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Ko H, Song J, Chi SA, Lee SY, Kim SJ, Lee CH, Park CS, Choi ES, An HS, Kang IS, Yoon JK, Baek JS, Lee JY, Lee J, Huh J, Ahn KJ, Jung SY, Cha SG, Kim YH, Lee YS. The long-term effects of the fenestration in patients with extracardiac Fontan circulation-a multicenter Korean cohort study based on national Fontan registry. Front Cardiovasc Med 2024; 11:1341882. [PMID: 38774663 PMCID: PMC11106450 DOI: 10.3389/fcvm.2024.1341882] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2023] [Accepted: 04/22/2024] [Indexed: 05/24/2024] Open
Abstract
Introduction The long-term effects of fenestration in patients with Fontan circulation remain unclear. We aim to evaluate the fenestration impact on early and late outcomes in patients with extracardiac Fontan (ECF) using a propensity score matching analysis. Methods We performed an extensive retrospective multicenter clinical data review of the Korean Fontan registry and included 1,233 patients with surgical ECF (779 fenestrated, 454 non-fenestrated). Demographics, baseline, and follow-up data were collected and comprehensively analyzed. Patients were divided into two groups according to the baseline presence or absence of surgical fenestration. Subsequently, patients were sub-divided according to the fenestration status at the last follow-up. Propensity-score matching was performed to account for collected data between the 2 groups using a multistep approach. The primary outcomes were survival and freedom from Fontan failure (FFF). We also looked at postoperative hemodynamics, cardiopulmonary exercise test results, oxygen saturations, and functional status. Results After propensity-score matching (454 matched pairs), there was no difference in survival or FFF between the 2 groups. However, ECF patients with baseline fenestration had significantly lower oxygen saturation (p = 0.001) and lower functional status (p < 0.001). Patients with fenestration had significantly longer bypass times, higher postoperative central venous pressure, higher postoperative left atrial pressure, and less prolonged pleural effusion in the early postoperative period. The propensity score matching according to the fenestration status at the last follow-up (148 matched pairs) showed that patients with a persistent fenestration had significantly lower oxygen saturation levels (p < 0.001). However there were no intergroup differences in the functional status, survival and FFF. Conclusions Our results showed no long-term benefits of the Fenestration in terms of survival and FFF. Patients with persistent fenestration showed oxygen desaturation but no difference in exercise intolerance was shown between the 2 groups.
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Affiliation(s)
- Hoon Ko
- Department of Pediatrics, Pusan National University Yangsan Hospital, Pusan National University School of Medicine, Yangsan, Republic of Korea
| | - Jinyoung Song
- Department of Pediatrics, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Sang Ah Chi
- Department of Health Sciences and Technology, Samsung Advanced Institute for Health Sciences & Technology, Sungkyunkwan University, Seoul, Republic of Korea
- Biomedical Statistics Center, Samsung Medical Center, Research Institute for Future Medicine, Seoul, Republic of Korea
| | - Sang-Yun Lee
- Department of Pediatrics, College of Medicine, Seoul National University Children’s Hospital, Seoul, Republic of Korea
| | - Soo-Jin Kim
- Department of Pediatrics, Sejong General Hospital, Bucheon, Republic of Korea
| | - Chang-Ha Lee
- Department of Thoracic and Cardiovascular Surgery, Sejong General Hospital, Bucheon, Republic of Korea
| | - Chun Soo Park
- Department of Thoracic and Cardiovascular Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Eun Seok Choi
- Department of Thoracic and Cardiovascular Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Hyo Soon An
- Department of Pediatrics, College of Medicine, Seoul National University Children’s Hospital, Seoul, Republic of Korea
| | - I. Seok Kang
- Department of Pediatrics, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Ja Kyoung Yoon
- Department of Pediatrics, Sejong General Hospital, Bucheon, Republic of Korea
| | - Jae-Suk Baek
- Department of Pediatrics, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Jae-Young Lee
- Department of Pediatrics, College of Medicine, Seoul St. Mary’s Hospital, The Catholic University of Korea, Seoul, Republic of Korea
| | - Joowon Lee
- Department of Pediatrics, College of Medicine, Seoul National University Bundang Hospital, Sungnam, Republic of Korea
| | - June Huh
- Department of Pediatrics, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Kyung-Jin Ahn
- Department of Pediatric Cardiology, Gachon University Gil Medical Center, Incheon, Republic of Korea
| | - Se Yong Jung
- Department of Pediatrics, Severance Cardiovascular Hospital, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Seul Gi Cha
- Department of Pediatrics, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Yeo-Hyang Kim
- Department of Pediatrics, Kyungbook National University School of Medicine, Daegu, Republic of Korea
| | - Young-Seok Lee
- Department of Pediatrics, Dong-A University Hospital, Busan, Republic of Korea
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Hill GD, Wu DT, Ferguson ME, Flores S, Ginde S, Hill KD, Johansen M, Newburger JW, Gao Z, Cnota JF. Preoperative Hemodynamics Impact the Benefit of Fenestration on Fontan Postoperative Length of Stay. JACC. ADVANCES 2024; 3:100846. [PMID: 38606347 PMCID: PMC11008224 DOI: 10.1016/j.jacadv.2024.100846] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/09/2023] [Revised: 11/07/2023] [Accepted: 11/30/2023] [Indexed: 04/13/2024]
Abstract
BACKGROUND Utilization of Fontan fenestration varies considerably by center. OBJECTIVES Using a multicenter Pediatric Heart Network dataset linking surgical and preoperative hemodynamic variables, the authors evaluated factors associated with use of Fontan fenestration and the impact of fenestration on post-Fontan length of stay (LOS). METHODS Patients 2 to 6 years old at Fontan surgery from 2010 to 2020 with catheterization<1 year prior were included. Factors associated with fenestration were evaluated using multivariable logistic regression adjusting for key covariates. Restrictive cubic spline analysis was used to evaluate potential cut-points for hemodynamic variables associated with longer postoperative LOS stratified by fenestration with multivariable linear regression to evaluate the magnitude of effect. RESULTS Fenestration was used in 465 of 702 patients (66.2%). Placement of a fenestration was associated with center (range 27%-93% use, P < 0.0001) and Fontan type (OR: 14.1 for lateral tunnel vs extracardiac conduit, P < 0.0001). No hemodynamic variable was independently associated with fenestration. In a multivariable linear model adjusting for center, a center-fenestration interaction, prematurity, preoperative mean pulmonary artery pressure (mPAP), and cardiac index, fenestration was associated with shorter hospital LOS after Fontan (P = 0.0024). The benefit was most pronounced at mPAP ≥13 mm Hg (median LOS: 9 vs 12 days, P = 0.001). CONCLUSIONS There is wide center variability in use of Fontan fenestration that is not explained by preoperative hemodynamics. Fenestration is independently associated with shorter LOS, and those with mPAP ≥13 mm Hg at pre-Fontan catheterization benefit the most. We propose this threshold as minimal criteria for fenestration.
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Affiliation(s)
- Garick D. Hill
- Division of Cardiology, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio, USA
- Department of Pediatrics, College of Medicine, University of Cincinnati, Cincinnati, Ohio, USA
| | - Danny T.Y. Wu
- Division of Cardiology, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio, USA
- Department of Pediatrics, College of Medicine, University of Cincinnati, Cincinnati, Ohio, USA
- Department of Biomedical Informatics, College of Medicine, University of Cincinnati, Cincinnati, Ohio, USA
| | - M. Eric Ferguson
- Children’s Healthcare of Atlanta, Emory University, Atlanta, Georgia, USA
| | - Saul Flores
- Section of Critical Care Medicine and Cardiology, Department of Pediatrics, Texas Children's Hospital, Baylor College of Medicine, Houston, Texas, USA
| | - Salil Ginde
- Department of Medicine and Pediatrics, Children’s Wisconsin, Milwaukee, Wisconsin, USA
| | - Kevin D. Hill
- Department of Pediatrics, Duke Pediatric and Adult Congenital Heart Center, Duke Children’s Hospital, Durham, North Carolina, USA
| | - Michael Johansen
- Division of Cardiology, Riley Children’s Hospital at Indiana University Health, Indianapolis, Indiana, USA
| | - Jane W. Newburger
- Department of Cardiology, Boston Children’s Hospital, Department of Pediatrics, Harvard Medical School, Boston, Massachusetts, USA
| | - Zhiqian Gao
- The Heart Institute Research Core, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio, USA
| | - James F. Cnota
- Division of Cardiology, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio, USA
- Department of Pediatrics, College of Medicine, University of Cincinnati, Cincinnati, Ohio, USA
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Transcatheter Fontan Fenestration Closure: Sustained Improvements in Oxygen Saturation with Minimal Morbidity and Mortality. Pediatr Cardiol 2022; 44:922-926. [PMID: 36565311 DOI: 10.1007/s00246-022-03077-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/05/2022] [Accepted: 12/14/2022] [Indexed: 12/25/2022]
Abstract
Fontan fenestration decreases central venous pressure and preserves cardiac output while decreasing systemic oxygen saturation. Transcatheter fenestration closure increases oxygen saturation, though the persistence of this increase and the long-term incidence of adverse outcomes such as death and heart transplant remain unknown. We describe immediate and long-term clinical and adverse outcomes following fenestration closure. Catheterization, echocardiogram, and clinic reports were reviewed following transcatheter Fontan fenestration closure. Data were reported as n (%) and median (IQR). Continuous variables were compared using Wilcoxon ranked sum test. 51 patients had fenestration closure 0.9 (0.7-1.5) years following extracardiac Fontan operation. Most (84%) were closed with Amplatzer Septal Occluders. Systemic O2 saturation immediately increased from 87 (83-89) to 95 (94-97)%, P < 0.05. Cardiac index decreased from 4 (3-5) to 2.9 (2.6-3.5) L/min/m2. Fontan pressure and pulmonary vascular resistance were not significantly changed. Clinical follow-up duration for all patients was 7.3 (range 1.3-16) years. Oxygen saturation at last follow-up was 94.5 (92-97)% and did not decrease over time (P < 0.05). One patient (2%) developed protein losing enteropathy, 1 (2%) had heart transplant, and 1 (2%) patient died 9.4 years following fenestration closure. No patient required fenestration re-creation following closure. Transcatheter Fontan fenestration closure leads to sustained increases in systemic oxygen saturation and a low incidence of adverse outcomes such as death and transplant. Further study comparing fenestration closure to non-closure and longer follow-up duration are required to determine if there is a survival benefit to fenestration closure.
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Heinisch PP, Metz P, Staehler H, Mayr B, Vodiskar J, Strbad M, Ruf B, Ewert P, Hager A, Hörer J, Ono M. Pleural and mediastinal effusions after the extracardiac total cavopulmonary connection: Risk factors and impact on outcome. Front Cardiovasc Med 2022; 9:1026445. [DOI: 10.3389/fcvm.2022.1026445] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2022] [Accepted: 10/17/2022] [Indexed: 11/11/2022] Open
Abstract
BackgroundThis study investigated the volume and duration of pleural and mediastinal effusions following extracardiac total cavopulmonary connection, as well as preoperative risk factors and their impact on outcome.Materials and methodsA total of 210 patients who underwent extracardiac total cavopulmonary connection at our center between 2012 and 2020 were included in this study. Postoperative daily amount of pleural and mediastinal drainage were collected and factors influencing duration and amount of effusions were analyzed. The impact of effusions on adverse events was analyzed.ResultsMedian age at extracardiac total cavopulmonary connection was 2.2 (interquartile range, 1.8–2.7) years with median weight of 11.6 (10.7–13.0) kg. Overall duration of drainage after extracardiac total cavopulmonary connection was 9 (6–17) days. The total volume of mediastinal, right pleural, and left pleural drainage was 18.8 (11.9–36.7), 64.4 (27.4–125.9), and 13.6 (0.0–53.5) mL/kg, respectively. Hypoplastic left heart syndrome (p = 0.004) and end-diastolic pressure (p = 0.044) were associated with high volume of drainages, and hypoplastic left heart syndrome (p = 0.007), presence of aortopulmonary collaterals (p = 0.002), and high end-diastolic pressure (p = 0.023) were associated with long duration of drainages. Dextrocardia was associated with higher volume (p < 0.001) and longer duration (p = 0.006) of left pleural drainage. Duration of drainage was associated with adverse events following extracardiac total cavopulmonary connection (p = 0.015).ConclusionVolume and duration of pleural and mediastinal effusions following extracardiac total cavopulmonary connection were related with hypoplastic left heart syndrome, aortopulmonary collaterals, and end-diastolic pressure. The duration of drainage for effusions was a risk factor for adverse events after total cavopulmonary connection.
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Influence of fenestration on long-term Fontan survival. Cardiol Young 2022; 32:1021-1026. [PMID: 34462027 DOI: 10.1017/s1047951121003516] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
INTRODUCTION Fenestration in the total cavopulmonary connection system may improve the outcome of patients with significant risk factors for Fontan haemodynamics. Our study aims to analyse the difference in long-term survival between non-fenestrated and fenestrated patients. METHODS All consecutive patients (n = 351) who underwent total cavopulmonary connection between 1992 and 2016 were identified. Six early deaths were excluded resulting in a group of 345 patients. Median (interquartile range,) length of follow-up was 14.4 (7.1-19.7) years. Freedom from the composite endpoint of death, total cavopulmonary connection take-down or indication for a heart transplant was analysed. RESULTS Fenestration was absent in 237 patients (68.7%, Group 1), was created and closed later in 79 patients (22.9%, Group 2), and remained open in 29 patients (8.4%, Group 3). Mean survival probability until composite endpoint was 97.1 and 92.9% at 10 and 20 years, respectively. Patients with patent fenestration had worse survival (p < 0.001) as compared to both the non-fenestrated and fenestration closure groups. Despite a similar outcome, exercise capacity was lower in Group 2 than 1 (p = 0.013). In 58 patients with interventional fenestration closure, Nakata index was lower at the time of closure than pre-operatively, and both the pressure in the circuit and oxygen saturation in the aorta increased significantly (p < 0.001). CONCLUSIONS Patients with persisting risk factors preventing fenestration closure are at higher risk of reaching the composite endpoint. Patients after fenestration closure have the worse functional outcome; their survival is, however, not different from the non-fenestrated group.
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Marelli A, Beauchesne L, Colman J, Ducas R, Grewal J, Keir M, Khairy P, Oechslin E, Therrien J, Vonder Muhll IF, Wald RM, Silversides C, Barron DJ, Benson L, Bernier PL, Horlick E, Ibrahim R, Martucci G, Nair K, Poirier NC, Ross HJ, Baumgartner H, Daniels CJ, Gurvitz M, Roos-Hesselink JW, Kovacs AH, McLeod CJ, Mulder BJ, Warnes CA, Webb GD. Canadian Cardiovascular Society 2022 Guidelines for Cardiovascular Interventions in Adults With Congenital Heart Disease. Can J Cardiol 2022; 38:862-896. [PMID: 35460862 DOI: 10.1016/j.cjca.2022.03.021] [Citation(s) in RCA: 32] [Impact Index Per Article: 16.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2021] [Revised: 03/15/2022] [Accepted: 03/30/2022] [Indexed: 12/12/2022] Open
Abstract
Interventions in adults with congenital heart disease (ACHD) focus on surgical and percutaneous interventions in light of rapidly evolving ACHD clinical practice. To bring rigour to our process and amplify the cumulative nature of evidence ACHD care we used the ADAPTE process; we systematically adjudicated, updated, and adapted existing guidelines by Canadian, American, and European cardiac societies from 2010 to 2020. We applied this to interventions related to right and left ventricular outflow obstruction, tetralogy of Fallot, coarctation, aortopathy associated with bicuspid aortic valve, atrioventricular canal defects, Ebstein anomaly, complete and congenitally corrected transposition, and patients with the Fontan operation. In addition to tables indexed to evidence, clinical flow diagrams are included for each lesion to facilitate a practical approach to clinical decision-making. Excluded are recommendations for pacemakers, defibrillators, and arrhythmia-directed interventions covered in separate designated documents. Similarly, where overlap occurs with other guidelines for valvular interventions, reference is made to parallel publications. There is a paucity of high-level quality of evidence in the form of randomized clinical trials to support guidelines in ACHD. We accounted for this in the wording of the strength of recommendations put forth by our national and international experts. As data grow on long-term follow-up, we expect that the evidence driving clinical practice will become increasingly granular. These recommendations are meant to be used to guide dialogue between clinicians, interventional cardiologists, surgeons, and patients making complex decisions relative to ACHD interventions.
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Affiliation(s)
- Ariane Marelli
- McGill University Health Centre, Montréal, Québec, Canada.
| | - Luc Beauchesne
- University of Ottawa Heart Institute, Ottawa, Ontario, Canada
| | - Jack Colman
- Toronto Adult Congenital Heart Disease Program, Division of Cardiology, Peter Munk Cardiac Centre, University Health Network, University of Toronto, Toronto, Ontario, Canada
| | - Robin Ducas
- St. Boniface General Hospital, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Jasmine Grewal
- St. Paul's Hospital, University of British Columbia, Vancouver, British Columbia, Canada
| | | | - Paul Khairy
- Montreal Heart Institute, Université de Montréal, Montréal, Québec, Canada
| | - Erwin Oechslin
- Toronto Adult Congenital Heart Disease Program, Division of Cardiology, Peter Munk Cardiac Centre, University Health Network, University of Toronto, Toronto, Ontario, Canada
| | - Judith Therrien
- Jewish General Hospital, MAUDE Unit, McGill University, Montréal, Québec, Canada
| | | | - Rachel M Wald
- Toronto Adult Congenital Heart Disease Program, Division of Cardiology, Peter Munk Cardiac Centre, University Health Network, University of Toronto, Toronto, Ontario, Canada
| | - Candice Silversides
- Toronto Adult Congenital Heart Disease Program, Division of Cardiology, Peter Munk Cardiac Centre, University Health Network, University of Toronto, Toronto, Ontario, Canada
| | | | - Lee Benson
- The Hospital for Sick Children, University Health Network, Toronto, Ontario, Canada
| | - Pierre-Luc Bernier
- McGill University Health Centre, Montreal Heart Institute, Montréal, Québec, Canada
| | - Eric Horlick
- Toronto Adult Congenital Heart Disease Program, Division of Cardiology, Peter Munk Cardiac Centre, University Health Network, University of Toronto, Toronto, Ontario, Canada
| | - Réda Ibrahim
- Montreal Heart Institute, Université de Montréal, Montréal, Québec, Canada
| | | | - Krishnakumar Nair
- Toronto Adult Congenital Heart Disease Program, Division of Cardiology, Peter Munk Cardiac Centre, University Health Network, University of Toronto, Toronto, Ontario, Canada
| | - Nancy C Poirier
- Université de Montréal, CHU-ME Ste-Justine, Institut de Cardiologie de Montréal, Montréal, Québec, Canada
| | - Heather J Ross
- Toronto Adult Congenital Heart Disease Program, Division of Cardiology, Peter Munk Cardiac Centre, University Health Network, University of Toronto, Toronto, Ontario, Canada
| | - Helmut Baumgartner
- Department of Cardiology III: Adult Congenital and Valvular Heart Disease, University Hospital Muenster, Muenster, Germany
| | - Curt J Daniels
- The Ohio State University Medical Center, Columbus, Ohio, USA
| | - Michelle Gurvitz
- Boston Adult Congenital Heart Program, Boston Children's Hospital, Boston, Massachusetts, USA
| | | | - Adrienne H Kovacs
- Department of Medicine, Oregon Health & Science University, Portland, Oregon, USA
| | | | | | | | - Gary D Webb
- Cincinnati Children's Hospital Heart Institute, Cincinnati, Ohio, USA
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Herrmann JE, Selamet Tierney ES. Exercise Capacity and Training Programs in Paediatric Fontan Patients: A Systematic Review. CJC PEDIATRIC AND CONGENITAL HEART DISEASE 2022; 1:108-118. [PMID: 37970491 PMCID: PMC10642096 DOI: 10.1016/j.cjcpc.2022.04.005] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/10/2022] [Accepted: 04/19/2022] [Indexed: 11/17/2023]
Abstract
Background Exercise training programs can effectively enhance exercise capacity in adults with congenital heart disease, including Fontan patients. However, few studies have explored the impact of exercise training exclusively on paediatric Fontan cohorts. This study systematically reviews exercise capacity in paediatric Fontan patients and the impact of training programs on their cardiovascular health. Methods Medline and Embase were searched for articles published between January 1990 and November 2021. Studies were included in which data could be analyzed discretely for patients who had undergone the Fontan procedure and were ≤20 years old at the time of study. Cardiopulmonary exercise parameters were extracted from all studies, and training protocols were collected from training programs. Results The studies demonstrated that Fontan patients exhibit significantly diminished peak exercise capacity relative to healthy peers. We identified 9 training programs that exclusively studied Fontan patients ≤20 years. The programs ranged from 6 weeks to 12 months in duration, with 8 programs incorporating aerobic activity and 1 focused only on inspiratory muscle training. At least 1 measure of maximal or submaximal exercise capacity improved significantly within each program in which statistical analysis was performed, with no reported adverse events. There were 2 additional training programs in which the patients were predominantly (>65%), but not exclusively, Fontan patients. Conclusions Overall, the results indicate that exercise training programs can safely and effectively improve at least 1 measure of exercise capacity in paediatric Fontan patients.
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Affiliation(s)
- Jessica E. Herrmann
- Department of Pediatrics/Cardiology, Stanford University School of Medicine, Stanford, California, USA
| | - Elif Seda Selamet Tierney
- Department of Pediatrics/Cardiology, Stanford University School of Medicine, Stanford, California, USA
- Division of Pediatric Cardiology, Lucile Packard Children’s Hospital, Palo Alto, California, USA
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Daley M, Buratto E, King G, Grigg L, Iyengar A, Alphonso N, Bullock A, Celermajer DS, Ayer J, Robertson T, d'Udekem Y, Konstantinov IE. Impact of Fontan Fenestration on Long-Term Outcomes: A Propensity Score-Matched Analysis. J Am Heart Assoc 2022; 11:e026087. [PMID: 35621213 PMCID: PMC9238726 DOI: 10.1161/jaha.122.026087] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background The long-term impact of fenestration at the time of Fontan operation remains unclear. We aimed to review the early and long-term impact of Fontan fenestration in the Australia and New Zealand cohort. Methods and Results We reviewed 1443 patients (621 fenestrated, 822 nonfenestrated) from the Australia and New Zealand Fontan registry. Data were collected on preoperative demographics, operative details, and follow-up. Propensity-score matching was performed to account for the various preoperative and operative differences and risk factors. Primary outcomes were survival and freedom from failure. Median follow-up was 10.6 years. After propensity-score matching (407 matched pairs), there was no difference in survival (87% versus 90% at 20 years; P=0.16) or freedom from failure (73% versus 80% at 20 years; P=0.10) between patients with and without fenestration, respectively. Although patients with fenestration had longer bypass and cross-clamp times (P<0.001), there was no difference in hospital length of stay or prolonged pleural effusions (P=0.80 and P=0.46, respectively). Freedom from systemic and Fontan circuit thromboembolism was higher in the nonfenestrated group (89%; 95% CI, 88%-95%) than the fenestrated group (84%; 95% CI, 77%-89%; P=0.03). There was no difference in incidence of plastic bronchitis, protein-losing enteropathy, New York Heart Association Class III/IV symptoms, or Fontan takedown. Conclusions In the propensity score-matched analysis we have demonstrated no difference in long-term survival or freedom from Fontan failure in patients with and without fenestration. There was a higher incidence of long-term thromboembolic events in patients with fenestration. Overall, it appears that fenestration in Fontan circulation does not bring long-term benefits.
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Affiliation(s)
- Michael Daley
- Department of Cardiac Surgery Royal Children's Hospital Melbourne Australia.,Department of Paediatrics University of Melbourne Melbourne Australia.,Heart Research Group Murdoch Children's Research Institute Melbourne Australia
| | - Edward Buratto
- Department of Cardiac Surgery Royal Children's Hospital Melbourne Australia.,Department of Paediatrics University of Melbourne Melbourne Australia.,Heart Research Group Murdoch Children's Research Institute Melbourne Australia
| | - Gregory King
- Department of Cardiac Surgery Royal Children's Hospital Melbourne Australia.,Department of Paediatrics University of Melbourne Melbourne Australia.,Heart Research Group Murdoch Children's Research Institute Melbourne Australia
| | - Leeanne Grigg
- Department of Cardiology Royal Melbourne Hospital Melbourne Australia
| | - Ajay Iyengar
- Green Lane Paediatric and Congenital Cardiac Service Starship Children's Health Auckland New Zealand.,Department of Surgery University of Auckland Auckland New Zealand
| | - Nelson Alphonso
- Department of Cardiac Surgery Queensland Children's Hospital Brisbane Australia.,Queensland Paediatric Cardiac ResearchChild Health Research CentreUniversity of Queensland Brisbane Australia
| | - Andrew Bullock
- Department of Cardiology Perth Children's Hospital Perth Australia.,Adult Congenital Cardiology Division Cardiovascular Medicine Sir Charles Gardiner Hospital Perth Australia
| | - David S Celermajer
- Department of Medicine The University of Sydney Sydney Australia.,Department of Cardiology Royal Prince Alfred Hospital Sydney Australia
| | - Julian Ayer
- The Heart Centre for Children The Children's Hospital at Westmead Sydney Australia.,Discipline of Paediatrics and Child Health The University of Sydney Sydney Australia
| | - Terry Robertson
- Department of Cardiology, Women and Children's Hospital Adelaide Australia
| | - Yves d'Udekem
- The Division of Cardiovascular Surgery Children's National Heart InstituteChildren's National Hospital Washington DC
| | - Igor E Konstantinov
- Department of Cardiac Surgery Royal Children's Hospital Melbourne Australia.,Department of Paediatrics University of Melbourne Melbourne Australia.,Heart Research Group Murdoch Children's Research Institute Melbourne Australia
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Niemann A, Rinne K, Hansen JH, Scheewe J, Uebing A, Voges I. Effect of Leisure Sports on Exercise Capacity and Quality of Life in Patients with a Fontan Circulation. Am J Cardiol 2022; 171:140-145. [PMID: 35279276 DOI: 10.1016/j.amjcard.2022.01.060] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/16/2021] [Revised: 01/18/2022] [Accepted: 01/25/2022] [Indexed: 11/01/2022]
Abstract
Despite improvement in survival, patients with a Fontan circulation are at risk for numerous complications, and exercise capacity and quality of life are usually reduced compared with healthy controls. However, only a few studies have assessed the impact of the amount of sporting activity on exercise capacity and health-related quality of life. We analyzed cardiopulmonary exercise tests (CPET) in a large cohort of patients with a Fontan circulation. Questionnaires were used to assess health-related quality of life and sporting activity. A total of 79 patients with a median age of 13.0 (6.5 to 34.4) years at CPET were included (female, n = 31). Questionnaires revealed that 80% of patients (n = 63) do leisure sports with 43% (n = 27) exercising more than 2 hours per /week. In a subgroup analysis on pediatric patients (n = 52) we found that nearly all participate in school sports (n = 51) and report good subjective health (n = 48). In the pediatric subgroup, oxygen uptake at the anaerobic threshold and peak oxygen uptake correlated with subjective health (p <0.05) and the amount of leisure sports activity (p <0.01). In the overall cohort, running time and running distance were significantly associated with the hours of sports per week (p <0.01). CPET results did not significantly differ between single right and single left ventricle patients. Furthermore, an open fenestration was not associated with reduced exercise capacity. In conclusion, most patients with a Fontan circulation participate in leisure sports and report good subjective healthiness. In pediatric patients, increased sports activity is associated with better exercise capacity and subjective healthiness.
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Hara M, Hyodo A, Kimura H, Hiraki T. Transfenestration Doppler Assessment During Laparoscopic Pheochromocytoma Resection in a Patient With Fontan Circulation. J Cardiothorac Vasc Anesth 2022; 36:3655-3661. [PMID: 35659830 DOI: 10.1053/j.jvca.2022.04.046] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/09/2022] [Revised: 04/27/2022] [Accepted: 04/29/2022] [Indexed: 11/11/2022]
Affiliation(s)
- Masato Hara
- Department of Anesthesiology, Kurume University School of Medicine, Fukuoka, Japan.
| | - Ayako Hyodo
- Department of Anesthesiology, Kurume University School of Medicine, Fukuoka, Japan
| | - Hiroko Kimura
- Department of Anesthesiology, Kurume University School of Medicine, Fukuoka, Japan
| | - Teruyuki Hiraki
- Department of Anesthesiology, Kurume University School of Medicine, Fukuoka, Japan
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11
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Şimşek B, Özyüksel A, Demiroluk Ş, Saygı M, Bilal MS. Early outcomes of fenestrated intra-extracardiac Fontan procedure: Insights, experiences, and expectations. J Card Surg 2022; 37:1301-1308. [PMID: 35226377 DOI: 10.1111/jocs.16366] [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: 11/28/2021] [Revised: 01/04/2022] [Accepted: 01/18/2022] [Indexed: 11/29/2022]
Abstract
BACKGROUND Intraextracardiac Fontan procedure (FP) aimed to combine the advantages of lateral tunnel and extracardiac conduit modifications of the original technique. Herein, we present our early outcomes in patients with intraextracardiac fenestrated FP. METHODS A retrospective analysis was performed to evaluate intraextracardiac fenestrated Fontan patients between 2014 and 2021. Seventeen patients were operated on with a mean age and body weight of 9.1 ± 5.5 years and 28.6 ± 14.6 kg. RESULTS Sixteen patients (94%) were palliated as univentricular physiology with hypoplasia of one of the ventricles. One patient (6%) with well-developed two ventricles with double outlet right ventricle and complete atrioventricular septal defect had straddling of the chordae prohibiting a biventricular repair. All of the patients had cavopulmonary anastomosis before Fontan completion, except one case. Fenestration was performed in all cases. Postoperative mean pulmonary artery pressures and arterial oxygen saturation levels at follow-up were 10 ± 2.4 mmHg and 91.3 ± 2.7%, respectively. Mean duration of pleural drainage was 5.4 ± 2.3 days. All of the fenestrations are patent at a mean follow-up period of 4.8 ± 7.7 years, except one case. Any morbidity and mortality were not encountered. CONCLUSIONS Early outcomes of intraextracardiac fenestrated FP are encouraging. This procedure may improve the results in a patient population who should be palliated as univentricular physiology, especially in cases with complex cardiac anatomy.
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Affiliation(s)
- Baran Şimşek
- Department of Cardiovascular Surgery, Medicana International Hospital, Istanbul, Turkey
| | - Arda Özyüksel
- Department of Cardiovascular Surgery, Medicana International Hospital, Istanbul, Turkey.,Department of Cardiovascular Surgery, Biruni University, Istanbul, Turkey
| | - Şener Demiroluk
- Department of Anesthesiology, Medicana International Hospital, Istanbul, Turkey
| | - Murat Saygı
- Department of Pediatric Cardiology, Medicana International Hospital, Istanbul, Turkey
| | - Mehmet S Bilal
- Department of Cardiovascular Surgery, Medicana International Hospital, Istanbul, Turkey
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12
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Dirks S, Kramer P, Schleiger A, Speck HM, Wolfarth B, Thouet T, Berger F, Sallmon H, Ovroutski S. Home-Based Long-Term Physical Endurance and Inspiratory Muscle Training for Children and Adults With Fontan Circulation—Initial Results From a Prospective Study. Front Cardiovasc Med 2022; 8:784648. [PMID: 35198605 PMCID: PMC8858796 DOI: 10.3389/fcvm.2021.784648] [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: 09/28/2021] [Accepted: 12/28/2021] [Indexed: 11/13/2022] Open
Abstract
BackgroundPatients with congenital heart disease (CHD)—including those after Fontan operation—are encouraged to be physically active.AimTo prospectively determine the effects of an individually adapted, home-based cycle ergometer endurance training in combination with inspiratory muscle training (IMT) in pediatric and adult Fontan patients. We, herein, report the results of the initial 10-months follow-up (phase 1).Methods18 patients (median age 16.5 years; range 10-43 years) completed baseline check-ups, and 4 and 10 months follow-up visits, which each included cardiopulmonary exercise testing (CPET), bodyplethysmography (including measurement of respiratory muscle strength), and a quality of life questionnaire (PedsQL™). The training program consisted of a home-based cycle ergometer endurance training on a “Magbike® AM-5i/3i” (DKN Technology®, Clermont-Ferrand, France) and IMT with a handheld “POWERbreathe® Medic plus” device. Patients performed 90 min of endurance training per week in addition to IMT (30 breaths per day, 6-7 times per week). After the first 4 months, patients underwent additional interval training.ResultsAfter 10 months of training, we observed significant increases in maximum relative workload (W/kg, p = 0.003) and in maximum inspiratory (MIP, p = 0.002) and expiratory (MEP, p = 0.008) pressures. Peak VO2 values did not increase significantly as compared to baseline (p = 0.12) in the entire cohort (n = 18), but reached statistical significance in a subgroup analysis of teenage/adult patients (n = 14; p = 0.03). Patients' subjective quality of life did not show any significant changes after 10 months of training.DiscussionIn Fontan patients, an individually adapted home-based training is safe and associated with improvements in some CPET variables. However, these improvements did not translate into an improved QoL after 10 months. With an unclear, but most likely negative, impact of the COVID-19 pandemic, improvements in QoL may become evident during further follow-up (phase 2 of the study).
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Affiliation(s)
- Stefan Dirks
- Department of Congenital Heart Disease—Pediatric Cardiology, Deutsches Herzzentrum Berlin, Berlin, Germany
| | - Peter Kramer
- Department of Congenital Heart Disease—Pediatric Cardiology, Deutsches Herzzentrum Berlin, Berlin, Germany
| | - Anastasia Schleiger
- Department of Congenital Heart Disease—Pediatric Cardiology, Deutsches Herzzentrum Berlin, Berlin, Germany
| | - Hans-Martin Speck
- Department of Congenital Heart Disease—Pediatric Cardiology, Deutsches Herzzentrum Berlin, Berlin, Germany
| | - Bernd Wolfarth
- Department of Sports Medicine, Charité—Universitätsmedizin Berlin, Berlin, Germany
| | - Thomas Thouet
- Department of Sports Medicine, Charité—Universitätsmedizin Berlin, Berlin, Germany
| | - Felix Berger
- Department of Congenital Heart Disease—Pediatric Cardiology, Deutsches Herzzentrum Berlin, Berlin, Germany
- Department of Pediatric Cardiology, Charité—Universitätsmedizin Berlin, Berlin, Germany
- German Centre for Cardiovascular Research (DZHK), Berlin, Germany
| | - Hannes Sallmon
- Department of Congenital Heart Disease—Pediatric Cardiology, Deutsches Herzzentrum Berlin, Berlin, Germany
- Department of Pediatric Cardiology, Charité—Universitätsmedizin Berlin, Berlin, Germany
| | - Stanislav Ovroutski
- Department of Congenital Heart Disease—Pediatric Cardiology, Deutsches Herzzentrum Berlin, Berlin, Germany
- *Correspondence: Stanislav Ovroutski
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13
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Ciliberti P, Ciancarella P, Bruno P, Curione D, Bordonaro V, Lisignoli V, Panebianco M, Chinali M, Secinaro A, Galletti L, Guccione P. Cardiac Imaging in Patients After Fontan Palliation: Which Test and When? Front Pediatr 2022; 10:876742. [PMID: 35652057 PMCID: PMC9149285 DOI: 10.3389/fped.2022.876742] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/15/2022] [Accepted: 04/13/2022] [Indexed: 11/13/2022] Open
Abstract
The Fontan operation represents the final stage of a series of palliative surgical procedures for children born with complex congenital heart disease, where a "usual" biventricular physiology cannot be restored. The palliation results in the direct connection of the systemic venous returns to the pulmonary arterial circulation without an interposed ventricle. In this unique physiology, systemic venous hypertension and intrathoracic pressures changes due to respiratory mechanics play the main role for propelling blood through the pulmonary vasculature. Although the Fontan operation has dramatically improved survival in patients with a single ventricle congenital heart disease, significant morbidity is still a concern. Patients with Fontan physiology are in fact suffering from a multitude of complications mainly due to the increased systemic venous pressure. Consequently, these patients need close clinical and imaging monitoring, where cardiac exams play a key role. In this article, we review the main cardiac imaging modalities available, summarizing their main strengths and limitations in this peculiar setting. The main purpose is to provide a practical approach for all clinicians involved in the care of these patients, even for those less experienced in cardiac imaging.
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Affiliation(s)
- Paolo Ciliberti
- Department of Cardiac Surgery, Cardiology, Heart and Lung Transplantation Bambino Gesu' Children's Hospital, IRCCS, Rome, Italy
| | - Paolo Ciancarella
- Advanced Cardiothoracic Imaging Unit, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
| | - Pasqualina Bruno
- Department of Cardiac Surgery, Cardiology, Heart and Lung Transplantation Bambino Gesu' Children's Hospital, IRCCS, Rome, Italy
| | - Davide Curione
- Advanced Cardiothoracic Imaging Unit, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
| | - Veronica Bordonaro
- Advanced Cardiothoracic Imaging Unit, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
| | - Veronica Lisignoli
- Department of Cardiac Surgery, Cardiology, Heart and Lung Transplantation Bambino Gesu' Children's Hospital, IRCCS, Rome, Italy
| | - Mario Panebianco
- Department of Cardiac Surgery, Cardiology, Heart and Lung Transplantation Bambino Gesu' Children's Hospital, IRCCS, Rome, Italy
| | - Marcello Chinali
- Department of Cardiac Surgery, Cardiology, Heart and Lung Transplantation Bambino Gesu' Children's Hospital, IRCCS, Rome, Italy
| | - Aurelio Secinaro
- Advanced Cardiothoracic Imaging Unit, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
| | - Lorenzo Galletti
- Department of Cardiac Surgery, Cardiology, Heart and Lung Transplantation Bambino Gesu' Children's Hospital, IRCCS, Rome, Italy
| | - Paolo Guccione
- Department of Cardiac Surgery, Cardiology, Heart and Lung Transplantation Bambino Gesu' Children's Hospital, IRCCS, Rome, Italy
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14
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Greenleaf CE, Lim ZN, Li W, LaPar DJ, Salazar JD, Corno AF. Impact on clinical outcomes from transcatheter closure of the Fontan fenestration: A systematic review and meta-analysis. Front Pediatr 2022; 10:915045. [PMID: 36268038 PMCID: PMC9576841 DOI: 10.3389/fped.2022.915045] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/07/2022] [Accepted: 08/26/2022] [Indexed: 11/25/2022] Open
Abstract
BACKGROUND Meta-analysis of the impact on clinical outcome from transcatheter closure of Fontan fenestration. METHODS Cochrane, Embase, MEDLINE, and Open-Gray were searched. Parameters such as changes in oxygen saturation, cavo-pulmonary pressure, maximum heart rate during exercise, exercise duration, and oxygen saturation after fenestration closure were pooled and statistical analysis performed. RESULTS Among 922 publications, 12 retrospective observational studies were included. The included studies involved 610 patients, of which 552 patients (90.5%) had a fenestration. Of those patients, 505 patients (91.5%) underwent attempt at trans-catheter closure. When it could be estimated, the pooled overall mean age at trans-catheter fenestration closure was 6.6 ± 7.4 years, and the mean follow-up time was 34.4 ± 10.7 months. There were 32 minor (6.3%) and 20 major (4.0%) complications during or after trans-catheter Fontan fenestration closure. The forest plots demonstrate that following fenestration closure, there was a significant increase in the mean arterial oxygen saturation of 7.9% (95% CI 6.4-9.4%, p < 0.01). There was also a significant increase in the mean cavo-pulmonary pressure of 1.4 mmHg (95% CI 1.0-1.8 mmHg, p < 0.01) following fenestration closure. The exercise parameters reported in 3 studies also favored closing the fenestration as well, yet the exercise duration increase of 1.7 min (95% CI 0.7-2.8 min, p < 0.01) after fenestration closure is probably clinically insignificant. CONCLUSION Late closure of a Fontan fenestration has the impact of improving resting oxygen saturation, exercise oxygen saturation, and a modest improvement of exercise duration. These clinical benefits, however, may be at the expense of tolerating slightly higher cavo-pulmonary mean pressures.
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Affiliation(s)
- Christopher E Greenleaf
- Pediatric and Congenital Cardiac Surgery, Children's Heart Institute, Memorial Hermann Children's Hospital, UTHealth, McGovern Medical School, Houston, TX, United States
| | - Zhia Ning Lim
- University College of London (UCL) Great Ormond Street Institute of Child Health, University College London, London, United Kingdom
| | - Wen Li
- Division of Clinical and Translational Sciences, Department of Internal Medicine, UTHealth, McGovern Medical School, Houston, TX, United States
| | - Damien J LaPar
- Pediatric and Congenital Cardiac Surgery, Children's Heart Institute, Memorial Hermann Children's Hospital, UTHealth, McGovern Medical School, Houston, TX, United States
| | - Jorge D Salazar
- Pediatric and Congenital Cardiac Surgery, Children's Heart Institute, Memorial Hermann Children's Hospital, UTHealth, McGovern Medical School, Houston, TX, United States
| | - Antonio F Corno
- Pediatric and Congenital Cardiac Surgery, Children's Heart Institute, Memorial Hermann Children's Hospital, UTHealth, McGovern Medical School, Houston, TX, United States
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15
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Becker K, Uebing A, Hansen JH. Pulmonary vascular disease in Fontan circulation-is there a rationale for pulmonary vasodilator therapies? Cardiovasc Diagn Ther 2021; 11:1111-1121. [PMID: 34527537 DOI: 10.21037/cdt-20-431] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2020] [Accepted: 06/29/2020] [Indexed: 12/21/2022]
Abstract
The Fontan circulation is a palliative concept for patients with univentricular hearts. The central veins are connected directly to the pulmonary arteries (cavo-pulmonary connection) to separate the pulmonary and the systemic circulation. There is no sub-pulmonary ventricle that generates pressure to drive blood through the pulmonary arteries. Pulmonary blood flow is determined by central venous pressure (CVP) and pulmonary vascular resistance (PVR). The capability of the Fontan circulation to compensate for alterations in PVR is limited, as CVP can only be increased within narrow ranges without adverse clinical consequences. Consequently, systemic ventricular preload and cardiac output are dependent on a healthy lung with low PVR. Failure of the Fontan circulation is relatively common. In addition to ventricular dysfunction, maladaptive pulmonary vascular remodeling resulting in increased pulmonary resistance may play a key role. The pathophysiology of the maladaptive vascular processes remains largely unclear and diagnosis of an increased PVR is challenging in Fontan circulation as accurate measurement of pulmonary arterial blood flow is difficult. In the absence of a sub-pulmonary ventricle, pulmonary artery pressure will almost never reach the threshold conventionally used to define pulmonary arterial hypertension. There is a need for markers of pulmonary vascular disease complementary to invasive hemodynamic data in Fontan patients. In order to treat or prevent failure of the Fontan circulation, pathophysiological considerations support the use of pulmonary vasodilators to augment pulmonary blood flow and systemic ventricular preload and lower CVP. However, to date the available trial data have neither yielded enough evidence to support routine use of pulmonary vasodilators in every Fontan patient nor have they been helpful in defining subgroups of patients that might benefit from such therapies. This review discusses potential pathomechanisms of pulmonary vascular disease; it summarizes the current knowledge of the effects and efficacy of pulmonary vasodilator therapy in Fontan patients and tries to outline areas of potential future research on the diagnosis and treatment of pulmonary vascular disease and Fontan failure.
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Affiliation(s)
- Kolja Becker
- Department of Congenital Heart Disease and Pediatric Cardiology, University Hospital of Schleswig-Holstein, Campus Kiel, Kiel, Germany
| | - Anselm Uebing
- Department of Congenital Heart Disease and Pediatric Cardiology, University Hospital of Schleswig-Holstein, Campus Kiel, Kiel, Germany.,DZHK (German Center for Cardiovascular Research), Partner Site Hamburg/Kiel/Lübeck, Germany
| | - Jan Hinnerk Hansen
- Department of Congenital Heart Disease and Pediatric Cardiology, University Hospital of Schleswig-Holstein, Campus Kiel, Kiel, Germany.,DZHK (German Center for Cardiovascular Research), Partner Site Hamburg/Kiel/Lübeck, Germany
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16
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Stephens EH, Talwar AA, Devlin PJ, Eltayeb O, Mongé MC, Tsao S, Backer CL. 24-Year Results of Nonfenestrated Extracardiac Fontan Including Fontan Conversions. Ann Thorac Surg 2021; 112:619-625. [DOI: 10.1016/j.athoracsur.2020.06.019] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/12/2020] [Revised: 05/12/2020] [Accepted: 06/01/2020] [Indexed: 10/23/2022]
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17
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Ozawa H, Hoashi T, Ohuchi H, Kurosaki K, Ichikawa H. Long-Term Outcomes After Fenestration Closure in High-Risk Fontan Candidates. Pediatr Cardiol 2021; 42:1356-1364. [PMID: 33881601 DOI: 10.1007/s00246-021-02619-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/09/2020] [Accepted: 04/15/2021] [Indexed: 10/21/2022]
Abstract
The study aimed to assess the long-term outcomes after fenestration closure in patients at risk for Fontan failure. Of 119 patients who underwent Fontan operation between 1995 and 2004, fenestration was not created in 89 patients (NF group) and created in 30 patients with hypoplastic left heart syndrome, heterotaxy syndrome, high pulmonary arterial pressure, high systemic ventricular end-diastolic pressure, low ventricular ejection fraction, or atrioventricular valve regurgitation. All fenestrations were closed spontaneously or by catheter/surgical interventions, excepting two patients, and therefore, they were excluded. In fenestration group, patients with pre-Fontan mean pulmonary arterial pressure ≥ 15 mmHg or systemic atrioventricular valve regurgitation ≥ moderate were classified as high-risk Fontan candidates (F-HR group, n = 16), and the remaining patients were as standard-risk (F-SR group, n = 12). Protein-losing enteropathy-free survival rates did not differ among the three groups (p = 0.72). Serial follow-up catheter examinations after Fontan operation were completed in 69 patients in NF group and 11 patients in both F-SR and F-HR groups. Cardiac index and pulmonary vascular resistance significantly and similarly decreased over time in all groups, though the F-HR group showed lowest arterial oxygen saturation, lowest cardiac index, and highest pulmonary vascular resistance. The F-HR group also showed much veno-venous collaterals (p = 0.049), low peak oxygen consumption (p = 0.019), and low anaerobic threshold (p = 0.023) as compared to those in the F-SR group. In F-HR group, cyanosis remained after fenestration closure due to transformation from fenestration to veno-venous collaterals, which resulted in elevation of pulmonary vascular resistance, low cardiac index, and deterioration of exercise tolerance.
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Affiliation(s)
- Hideto Ozawa
- Department of Pediatric Cardiovascular Surgery, National Cerebral and Cardiovascular Center, 6-1 Kishibe-Shimmachi, Suita, Osaka, 564-8565, Japan
| | - Takaya Hoashi
- Department of Pediatric Cardiovascular Surgery, National Cerebral and Cardiovascular Center, 6-1 Kishibe-Shimmachi, Suita, Osaka, 564-8565, Japan.
| | - Hideo Ohuchi
- Department of Pediatric Cardiology, National Cerebral and Cardiovascular Center, Suita, Japan
| | - Kenichi Kurosaki
- Department of Pediatric Cardiology, National Cerebral and Cardiovascular Center, Suita, Japan
| | - Hajime Ichikawa
- Department of Pediatric Cardiovascular Surgery, National Cerebral and Cardiovascular Center, 6-1 Kishibe-Shimmachi, Suita, Osaka, 564-8565, Japan
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18
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Dagan T, Bruckheimer E, Amir G, Frenkel G, Levinson M, Lowenthal A, Birk E. The effects of oral pulmonary vasodilator therapy on poor candidates for fenestration closure in patients with a fontan circulation. INTERNATIONAL JOURNAL OF CARDIOLOGY CONGENITAL HEART DISEASE 2021. [DOI: 10.1016/j.ijcchd.2021.100090] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022] Open
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19
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Tran DL, Gibson H, Maiorana AJ, Verrall CE, Baker DW, Clode M, Lubans DR, Zannino D, Bullock A, Ferrie S, Briody J, Simm P, Wijesekera V, D'Almeida M, Gosbell SE, Davis GM, Weintraub R, Keech AC, Puranik R, Ugander M, Justo R, Zentner D, Majumdar A, Grigg L, Coombes JS, d'Udekem Y, Morris NR, Ayer J, Celermajer DS, Cordina R. Exercise Intolerance, Benefits, and Prescription for People Living With a Fontan Circulation: The Fontan Fitness Intervention Trial (F-FIT)-Rationale and Design. Front Pediatr 2021; 9:799125. [PMID: 35071139 PMCID: PMC8771702 DOI: 10.3389/fped.2021.799125] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/21/2021] [Accepted: 12/07/2021] [Indexed: 12/16/2022] Open
Abstract
Background: Despite developments in surgical techniques and medical care, people with a Fontan circulation still experience long-term complications; non-invasive therapies to optimize the circulation have not been established. Exercise intolerance affects the majority of the population and is associated with worse prognosis. Historically, people living with a Fontan circulation were advised to avoid physical activity, but a small number of heterogenous, predominantly uncontrolled studies have shown that exercise training is safe-and for unique reasons, may even be of heightened importance in the setting of Fontan physiology. The mechanisms underlying improvements in aerobic exercise capacity and the effects of exercise training on circulatory and end-organ function remain incompletely understood. Furthermore, the optimal methods of exercise prescription are poorly characterized. This highlights the need for large, well-designed, multi-center, randomized, controlled trials. Aims and Methods: The Fontan Fitness Intervention Trial (F-FIT)-a phase III clinical trial-aims to optimize exercise prescription and delivery in people with a Fontan circulation. In this multi-center, randomized, controlled study, eligible Fontan participants will be randomized to either a 4-month supervised aerobic and resistance exercise training program of moderate-to-vigorous intensity followed by an 8-month maintenance phase; or usual care (control group). Adolescent and adult (≥16 years) Fontan participants will be randomized to either traditional face-to-face exercise training, telehealth exercise training, or usual care in a three-arm trial with an allocation of 2:2:1 (traditional:telehealth:control). Children (<16 years) will be randomized to either a physical activity and exercise program of moderate-to-vigorous intensity or usual care in a two-arm trial with a 1:1 allocation. The primary outcome is a change in aerobic exercise capacity (peak oxygen uptake) at 4-months. Secondary outcomes include safety, and changes in cardiopulmonary exercise testing measures, peripheral venous pressure, respiratory muscle and lung function, body composition, liver stiffness, neuropsychological and neurocognitive function, physical activity levels, dietary and nutritional status, vascular function, neurohormonal activation, metabolites, cardiac function, quality of life, musculoskeletal fitness, and health care utilization. Outcome measures will be assessed at baseline, 4-months, and 12-months. This manuscript will describe the pathophysiology of exercise intolerance in the Fontan circulation and the rationale and protocol for the F-FIT.
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Affiliation(s)
- Derek L Tran
- Department of Cardiology, Royal Prince Alfred Hospital, Sydney, NSW, Australia.,Central Clinical School, The University of Sydney School of Medicine, Sydney, NSW, Australia.,Charles Perkins Centre, Heart Research Institute, Sydney, NSW, Australia.,Faculty of Medicine and Health, The University of Sydney, Sydney, NSW, Australia
| | - Hannah Gibson
- Charles Perkins Centre, Heart Research Institute, Sydney, NSW, Australia
| | - Andrew J Maiorana
- School of Allied Health, Curtin University, Perth, WA, Australia.,Allied Health Department, Fiona Stanley Hospital, Perth, WA, Australia
| | - Charlotte E Verrall
- The University of Sydney Westmead Clinical School, Sydney, NSW, Australia.,Heart Centre for Children, The Children's Hospital at Westmead, Sydney, NSW, Australia
| | - David W Baker
- Department of Cardiology, Royal Prince Alfred Hospital, Sydney, NSW, Australia.,Central Clinical School, The University of Sydney School of Medicine, Sydney, NSW, Australia
| | - Melanie Clode
- Heart Research Group, Murdoch Children's Research Institute, Melbourne, VIC, Australia
| | - David R Lubans
- School of Education, Priority Research Centre for Physical Activity and Nutrition, The University of Newcastle, Newcastle, NSW, Australia
| | - Diana Zannino
- Heart Research Group, Murdoch Children's Research Institute, Melbourne, VIC, Australia
| | - Andrew Bullock
- Paediatric and Adult Congenital Cardiology, Perth Children's Hospital, Perth, WA, Australia
| | - Suzie Ferrie
- Department of Nutrition and Dietetics, Royal Prince Alfred Hospital, Sydney, NSW, Australia
| | - Julie Briody
- Department of Nuclear Medicine, The Children's Hospital at Westmead, Sydney, NSW, Australia
| | - Peter Simm
- Heart Research Group, Murdoch Children's Research Institute, Melbourne, VIC, Australia
| | - Vishva Wijesekera
- Department of Cardiology, The Prince Charles Hospital, Brisbane, QLD, Australia
| | - Michelle D'Almeida
- Charles Perkins Centre, Heart Research Institute, Sydney, NSW, Australia
| | - Sally E Gosbell
- Central Clinical School, The University of Sydney School of Medicine, Sydney, NSW, Australia.,Charles Perkins Centre, Heart Research Institute, Sydney, NSW, Australia.,Heart Centre for Children, The Children's Hospital at Westmead, Sydney, NSW, Australia
| | - Glen M Davis
- Faculty of Medicine and Health, The University of Sydney, Sydney, NSW, Australia
| | - Robert Weintraub
- Heart Research Group, Murdoch Children's Research Institute, Melbourne, VIC, Australia.,Department of Cardiology, The Royal Children's Hospital, Melbourne, VIC, Australia
| | - Anthony C Keech
- Department of Cardiology, Royal Prince Alfred Hospital, Sydney, NSW, Australia.,Central Clinical School, The University of Sydney School of Medicine, Sydney, NSW, Australia.,NHMRC Clinical Trials Centre, The University of Sydney, Sydney, NSW, Australia
| | - Rajesh Puranik
- Department of Cardiology, Royal Prince Alfred Hospital, Sydney, NSW, Australia.,Central Clinical School, The University of Sydney School of Medicine, Sydney, NSW, Australia
| | - Martin Ugander
- Royal North Shore Hospital, The Kolling Institute, Sydney, NSW, Australia
| | - Robert Justo
- Paediatric Cardiac Service, Queensland Children's Hospital, Brisbane, QLD, Australia
| | - Dominica Zentner
- The University of Melbourne Medical School, Melbourne, VIC, Australia.,Department of Cardiology, The Royal Melbourne Hospital, Melbourne, VIC, Australia
| | - Avik Majumdar
- Central Clinical School, The University of Sydney School of Medicine, Sydney, NSW, Australia.,Australian National Liver Transplant Unit, AW Morrow Gastroenterology and Liver Centre, Royal Prince Alfred Hospital, Camperdown, NSW, Australia
| | - Leeanne Grigg
- The University of Melbourne Medical School, Melbourne, VIC, Australia.,Department of Cardiology, The Royal Melbourne Hospital, Melbourne, VIC, Australia
| | - Jeff S Coombes
- School of Human Movement and Nutrition Sciences, Centre for Research on Exercise, Physical Activity, and Health, The University of Queensland, Brisbane, QLD, Australia
| | - Yves d'Udekem
- Division of Cardiac Surgery, Children's National Hospital, Washington, DC, United States
| | - Norman R Morris
- Allied Health Collaborative and Queensland Lung Transplant Service, The Prince Charles Hospital, Brisbane, QLD, Australia.,School of Health Sciences and Social Work, Griffith University, Gold Coast, QLD, Australia
| | - Julian Ayer
- The University of Sydney Westmead Clinical School, Sydney, NSW, Australia.,Heart Centre for Children, The Children's Hospital at Westmead, Sydney, NSW, Australia
| | - David S Celermajer
- Department of Cardiology, Royal Prince Alfred Hospital, Sydney, NSW, Australia.,Central Clinical School, The University of Sydney School of Medicine, Sydney, NSW, Australia.,Charles Perkins Centre, Heart Research Institute, Sydney, NSW, Australia
| | - Rachael Cordina
- Department of Cardiology, Royal Prince Alfred Hospital, Sydney, NSW, Australia.,Central Clinical School, The University of Sydney School of Medicine, Sydney, NSW, Australia.,Charles Perkins Centre, Heart Research Institute, Sydney, NSW, Australia.,Heart Research Group, Murdoch Children's Research Institute, Melbourne, VIC, Australia
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20
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Toncu A, Rădulescu CR, Dorobanţu D, Stoica Ș. Does routine fenestration improve early and late postoperative outcomes in patients undergoing Fontan palliation? Interact Cardiovasc Thorac Surg 2020; 30:773-779. [PMID: 32243525 DOI: 10.1093/icvts/ivaa002] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2019] [Revised: 11/28/2019] [Accepted: 01/06/2020] [Indexed: 11/13/2022] Open
Abstract
A best evidence topic in cardiac surgery was written according to a structured protocol. The question addressed was: 'In [patients undergoing Fontan palliation] does [fenestration] affect [early and late postoperative outcomes]?' Altogether 509 papers were found using the reported search, of which 11 papers represented the best evidence to answer the clinical question. The authors, journal, date and country of publication, patient group studied, study type, relevant outcomes and results of these papers are tabulated. Current data suggest that the use of fenestration has advantages in the immediate postoperative course, with fewer complications such as pleural effusions, shorter hospitalization and decreased early Fontan failure, but comparable long-term outcomes to a non-fenestrated approach. Fenestration should be used in high-risk patients or based on the haemodynamic parameters measured before weaning from cardiopulmonary bypass. Routine use may potentially lead to additional late fenestration closure procedures in some patients, without improving long-term outcomes.
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Affiliation(s)
- Alexandra Toncu
- Department of Cardiac Surgery, Bristol Royal Hospital for Children, Bristol, UK
| | - Cristina Ramona Rădulescu
- Department of Adult Congenital Heart Disease, Bristol Heart Institute, Bristol, UK.,Department of Pediatric Cardiology, Bristol Royal Hospital for Children, Bristol, UK.,Department of Pediatrics, "Carol Davila" University of Medicine and Pharmacy, Bucharest, Romania
| | - Dan Dorobanţu
- University of Exeter, College of Life and Environmental Sciences, Exeter, UK.,Department of Cardiology, Bristol Royal Hospital for Children, Bristol, UK
| | - Șerban Stoica
- Department of Cardiac Surgery, Bristol Royal Hospital for Children, Bristol, UK.,Department of Adult Congenital Heart Disease, Bristol Heart Institute, Bristol, UK
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Thatte N, Dimas V, Nugent A, Zellers T, Forbess J, Zabala L, Zhang S, Veeram Reddy SR. Use of institutional criteria for transcatheter device closure of Fontan fenestration - Midterm outcomes. Ann Pediatr Cardiol 2020; 13:327-333. [PMID: 33311921 PMCID: PMC7727914 DOI: 10.4103/apc.apc_154_19] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/08/2020] [Revised: 03/25/2020] [Accepted: 07/23/2020] [Indexed: 11/06/2022] Open
Abstract
Background: There are no established criteria to decide suitability for Fontan fenestration closure. Our institution has the following criteria: an unobstructed Fontan pathway with no significant decompressing venovenous collaterals, baseline Fontan pressure ≤15 mmHg, baseline cardiac index ≥2 L/min/m2, and a decrease in cardiac index ≤20% with test occlusion of the fenestration. Objective: The objective of the study was to review midterm outcomes following device closure of Fontan fenestration using institutional criteria. Materials and Methods: A retrospective review was performed of patients who underwent catheterization with prior fenestrated Fontan procedure between May 2005 and January 2015. Patients were classified as those who underwent successful closure (A), had closure deferred due to failure to meet criteria (B), or were not referred for closure (C). Results: There were 42 patients in Group A, 10 in Group B, and 150 in Group C. The mean Fontan pressure increased from 13.1 ± 2.1 to 14.5 ± 2.1mmHg in Group A and 14.6 ± 1.5 to 15.7 ± 2.2 mmHg in Group B (P = not significant). With test occlusion, cardiac index fell by 18.12% ± 15.68% in Group A and 33.75% ± 14.98% in Group B (P = 0.019). At a median of 46 month follow-up, oxygen saturation increased significantly from 85.15% ± 6.29% at baseline to 94.6% ± 4.43% (P < 0.001) in Group A but with no statistically significant difference in the rates of plastic bronchitis, protein-losing enteropathy, stroke, or heart transplantation between the three groups. Conclusions: Using institutional criteria, transcatheter device closure of Fontan fenestration was followed by significant increase in oxygen saturations and no statistically significant difference in morbidity or mortality between closure and nonclosure groups.
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Affiliation(s)
- Nikhil Thatte
- Department of Cardiology, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Vivian Dimas
- Department of Pediatrics, Children's Medical Center, University of Texas Southwestern, Dallas, Texas, USA
| | - Alan Nugent
- Department of Pediatrics, Ann and Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Thomas Zellers
- Department of Pediatrics, Children's Medical Center, University of Texas Southwestern, Dallas, Texas, USA
| | - Joseph Forbess
- Department of Surgery, Ann and Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Luis Zabala
- Department of Anesthesiology and Pain Management, Children's Medical Center, University of Texas Southwestern, Dallas, Texas, USA
| | - Song Zhang
- Department of Population and Data Sciences, University of Texas Southwestern, Dallas, Texas, USA
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22
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Bouhout I, Ben-Ali W, Khalaf D, Raboisson MJ, Poirier N. Effect of Fenestration on Fontan Procedure Outcomes: A Meta-Analysis and Review. Ann Thorac Surg 2020; 109:1467-1474. [DOI: 10.1016/j.athoracsur.2019.12.020] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/07/2019] [Revised: 12/04/2019] [Accepted: 12/09/2019] [Indexed: 11/16/2022]
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23
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Extracardiac Fontan Fenestration Device Closure with Amplatzer Vascular Plug II and Septal Occluder: Procedure Results and Medium-Term Follow-Up. Pediatr Cardiol 2020; 41:703-708. [PMID: 31894396 DOI: 10.1007/s00246-019-02283-0] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/17/2019] [Accepted: 12/18/2019] [Indexed: 10/25/2022]
Abstract
The objective of this study was to determine medium-term morbidity and mortality of patients who have undergone device closure of an extracardiac Fontan fenestration with an Amplatzer Vascular Plug II (AVPII) or Septal Occluder (ASO). A secondary objective was to compare medium-term morbidity and mortality between these patients and other fenestrated Fontan patients. A retrospective chart review was performed on patients who underwent an extracardiac fenestrated Fontan procedure between 1992 and 2015 at Cardinal Glennon Children's Medical Center. Procedural and follow-up data were obtained and compared between those who underwent fenestration closure and those who did not. Additional outcome measures included whether the fenestration had spontaneously closed, morbidity and mortality, oxygen saturations, and hemodynamics pre- and post-closure. Fifty-nine of 118 patients (50%) with a fenestrated Fontan underwent 60 device closures of the fenestration. Thirty-two (53%) of these were with the AVPII and 28 (47%) with the ASO. There was one device embolization. At a median follow-up of 3.9 years, five patients suffered morbidity, including 2 with arrhythmias, 1 with plastic bronchitis, 1 with protein losing enteropathy, and 1 with stroke. There were no cardiopulmonary deaths in this group. Twenty-three of 118 patients (19%) had spontaneous closure. There was no difference in morbidity and mortality between patients who underwent percutaneous fenestration closure and those who either had spontaneous closure or a persistently patent fenestration. Device closure of Fontan fenestrations is a safe and effective procedure with minimal morbidity and mortality comparable to other patients with fenestrations.
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24
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Marshall KH, D'Udekem Y, Sholler GF, Opotowsky AR, Costa DSJ, Sharpe L, Celermajer DS, Winlaw DS, Newburger JW, Kasparian NA. Health-Related Quality of Life in Children, Adolescents, and Adults With a Fontan Circulation: A Meta-Analysis. J Am Heart Assoc 2020; 9:e014172. [PMID: 32172648 PMCID: PMC7335513 DOI: 10.1161/jaha.119.014172] [Citation(s) in RCA: 36] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background People with a Fontan circulation experience a range of physical, psychosocial and neurodevelopmental challenges alongside, or caused by, their cardiac condition, with significant consequences for health‐related quality of life (HRQOL). We meta‐analyzed HRQOL outcomes reported by people with a Fontan circulation or their proxies and evaluated predictors of poorer HRQOL. Methods and Results Six electronic databases were searched for peer‐reviewed, English‐language articles published before March 2019. Standardized mean differences (SMD) were calculated using fixed and random‐effects models. Fifty articles reporting on 29 unique studies capturing HRQOL outcomes for 2793 people with a Fontan circulation and 1437 parent‐proxies were analyzed. HRQOL was lower in individuals with a Fontan circulation compared with healthy referents or normative samples (SMD, −0.92; 95% CI, −1.36 to −0.48; P<0.001). Lower scores were reported across all HRQOL domains, with the largest differences found for physical (SMD, −0.90; 95% CI, −1.13 to −0.67; P<0.001) and school/work functioning (SMD, −0.71; 95% CI, −0.90 to −0.52; P<0.001). Meta‐regression analyses found no significant predictors of self‐reported physical functioning, but older age at Fontan operation was associated with poorer emotional functioning (β=−0.124; P=0.004), and diagnosis of hypoplastic left heart was associated with poorer social functioning (β=−0.007; P=0.048). Sensitivity analyses showed use of the PedsQL Core Module was associated with lower HRQOL scores compared with the Short‐Form Health Survey‐36. Conclusions HRQOL outcomes for people with a Fontan circulation are lower than the general population. Optimal care acknowledges the lifelong impact of the Fontan circulation on HRQOL and offers targeted strategies to improve outcomes for this growing population.
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Affiliation(s)
- Kate H Marshall
- Heart Centre for Children The Children's Hospital at Westmead Sydney New South Wales Australia.,Discipline of Paediatrics School of Women's and Children's Health University of New South Wales Medicine The University of New South Wales Sydney New South Wales Australia
| | - Yves D'Udekem
- Heart Research Group Murdoch Children's Research Institute Melbourne Victoria Australia.,Department of Cardiac Surgery The Royal Children's Hospital Melbourne Victoria Australia
| | - Gary F Sholler
- Heart Centre for Children The Children's Hospital at Westmead Sydney New South Wales Australia.,Sydney Medical School The University of Sydney New South Wales Australia
| | - Alexander R Opotowsky
- Department of Pediatrics University of Cincinnati College of Medicine Cincinnati Ohio United States.,Cincinnati Adult Congenital Heart Disease Program Heart Institute Cincinnati Children's Hospital Cincinnati Ohio United States.,Department of Cardiology Boston Children's Hospital Boston Massachusetts United States.,Harvard Medical School Boston Massachusetts United States
| | - Daniel S J Costa
- Sydney Medical School The University of Sydney New South Wales Australia.,Pain Management Research Institute Royal North Shore Hospital Sydney New South Wales Australia
| | - Louise Sharpe
- School of Psychology The University of Sydney New South Wales Australia
| | - David S Celermajer
- Sydney Medical School The University of Sydney New South Wales Australia.,Department of Cardiology Royal Prince Alfred Hospital Sydney New South Wales Australia
| | - David S Winlaw
- Heart Centre for Children The Children's Hospital at Westmead Sydney New South Wales Australia.,Sydney Medical School The University of Sydney New South Wales Australia
| | - Jane W Newburger
- Department of Cardiology Boston Children's Hospital Boston Massachusetts United States.,Harvard Medical School Boston Massachusetts United States
| | - Nadine A Kasparian
- Heart Centre for Children The Children's Hospital at Westmead Sydney New South Wales Australia.,Discipline of Paediatrics School of Women's and Children's Health University of New South Wales Medicine The University of New South Wales Sydney New South Wales Australia.,Department of Pediatrics University of Cincinnati College of Medicine Cincinnati Ohio United States.,Cincinnati Children's Center for Heart Disease and the Developing Mind Heart Institute and Division of Behavioral Medicine & Clinical Psychology Cincinnati Children's Hospital Cincinnati Ohio United States
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25
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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: 234] [Impact Index Per Article: 58.5] [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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Zentner D, Celermajer DS, Gentles T, d’Udekem Y, Ayer J, Blue GM, Bridgman C, Burchill L, Cheung M, Cordina R, Culnane E, Davis A, du Plessis K, Eagleson K, Finucane K, Frank B, Greenway S, Grigg L, Hardikar W, Hornung T, Hynson J, Iyengar AJ, James P, Justo R, Kalman J, Kasparian N, Le B, Marshall K, Mathew J, McGiffin D, McGuire M, Monagle P, Moore B, Neilsen J, O’Connor B, O’Donnell C, Pflaumer A, Rice K, Sholler G, Skinner JR, Sood S, Ward J, Weintraub R, Wilson T, Wilson W, Winlaw D, Wood A. Management of People With a Fontan Circulation: a Cardiac Society of Australia and New Zealand Position statement. Heart Lung Circ 2020; 29:5-39. [DOI: 10.1016/j.hlc.2019.09.010] [Citation(s) in RCA: 24] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2019] [Accepted: 09/16/2019] [Indexed: 02/07/2023]
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Daley M, du Plessis K, Zannino D, Hornung T, Disney P, Cordina R, Grigg L, Radford DJ, Bullock A, d'Udekem Y. Reintervention and survival in 1428 patients in the Australian and New Zealand Fontan Registry. Heart 2019; 106:751-757. [DOI: 10.1136/heartjnl-2019-315430] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/18/2019] [Revised: 09/27/2019] [Accepted: 10/08/2019] [Indexed: 11/03/2022] Open
Abstract
ObjectivePatients undergoing single-ventricle palliation have experienced significant improvement in survival in the recent era. However, a substantial proportion of these patients undergo reoperations. We performed a review of the Australia and New Zealand (ANZ) Fontan Registry to determine the overall reintervention and reoperative burden in these patients.MethodsA retrospective longitudinal cohort study was performed using data from patients who underwent a Fontan operation between 1975 and 2016 from the ANZ Fontan Registry. The data obtained included Fontan operation, reinterventions and most recent follow-up status. We examined the type and timing of reinterventions and survival.ResultsOf the 1428 patients identified, 435 (30%) underwent at least one reintervention after the Fontan operation: 110 patients underwent early reintervention and 413 underwent late reinterventions. Excluding Fontan conversion and transplantation, 220 patients underwent at least one interventional procedure and 209 patients underwent at least one reoperation. Fenestration closure and pacemaker-related procedures were the most common catheter and surgical interventions, respectively. The cumulative incidence of reintervention following Fontan was 23%, 37% and 55% at 10, 20 and 30 years, respectively. Survival and freedom from failure were worse in patients requiring later reintervention after Fontan surgery (51% vs 83% and 42% vs 69%, respectively at 30 years, p<0.001). This difference persisted after excluding pacemaker-related procedures (p<0.001). Operative mortality for non-pacemaker late reoperations after Fontan was 6%.ConclusionsA substantial proportion of Fontan patients require further intervention to maintain effective single-ventricle circulation. Patients undergoing reoperation after Fontan have higher rates of mortality and failure, despite intervention.
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Abstract
BACKGROUND The benefits of fenestration for patients undergoing Fontan procedure seem controversial at early and late postoperative stages. OBJECTIVE We aimed to compare the outcomes between the fenestrated and non-fenestrated Fontan procedures. METHODS Studies comparing the fenestrated and non-fenestrated Fontan procedures were identified by searching the PubMed, EMBASE, and Cochrane Library databases until July 2018. The assessed variables included postoperative oxygen saturation (SaO2), pulmonary artery pressure, mortality, cardiopulmonary bypass (CPB) time, ventilation time, intensive care unit stay, hospital stay, chest tube duration, protein-losing enteropathy, arrhythmia, and other follow-up outcomes including reintervention, stroke/thrombosis, and peak oxygen consumption. A random-effect/fixed-effect model was used to summarize the estimates of the mean difference (MD)/odds ratio (OR) with 95% confidence interval (CI). Subgroup analysis stratified by early and late outcomes was performed. RESULTS A total of 1929 Fontan patients from 14 studies were included. The early postoperative SaO2 was lower with fenestration than without fenestration (MD -2.52, 95% CI -4.16 to -0.87, P <.05); however, the late postoperative SaO2 showed no difference between the 2 approaches. The CPB time was shorter without fenestration than with fenestration (MD 10.72, 95% CI 2.54-18.9, P <.05); however, the incidence of arrhythmia was lower with fenestration than without fenestration (OR 0.43, 95% CI 0.25-0.75, P <.05). Other variables showed no significant differences between the 2 approaches in Fontan patients. CONCLUSION Fenestration appears to result in a lower incidence of arrhythmia but with a longer CPB time and lower early SaO2. Other outcomes are comparable between the 2 approaches.
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Affiliation(s)
- Dongxu Li
- Department of Cardiovascular Surgery
| | - Mengsi Li
- Department of Anesthesiology, West China Hospital, Sichuan University, Chengdu, Sichuan
| | - Xu Zhou
- Evidence-based Medicine Research Center, School of Basic Medical Sciences, Jiangxi University of Traditional Chinese Medicine, Jiangxi, China
| | - Qi An
- Department of Cardiovascular Surgery
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Hill GD, Ghanayem NS, Hraska V, Jacobsen RM, Mitchell ME, Woods RK, Ginde S. Variation in the use of Fontan fenestration in the current surgical era. PROGRESS IN PEDIATRIC CARDIOLOGY 2019. [DOI: 10.1016/j.ppedcard.2018.08.007] [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: 10/28/2022]
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30
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Management of Stroke in Neonates and Children: A Scientific Statement From the American Heart Association/American Stroke Association. Stroke 2019; 50:e51-e96. [DOI: 10.1161/str.0000000000000183] [Citation(s) in RCA: 240] [Impact Index Per Article: 48.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
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31
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32
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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: 503] [Impact Index Per Article: 83.8] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
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33
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Smaś-Suska M, Róg B, Weryński P, Płazak W, Komar M, Olszowska M, Podolec P, Tomkiewicz-Pająk L. Long-Term Effects of Percutaneous Fenestration Following the Fontan Procedure in Adult Patients with Congenital Univentricular Heart. Med Sci Monit 2018; 24:3506-3513. [PMID: 29802801 PMCID: PMC5996839 DOI: 10.12659/msm.905786] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
Abstract
Background The Fontan procedure, performed for univentricular heart, may also include the technique of percutaneous fenestration to create a small atrial septal defect (ASD) and a right-to-left shunt. The aim of this study was to evaluate the long-term effects of fenestration in adult patients who had a Fontan procedure for univentricular heart. Material/Methods Fontan surgery was performed in 39 patients, including 19 (49%) patients with fenestration (Group I), and 20 (51%) patients without the fenestration procedure (Group II). Laboratory tests in both groups included echocardiography, plethysmography, cardiopulmonary exercise testing, and 24-hour Holter monitoring. Results Compared with patients in Group I, patients in Group II had a significantly increased level of N-terminal pro-brain natriuretic peptide (NT-proBNP) (p=0.04), alkaline phosphatase (ALP) (p=0.01) and a significant increase in frequency of atrial fibrillation (p=0.04). Patients in Group I had a significantly increased systemic ventricular ejection fraction (SVEF) (p=0.05) and increased heart rate (HR) (p=0.006), heart rate reserve (HRR) (p=0.02), ventilatory equivalent (VE) (p=0.01), and VO2 peak (p=0.05) on cardiopulmonary exercise testing (CPET). Renal, hematologic, and ventilatory parameters, and incidence of thromboembolism showed no significant differences between the groups. Conclusions Long-term follow-up of patients who underwent Fontan procedures with percutaneous fenestration had improved single ventricular function, lower NT-proBNP levels, improved exercise capacity, and reduced ALP levels. These findings indicate that percutaneous fenestration closure should be considered for adult patients who have undergone Fontan procedure for univentricular heart.
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Affiliation(s)
- Monika Smaś-Suska
- Departament of Cardiac and Vascular Diseases, Institute of Cardiology, Jagiellonian University Medical College, Cracow, Poland
| | - Beata Róg
- Outpatient Department of Cardiology and Cardiac Surgery, Institute of Cardiology, Jagiellonian University Medical College, Cracow, Poland
| | - Piotr Weryński
- Department of Pediatric Cardiology, Polish-American Institute of Pediatrics (PAIP), Jagiellonian University, Medical College, Cracow, Poland
| | - Wojciech Płazak
- Departament of Cardiac and Vascular Diseases, Institute of Cardiology, Jagiellonian University Medical College, Cracow, Poland
| | - Monika Komar
- Departament of Cardiac and Vascular Diseases, Institute of Cardiology, Jagiellonian University Medical College, Cracow, Poland
| | - Maria Olszowska
- Departament of Cardiac and Vascular Diseases, Institute of Cardiology, Jagiellonian University Medical College, Cracow, Poland
| | - Piotr Podolec
- Departament of Cardiac and Vascular Diseases, Institute of Cardiology, Jagiellonian University Medical College, Cracow, Poland
| | - Lidia Tomkiewicz-Pająk
- Departament of Cardiac and Vascular Diseases, Institute of Cardiology, Jagiellonian University Medical College, Cracow, Poland
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Peer SM, Deatrick KB, Johnson TJ, Haft JW, Pagani FD, Ohye RG, Bove EL, Rojas-Peña A, Si MS. Mechanical Circulatory Support for the Failing Fontan: Conversion to Assisted Single Ventricle Circulation—Preliminary Observations. World J Pediatr Congenit Heart Surg 2018; 9:31-37. [DOI: 10.1177/2150135117733968] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
Background: Mechanical circulatory support (MCS) of a failing Fontan circulation remains challenging. We hypothesized that MCS can be provided by converting the Fontan circulation into a mechanically assisted single ventricle parallel circulation (MASVC). Methods: A porcine model of functionally univentricular circulation was created under cardiopulmonary bypass (CPB) by performing an atrial septectomy, tricuspid valvectomy, and interrupting antegrade pulmonary blood flow. A centrifugal flow pump was placed with inflow from the common atrium. Eight millimeter Dacron grafts anastomosed to the ascending aorta and main pulmonary artery supplied systemic (Qs) and pulmonary (Qp) blood flow. Ultrasonic flow probes were used to measure Qs and Qp after weaning from CPB. The Qp/Qs ratio was regulated using an adjustable clamp. Hemodynamic and laboratory data were recorded. Results: All four animals were successfully weaned from CPB onto the MASVC for a duration of two hours. Mechanically assisted single ventricle parallel circulation achieved satisfactory hemodynamics. As anticipated, the arterial oxygen saturation and partial pressure of oxygen in arterial blood were lower in the MASVC compared to baseline biventricular circulation. At the conclusion of the study, there was a trend towards a decrease in the mixed venous saturation with increasing oxygen extraction compared to the baseline. Serum lactate levels increased after weaning from CPB and did not return to baseline after two hours of support. Conclusion: Mechanically assisted single ventricle parallel circulation can be established in a single ventricle animal model. This strategy could potentially provide MCS of a single ventricle circulation. Studies with longer duration of support are required to assess adequacy of support and long-term sustainability.
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Affiliation(s)
- Syed M. Peer
- Department of Cardiac Surgery, University of Michigan Medical School, Ann Arbor, MI, USA
- Department of Pediatric Cardiac Surgery, University of Minnesota, Minneapolis, MN, USA
| | - Kristopher B. Deatrick
- Department of Cardiac Surgery, University of Michigan Medical School, Ann Arbor, MI, USA
| | - Thomas J. Johnson
- Department of Surgery-Section of Transplantation, ECMO Laboratory, University of Michigan Medical School, Ann Arbor, MI, USA
| | - Jonathan W. Haft
- Department of Cardiac Surgery, University of Michigan Medical School, Ann Arbor, MI, USA
| | - Francis D. Pagani
- Department of Cardiac Surgery, University of Michigan Medical School, Ann Arbor, MI, USA
| | - Richard G. Ohye
- Department of Cardiac Surgery, University of Michigan Medical School, Ann Arbor, MI, USA
| | - Edward L. Bove
- Department of Cardiac Surgery, University of Michigan Medical School, Ann Arbor, MI, USA
| | - Alvaro Rojas-Peña
- Department of Surgery-Section of Transplantation, ECMO Laboratory, University of Michigan Medical School, Ann Arbor, MI, USA
| | - Ming-Sing Si
- Department of Cardiac Surgery, University of Michigan Medical School, Ann Arbor, MI, USA
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Lo Rito M, Al-Radi OO, Saedi A, Kotani Y, Ben Sivarajan V, Russell JL, Caldarone CA, Van Arsdell GS, Honjo O. Chylothorax and pleural effusion in contemporary extracardiac fenestrated fontan completion. J Thorac Cardiovasc Surg 2017; 155:2069-2077. [PMID: 29249497 DOI: 10.1016/j.jtcvs.2017.11.046] [Citation(s) in RCA: 30] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/24/2017] [Revised: 10/27/2017] [Accepted: 11/11/2017] [Indexed: 11/29/2022]
Abstract
BACKGROUND We hypothesized that chylothorax could be a sign of intolerance to the Fontan physiology, and thus patients who develop chylothorax or pleural effusion have worse medium-term to long-term survival. METHODS A total of 324 patients who underwent the Fontan operation between 2000 and 2013 were included. Chylothorax was defined as ≥5 mL/kg/day of chylomicron-positive chest drainage fluid no earlier than postoperative day 5 or drainage with >80% lymphocytes. Outcomes were compared between the chylothorax and non-chylothorax groups by the Kaplan-Meier method and log-rank test. Independent predictors of chylothorax and number of days of any chest drainage were analyzed with multivariable logistic regression and multivariable generalized negative binomial regression for count data, respectively. RESULTS Chylothorax occurred in 78 patients (24%). Compared with the non-chylothorax group, the chylothorax group had a longer duration of chest tube requirement (median, 18 days vs 9 days; P < .000) and a longer length of hospital stay (median, 19 days vs 10 days; P < .000). Eight patients (10.3%) required thoracic duct ligation. The chylothorax group had lower freedom from death (P = .013) and from composite adverse events (P = .021). No predictor was found for chylothorax. Pulmonary atresia (P = .031) and pre-Fontan pulmonary artery pressure (P = .01) were predictive of prolonged pleural effusion (>14 days). CONCLUSIONS Occurrence of chylothorax following the Fontan operation can be a marker of poorer medium-term clinical outcomes. It is difficult to predict occurrence of chylothorax owing to its multifactorial nature and involvement of lymphatic compensatory capacity that is unmasked only after the Fontan operation.
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Affiliation(s)
- Mauro Lo Rito
- Department of Cardiac Surgery, IRCCS Policlinico San Donato, Milan, Italy
| | - Osman O Al-Radi
- Department of Surgery, King Abdulaziz University, Jeddah, Saudi Arabia
| | - Arezou Saedi
- Division of Cardiovascular Surgery, Labatt Family Heart Centre, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Yasuhiro Kotani
- Department of Cardiovascular Surgery, Okayama University, Okayama, Japan
| | - V Ben Sivarajan
- Pediatric Cardiac Intensive Care, Department of Pediatrics, Stollery Children's Hospital, Faculty of Medicine & Dentistry, University of Alberta, Edmonton, Alberta, Canada
| | - Jennifer L Russell
- Division of Cardiology, Labatt Family Heart Centre, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Christopher A Caldarone
- Division of Cardiovascular Surgery, Labatt Family Heart Centre, The Hospital for Sick Children, Toronto, Ontario, Canada; Department of Surgery, University of Toronto, Toronto, Ontario, Canada
| | - Glen S Van Arsdell
- Division of Cardiovascular Surgery, Labatt Family Heart Centre, The Hospital for Sick Children, Toronto, Ontario, Canada; Department of Surgery, University of Toronto, Toronto, Ontario, Canada
| | - Osami Honjo
- Division of Cardiovascular Surgery, Labatt Family Heart Centre, The Hospital for Sick Children, Toronto, Ontario, Canada; Department of Surgery, University of Toronto, Toronto, Ontario, Canada.
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Atz AM, Zak V, Mahony L, Uzark K, D'agincourt N, Goldberg DJ, Williams RV, Breitbart RE, Colan SD, Burns KM, Margossian R, Henderson HT, Korsin R, Marino BS, Daniels K, McCrindle BW. Longitudinal Outcomes of Patients With Single Ventricle After the Fontan Procedure. J Am Coll Cardiol 2017; 69:2735-2744. [PMID: 28571639 DOI: 10.1016/j.jacc.2017.03.582] [Citation(s) in RCA: 180] [Impact Index Per Article: 25.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/19/2016] [Revised: 03/19/2017] [Accepted: 03/29/2017] [Indexed: 10/19/2022]
Abstract
BACKGROUND Multicenter longitudinal objective data for survival into adulthood of patients who have undergone Fontan procedures are lacking. OBJECTIVES This study sought to describe transplant-free survival and explore relationships between laboratory measures of ventricular performance and functional status over time. METHODS Exercise testing, echocardiography, B-type natriuretic peptide, functional health assessment, and medical history abstraction were repeated 9.4 ± 0.4 years after the Fontan Cross-Sectional Study (Fontan 1) and compared with previous values. Cox regression analysis explored risk factors for interim death or cardiac transplantation. RESULTS From the original cohort of 546 subjects, 466 were contacted again, and 373 (80%) were enrolled at 21.2 ± 3.5 years of age. Among subjects with paired testing, the percent predicted maximum oxygen uptake decreased (69 ± 14% vs. 61 ± 16%; p < 0.001; n = 95), ejection fraction decreased (58 ± 11% vs. 55 ± 10%; p < 0.001; n = 259), and B-type natriuretic peptide increased (median [interquartile range] 13 [7 to 25] pg/mol vs. 18 [9 to 36] pg/mol; p < 0.001; n = 340). At latest follow-up, a lower Pediatric Quality of Life Inventory physical summary score was associated with poorer exercise performance (R2 adjusted = 0.20; p < 0.001; n = 274). Cumulative complications since the Fontan procedure included additional cardiac surgery (32%), catheter intervention (62%), arrhythmia treatment (32%), thrombosis (12%), and protein-losing enteropathy (8%). Since Fontan 1, 54 subjects (10%) have received a heart transplant (n = 23) or died without transplantation (n = 31). The interval risk of death or/cardiac transplantation was associated with poorer ventricular performance and functional health status assessed at Fontan 1, but it was not associated with ventricular morphology, the subject's age, or the type of Fontan connection. CONCLUSIONS Interim transplant-free survival over 12 years in this Fontan cohort was 90% and was independent of ventricular morphology. Exercise performance decreased and was associated with worse functional health status. Future interventions might focus on preserving exercise capacity. (Relationship Between Functional Health Status and Ventricular Performance After Fontan-Pediatric Heart Network; NCT00132782).
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Affiliation(s)
- Andrew M Atz
- Medical University of South Carolina, Charleston, South Carolina.
| | - Victor Zak
- New England Research Institutes, Watertown, Massachusetts
| | - Lynn Mahony
- University of Texas Southwestern Medical Center, Dallas, Texas
| | | | | | | | | | | | | | - Kristin M Burns
- National Heart, Lung, and Blood Institute, Bethesda, Maryland
| | | | | | | | | | | | - Brian W McCrindle
- University of Toronto, The Hospital for Sick Children, Toronto, Ontario, Canada
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Heal ME, Jackson LB, Atz AM, Butts RJ. Effects of persistent Fontan fenestration patency on cardiopulmonary exercise testing variables. CONGENIT HEART DIS 2017; 12:399-402. [PMID: 28618202 DOI: 10.1111/chd.12451] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/21/2016] [Revised: 01/02/2017] [Accepted: 01/09/2017] [Indexed: 11/28/2022]
Abstract
Cardiopulmonary exercise testing (CPET) aids in clinical assessment of patients with Fontan circulation. Effects of persistent fenestration on CPET variables have not been clearly defined. Associations between fenestration and CPET variables at anaerobic threshold (AT) and peak exercise were explored in the Pediatric Heart Network Fontan Cross-Sectional Study cohort. Fenestration patency was associated with a greater decrease in oxygen saturation from rest to peak exercise (fenestration -4.9 ± 3.8 v. nonfenestration -3 ± 3.5; P < .001). Physiological dead space at peak exercise was higher in fenestrated v. nonfenestrated (25.2 ± 16.1 v. 21.4 ± 15.2; P = .03). There was a weak association between fenestration patency and maximal work and heart rate. Fenestration patency was also weakly correlated with oxygen pulse, work and VE/VCO2 at AT. The effect of persistent fenestration on CPET measurements was minimal in this study, likely due to the cross-sectional design.
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Affiliation(s)
- M Elisabeth Heal
- Children's Hospital of Philadelphia, Department of Pediatrics, Division of Cardiology, Philadelphia, PA 19104, USA
| | - Lanier B Jackson
- Department of Pediatrics, Division of Cardiology, Medical University of South Carolina, Charleston, SC 29425
| | - Andrew M Atz
- Department of Pediatrics, Division of Cardiology, Medical University of South Carolina, Charleston, SC 29425
| | - Ryan J Butts
- Department of Pediatrics, Division of Cardiology, University of Texas Southwestern, Dallas, TX 75235
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Effect of Fenestration on Early Postoperative Outcome in Extracardiac Fontan Patients with Different Risk Levels. Pediatr Cardiol 2017; 38:643-649. [PMID: 28116475 DOI: 10.1007/s00246-016-1561-x] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/25/2016] [Accepted: 12/29/2016] [Indexed: 10/20/2022]
Abstract
Although fenestration is used to improve the postoperative course of Fontan patients, the effect of fenestration on the extracardiac Fontan seems controversial especially at early postoperation. One hundred and eighty-three patients from January 2004 to June 2013 undergoing an extracardiac Fontan operation were retrospectively selected for this study. We divided the patients into low risk (93 patients) and high risk (90 patients) groups according to the risk factors recognized by previous studies and then compared the perioperative data between the nonfenestrated and fenestrated patients in each group. In both groups there was no significant difference in preoperative and operative data between the nonfenestrated and fenestrated patients. The postoperative blood oxygen saturation of fenestrated patients was significantly lower (p < 0.01) in each group. In the high risk group the chest tube volume (1153 mL vs. 1739 mL, p = 0.021) and chest tube duration (11.9 days vs. 17.0 days, p = 0.028) of fenestrated patients were lower comparing to nonfenestrated patients, while the chest tube volume and chest tube duration were similar between the nonfenestrated and fenestrated patients in the low risk group. The morbidity and mortality of nonfenestrated and fenestrated patients were similar in both groups (p > 0.05). Although fenestration was associated with lower postoperative oxygen saturation, fenestration showed better postoperative outcomes regarding the chest tube volume and duration for the high-risk patients. Considering the similar early postoperative outcomes of nonfenestrated and fenestrated patients in low risk group, our data indicate that fenestration for the high-risk patients should be performed.
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Góreczny S, Dryżek P, Morgan GJ, Mazurek-Kula A, Moll JJ, Moll JA, Qureshi S, Moszura T. Fenestration closure with Amplatzer Duct Occluder II in patients after total cavo-pulmonary connection. Arch Med Sci 2017; 13:337-345. [PMID: 28261286 PMCID: PMC5332453 DOI: 10.5114/aoms.2016.61836] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/04/2015] [Accepted: 03/16/2015] [Indexed: 11/17/2022] Open
Abstract
INTRODUCTION Creation of a fenestration during completion of a total cavopulmonary connection (TCPC) has been associated with a reduction in early mortality and morbidity. However, the long-term benefits are negated by an associated limitation in exercise tolerance and the potential risks of thrombo-embolic complications. We sought to describe the safety and efficacy of an Amplatzer Duct Occluder II (ADO II) for transcatheter fenestration closure following TCPC. MATERIAL AND METHODS Between January 2000 and July 2014, 102 patients underwent percutaneous closure of extra-cardiac TCPC fenestrations with a range of devices. Patients in whom fenestration closure was performed with an ADO II and who had at least 6 months of follow-up were included in this study. RESULTS Forty-seven patients had successful fenestration occlusion with an ADO II. The mean oxygen saturation and mean systemic venous pressures increased from 84.8 ±6.1% before to 97.6 ±2.9% (p < 0.001) after and from 14.2 ±2.15 mm Hg before to 15.6 ±2.2 mm Hg after closure (p < 0.001). Eight patients developed heart failure symptoms, managed by optimization of medical therapy, with 1 patient requiring device removal to reopen the fenestration. Color Doppler transthoracic echocardiography demonstrated residual flow across the device in 18 (38%), 10 (22%), 5 (11%) and 4 (9%) patients before discharge, at 1 and 6 months, and at the latest outpatient visit, respectively. CONCLUSIONS The ADO II can be safely and effectively used to close fenestrations in extra-cardiac type Fontan completions. Many of the design features of this device confer potential benefit in this population.
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Affiliation(s)
- Sebastian Góreczny
- Department of Cardiology, Polish Mother’s Memorial Hospital, Research Institute, Lodz, Poland
| | - Paweł Dryżek
- Department of Cardiology, Polish Mother’s Memorial Hospital, Research Institute, Lodz, Poland
| | - Gareth J. Morgan
- Department of Congenital Heart Disease, Evelina London Children’s Hospital, Guy’s and St Thomas’ NHS Foundation Trust, London, United Kingdom
| | - Anna Mazurek-Kula
- Department of Cardiology, Polish Mother’s Memorial Hospital, Research Institute, Lodz, Poland
| | - Jacek J. Moll
- Department of Cardiac Surgery, Polish Mother’s Memorial Hospital, Research Institute, Lodz, Poland
| | - Jadwiga A. Moll
- Department of Cardiology, Polish Mother’s Memorial Hospital, Research Institute, Lodz, Poland
| | - Shakeel Qureshi
- Department of Congenital Heart Disease, Evelina London Children’s Hospital, Guy’s and St Thomas’ NHS Foundation Trust, London, United Kingdom
| | - Tomasz Moszura
- Department of Cardiology, Polish Mother’s Memorial Hospital, Research Institute, Lodz, Poland
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The Long-Term Management of Children and Adults with a Fontan Circulation: A Systematic Review and Survey of Current Practice in Australia and New Zealand. Pediatr Cardiol 2017; 38:56-69. [PMID: 27787594 DOI: 10.1007/s00246-016-1484-6] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/03/2016] [Accepted: 10/15/2016] [Indexed: 01/28/2023]
Abstract
Although long-term survival is now the norm, Fontan patients face significant morbidity and premature mortality. Wide variation exists in long-term Fontan management. With an aim of improving their long-term management, we conducted a systematic review to identify best available evidence and gaps in knowledge for future research focus. We also surveyed cardiologists in Australia and New Zealand managing Fontan patients, to determine the alignment of current local practice with best available evidence. A systematic review was conducted using strict search criteria (PRISMA guidelines), pertaining to long-term Fontan management. All adult congenital and paediatric cardiologists registered with The Australia and New Zealand Fontan Registry were invited to respond to an online survey. Reasonable quality evidence exists for non-inferiority of aspirin over warfarin for thromboprophylaxis in standard-risk Fontan patients. No strong evidence is currently available for the routine use of ACE inhibitors, beta blockers or pulmonary vasodilators. Little evidence exists regarding optimal arrhythmia treatment, exercise restriction/prescription, routine fenestration closure, elective Fontan conversion and screening/management of liver abnormalities. Although pregnancy is generally well tolerated, there are high rates of miscarriage and premature delivery. Thirty-nine out of 78 (50 %) cardiologists responded to the survey. Heterogeneity in response was demonstrated with regard to long-term anti-coagulation, other medication use, fenestration closure and pregnancy and contraception counselling. Substantial gaps in our knowledge remain with regard to the long-term management of Fontan patients. This is reflected in the survey of cardiologists managing these patients. We have identified a number of key areas for future research.
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Early Postoperative Albumin Administration Contributes to Morbidity After the Fontan Operation. Pediatr Cardiol 2016; 37:1278-83. [PMID: 27278633 DOI: 10.1007/s00246-016-1429-0] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/18/2016] [Accepted: 05/26/2016] [Indexed: 10/21/2022]
Abstract
The Fontan operation has low mortality, but is associated with significant postoperative morbidity, including prolonged chest tube output (PCTO), which is associated with prolonged hospital length of stay (PLOS). We sought to identify variables present early in the clinical course that could predict patients at high risk for PCTO and PLOS. Retrospective data were collected on 84 Fontan (extracardiac conduit) operations from 1/2008 to 12/2013 at a single institution. PCTO was defined as ≥8 days (>75th percentile); PLOS was defined as ≥12 days postoperatively (>75th percentile). Multivariate regression was used to determine covariates associated with PCTO and PLOS. Median age was 3.5 years (IQR 3-5); weight was 14.5 kg (IQR 13-17). There was no mortality. LOS was 9 days (IQR 3-11), and duration of chest tube drainage 6 days (IQR 5-8) at 15 ml/kg/day (IQR 9-20). In univariate analysis, only systemic right ventricle, 24-h 5 % albumin administration, 24-h fluid balance, and 12-h inotrope score were associated with PCTO. In multivariate analysis, only 5 % albumin administration in first 24 h (p < 0.001) and PCTO were independently associated with PLOS. ROC curve analysis showed patients receiving >25 ml/kg of 5 % albumin in first 24-h predicted PLOS (94 % specificity, 93 % sensitivity, AUC = 0.95, p < 0.001). Increased colloid in the first 24-h post-CPB strongly predicts PCTO and PLOS after Fontan operation, potentially providing an early identification of a cohort with unfavorable Fontan physiology. A better understanding of the role of colloid resuscitation after Fontan is necessary, and efforts to reduce perioperative colloid administration could decrease hospital morbidity.
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Abstract
OBJECTIVES The objective of this article is to review the particular tendencies as well as specific concerns of bleeding and clotting in children with critical cardiac disease. DATA SOURCE MEDLINE and PubMed. CONCLUSION Children with critical heart disease are at particular risk for bleeding and clotting secondary to intrinsic as well as extrinsic factors. We hope that this review will aid the clinician in managing the unique challenges of bleeding and clotting in this patient population, and serve as a springboard for much needed research in this area.
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Charlagorla P, Breinholt JP. Creating a Fontan fenestration in a child with dextrocardia and interrupted inferior vena cava. Ann Pediatr Cardiol 2016; 9:179-82. [PMID: 27212858 PMCID: PMC4867808 DOI: 10.4103/0974-2069.173547] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Plastic bronchitis is a rare life-threatening complication of the Fontan operation. Transcatheter Fontan fenestration can ameliorate symptoms by decompressing elevated venous pressures. Transcatheter creation of a fenestration can be technically challenging in cases with complex venous anatomy. We report a case of a 5-year-old boy with heterotaxy, dextrocardia with unbalanced atrioventricular canal (AVC), atrial and visceral situs inversus, left-sided superior vena cava (SVC), and left-sided interrupted inferior vena cava (IVC) with azygos continuation. With few modifications to the equipment, a successful Fontan fenestration with stent implantation was performed via transjugular approach. At 2-year follow-up, his symptoms of plastic bronchitis improved significantly.
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Affiliation(s)
- Pradeepkumar Charlagorla
- Department of Pediatrics, Division of Cardiology, Riley Hospital for Children, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - John P Breinholt
- Department of Pediatrics, Division of Cardiology, Riley Hospital for Children, Indiana University School of Medicine, Indianapolis, Indiana, USA
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Zou M, Wang Y, Cui H, Ma L, Yang S, Xia Y, Chen W, Chen X. Outcomes of total cavopulmonary connection for single ventricle palliation. J Thorac Dis 2016; 8:43-51. [PMID: 26904211 DOI: 10.3978/j.issn.2072-1439.2016.01.41] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
BACKGROUND The aim of this study was to review the early and mid-term outcomes of the total cavopulmonary connection (TCPC) procedure and evaluate risk factors for prolonged pleural effusions. METHODS The clinical records of 82 consecutive patients, who underwent a TCPC operation between January 2008 and December 2013, were reviewed for incidence of prolonged pleural effusions, duration of ventilation time and pleural drainage, length of intensive care unit (ICU) stay, and early and mid-term morbidity and mortality. RESULTS The median age at surgery was 3.0 years. The main single ventricle diagnoses included 18 cases of a double-inlet single ventricle, 17 cases of heterotaxy, 16 cases of tricuspid atresia, 4 cases of mitral atresia, 12 cases of unbalanced complete atrioventricular canal (CAVC), 5 cases of double-outlet right ventricle (DORV) combined with ventricular septal defect (VSD) and pulmonary stenosis (PS), 4 cases of transposition of the great arteries (TGA) combined with VSD and PS, 4 cases of corrected transposition of great arteries (cTGA) combined VSD and PS, and 2 cases of criss-cross heart. Preoperative mean pulmonary artery pressure (mPAP) was 13.66±2.21 mmHg with 23.2% (n=19) higher than 15 mmHg. A total of 61 (74.4%) patients underwent a fenestration. The perioperative mortality was 4.9%. The median duration of pleural effusion was 10 days (range, 3-80 days), and prolonged pleural effusions occurred in 16 (19.5%) patients. Multivariable analysis revealed that mPAP >15 mmHg was independently associated with prolonged pleural effusions (OR, 8.33; 95% CI, 2.33-29.74; P=0.001), and creation of a fenestration was associated with decreased odds of effusion (OR, 0.21; 95% CI, 0.06-0.74; P=0.015). Five-year estimated Kaplan-Meier survival of two-stage TCPC was significantly higher than that of one-stage group(96.7% vs. 79.7%, P=0.023). Patients with heterotaxy or obstructed totally anomalous pulmonary venous connection (TAPVC) had significantly worse mid-term survival. CONCLUSIONS Staged TCPC improved the early and mid-term survival of patients with a single ventricle. mPAP >15 mmHg was independently associated with prolonged pleural effusions and a fenestration significantly associated with a lower odds of effusion.
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Affiliation(s)
- Minghui Zou
- Department of Cardiovascular Surgery, Guangzhou Women and Children's Medical Center, Guangzhou Medical University, Guangzhou 510623, China
| | - Yanfei Wang
- Department of Cardiovascular Surgery, Guangzhou Women and Children's Medical Center, Guangzhou Medical University, Guangzhou 510623, China
| | - Hujun Cui
- Department of Cardiovascular Surgery, Guangzhou Women and Children's Medical Center, Guangzhou Medical University, Guangzhou 510623, China
| | - Li Ma
- Department of Cardiovascular Surgery, Guangzhou Women and Children's Medical Center, Guangzhou Medical University, Guangzhou 510623, China
| | - Shengchun Yang
- Department of Cardiovascular Surgery, Guangzhou Women and Children's Medical Center, Guangzhou Medical University, Guangzhou 510623, China
| | - Yuansheng Xia
- Department of Cardiovascular Surgery, Guangzhou Women and Children's Medical Center, Guangzhou Medical University, Guangzhou 510623, China
| | - Weidan Chen
- Department of Cardiovascular Surgery, Guangzhou Women and Children's Medical Center, Guangzhou Medical University, Guangzhou 510623, China
| | - Xinxin Chen
- Department of Cardiovascular Surgery, Guangzhou Women and Children's Medical Center, Guangzhou Medical University, Guangzhou 510623, China
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Pihkala JI, Järvelä M, Boldt T, Jokinen E, Liikanen I, Mattila I, Eerola A. Fate of fenestration in children treated with fontan operation. Catheter Cardiovasc Interv 2015; 87:E233-9. [DOI: 10.1002/ccd.26324] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/22/2015] [Accepted: 10/09/2015] [Indexed: 11/08/2022]
Affiliation(s)
- Jaana I. Pihkala
- Department of Pediatric Cardiology; Children's Hospital, University of Helsinki and Helsinki University Hospital; Helsinki Finland
| | - Merit Järvelä
- Department of Pediatric Cardiology; Children's Hospital, University of Helsinki and Helsinki University Hospital; Helsinki Finland
| | - Talvikki Boldt
- Department of Pediatric Cardiology; Children's Hospital, University of Helsinki and Helsinki University Hospital; Helsinki Finland
| | - Eero Jokinen
- Department of Pediatric Cardiology; Children's Hospital, University of Helsinki and Helsinki University Hospital; Helsinki Finland
| | - Ilkka Liikanen
- Department of Pediatric Cardiology; Children's Hospital, University of Helsinki and Helsinki University Hospital; Helsinki Finland
| | - Ilkka Mattila
- Department of Pediatric and Transplantation Surgery; Children's Hospital, University of Helsinki and Helsinki University Hospital; Helsinki Finland
| | - Anneli Eerola
- Department of Pediatrics; University Hospital of Tampere; Tampere Finland
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Pike NA, Okuhara CA, Toyama J, Gross BP, Wells WJ, Starnes VA. Reduced pleural drainage, length of stay, and readmissions using a modified Fontan management protocol. J Thorac Cardiovasc Surg 2015; 150:481-7. [DOI: 10.1016/j.jtcvs.2015.06.042] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/10/2015] [Revised: 06/09/2015] [Accepted: 06/14/2015] [Indexed: 10/23/2022]
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Bolin EH, Maskatia SA, Tate AL, Petit CJ. Older Age at Completion of Fontan Procedure Is Associated with Improved Percentage of Predicted Maximum Oxygen Uptake. Tex Heart Inst J 2015; 42:333-40. [PMID: 26413015 DOI: 10.14503/thij-14-4178] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
We tested the hypothesis that later completion of the Fontan procedure is associated with improved exercise capacity in the current period of staged single-ventricle palliation. We performed a retrospective study, in Fontan patients, of exercise stress test data from April 2003 through March 2011. Patients were included if they had received staged palliations in accordance with current surgical strategy, defined as the performance of a superior cavopulmonary connection at ≤1 year of age, followed in subsequent years by Fontan completion. Patients with a pacemaker or respiratory exchange ratio <1 were excluded. Early and late Fontan groups were created on the basis of whether Fontan completion had been performed at <4 or ≥ 4 years of age. The primary predictor variable was age at Fontan completion, and the primary marker of exercise performance was the percentage of predicted maximum oxygen consumption. During the study period, 55 patients were identified (mean age, 11.7 ± 2.8 yr). Older age at Fontan completion correlated positively with higher percentages of predicted maximum oxygen consumption (R=0.286, P=0.034). Patients in whom Fontan completion was performed at ≥4 years of age had higher percentages of predicted maximum oxygen consumption than did those in whom completion was at <4 years of age (84.4 ± 21.5 vs 72.9 ± 18.1; P=0.041). Later Fontan completion might be associated with improved exercise capacity in patients palliated in accordance with contemporary surgical strategy.
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Rupp S, Schieke C, Kerst G, Mazhari N, Moysich A, Latus H, Michel-Behnke I, Akintuerk H, Schranz D. Creation of a transcatheter fenestration in children with failure of fontan circulation: Focus on extracardiac conduit connection. Catheter Cardiovasc Interv 2015; 86:1189-94. [DOI: 10.1002/ccd.26042] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/03/2015] [Accepted: 05/08/2015] [Indexed: 11/09/2022]
Affiliation(s)
- Stefan Rupp
- Pediatric Heart Center, University of Giessen and Marburg; Giessen Germany
| | - Christin Schieke
- Pediatric Heart Center, University of Giessen and Marburg; Giessen Germany
| | - Gunter Kerst
- Pediatric Heart Center, University of Giessen and Marburg; Giessen Germany
| | - Nona Mazhari
- Pediatric Heart Center, University of Giessen and Marburg; Giessen Germany
| | - Axel Moysich
- Pediatric Heart Center, University of Giessen and Marburg; Giessen Germany
| | - Heiner Latus
- Pediatric Heart Center, University of Giessen and Marburg; Giessen Germany
| | - Ina Michel-Behnke
- Division of Pediatric Cardiology, Department of Pediatrics and Adolescent Medicine; Medical University Vienna; Vienna Austria
| | - Hakan Akintuerk
- Pediatric Heart Center, University of Giessen and Marburg; Giessen Germany
| | - Dietmar Schranz
- Pediatric Heart Center, University of Giessen and Marburg; Giessen Germany
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Closure of Fontan fenestration with the use of covered stents: short- and mid-term results in a cohort of 50 patients. Cardiol Young 2015; 25:868-73. [PMID: 24914999 DOI: 10.1017/s1047951114000894] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
OBJECTIVE The use of covered stents to close fenestration in total cavopulmonary connection is presented. METHODS We retrospectively reviewed data of all patients undergoing the procedure of a covered stent to close fenestration of total cavopulmonary connection between 2005 and 2012. RESULTS A total of 50 patients met the inclusion criteria. Median age and weight were 7.7 years and 20 kg, respectively. Median interval between Fontan completion and fenestration closure was 13 months. The femoral vein was used in 42 patients and the jugular vein in eight patients. Of the patients, seven received two stents. Covered stents were CP stents in 42 patients and Atrium Advanta V12 in eight patients. BIB balloons were used in 24 patients and simple balloons in 18 patients. Simultaneous occlusion of venous collaterals was observed in five patients. Median procedural and fluoroscopy times were 49 and 8 minutes, respectively. Mean central venous pressure rose from 10 to 12 mmHg. Mean oxygen saturation increased from 88% to 96%. Full occlusion was confirmed in 47 patients. The remaining had residual shunts: two patients had intracardiac Fontan, and one patient had a stent that could not be fully opened. Following the procedure, five patients had local bleeding, and three delayed discharge 48 hours after the procedure. There was no thromboembolic event after a mean follow-up of 49 months. CONCLUSION Covered stent is a good option to close fenestration in extracardiac total cavopulmonary connection. It is safe, easily achievable with low fluoroscopy time, with very low risk of complication or failure. Good results are sustainable when excluding patients with none circular pathway.
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Sunstrom RE, Muralidaran A, Gerrah R, Reed RD, Good MK, Armsby LR, Rekito AJ, Zubair MM, Langley SM. A Defined Management Strategy Improves Early Outcomes After the Fontan Procedure: The Portland Protocol. Ann Thorac Surg 2015; 99:148-55. [DOI: 10.1016/j.athoracsur.2014.06.121] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/28/2014] [Revised: 06/11/2014] [Accepted: 06/13/2014] [Indexed: 11/25/2022]
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