, Michelson AD, Justino H, Bonnet D, Harris KC, Jefferies J, McCrindle BW, Li JS. Rivaroxaban, a direct Factor Xa inhibitor, versus acetylsalicylic acid as thromboprophylaxis in children post-Fontan procedure: Rationale and design of a prospective, randomized trial (the UNIVERSE study). Am Heart J 2019; 213:97-104. [PMID: 31132584 DOI: 10.1016/j.ahj.2019.04.009] [Citation(s) in RCA: 25] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/15/2018] [Accepted: 04/16/2019] [Indexed: 11/19/2022]
Abstract
BACKGROUND The Fontan procedure is the final step of the 3-stage palliative procedure commonly performed in children with single ventricle physiology. Thrombosis remains an important complication in children after this procedure. To date, guideline recommendations for the type and duration of thromboprophylaxis after Fontan surgery are mainly based on extrapolation of knowledge gained from adults at risk for thrombosis in other clinical settings. Warfarin is being used off-label, and because of its multiple interactions with other drugs and food, a new alternative is highly desirable. Rivaroxaban, a direct Factor Xa inhibitor with a predictable pharmacokinetic profile, is a candidate to address this medical need. STUDY DESIGN The UNIVERSE study is a prospective, open-label, active-controlled, multicenter study in children 2 to 8 years of age who have single ventricle physiology and had the Fontan procedure within the 4 months preceding enrollment. This study consists of 2 parts. In Part A, rivaroxaban pharmacokinetics, pharmacodynamics, safety, and tolerability are assessed to validate the pediatric dosing selected. In Part B, safety and efficacy of rivaroxaban versus acetylsalicylic acid are evaluated for thromboprophylaxis in children post-Fontan procedure. Children in each part will receive study drug for 12 months. Part A has been completed with 12 children enrolled. Enrollment into Part B is currently ongoing. CONCLUSIONS The UNIVERSE study aims to provide dosing, pharmacokinetics/pharmacodynamics, safety, and efficacy information on the use of rivaroxaban, an oral anticoagulant, versus acetylsalicylic acid, an antiplatelet agent, in children with single ventricle physiology after the Fontan procedure.
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Affiliation(s)
| | - Xiangwen Dong
- Janssen Research and Development, LLC., Raritan, NJ 08869
| | - Liping Zhang
- Janssen Research and Development, LLC., Raritan, NJ 08869
| | | | | | | | | | - Kevin C Harris
- Children's Heart Centre, BC Children's Hospital, Vancouver, BC V6H 3N1, Canada
| | - John Jefferies
- The Heart Institute, Cincinnati Children's Hospital Medical Centre, Cincinnati, OH 45229
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Yang H, Veldtman GR, Bouma BJ, Budts W, Niwa K, Meijboom F, Scognamiglio G, Egbe AC, Schwerzmann M, Broberg C, Morissens M, Buber J, Tsai S, Polyzois I, Post MC, Greutmann M, Van Dijk A, Mulder BJ, Aboulhosn J. Non-vitamin K antagonist oral anticoagulants in adults with a Fontan circulation: are they safe. Open Heart 2019; 6:e000985. [PMID: 31245011 PMCID: PMC6560660 DOI: 10.1136/openhrt-2018-000985] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/05/2018] [Revised: 04/24/2019] [Accepted: 05/06/2019] [Indexed: 12/30/2022] Open
Abstract
Background In Fontan patients with atrial arrhythmias (AA), non-vitamin K antagonist oral anticoagulants(NOACs) have a class III recommendation according to the Pediatric & Congenital Electrophysiology Society (PACES)/Heart Rhythm Society (HRS) guideline in 2014, due to lack of data on outcomes as opposed to evidence of harm. To address this gap in data, we investigated the safety and efficacy of NOACs in adults with a Fontan circulation in a worldwide study. Methods This is an international multicentre prospective cohort study, using data from the NOTE (non-vitamin K antagonist oral anticoagulants for thromboembolic prevention in patients with congenital heart disease) registry. The study population comprised consecutive adults with a Fontan circulation using NOACs. Follow-up took place at 6 months and yearly thereafter. The primary endpoints were thromboembolism and major bleeding. Secondary endpoint was minor bleeding. Results From April 2014 onward, 74 patients (mean age 32±10 years (range 18–68), 54% male) with a Fontan circulation using NOACs were included. During a median follow-up of 1.2 (IQR 0.8–2.0) years, three thromboembolic events (2.9 per 100 patient-years (95% CI 0.7 to 7.6)) and three major bleedings (2.9 per 100 patient-years (95% CI 0.7 to 7.6)) occurred in five atriopulmonary Fontan and one total cavopulmonary connection Fontan patients with AA. Fifteen patients experienced minor bleeding episodes (15.8 per 100 patient-years (95% CI 9.1 to 25.2)). In patients (n=37) using vitamin K antagonists (VKAs) prior to the initiation of NOAC, annual incidence of historical thromboembolic events and major bleeding were 2.4% (95% CI 0.4% to 7.4%) (n = 2) and 1.2% (95% CI 0.7% to 5.1%) (n = 1), respectively. Conclusions In this review of the largest Fontan cohort using NOACs with prospective follow-up, NOACs appear to be well tolerated and their efficacy and safety during short-term follow-up seem comparable to VKAs. Longer term data are required to confirm these promising short-term results.
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Affiliation(s)
- Hayang Yang
- Deparment of Cardiology, AMC, Amsterdam, The Netherlands
| | - Gruschen R Veldtman
- Adolescent and Adult Congenital Heart Disease Program, Cincinnati Children's Hospital Medical Centre, Cincinnati, Ohio, USA
| | - Berto J Bouma
- Cardiology, Academical Medical Center-University of Amsterdam, Amsterdam, The Netherlands
| | - Werner Budts
- Department of Cardiology, University Hospital Gasthuisberg, Leuven, Belgium
| | - Koichiro Niwa
- Deparment of Cardiology, St Luke's International Hospital, Tokyo, Japan
| | - Folkert Meijboom
- Cardiology, University Medical Centre Utrecht, Utrecht, Netherlands
| | | | - Alexander Chima Egbe
- Deparment of Medicine, Division of Cardiovascular Diseases, Mayo Clinic, Rochester, New York, USA
| | - Markus Schwerzmann
- Adult Congenital Heart Diseae Program, University Hospital Inselspital, Bern, Switzerland
| | - Craig Broberg
- Knight Cardiovascular Institute, Oregon Health & Sciences University, Portland, Oregon, USA
| | | | | | - Shane Tsai
- Department of Cardiology, University of Nebraska Medical Centre, Omaha, Nebraska, USA
| | - Ioannis Polyzois
- Adult Congenital Heart Centre and Centre for Pulmonary Hypertension, Royal Brompton Hospital, London, UK
| | - Martijn C Post
- Department of Cardiology, St Antonius Hospital, Nieuwegein, The Netherlands
| | | | - Arie Van Dijk
- Cardiology, Nijmegen University Medical Center, Nijmegen, The Netherlands
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Smith JMC, Andrade JG, Human D, Field TS. Adults With Complex Congenital Heart Disease: Cerebrovascular Considerations for the Neurologist. Front Neurol 2019; 10:329. [PMID: 31019488 PMCID: PMC6458261 DOI: 10.3389/fneur.2019.00329] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2018] [Accepted: 03/18/2019] [Indexed: 01/15/2023] Open
Abstract
As infant and childhood mortality has decreased in congenital heart disease, this population is increasingly reaching adulthood. Adults with congenital heart disease (ACHD) represent a group with increased risk of stroke, silent brain infarcts, and vascular cognitive impairment. Cyanotic and other complex cardiac lesions confer the greatest risk of these cerebrovascular insults. ACHD patients, in addition to having an increased risk of stroke from structural cardiac issues and associated physiological changes, may have an accelerated burden of conventional vascular risk factors, including hypertension and impaired glucose metabolism. Adult neurologists should be aware of the risks of clinically evident and subclinical cerebrovascular disease in this population. We review the existing evidence on primary and secondary stroke prevention in individuals with complex congenital heart disease, and identify knowledge gaps in need of further research, including treatment of acute stroke in this population. Multisystemic genetic syndromes are outside the scope of this review.
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Affiliation(s)
- Jonathan M C Smith
- M.D. Senior Pediatric Neurology Resident, University of British Columbia, Vancouver, BC, Canada
| | - Jason G Andrade
- FRCPC Clinical Associate Professor of Cardiology, University of British Columbia, Vancouver, BC, Canada
| | - Derek Human
- FRCPC, Clinical Professor of Pediatric Cardiology, BC Children's Hospital, University of British Columbia, Vancouver, BC, Canada
| | - Thalia S Field
- M.D. Senior Pediatric Neurology Resident, University of British Columbia, Vancouver, BC, Canada.,FRCPC Clinical Associate Professor of Cardiology, University of British Columbia, Vancouver, BC, Canada.,FRCPC, Clinical Professor of Pediatric Cardiology, BC Children's Hospital, University of British Columbia, Vancouver, BC, Canada
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Brida M, Diller GP, Nashat H, Strozzi M, Milicic D, Baumgartner H, Gatzoulis MA. Pharmacological therapy in adult congenital heart disease: growing need, yet limited evidence. Eur Heart J 2018; 40:1049-1056. [DOI: 10.1093/eurheartj/ehy480] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/22/2018] [Revised: 06/14/2018] [Accepted: 07/24/2018] [Indexed: 12/22/2022] Open
Affiliation(s)
- Margarita Brida
- Adult Congenital Heart Centre, Centre for Pulmonary Hypertension, Royal Brompton Hospital, Sydney St, Chelsea London, UK
- National Heart and Lung Institute, Imperial College, Kensington London, UK
- Division of Adult Congenital and Valvular Heart Disease, Department of Cardiovascular Medicine, University Hospital Muenster, Albert-Schweitzer-Straße 33, Münster, Germany
- Division of Valvular Heart Disease and Adult Congenital Heart Disease, Department of Cardiovascular Medicine, University Hospital Centre Zagreb, Kispaticeva 12, Zagreb, Croatia
| | - Gerhard-Paul Diller
- Adult Congenital Heart Centre, Centre for Pulmonary Hypertension, Royal Brompton Hospital, Sydney St, Chelsea London, UK
- National Heart and Lung Institute, Imperial College, Kensington London, UK
- Division of Adult Congenital and Valvular Heart Disease, Department of Cardiovascular Medicine, University Hospital Muenster, Albert-Schweitzer-Straße 33, Münster, Germany
| | - Heba Nashat
- Adult Congenital Heart Centre, Centre for Pulmonary Hypertension, Royal Brompton Hospital, Sydney St, Chelsea London, UK
| | - Maja Strozzi
- Division of Valvular Heart Disease and Adult Congenital Heart Disease, Department of Cardiovascular Medicine, University Hospital Centre Zagreb, Kispaticeva 12, Zagreb, Croatia
| | - Davor Milicic
- Division of Valvular Heart Disease and Adult Congenital Heart Disease, Department of Cardiovascular Medicine, University Hospital Centre Zagreb, Kispaticeva 12, Zagreb, Croatia
| | - Helmut Baumgartner
- Division of Adult Congenital and Valvular Heart Disease, Department of Cardiovascular Medicine, University Hospital Muenster, Albert-Schweitzer-Straße 33, Münster, Germany
| | - Michael A Gatzoulis
- Adult Congenital Heart Centre, Centre for Pulmonary Hypertension, Royal Brompton Hospital, Sydney St, Chelsea London, UK
- National Heart and Lung Institute, Imperial College, Kensington London, UK
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Stout KK, Daniels CJ, Aboulhosn JA, Bozkurt B, Broberg CS, Colman JM, Crumb SR, Dearani JA, Fuller S, Gurvitz M, Khairy P, Landzberg MJ, Saidi A, Valente AM, Van Hare GF. 2018 AHA/ACC Guideline for the Management of Adults With Congenital Heart Disease: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines. J Am Coll Cardiol 2018; 73:e81-e192. [PMID: 30121239 DOI: 10.1016/j.jacc.2018.08.1029] [Citation(s) in RCA: 487] [Impact Index Per Article: 81.2] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
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2018 AHA/ACC Guideline for the Management of Adults With Congenital Heart Disease: Executive Summary: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines. J Am Coll Cardiol 2018; 73:1494-1563. [PMID: 30121240 DOI: 10.1016/j.jacc.2018.08.1028] [Citation(s) in RCA: 319] [Impact Index Per Article: 53.2] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
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Affiliation(s)
- Gunter Balling
- Department of Pediatric Cardiology and Congenital Heart Diseases, German Heart Center, Technical University Munich, Munich, Germany.
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35
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Georgekutty J, Kazerouninia A, Wang Y, Ermis PR, Parekh DR, Franklin WJ, Lam WW. Novel oral anticoagulant use in adult Fontan patients: A single center experience. CONGENIT HEART DIS 2018; 13:541-547. [DOI: 10.1111/chd.12603] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/30/2017] [Revised: 12/16/2017] [Accepted: 02/20/2018] [Indexed: 12/21/2022]
Affiliation(s)
- Justin Georgekutty
- Division of Pediatric Cardiology; Cohen Children's Medical Center/Northwell Health; New Hyde Park New York USA
| | - Amir Kazerouninia
- Department of Internal Medicine/Department of Pediatrics; Baylor College of Medicine; Houston Texas USA
| | - YunFei Wang
- Section of Pediatric Cardiology, Texas Children's Hospital/Baylor College of Medicine; Houston Texas USA
| | - Peter R. Ermis
- Division of Adult Congenital Cardiology, Texas Children's Hospital/Baylor College of Medicine; Houston Texas USA
| | - Dhaval R. Parekh
- Division of Adult Congenital Cardiology, Texas Children's Hospital/Baylor College of Medicine; Houston Texas USA
| | - Wayne J. Franklin
- Division of Adult Congenital Cardiology, Texas Children's Hospital/Baylor College of Medicine; Houston Texas USA
| | - Wilson W. Lam
- Division of Adult Congenital Cardiology, Texas Children's Hospital/Baylor College of Medicine; Houston Texas USA
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Daniels CJ, Bradley EA, Landzberg MJ, Aboulhosn J, Beekman RH, Book W, Gurvitz M, John A, John B, Marelli A, Marino BS, Minich LL, Poterucha JJ, Rand EB, Veldtman GR. Fontan-Associated Liver Disease. J Am Coll Cardiol 2017; 70:3173-3194. [DOI: 10.1016/j.jacc.2017.10.045] [Citation(s) in RCA: 110] [Impact Index Per Article: 15.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
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37
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Anticoagulation for Thromboembolic Risk Reduction in Adults With Congenital Heart Disease. Can J Cardiol 2017; 33:1597-1603. [DOI: 10.1016/j.cjca.2017.08.009] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2017] [Revised: 07/29/2017] [Accepted: 08/08/2017] [Indexed: 01/29/2023] Open
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Diagnosis and Management of Noncardiac Complications in Adults With Congenital Heart Disease: A Scientific Statement From the American Heart Association. Circulation 2017; 136:e348-e392. [DOI: 10.1161/cir.0000000000000535] [Citation(s) in RCA: 106] [Impact Index Per Article: 15.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
Life expectancy and quality of life for those born with congenital heart disease (CHD) have greatly improved over the past 3 decades. While representing a great advance for these patients, who have been able to move from childhood to successful adult lives in increasing numbers, this development has resulted in an epidemiological shift and a generation of patients who are at risk of developing chronic multisystem disease in adulthood. Noncardiac complications significantly contribute to the morbidity and mortality of adults with CHD. Reduced survival has been documented in patients with CHD with renal dysfunction, restrictive lung disease, anemia, and cirrhosis. Furthermore, as this population ages, atherosclerotic cardiovascular disease and its risk factors are becoming increasingly prevalent. Disorders of psychosocial and cognitive development are key factors affecting the quality of life of these individuals. It is incumbent on physicians who care for patients with CHD to be mindful of the effects that disease of organs other than the heart may have on the well-being of adults with CHD. Further research is needed to understand how these noncardiac complications may affect the long-term outcome in these patients and what modifiable factors can be targeted for preventive intervention.
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Cauldwell M, Steer PJ, Bonner S, Asghar O, Swan L, Hodson K, Head CEG, Jakes AD, Walker N, Simpson M, Bolger AP, Siddiqui F, English KM, Maudlin L, Abraham D, Sands AJ, Mohan AR, Curtis SL, Coats L, Johnson MR. Retrospective UK multicentre study of the pregnancy outcomes of women with a Fontan repair. Heart 2017; 104:401-406. [DOI: 10.1136/heartjnl-2017-311763] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/26/2017] [Revised: 08/04/2017] [Accepted: 08/04/2017] [Indexed: 11/03/2022] Open
Abstract
BackgroundThe population of women of childbearing age palliated with a Fontan repair is increasing. The aim of this study was to describe the progress of pregnancy and its outcome in a cohort of patients with a Fontan circulation in the UK.MethodsA retrospective study of women with a Fontan circulation delivering between January 2005 and November 2016 in 10 specialist adult congenital heart disease centres in the UK.Results50 women had 124 pregnancies, resulting in 68 (54.8%) miscarriages, 2 terminations of pregnancy, 1 intrauterine death (at 30 weeks), 53 (42.7%) live births and 4 neonatal deaths. Cardiac complications in pregnancies with a live birth included heart failure (n=7, 13.5%), arrhythmia (n=6, 11.3%) and pulmonary embolism (n=1, 1.9%). Very low baseline maternal oxygen saturations at first obstetric review were associated with miscarriage. All eight women with saturations of less than 85% miscarried, compared with 60 of 116 (51.7%) who had baseline saturations of ≥85% (p=0.008). Obstetric and neonatal complications were common: preterm delivery (n=39, 72.2%), small for gestational age (<10th percentile, n=30, 55.6%; <5th centile, n=19, 35.2%) and postpartum haemorrhage (n=23, 42.6%). There were no maternal deaths in the study period.ConclusionWomen with a Fontan circulation have a high rate of miscarriage and, even if pregnancy progresses to a viable gestational age, a high rate of obstetric and neonatal complications.
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Schilling C, Dalziel K, Iyengar AJ, d’Udekem Y. The Cost Differential Between Warfarin Versus Aspirin Treatment After a Fontan Procedure. Heart Lung Circ 2017; 26:e44-e47. [DOI: 10.1016/j.hlc.2017.02.003] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2015] [Revised: 01/23/2017] [Accepted: 02/01/2017] [Indexed: 10/20/2022]
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Effect of Fontan-Associated Morbidities on Survival With Intact Fontan Circulation. Am J Cardiol 2017; 119:1866-1871. [PMID: 28385177 DOI: 10.1016/j.amjcard.2017.03.004] [Citation(s) in RCA: 57] [Impact Index Per Article: 8.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/26/2016] [Revised: 03/01/2017] [Accepted: 03/01/2017] [Indexed: 11/23/2022]
Abstract
Although survival after the Fontan operation has improved, little is known about the burden of major medical morbidities associated with the modern total cavopulmonary connection (TCPC). A total of 773 consecutive patients who underwent a first Fontan operation at our institution between 1992 and 2009 were retrospectively reviewed. All subjects underwent TCPC (53% lateral tunnel, 47% extracardiac conduit). Median length of follow-up was 5.3 years (interquartile range 1.4 to 11.2), and 30% had follow-up >10 years. Freedom from a composite medical morbidity outcome (protein-losing enteropathy, plastic bronchitis, serious thromboembolic event, or tachyarrhythmia) was 47% at 20 years (95% confidence interval [CI] 38 to 55). Independent risk factors for morbidity included pre-Fontan atrioventricular valve regurgitation (hazard ratio [HR] 1.7, 95% CI 1.2 to 2.4, p = 0.001), pleural drainage >14 days (HR 1.5, 95% CI 1.01 to 2.2, p = 0.04), and longer cross-clamp time (HR 1.2 per 10 minutes, 95% CI 1.06 to 1.3, p = 0.004) at the time of TCPC. Surgical era, Fontan type, and ventricular morphology were not associated with the composite outcome. Presence of Fontan-associated morbidity was associated with a 36-fold increase in the risk of subsequent Fontan takedown, heart transplantation, or death (95% CI 17 to 76, p <0.001). For patients without any component of the composite outcome, freedom from Fontan failure was 98% at 20 years (95% CI 96 to 99). Medical morbidities after TCPC are common and significantly reduce the longevity of the Fontan circulation. However, for those patients who remain free from the composite morbidity outcome, 20-year survival with intact Fontan circulation is encouraging.
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Prabhu S, Anderson B, Ward C, Karl T, Alphonso N. Anticoagulation for Interventional Extracardiac Fontan. World J Pediatr Congenit Heart Surg 2017; 8:417-418. [PMID: 28520536 DOI: 10.1177/2150135117704619] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Sudesh Prabhu
- Lady Cilento Children's Hospital, Brisbane, Queensland, Australia
| | - Ben Anderson
- Lady Cilento Children's Hospital, Brisbane, Queensland, Australia
| | - Cameron Ward
- Lady Cilento Children's Hospital, Brisbane, Queensland, Australia
| | - Tom Karl
- University of Queensland, Brisbane, Queensland, Australia
| | - Nelson Alphonso
- Lady Cilento Children's Hospital, Brisbane, Queensland, Australia
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Faircloth JM, Miner KM, Alsaied T, Nelson N, Ciambarella J, Mizuno T, Palumbo JS, Vinks AA, Veldtman GR. Time in therapeutic range as a marker for thrombotic and bleeding outcomes in Fontan patients. J Thromb Thrombolysis 2017; 44:38-47. [DOI: 10.1007/s11239-017-1499-8] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Miner PD, Canobbio MM, Pearson DD, Schlater M, Balon Y, Junge KJ, Bhatt A, Barber D, Nickolaus MJ, Kovacs AH, Moons P, Shaw K, Fernandes SM. Contraceptive Practices of Women With Complex Congenital Heart Disease. Am J Cardiol 2017; 119:911-915. [PMID: 28087052 DOI: 10.1016/j.amjcard.2016.11.047] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/06/2016] [Revised: 11/22/2016] [Accepted: 11/22/2016] [Indexed: 10/20/2022]
Abstract
Understanding the contraceptive practices of women with complex congenital heart disease (CHD) and providing them individualized contraception counseling may prevent adverse events and unplanned high-risk pregnancies. Given this, we sought to examine the contraceptive practices in women with CHD, describe adverse events associated with contraceptive use, and describe the provision of contraception counseling. Women >18 years were recruited from 2011 to 2014 from 9 adult CHD (ACHD) centers throughout North America. Subjects completed a 48-item questionnaire regarding contraceptive use and perceptions of contraception counseling, and a medical record review was performed. Of 505 subjects, median age was 33 (interquartile range 26 to 44) and 81% had CHD of moderate or great complexity. The majority (86%, 435 of 505) of the cohort had used contraception. The types included barrier methods (87%), oral contraception (OC) 84%, intrauterine device (18%), Depo-Provera (15%), vaginal ring (7%), patch (6%), hormonal implant (2%), Plan B (19%), and sterilization (16%). Overall OC use was not significantly different by CHD complexity. Women with CHD of great complexity were more likely to report a thrombotic event while taking OC than those with less complex CHD (9% vs 1%, p = 0.003). Contraception counseling by the ACHD team was noted by 43% of subjects. Unplanned pregnancy was reported by 25% with no statistical difference by CHD complexity. In conclusion, contraceptive practices of women with complex CHD are highly variable, and the prevalence of blood clots while taking OC is not insignificant while provision of contraception counseling by ACHD providers appears lacking.
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Egbe AC, Connolly HM, Niaz T, Yogeswaran V, Taggart NW, Qureshi MY, Poterucha JT, Khan AR, Driscoll DJ. Prevalence and outcome of thrombotic and embolic complications in adults after Fontan operation. Am Heart J 2017; 183:10-17. [PMID: 27979032 DOI: 10.1016/j.ahj.2016.09.014] [Citation(s) in RCA: 45] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/30/2016] [Accepted: 09/06/2016] [Indexed: 11/15/2022]
Abstract
There are limited studies of thrombotic and embolic complications (TEC) in the adult Fontan population. The purpose of the study was to determine the prevalence, risk factors, and outcomes of TECs in this population. METHODS Retrospective review of adults with a previous Fontan operation, with follow-up at Mayo Clinic, 1994-2014. Systemic TEC was defined as intracardiac thrombus, ischemic stroke, or systemic arterial embolus. Nonsystemic TEC was defined as Fontan conduit/right atrial thrombus or pulmonary embolus. RESULTS We identified 387 patients with a mean (SD) age of 28 (7) years and a mean follow-up of 8 (2) years. An atriopulmonary connection (APC) was done for 286 patients (74%). Atrial arrhythmias were present in 278 (72%). There were 121 TECs (systemic n=36, nonsystemic n=85) in 98 patients (25%). Risk factors for systemic TEC were atrial arrhythmia (hazard ratio 2.28, P=.001) and APC (hazard ratio 1.98, P=.02); nonsystemic TEC also had similar risk factors. All 98 patients received warfarin. Warfarin was discontinued in 10 of 98 because of bleeding, and 8 of these 10 subsequently had a second TEC. Among the 82 patients who had follow-up imaging, 16 (20%) had resolution of thrombus. In total, 24 of 98 patients had a second TEC, most of whom had inadequate anticoagulation. CONCLUSIONS Thrombotic and embolic complication was not uncommon; risk factors for TEC were APC and atrial arrhythmias. Most patients were treated successfully with warfarin alone. A second TEC occurred in most patients whose anticoagulation was discontinued because of bleeding events.
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Affiliation(s)
- Alexander C Egbe
- Division of Cardiovascular Diseases, Mayo Clinic, Rochester, MN.
| | | | - Talha Niaz
- Department of Pediatric, Mayo Clinic, Rochester, MN
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Blood coagulation abnormalities and the usefulness of D-dimer level for detecting intracardiac thrombosis in adult Fontan patients. Int J Cardiol 2016; 224:139-144. [DOI: 10.1016/j.ijcard.2016.09.017] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/02/2016] [Revised: 09/06/2016] [Accepted: 09/12/2016] [Indexed: 01/19/2023]
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Vaughn G, Moore J, Lamberti J, Canter C. Management of the failing Fontan: Medical, interventional and surgical treatment. PROGRESS IN PEDIATRIC CARDIOLOGY 2016. [DOI: 10.1016/j.ppedcard.2016.07.007] [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: 10/21/2022]
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Clift P, Celermajer D. Managing adult Fontan patients: where do we stand? Eur Respir Rev 2016; 25:438-450. [PMID: 27903666 PMCID: PMC9487559 DOI: 10.1183/16000617.0091-2016] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2016] [Accepted: 10/13/2016] [Indexed: 01/10/2023] Open
Abstract
The Fontan operation is performed as a palliative procedure to improve survival in infants born with a functionally univentricular circulation. The success of the operation is demonstrated by a growing adult Fontan population that exists with this unique physiology. Late follow-up has demonstrated expected and unexpected sequelae, and has shown multisystem effects of this circulation. This review discusses the challenges of managing the late complications in terms of understanding this unique physiology and the innovative therapeutic interventions that are being investigated. The challenge remains to maintain quality of life for adult survivors, as well as extending life expectancy. Innovative solutions are required to meet the challenges of the Fontan circulation faced in adult lifehttp://ow.ly/XTSm305oH8b
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Thromboprophylaxis for atrial arrhythmias in congenital heart disease: A multicenter study. Int J Cardiol 2016; 223:729-735. [DOI: 10.1016/j.ijcard.2016.08.223] [Citation(s) in RCA: 55] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/07/2016] [Accepted: 08/12/2016] [Indexed: 11/18/2022]
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Abstract
This review attempts to answer the common questions faced by a clinician regarding thromboembolism and thromboprophylaxis in patients following Fontan surgery. The review is in an easy to understand question and answer format and discusses the currently available literature on the subject in an attempt to arrive at practical clinically relevant solutions. Patients who have undergone the Fontan operation are at a high risk for thromboembolism. Based on available evidence, there is a strong rationale for thromboprophylaxis. However, it is not clear as to which agent should be administered to prevent thromboembolic events. While the available evidence suggests that antiplatelet agents alone may be as good as oral anticoagulants, there is a need for a large multicenter randomized control trial comparing these two common strategies to deliver a clear verdict.
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Affiliation(s)
- Sangeetha Viswanathan
- Department of Paediatric Cardiology, SRM Institute of Medical Sciences, Chennai, Tamil Nadu, India
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