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Domínguez Del Castillo JJ, Merino Cejas CM, Gómez Guzmán E, Frías Pérez MA. Bridge to transplant in single-ventricle anatomy: subpulmonary support with EXCOR ventricular assist device associated with pulmonary artery reconstruction. Eur J Cardiothorac Surg 2024; 65:ezae174. [PMID: 38656949 DOI: 10.1093/ejcts/ezae174] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/09/2024] [Revised: 04/05/2024] [Accepted: 04/22/2024] [Indexed: 04/26/2024] Open
Abstract
Patients with a single ventricle circulation continue to be a challenge for a heart transplant. The patients in this cohort, often in poor clinical condition with frequent hepatic and renal impairment having undergone previous multiple surgical procedures, are often allosensitive and consequently have an increased risk of post-transplant complications. Although the most recently published series results are improved, this group of patients, with preserved ventricular function, continues to have a higher mortality rate. Moreover, the operation can be complicated by anatomical differences among the pulmonary arteries. This case report presents a child with tricuspid atresia and pulmonary vascular resistance contraindicating Fontan surgery, unfavourable anatomy of the central pulmonary arteries and in poor clinical condition. An EXCOR ventricular assist device (Berlin Heart) was used for sub- pulmonary mechanical circulatory support and pulmonary bifurcation reconstruction, as a bridge to a transplant.
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Affiliation(s)
| | | | - Elena Gómez Guzmán
- Pediatric Cardiology Unit, Reina Sofía University Hospital, Córdoba, Spain
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2
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Chaix MA, Ibrahim R, Tardif JC, Roy C, Mongeon FP, Dore A, Mondésert B, Khairy P. Pulmonary vascular disease and optical coherence tomography imaging in patients with Fontan palliation. Expert Rev Cardiovasc Ther 2024; 22:153-158. [PMID: 38477934 DOI: 10.1080/14779072.2024.2330657] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/21/2023] [Accepted: 03/11/2024] [Indexed: 03/14/2024]
Abstract
INTRODUCTION The Fontan procedure is the palliative procedure of choice for patients with single ventricle physiology. Pulmonary vascular disease (PVD) is an important contributor to Fontan circulatory failure. AREAS COVERED We review the pathophysiology of PVD in patients with Fontan palliation and share our initial experience with optical coherence tomography (OCT) in supplementing standard hemodynamics in characterizing Fontan-associated PVD. In the absence of a sub-pulmonary ventricle, low pulmonary vascular resistance (PVR; ≤2 WU/m2) is required to sustain optimal pulmonary blood flow. PVD is associated with adverse pulmonary artery (PA) remodeling resulting from the non-pulsatile low-shear low-flow circulation. Predisposing factors to PVD include impaired PA growth, endothelial dysfunction, hypercoagulable state, and increased ventricular end-diastolic pressure. OCT parameters that show promise in characterizing Fontan-associated PVD include the PA intima-to-media ratio and wall area ratio (i.e. difference between the whole-vessel area and the luminal area divided by the whole-vessel area). EXPERT OPINION OCT carries potential in characterizing PVD in patients with Fontan palliation. PA remodeling is marked by intimal hyperplasia, with medial regression. Further studies are required to determine the role of OCT in informing management decisions and assessing therapeutic responses.
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Affiliation(s)
- Marie-A Chaix
- Adult Congenital Heart Center, Montreal Heart Institute, Department of Medicine, Université de Montréal, Montreal, Canada
- Research Center, Montreal Heart Institute; Department of Medicine, Université de Montréal, Montreal, Canada
| | - Réda Ibrahim
- Adult Congenital Heart Center, Montreal Heart Institute, Department of Medicine, Université de Montréal, Montreal, Canada
| | - Jean-Claude Tardif
- Research Center, Montreal Heart Institute; Department of Medicine, Université de Montréal, Montreal, Canada
- Montreal Health Innovations Coordinating Center (MHICC), Montreal, Canada
| | - Colombe Roy
- Research Center, Montreal Heart Institute; Department of Medicine, Université de Montréal, Montreal, Canada
| | - François-Pierre Mongeon
- Adult Congenital Heart Center, Montreal Heart Institute, Department of Medicine, Université de Montréal, Montreal, Canada
| | - Annie Dore
- Adult Congenital Heart Center, Montreal Heart Institute, Department of Medicine, Université de Montréal, Montreal, Canada
| | - Blandine Mondésert
- Adult Congenital Heart Center, Montreal Heart Institute, Department of Medicine, Université de Montréal, Montreal, Canada
| | - Paul Khairy
- Adult Congenital Heart Center, Montreal Heart Institute, Department of Medicine, Université de Montréal, Montreal, Canada
- Research Center, Montreal Heart Institute; Department of Medicine, Université de Montréal, Montreal, Canada
- Montreal Health Innovations Coordinating Center (MHICC), Montreal, Canada
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3
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Egbe AC, Connolly HM. Heart Failure Staging and Indications for Advanced Therapies in Adults with Congenital Heart Disease. Heart Fail Clin 2024; 20:147-154. [PMID: 38462319 DOI: 10.1016/j.hfc.2023.12.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/12/2024]
Abstract
Heart failure (HF) is common in adults with congenital heart disease (CHD), and it is the leading cause of death in this population. Adults with CHD presenting with stage D HF have a poor prognosis, and early recognition of signs of advanced HF and referral for advanced therapies for HF offer the best survival as compared with other therapies. The indications for advanced therapies for HF outlined in this article should serve as a guide for clinicians to determine the optimal time for referral. Palliative care should be part of the multidisciplinary care model for HF in patients with CHD.
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Affiliation(s)
- Alexander C Egbe
- Department of Cardiovascular Medicine, Mayo Clinic and Foundation, 200 First Street Southwest, Rochester, MN 55905, USA.
| | - Heidi M Connolly
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN 55905, USA
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Miranda WR, Jain CC, Borlaug BA, Connolly HM, Burchill LJ, Van De Bruaene A, Egbe AC. Exercise catheterization in adults post-Fontan with normal and abnormal haemodynamic criteria: Insights into normal Fontan physiology. Eur J Heart Fail 2024; 26:314-323. [PMID: 38155533 PMCID: PMC10965386 DOI: 10.1002/ejhf.3119] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/24/2023] [Revised: 12/10/2023] [Accepted: 12/12/2023] [Indexed: 12/30/2023] Open
Abstract
AIM The normal (i.e. expected) haemodynamics in adults post-Fontan remain poorly delineated. Moreover, the definitions of elevated exercise pulmonary artery (PA) and PA wedge pressure (PAWP) for this population have not been described. METHODS AND RESULTS Seventy-two adults post-Fontan undergoing exercise catheterization were categorized into abnormal (Group I, n = 59; defined as resting mean PA ≥14 mmHg and/or PAWP ≥12 mmHg, ΔPAWP/Δsystemic flow [Qs] >2 mmHg/L/min, and/or ΔPA/Δpulmonary flow >3 mmHg/L/min) and normal (Group II, n = 13) haemodynamics. Thirty-nine patients with non-cardiac dyspnoea (NCD) were included as controls. There was no difference in exercise arterial oxygen saturation (87% [81-92] vs. 89% [85-93], p = 0.29), while exercise PA pressure (27 [23-31] vs. 16 [14.5-19.5] mmHg, p < 0.001) and PAWP were higher (21 [18-28] vs. 12 [8-14] mmHg, p < 0.001) in Group I. At peak exercise, Group I had lower heart rate (97 [81-120] vs. 133 [112.5-147.5] bpm, p < 0.001) and Qs response (67.3 [43.8-93.1] vs. 105.9 (82-118.5) % predicted, p < 0.001) than Group II. Exercise superior vena cava pressures were higher (16 [14-22.5] vs. 5.5 [3-7.3] mmHg, p < 0.001) and arterial oxygen saturation lower (89% [85-93] vs. 97% [96-98], p < 0.001) in Group II compared to NCD, while no differences in PAWP, stroke volume index, heart rate, or Qs response were seen. If defined as two standard deviations above mean values for Group II, elevated PAWP and mean PA pressure post-Fontan would correspond to 20.6 mmHg and 25.8 mmHg, respectively. CONCLUSION PAWP >20 mmHg and mean PA pressure >25 mmHg could be used to define elevated values during exercise in adults post-Fontan. The major discrepancy in exercise haemodynamics among Group II compared to controls appears to be the degree of systemic venous hypertension and arterial desaturation.
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Affiliation(s)
| | - C. Charles Jain
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN
| | - Barry A. Borlaug
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN
| | | | - Luke J. Burchill
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN
| | - Alexander Van De Bruaene
- Division of Structural and Congenital Cardiology, Department of Cardiovascular Sciences, KU Leuven, Leuven, Belgium
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Leone D, Buber J, Shafer K. Exercise as Medicine: Evaluation and Prescription for Adults with Congenital Heart Disease. Curr Cardiol Rep 2023; 25:1909-1919. [PMID: 38117446 DOI: 10.1007/s11886-023-02006-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 11/22/2023] [Indexed: 12/21/2023]
Abstract
PURPOSE OF REVIEW Understanding exercise physiology as it relates to adult congenital heart disease (ACHD) can be complex. Here we review fundamental physiologic principles and provide a framework for application to the unique ACHD patient population. RECENT FINDINGS ACHD exercise participation has changed dramatically in the last 50 years. A modern approach focuses on exercise principles and individual anatomic and physiologic considerations. With an evolving better understanding of ACHD exercise physiology, we can strategize plans for patients to participate in dynamic and static exercises. Newly developed technologies including wearable devices provide additive information for ACHD providers for further assessment and monitoring. Preparation and assessment for ACHD patients prior to exercise require a thoughtful, personalized approach. Exercise prescriptions can be formulated to adequately meet the needs of our patients.
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Affiliation(s)
- David Leone
- Division of Cardiology, University of Washington, Seattle, WA, USA
| | - Jonathan Buber
- Division of Cardiology, University of Washington, Seattle, WA, USA
| | - Keri Shafer
- Boston Children's Hospital, Boston, MA, USA.
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Venna A, Deshpande S, Downing T, John A, d'Udekem Y. Are dynamic measurements of central venous pressure in Fontan circulation during exercise or volume loading superior to resting measurements? Cardiol Young 2023:1-12. [PMID: 37981897 DOI: 10.1017/s1047951123003797] [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: 11/21/2023]
Abstract
BACKGROUND The main objective measure to assess the health of the Fontan circulation is the pressure measurement of the superior vena cava or pulmonary arteries. We reviewed the literature for benefits of measuring resting pressure in the Fontan circuit and explored whether dynamic measurement by volume loading or exercise has the potential to refine this diagnostic tool. METHODS PubMed was searched for articles showing a relationship between resting post-operative central venous pressure or pulmonary artery pressure and Fontan failure. Relationships between post-operative central venous pressure or pulmonary artery pressure and volume loading changes, such as during exercise or volume loading during cardiac catheterization, were also queried. RESULTS A total of 44 articles mentioned relationships between resting central venous pressure or pulmonary artery pressure and Fontan failure. Only 26 included an analysis between the variables and only seven of those articles found pressure to be predictive of Fontan failure. Ten articles examined the relationship between exercise or volume loading and outcomes and demonstrated a large individual variation of pressures under these dynamic conditions. CONCLUSIONS Based on current literature, there is not a lot of strong evidence to show that elevated resting central venous pressure or pulmonary artery pressure is predictive of Fontan failure. Some individuals experience dramatic increases in central venous pressure or pulmonary artery pressure under increased loading conditions with exercise or bolus fluid infusion, while others experience increases closer to that of a healthy control population. Further studies are needed to examine whether more dynamic and continuous monitoring of systemic venous pressures might better predict outcomes in patients with Fontan circulation.
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Affiliation(s)
- Alyssia Venna
- Division of Cardiac Surgery, Children's National Hospital, Washington, DC, USA
| | | | - Tacy Downing
- Division of Cardiology, Children's National Health System, Washington, DC, USA
| | - Anitha John
- Division of Cardiology, Children's National Health System, Washington, DC, USA
| | - Yves d'Udekem
- Division of Cardiac Surgery, Children's National Hospital, Washington, DC, USA
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Egbe AC, Younis A, Miranda WR, Jain CC, Burchill LJ, Dearani JA, Stephens EH, Connolly HM. Relation Between Preoperative Hypoxia and Postoperative Oxygen Saturation in Patients Post-Fontan Palliation Who Undergo Heart Transplant. Am J Cardiol 2023; 205:325-326. [PMID: 37633068 PMCID: PMC10798178 DOI: 10.1016/j.amjcard.2023.08.033] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/05/2023] [Accepted: 08/07/2023] [Indexed: 08/28/2023]
Affiliation(s)
- Alexander C Egbe
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota.
| | - Ahmed Younis
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota
| | - William R Miranda
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota
| | - C Charles Jain
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota
| | - Luke J Burchill
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota
| | - Joseph A Dearani
- Department of Cardiovascular Surgery, Mayo Clinic, Rochester, Minnesota
| | | | - Heidi M Connolly
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota
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Najashi KA, Najashi NA, Ahmed T, Abdelnaeem R, Alolit S, Zuaybir AA, Atiyah M, Trout AT, Alsaied T, Veldtman GR. The prognostic role of liver volumetry in Fontan patients. Cardiol Young 2023; 33:1834-1839. [PMID: 36258282 DOI: 10.1017/s1047951122002992] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
BACKGROUND AND HYPOTHESES High venous pressures and associated hepatic congestion are important drivers for Fontan-associated liver disease. The prognostic significance of hepatomegaly as a marker of congestion however is not well defined and is further explored in this research study. METHODS Fontan patients who have had liver ultrasound scans were identified from the Prince Sultan Cardiac Centre Fontan Database and had their anatomic, surgical, clinical histories abstracted from the electronic medical records following institutional ethics approval. Liver volumes were determined retrospectively from reviewing individual US images, and these, divided into tertiles, were analysed in the context of the predefined endpoints of (i) Primary - death or heart or liver transplantation, or (ii) Secondary - combined endpoint of death, transplantation, arrhythmia, or protein-losing enteropathy. RESULTS Mean indexed liver volumes for the entire cohort (n = 199) were 1065.1 ± 312.1 ml/m2, range 387 to 2071 ml/m2. Patients with the largest liver volumes (highest tertile) were less likely to have a functioning fenestration compared to those in the lowest tertile 44% versus 56% p = 0.016 and experienced the highest burden of mortality and heart or heart-liver transplantation, p = 0.016, and were more likely to reach the composite endpoint of death, protein-losing enteropathy, arrhythmia, or transplantation, p = 0.010. Liver volumes had an overall predictive accuracy for the combined outcome of 61% (CI 53%, 67%, p = 0.009). CONCLUSIONS Liver volumetry may serve as a potentially important congestion biomarker for adverse outcomes after the Fontan operation.
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Affiliation(s)
- Khalid Al Najashi
- Pediatric Cardiology Department, Prince Sultan Cardiac Center, Riyadh, Saudi Arabia
| | - Nejoud Al Najashi
- Radiology Department, Prince Sultan Medical Military City, Riyadh, Saudi Arabia
| | - Taghreed Ahmed
- Pediatric Cardiology Department, Prince Sultan Cardiac Center, Riyadh, Saudi Arabia
| | - Rayan Abdelnaeem
- Pediatric Cardiology Department, Prince Sultan Cardiac Center, Riyadh, Saudi Arabia
| | - Sultan Alolit
- Radiology Department, Prince Sultan Medical Military City, Riyadh, Saudi Arabia
| | - Amani Al Zuaybir
- Radiology Department, Prince Sultan Medical Military City, Riyadh, Saudi Arabia
| | - Merna Atiyah
- Pediatric Cardiology Department, Prince Sultan Cardiac Center, Riyadh, Saudi Arabia
| | - Andrew T Trout
- Department of Radiology, Cincinnati Children's Hospital Medical Center and University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Tarek Alsaied
- Paediatric Cardiology, UPMC Children's Hospital of Pittsburgh, PA, USA
| | - Gruschen R Veldtman
- Scottish Adult Congenital Cardiac Service, Golden Jubilee National Hospital, Glasgow, Scotland, UK
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9
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Egbe AC, Miranda WR, Jain CC, Anderson JH, Younis A, Abozied O, Connolly HM. Prognostic Value of the Anatomic-Physiologic Classification in Adults With Congenital Heart Disease. Circ Heart Fail 2023; 16:e010404. [PMID: 37476989 PMCID: PMC10526749 DOI: 10.1161/circheartfailure.122.010404] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/01/2022] [Accepted: 06/01/2023] [Indexed: 07/22/2023]
Abstract
BACKGROUND The prognostic role of the congenital heart disease (CHD) anatomic/physiologic classification has not been systematically studied. The purpose of this study was to determine whether CHD physiologic stage provided improvement in prognostic power (to predict all-cause mortality) beyond conventional clinical risk models. METHODS Retrospective study of adults with CHD at the Mayo Clinic (2003-2019). The CHD physiologic stage was assessed at baseline and 36 (24-48) months, and patients were classified into stages A to D at these time points. Clinical stability (remaining in the same stage), clinical improvement (moving to less advanced stage), and clinical deterioration (moving to more advanced stage) were determined at 36 months. We defined conventional clinical risk indices as age/sex, functional class, comorbidities, cardiac procedures, hepatorenal dysfunction, and ventricular/valvular dysfunction. RESULTS Of 5321 patients, 1649 (31%), 1968 (37%), 1224 (23%), and 480 (9%) were in stages A, B, C, and D at baseline. Of 5321 patients, 4588 (86%) also had assessments at 36 months, and of these patients, 3347 (73%), 386 (8%), and 855 (19%) had clinical stability, deterioration, and improvement, respectively. Patients with clinical improvement were more likely to have undergone cardiac procedures between both assessments. Both baseline CHD physiologic stage (hazard ratio, 1.13 [95% CI, 1.09-1.17]; P<0.001, per unit increase in stage) and change in CHD physiologic stage (hazard ratio, 1.46 [95% CI, 1.32-1.61]; P=0.007, per unit increase in stage) were associated with mortality after adjustments for conventional risk indices and provided incremental improvement in prognostic power beyond conventional clinical risk models as evidence by an increase in C statistic from 0.702 (0.681-0.724) to 0.769 (0.754-0.787). CONCLUSIONS The CHD physiologic stage can potentially be used for risk stratification, as well as to monitor disease progression and response to therapy.
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Affiliation(s)
- Alexander C Egbe
- Department of Cardiovascular Medicine, Mayo Clinic Rochester, MN
| | | | - C Charles Jain
- Department of Cardiovascular Medicine, Mayo Clinic Rochester, MN
| | - Jason H Anderson
- Department of Cardiovascular Medicine, Mayo Clinic Rochester, MN
| | - Ahmed Younis
- Department of Cardiovascular Medicine, Mayo Clinic Rochester, MN
| | - Omar Abozied
- Department of Cardiovascular Medicine, Mayo Clinic Rochester, MN
| | - Heidi M Connolly
- Department of Cardiovascular Medicine, Mayo Clinic Rochester, MN
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Ishida H, Maeda J, Uchida K, Yamagishi H. Unique Pulmonary Hypertensive Vascular Diseases Associated with Heart and Lung Developmental Defects. J Cardiovasc Dev Dis 2023; 10:333. [PMID: 37623346 PMCID: PMC10455332 DOI: 10.3390/jcdd10080333] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2023] [Revised: 07/10/2023] [Accepted: 08/01/2023] [Indexed: 08/26/2023] Open
Abstract
Although pediatric pulmonary hypertension (PH) shares features and mechanisms with adult PH, there are also some significant differences between the two conditions. Segmental PH is a unique pediatric subtype of PH with unclear and/or multifactorial pathophysiological mechanisms, and is often associated with complex congenital heart disease (CHD), pulmonary atresia with ventricular septal defect, and aortopulmonary collateral arteries. Some cases of complex CHD, associated with a single ventricle after Fontan operation, show pathological changes in the small peripheral pulmonary arteries and pulmonary vascular resistance similar to those observed in pulmonary arterial hypertension (PAH). This condition is termed as the pediatric pulmonary hypertensive vascular disease (PPHVD). Recent advances in genetics have identified the genes responsible for PAH associated with developmental defects of the heart and lungs, such as TBX4 and SOX17. Targeted therapies for PAH have been developed; however, their effects on PH associated with developmental heart and lung defects remain to be established. Real-world data analyses on the anatomy, pathophysiology, genetics, and molecular biology of unique PPHVD cases associated with developmental defects of the heart and lungs, using nationwide and/or international registries, should be conducted in order to improve the treatments and prognosis of patients with these types of pediatric PH.
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Affiliation(s)
- Hidekazu Ishida
- Department of Pediatrics, Osaka University Graduate School of Medicine, 2-2 Yamadaoka, Suita 565-0871, Osaka, Japan;
| | - Jun Maeda
- Department of Cardiology, Tokyo Metropolitan Children’s Medical Center, 2-8-29 Musashidai, Fuchu 183-8561, Tokyo, Japan;
| | - Keiko Uchida
- Department of Pediatrics, Keio University of Medicine, 35 Shinanomachi, Shinjuku-ku 160-8582, Tokyo, Japan;
- Keio University Health Center, 4-1-1 Hiyoshi, Kohoku-ku, Yokohama 223-8521, Kanagawa, Japan
| | - Hiroyuki Yamagishi
- Department of Pediatrics, Keio University of Medicine, 35 Shinanomachi, Shinjuku-ku 160-8582, Tokyo, Japan;
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Ladrón-Abia R, Cejudo Ramos P, Valverde Pérez I, Camacho Fernández De Liger R, Wals-Rodríguez AJ, Rodríguez Puras MJ, Manso García B, Gallego P. Respiratory Muscle Function and Exercise Performance in Adult Patients with Fontan Circulation. J Clin Med 2023; 12:4593. [PMID: 37510707 PMCID: PMC10380466 DOI: 10.3390/jcm12144593] [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: 05/24/2023] [Revised: 07/06/2023] [Accepted: 07/08/2023] [Indexed: 07/30/2023] Open
Abstract
At rest, a good Fontan circulation can provide a normal cardiac output (CO). However, as a consequence of its unique hemodynamic nature, the limitations of the Fontan circuit are exposed during exercise. We aimed to provide a comprehensive assessment of the pathophysiology of exercise in adult Fontan patients (FPs) and identify factors limiting their functional capacity (FC). In a single-center study conducted in 37 FPs aged ≥16 years and 19 healthy-controls (HCs) who underwent CPET on a cycle ergometer in February and March 2022, the mean peakVO2 was 21 ± 5.4 mL/kg/min, which was 55% of the predicted value. Morphologically, the left single ventricle showed a higher peakVO2% predicted value (57.4 ± 14.4% vs. 43.4 ± 8.1%, p = 0.045). The factors associated with low peakVO2 values were an early flattened or descending O2 pulse at maximal exertion (52 ± 14% vs. 62 ± 12.5, p = 0.04 and 47.6 ± 9% vs. 60 ± 14, p = 0.018, respectively) and chronotropic insufficiency (53 ± 12% vs. 69.8 ± 20%, p = 0.008). The OUES was found to be a useful parameter to assess the FC in FPs in maximal and submaximal exercise testing. A strong positive correlation was observed between the %OUES and peakVO2%predicted (r = 0.726, p > 0.001). The lung function was impaired in the FPs, mostly with a mild restrictive pattern (56.8%). The FPs showed lower inspiratory muscle strength compared to the HCs but it was not statistically associated with either the peakVO2 or VE/VCO2 slope. Regular intense physical activity improves one's FC. Although FPs have inspiratory muscle weakness, its impact on their FC is unclear. The peakVO2% predicted grew progressively higher as the level of physical activity increased (low level 49.5 ± 14%, moderate level 55 ± 12%, intense level 69 ± 20%).
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Affiliation(s)
- Raquel Ladrón-Abia
- Adult Congenital Heart Disease Unit, Hospital Universitario Virgen del Rocío, Instituto de BioMedicina de Sevilla (IBIS), Avenida Manuel Siurot s/n, 41013 Sevilla, Spain
| | - Pilar Cejudo Ramos
- Medical-Surgical Service of Respiratory Diseases, Hospital Universitario Virgen del Rocío, Instituto de BioMedicina de Sevilla (IBIS), 41013 Sevilla, Spain
| | - Israel Valverde Pérez
- Paediatric Cardiology Unit, Hospital Infantil Virgen del Rocío, Instituto de BioMedicina de Sevilla (IBIS), 41013 Sevilla, Spain
| | - Rocío Camacho Fernández De Liger
- Adult Congenital Heart Disease Unit, Hospital Universitario Virgen del Rocío, Instituto de BioMedicina de Sevilla (IBIS), Avenida Manuel Siurot s/n, 41013 Sevilla, Spain
| | - Amadeo-José Wals-Rodríguez
- Adult Congenital Heart Disease Unit, Hospital Universitario Virgen del Rocío, Instituto de BioMedicina de Sevilla (IBIS), Avenida Manuel Siurot s/n, 41013 Sevilla, Spain
| | - María José Rodríguez Puras
- Adult Congenital Heart Disease Unit, Hospital Universitario Virgen del Rocío, Instituto de BioMedicina de Sevilla (IBIS), Avenida Manuel Siurot s/n, 41013 Sevilla, Spain
| | - Begoña Manso García
- Adult Congenital Heart Disease Unit, Hospital Universitario Virgen del Rocío, Instituto de BioMedicina de Sevilla (IBIS), Avenida Manuel Siurot s/n, 41013 Sevilla, Spain
- Paediatric Cardiology Unit, Hospital Infantil Virgen del Rocío, Instituto de BioMedicina de Sevilla (IBIS), 41013 Sevilla, Spain
| | - Pastora Gallego
- Adult Congenital Heart Disease Unit, Hospital Universitario Virgen del Rocío, Instituto de BioMedicina de Sevilla (IBIS), Avenida Manuel Siurot s/n, 41013 Sevilla, Spain
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12
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Miranda WR, Jain CC, Burchill LJ, Cabalka AK, Hagler DJ, Francois CJ, Connolly HM, Egbe AC. Correlation Between Fontan Pathway Diameter and Inferior-Superior Vena Cava Gradients in Adults Undergoing Exercise Catheterization. Circ Cardiovasc Interv 2023; 16:e012493. [PMID: 37192313 PMCID: PMC10198470 DOI: 10.1161/circinterventions.122.012493] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/18/2023]
Affiliation(s)
| | | | | | - Allison K. Cabalka
- Division of Cardiology, Department of Pediatric and Adolescent Medicine, Mayo Clinic
| | - Donald J. Hagler
- Department of Cardiovascular Medicine, Mayo Clinic
- Division of Cardiology, Department of Pediatric and Adolescent Medicine, Mayo Clinic
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13
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Hager A. Invasive Cardiopulmonary Exercise Testing in Patients With Fontan Circulation. J Am Coll Cardiol 2023; 81:1601-1604. [PMID: 37076214 DOI: 10.1016/j.jacc.2023.03.380] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/07/2023] [Accepted: 03/08/2023] [Indexed: 04/21/2023]
Affiliation(s)
- Alfred Hager
- Department for Congenital Heart Disease and Paediatric Cardiology, Deutsches Herzzentrum München, Technical University of Munich, Munich, Germany.
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Miranda WR, Jain CC, Borlaug BA, Jaffe AS, Connolly HM, Burchill LJ, Egbe AC. Exercise Capacity, NT-proBNP, and Exercise Hemodynamics in Adults Post-Fontan. J Am Coll Cardiol 2023; 81:1590-1600. [PMID: 37076213 DOI: 10.1016/j.jacc.2023.02.031] [Citation(s) in RCA: 12] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/05/2022] [Revised: 02/08/2023] [Accepted: 02/10/2023] [Indexed: 04/21/2023]
Abstract
BACKGROUND Cardiopulmonary exercise testing (CPET) and N-terminal pro-B-type natriuretic peptide (NT-proBNP) measurement are frequently performed in adults post-Fontan, but their correlations with exercise invasive hemodynamics are poorly understood. Moreover, whether exercise cardiac catheterization provides incremental prognostic information is unknown. OBJECTIVES The authors sought to correlate resting and exercise Fontan pressures (FP) and pulmonary artery wedge pressure (PAWP) with peak oxygen consumption (VO2) on CPET, NT-proBNP, and clinical outcomes. METHODS This was a retrospective cohort of 50 adults (age ≥18 years) post-Fontan undergoing supine exercise venous catheterization between 2018 and 2022. RESULTS Median age was 31.5 years (IQR: 23.7-36.5 years). Ventricular ejection fraction was 48.5% ± 13.0%. Exercise FP and PAWP were related to peak VO2 and ln NT-proBNP levels. Patients with peak VO2 <50% predicted had higher exercise FP (30.0 ± 6.8 mm Hg vs 19 mm Hg [IQR: 16-24 mm Hg]; P < 0.001) and PAWP (25.9 ± 6.3 mm Hg vs 15.1 ± 7.0 mm Hg; P <0.001) compared with those with more preserved exercise capacity. Exercise FP (30.0 ± 7.1 mm Hg vs 23.2 ± 7.2 mm Hg; P = 0.003) and PAWP (25.1 ± 6.7 mm Hg vs 18.8 ± 7.9 mm Hg; P = 0.006) were higher in those with NT-proBNP levels ≥300 pg/mL. During a follow-up of 0.9 years (IQR: 0.6-2.9 years), exercise FP and PAWP remained independently associated with a composite of death, cardiac transplantation, or hospitalization due to heart failure/refractory arrhythmias after adjusting for confounders. CONCLUSIONS In adults post-Fontan, resting and exercise FP and PAWP were inversely related to exercise capacity on noninvasive CPET, and exercise hemodynamics were directly related to NT-proBNP levels. Exercise FP and PAWP were independently associated with clinical outcomes and might be more sensitive than resting values to predict clinical outcomes.
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Affiliation(s)
- William R Miranda
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota, USA.
| | - C Charles Jain
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Barry A Borlaug
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Allan S Jaffe
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Heidi M Connolly
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Luke J Burchill
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Alexander C Egbe
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota, USA
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15
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Miranda WR, Borlaug BA, Jain CC, Anderson JH, Hagler DJ, Connolly HM, Egbe AC. Exercise-induced changes in pulmonary artery wedge pressure in adults post-Fontan versus heart failure with preserved ejection fraction and non-cardiac dyspnoea. Eur J Heart Fail 2023; 25:17-25. [PMID: 36194660 PMCID: PMC9910162 DOI: 10.1002/ejhf.2706] [Citation(s) in RCA: 11] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/08/2022] [Revised: 09/04/2022] [Accepted: 09/29/2022] [Indexed: 02/01/2023] Open
Abstract
AIMS Despite their universal predisposition, diagnosing diastolic dysfunction in patients post-Fontan palliation is challenging. Our aim was to compare exercise haemodynamics between adults post-Fontan and patients with heart failure with preserved ejection fraction (HFpEF) and non-cardiac dyspnoea (NCD). METHODS AND RESULTS Twenty-four adults (age ≥18 years) post-Fontan palliation with resting and exercise pulmonary artery wedge pressure (PAWP) measured during supine biking were identified. Forty-eight patients with HFpEF and 48 with NCD diagnosed at catheterization were selected for comparison. Mean age for Fontan patients was 30.3 ± 7.5 years; median ventricular ejection fraction was 52.5% (45-55.8), being <50% in 37.5%. Resting PAWP among Fontan patients was 10.2 ± 3.5 mmHg (>12 mmHg in 25%); PAWP was lower in Fontan patients than in HFpEF but higher than NCD. During exercise, PAWP was lower in the Fontan group than HFpEF (22.5 mmHg [19.3-28] vs. 28.2 ± 6.3; p = 0.0006) but higher than NCD (11.2 ± 4.2, p ≤ 0.0001). However, there were no differences in ΔPAWP/ΔQs between Fontan and HFpEF patients (4.0 [2.1-7.3] vs. 2.7 [1.6-4.4]; p = 0.10) with the ratio being higher post-Fontan than in NCD (0.6 [0.2-1.2]; p < 0.0001). ΔPAWP/ΔQs remained similar between HFpEF and Fontan patients even when those with ejection fraction <50% were excluded (2.7 [1.6-4.4] vs. 2.7 [1.0-5.8]; p = 0.97). CONCLUSION There were no differences in ΔPAWP/ΔQs ratios between post-Fontan and HFpEF patients, supporting markedly abnormal single ventricle compliance despite lower resting and exercise PAWP. Therefore, exercise invasive haemodynamics may represent a novel tool for the diagnosis of diastolic dysfunction in Fontan patients.
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Affiliation(s)
| | - Barry A. Borlaug
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN
| | - C. Charles Jain
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN
| | | | - Donald J. Hagler
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN
- Division of Cardiology, Department of Pediatric and Adolescent Medicine, Mayo Clinic, Rochester, MN
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16
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Rijnberg FM, van ‘t Hul LC, Hazekamp MG, van den Boogaard PJ, Juffermans JF, Lamb HJ, Terol Espinosa de Los Monteros C, Kroft LJM, Kenjeres S, le Cessie S, Jongbloed MRM, Westenberg JJM, Roest AAW, Wentzel JJ. Haemodynamic performance of 16-20-mm extracardiac Goretex conduits in adolescent Fontan patients at rest and during simulated exercise. Eur J Cardiothorac Surg 2022; 63:6808623. [PMID: 36342204 PMCID: PMC9972516 DOI: 10.1093/ejcts/ezac522] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/09/2022] [Revised: 10/03/2022] [Accepted: 11/06/2022] [Indexed: 11/09/2022] Open
Abstract
OBJECTIVES To date, it is not known if 16-20-mm extracardiac conduits are outgrown during somatic growth from childhood to adolescence. This study aims to determine total cavopulmonary connection (TCPC) haemodynamics in adolescent Fontan patients at rest and during simulated exercise and to assess the relationship between conduit size and haemodynamics. METHODS Patient-specific, magnetic resonance imaging-based computational fluid dynamic models of the TCPC were performed in 51 extracardiac Fontan patients with 16-20-mm conduits. Power loss, pressure gradient and normalized resistance were quantified in rest and during simulated exercise. The cross-sectional area (CSA) (mean and minimum) of the vessels of the TCPC was determined and normalized for flow rate (mm2/l/min). Peak (predicted) oxygen uptake was assessed. RESULTS The median age was 16.2 years (Q1-Q3 14.0-18.2). The normalized mean conduit CSA was 35-73% smaller compared to the inferior and superior vena cava, hepatic veins and left/right pulmonary artery (all P < 0.001). The median TCPC pressure gradient was 0.7 mmHg (Q1-Q3 0.5-0.8) and 2.0 (Q1-Q3 1.4-2.6) during rest and simulated exercise, respectively. A moderate-strong inverse non-linear relationship was present between normalized mean conduit CSA and TCPC haemodynamics in rest and exercise. TCPC pressure gradients of ≥1.0 at rest and ≥3.0 mmHg during simulated exercise were observed in patients with a conduit CSA ≤ 45 mm2/l/min and favourable haemodynamics (<1 mmHg during both rest and exercise) in conduits ≥125 mm2/l/min. Normalized TCPC resistance correlated with (predicted) peak oxygen uptake. CONCLUSIONS Extracardiac conduits of 16-20 mm have become relatively undersized in most adolescent Fontan patients leading to suboptimal haemodynamics.
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Affiliation(s)
- Friso M Rijnberg
- Corresponding author. Department of Cardiothoracic surgery, Leiden University Medical Center, Albinusdreef 2, 2333ZA, Leiden, the Netherlands, Telephone number:+31715262348 (F.M. Rijnberg)
| | - Luca C van ‘t Hul
- Department of Cardiology, Biomechanical Engineering, Erasmus MC, Rotterdam, Netherlands
| | - Mark G Hazekamp
- Department of Cardiothoracic Surgery, Leiden University Medical Center, Leiden, Netherlands
| | | | - Joe F Juffermans
- Department of Radiology, Leiden University Medical Center, Leiden, Netherlands
| | - Hildo J Lamb
- Department of Radiology, Leiden University Medical Center, Leiden, Netherlands
| | | | - Lucia J M Kroft
- Department of Radiology, Leiden University Medical Center, Leiden, Netherlands
| | - Sasa Kenjeres
- Department of Chemical Engineering, Faculty of Applied Sciences, Delft University of Technology and J.M. Burgers centrum Research School for Fluid Mechanics, Delft, Netherlands
| | - Saskia le Cessie
- Department of Clinical Epidemiology, Leiden University Medical Center, Leiden, Netherlands
| | - Monique R M Jongbloed
- Department of Cardiology and Anatomy & Embryology, Leiden University Medical Center, Leiden, Netherlands
| | - Jos J M Westenberg
- Department of Radiology, Leiden University Medical Center, Leiden, Netherlands
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17
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D'Angelo EC, Ciuca C, Egidy Assenza G. Management of Fontan failure. Heart 2022; 108:1822-1831. [PMID: 35973785 DOI: 10.1136/heartjnl-2022-321006] [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] [Indexed: 11/04/2022] Open
Affiliation(s)
- Emanuela Concetta D'Angelo
- Department of Cardio-Thoracic and Vascular Medicine, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | - Cristina Ciuca
- Department of Cardio-Thoracic and Vascular Medicine, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | - Gabriele Egidy Assenza
- Department of Cardio-Thoracic and Vascular Medicine, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
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18
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Miranda WR, Aboulhosn JA, Hagler DJ. Catheterization in Adults With Congenital Heart Disease: A Primer for the Noncongenital Proceduralist. JACC Cardiovasc Interv 2022; 15:907-921. [PMID: 35512915 DOI: 10.1016/j.jcin.2021.12.020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/13/2021] [Revised: 12/08/2021] [Accepted: 12/14/2021] [Indexed: 11/18/2022]
Abstract
Currently in the United States, more than 1 million adults have congenital heart disease. Therefore, it will be inevitable for providers performing cardiac catheterization to be faced with adults with repaired congenital heart abnormalities. Moreover, a meticulous approach to every cardiac catheterization procedure is mandatory to avoid missing unrecognized congenital lesions presenting in adulthood. The authors provide a primer for cardiac catheterization procedures in adults with congenital heart disease, reviewing key procedural components: flow calculation, detection of shunts according to different lesions, and, when indicated, ventricular angiography and coronary angiography.
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Affiliation(s)
- William R Miranda
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota, USA.
| | - Jamil A Aboulhosn
- Division of Adult Cardiology, Ahmanson/UCLA Adult Congenital Heart Disease Center, Los Angeles, California, USA
| | - Donald J Hagler
- Division of Cardiology, Department of Pediatric and Adolescent Medicine, Mayo Clinic, Rochester, Minnesota, USA
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19
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Miranda WR, Jain CC, Cabalka AK, Taggart NW, Connolly HM, Egbe AC. Exercise catheterization to unmask Fontan pathway obstruction. Can J Cardiol 2022; 38:1125-1126. [DOI: 10.1016/j.cjca.2022.04.027] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2022] [Revised: 03/30/2022] [Accepted: 04/21/2022] [Indexed: 11/02/2022] Open
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20
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The Fontan circulation: from ideal to failing hemodynamics and drug therapies for optimization. Can J Cardiol 2022; 38:1059-1071. [DOI: 10.1016/j.cjca.2022.04.014] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2021] [Revised: 04/13/2022] [Accepted: 04/14/2022] [Indexed: 12/19/2022] Open
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21
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Van De Bruaene A, Claessen G, Salaets T, Gewillig M. Late Fontan Circulatory Failure. What Drives Systemic Venous Congestion and Low Cardiac Output in Adult Fontan Patients? Front Cardiovasc Med 2022; 9:825472. [PMID: 35360011 PMCID: PMC8964135 DOI: 10.3389/fcvm.2022.825472] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2021] [Accepted: 02/02/2022] [Indexed: 12/23/2022] Open
Abstract
The Fontan circulation provides definite palliation for children born with a single anatomical or functional ventricle by diverting systemic venous blood directly to the pulmonary arteries, effectively rendering systemic venous return into portal vessels to the lung. Although this restores pulmonary blood flow and avoids the mixture of oxygenated and deoxygenated blood, it also results in elevated systemic venous pressures and low cardiac output. These are the two hallmarks of any Fontan circulation and the cause of Fontan circulatory failure later in life. We highlight the determinants of systemic venous return, its changed relationship with the pulmonary circulation, how it affects preload, and the changed role of the heart (myocardium, valves, and heart rate). By critically evaluating the components of the Fontan circulation, we hope to give some clues in how to optimize the Fontan circulation and avenues for future research.
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Affiliation(s)
- Alexander Van De Bruaene
- Division of Cardiology, Department of Cardiovascular Sciences, University Hospitals Leuven, KU Leuven, Leuven, Belgium
- *Correspondence: Alexander Van De Bruaene
| | - Guido Claessen
- Division of Cardiology, Department of Cardiovascular Sciences, University Hospitals Leuven, KU Leuven, Leuven, Belgium
| | - Thomas Salaets
- Division of Pediatric Cardiology, Department of Cardiovascular Sciences, University Hospitals Leuven, KU Leuven, Leuven, Belgium
| | - Marc Gewillig
- Division of Pediatric Cardiology, Department of Cardiovascular Sciences, University Hospitals Leuven, KU Leuven, Leuven, Belgium
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22
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Miranda WR, Jain CC, Borlaug BA, Connolly HM, Egbe AC. Exercise Invasive Hemodynamics in Adults Post-Fontan: A Novel Tool in Understanding Functional Limitation and Liver Disease. J Heart Lung Transplant 2022; 41:704-707. [DOI: 10.1016/j.healun.2022.02.023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2021] [Revised: 01/10/2022] [Accepted: 02/23/2022] [Indexed: 11/25/2022] Open
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23
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Mackie AS, Veldtman GR, Thorup L, Hjortdal VE, Dori Y. Plastic Bronchitis and Protein-Losing Enteropathy in the Fontan Patient: Evolving Understanding and Emerging Therapies. Can J Cardiol 2022; 38:988-1001. [DOI: 10.1016/j.cjca.2022.03.011] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2021] [Revised: 03/08/2022] [Accepted: 03/12/2022] [Indexed: 12/17/2022] Open
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24
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Invasive Hemodynamic Evaluation of the Fontan Circulation: Current Day Practice and Limitations. Curr Cardiol Rep 2022; 24:587-596. [PMID: 35230616 DOI: 10.1007/s11886-022-01679-4] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 02/03/2022] [Indexed: 12/29/2022]
Abstract
PURPOSE OF REVIEW Establishing the Fontan circulation has led to improved survival in patients born with complex congenital heart diseases. Despite early success, the long-term course of Fontan patients is complicated by multi-organ dysfunction, mainly due to a combination of low resting and blunted exercise-augmented cardiac output as well as elevated central venous (Fontan) pressure. Similarly, despite absolute hemodynamic differences compared to the normal population with biventricular circulation, the "normal" ranges of hemodynamic parameters specific to age-appropriate Fontan circulation have not been well defined. With the ever-increasing population of patients requiring Fontan correction, it is of utmost importance that an acceptable range of hemodynamics in this highly complex patient cohort is better defined. RECENT FINDINGS Multiple publications have described hemodynamic limitations and potential management options in patients with Fontan circulation; however, an acceptable range of hemodynamic parameters in this patient population has not been well defined. Identification of "normal" hemodynamic parameters among patients with Fontan circulation will allow physicians to more objectively define indications for intervention, which is a necessary first step to eliminate institutional and regional heterogeneity in Fontan management and potentially improve long-term clinical outcomes.
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25
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Khoury M, Cordina R. Exercise Training for People Living with a Fontan Circulation: An Underutilized Intervention. Can J Cardiol 2022; 38:1012-1023. [PMID: 35041931 DOI: 10.1016/j.cjca.2022.01.008] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2021] [Revised: 12/31/2021] [Accepted: 01/08/2022] [Indexed: 12/17/2022] Open
Abstract
Surgical repair for children born with single ventricle congenital heart disease, culminating in the Fontan operation, has resulted in dramatic improvements in survival; children born with these lesions are now typically expected to survive well into adulthood. Most, but not all, individuals with a Fontan circulation have reduced exercise capacity compared with the general population that in turn is associated with increased cardiovascular morbidity and mortality. The cause of reduced exercise capacity is multifactorial. A significant contributor is the absence of a subpulmonary ventricular pump, which limits preload and appropriate cardiac output augmentation to meet the increased metabolic demands that occur with exercise. While in its infancy relative to adults with acquired heart disease, the evidence to date suggests that exercise interventions to improve exercise capacity and Fontan physiology in children and adults with Fontan circulation are safe, effective and well tolerated. However, many knowledge gaps remain, including a detailed understanding of the unique physiological adaptations that occur, the optimal approach to exercise in this population and the effectiveness of home-based interventions utilizing telemedicine and remote physiologic monitoring technologies. Furthermore, the long-term impact of such interventions on the Fontan-cardiovascular system, physical activity levels, health-related quality of life, and late cardiovascular morbidity and mortality are not well characterized. In this review, we outline the factors associated with reduced exercise capacity in individuals with Fontan circulation, review the experience to date of dedicated interventions to improve exercise capacity, and highlight the current knowledge gaps in the field and priorities for further study.
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Affiliation(s)
- Michael Khoury
- Division of Pediatric Cardiology, Department of Pediatrics, University of Alberta, Edmonton, Alberta, Canada.
| | - Rachael Cordina
- Sydney Medical School, University of Sydney, Sidney, New South Wales, Australia; Department of Cardiology, Royal Prince Alfred Hospital, Sydney, New South Wales, Australia
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26
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Hsu S, Fang JC, Borlaug BA. Hemodynamics for the Heart Failure Clinician: A State-of-the-Art Review. J Card Fail 2022; 28:133-148. [PMID: 34389460 PMCID: PMC8748277 DOI: 10.1016/j.cardfail.2021.07.012] [Citation(s) in RCA: 29] [Impact Index Per Article: 14.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2021] [Revised: 07/19/2021] [Accepted: 07/21/2021] [Indexed: 01/03/2023]
Abstract
Heart failure (HF) fundamentally reflects an inability of the heart to provide adequate blood flow to the body without incurring the cost of increased cardiac filling pressures. This failure occurs first during the stressed state, but progresses until hemodynamic derangements become apparent at rest. As such, the measurement and interpretation of both resting and stressed hemodynamics serve an integral role in the practice of the HF clinician. In this review, we discuss conceptual and technical best practices in the performance and interpretation of both resting and invasive exercise hemodynamic catheterization, relate important pathophysiologic concepts to clinical care, and discuss updated, evidence-based applications of hemodynamics as they pertain to the full spectrum of HF conditions.
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Affiliation(s)
- Steven Hsu
- Division of Cardiology, Dept. of Medicine, Johns Hopkins University, Baltimore, Maryland
| | - James C Fang
- Division of Cardiology, Department of Medicine, University of Utah, Salt Lake City, Utah.
| | - Barry A Borlaug
- Division of Cardiology, Department of Medicine, Mayo Clinic, Rochester, Minnesota.
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27
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Sallmon H, Ovroutski S, Schleiger A, Photiadis J, Weber SC, Nordmeyer J, Berger F, Kramer P. Late Fontan failure in adult patients is predominantly associated with deteriorating ventricular function. Int J Cardiol 2021; 344:87-94. [PMID: 34563595 DOI: 10.1016/j.ijcard.2021.09.042] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/21/2021] [Revised: 08/19/2021] [Accepted: 09/20/2021] [Indexed: 12/24/2022]
Abstract
BACKGROUND The Fontan operation is a palliative procedure and a substantial number of patients eventually experiences late Fontan circulation failure. Previous concepts of Fontan failure implicate increasing pulmonary vascular resistance (PVR) as a key contributor to late circulatory failure. However, data to support this assumption are sparse. We sought to characterize longitudinal hemodynamic and echocardiographic findings in adult failing Fontan patients. METHODS We performed a retrospective cohort study in adult Fontan patients, identifying patients with Fontan failure. Hemodynamic, echocardiographic and clinical data were recorded. RESULTS Of 173 adult patients (median follow-up after Fontan 20.2 years [IQR 15.7-24.3]), 48 (28%) showed signs of clinical Fontan failure. Thirty-seven patients (77.1%) exhibited ventricular dysfunction (systolic dysfunction defined by ejection fraction ≤45%, n = 22, or diastolic dysfunction defined by systemic ventricular end-diastolic pressure (SVEDP) ≥12 mmHg, n = 15). Elevated indexed PVR (≥2.5 WU*m2) was only observed in 9 (18.8%) patients. Ejection fraction declined from 60% [IQR 55-65] to 47% [IQR 35-55] during follow-up (p < 0.001). Mean pulmonary artery pressure and SVEDP increased from 11 mmHg [IQR 9-15] to 15 mmHg [IQR 12-18] and from 7 mmHg [IQR 4-10] to 11 mmHg [IQR 8-15] (both p < 0.001), respectively, while indexed PVR did not change significantly (2.1 [IQR 1.1-2.4] vs. 1.7 [IQR 1.1-2.5] WU*m2, p = 0.949). Fontan failure-associated mortality during follow-up was substantial (23/48; 48%). CONCLUSIONS Systolic and diastolic ventricular dysfunction are frequent features in late Fontan failure in adults, while increases in PVR were rarely observed. The intricate interplay between hemodynamic compromises in Fontan failure deserves further research to optimize treatment strategies and outcome.
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Affiliation(s)
- Hannes Sallmon
- Department of Pediatric Cardiology, Charité - Universitätsmedizin Berlin, Germany; Department of Congenital Heart Disease/Pediatric Cardiology, German Heart Center Berlin, Germany
| | - Stanislav Ovroutski
- Department of Congenital Heart Disease/Pediatric Cardiology, German Heart Center Berlin, Germany
| | - Anastasia Schleiger
- Department of Congenital Heart Disease/Pediatric Cardiology, German Heart Center Berlin, Germany
| | - Joachim Photiadis
- Department of Congenital Heart Surgery, German Heart Center Berlin, Germany
| | - Sven C Weber
- Department of Pediatric Cardiology, Charité - Universitätsmedizin Berlin, Germany
| | - Johannes Nordmeyer
- Department of Congenital Heart Disease/Pediatric Cardiology, German Heart Center Berlin, Germany
| | - Felix Berger
- Department of Pediatric Cardiology, Charité - Universitätsmedizin Berlin, Germany; Department of Congenital Heart Disease/Pediatric Cardiology, German Heart Center Berlin, Germany; DZHK (German Center for Cardiovascular Research), Partner Site Berlin, Germany
| | - Peter Kramer
- Department of Congenital Heart Disease/Pediatric Cardiology, German Heart Center Berlin, Germany.
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28
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Jain CC, Egbe AC, Stephens EH, Connolly HM, Hagler DJ, Hilscher MB, Miranda WR. Systemic Venous Hypertension and Low Output Are Prevalent at Catheterization in Adults with Pulmonary Atresia and Intact Ventricular Septum Regardless of Repair Strategy. Semin Thorac Cardiovasc Surg 2021; 34:1312-1319. [PMID: 34688901 DOI: 10.1053/j.semtcvs.2021.10.006] [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: 10/12/2021] [Accepted: 10/15/2021] [Indexed: 12/24/2022]
Abstract
Patients with pulmonary atresia and intact ventricular septum (PA-IVS) require intervention early in life, and most survive to a definitive procedure of either Fontan circulation or right ventricle to pulmonary artery (RV-PA) repair. It remains unknown how surgical strategy impacts hemodynamics and comorbidities in adults. Retrospective analysis of adults (age ≥18 years) with PA-IVS undergoing hemodynamic catheterization at Mayo Clinic, MN between January 2000 through January 2020 was performed. 14 patients in the RV-PA group (71% biventricular, 29% 1.5 ventricle repair) and 19 post-Fontan patients [9 lateral tunnel (48%), 6 atriopulmonary (32%), and 4 extracardiac (21%)] were identified. Median age was 29 (21, 34) years. There were no differences in demographics and laboratory data (including MELD-XI) between groups. All patients assessed for liver disease had evidence of hepatic congestion or cirrhosis (14 in the Fontan group and 4 in the RV-PA group). Invasive hemodynamics were comparable between groups with the Fontan and RV-PA groups having similar systemic venous pressure (15.7±4.4 vs. 14.3±6.2, p = .44) and cardiac output (2.2±0.6 vs. 2.0±0.4 L/min/m2, p = .23). There was no difference in transplant-free survival (p = .92; 5-year transplant-free survival RV-PA 84%, Fontan 80%). Hemodynamic derangements, namely elevated systemic venous pressure and low cardiac output, are prevalent in patients with PA-IVS undergoing cardiac catheterization regardless of surgical strategy.
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Affiliation(s)
- C Charles Jain
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota
| | - Alexander C Egbe
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota
| | | | - Heidi M Connolly
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota
| | - Donald J Hagler
- Division of Cardiology, Department of Pediatric and Adolescent Medicine, Mayo Clinic, Rochester, Minnesota
| | - Moira B Hilscher
- Division of Gastroenterology and Hepatology, Department of Medicine, Mayo Clinic, Rochester, Minnesota
| | - William R Miranda
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota.
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29
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The pulmonary vascular bed in patients with functionally univentricular physiology and a Fontan circulation. Cardiol Young 2021; 31:1241-1250. [PMID: 34378498 DOI: 10.1017/s104795112100192x] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
Fontan palliation represents one of the most remarkable surgical advances in the management of individuals born with functionally univentricular physiology. The operation secures adult survival for all but a few with unfavourable anatomy and/or physiology. Inherent to the physiology is passive transpulmonary blood flow, which produces a vulnerability to adequate filling of the systemic ventricle at rest and during exertion. Similarly, the upstream effects of passive flow in the lungs are venous congestion and venous hypertension, especially marked during physical activity. The pulmonary vascular bed has emerged as a defining character on the stage of Fontan circulatory behaviour and clinical outcomes. Its pharmacologic regulation and anatomic rehabilitation therefore seem important strategic therapeutic targets. This review seeks to delineate the important aspects of pulmonary artery development and maturation in functionally univentricular physiology patients, pulmonary artery biology, pulmonary vascular reserve with exercise, and pulmonary artery morphologic and pharmacologic rehabilitation.
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Fuster V. Editor-in-Chief's Top Picks From 2020. J Am Coll Cardiol 2021; 77:937-997. [PMID: 33602476 DOI: 10.1016/j.jacc.2020.12.044] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Each week, I record audio summaries for every paper in JACC, as well as an issue summary. Although this process is quite time-consuming, I have become familiar with every paper that we publish. Thus, I have personally selected the top 100 papers (both Original Investigations and Review Articles) from the distinct specialties each year. In addition to my personal choices, I have included papers that have been the most accessed or downloaded on our websites, as well as those selected by the JACC Editorial Board members. In order to present the full breadth of this important research in a consumable fashion, we will present these abstracts in this issue of JACC, as well as their Central Illustrations. The highlights comprise the following sections: Basic & Translational Research, Cardiac Failure & Myocarditis, Cardiomyopathies & Genetics, Cardio-Oncology, Congenital Heart Disease, Coronary Disease & Interventions, Coronavirus (as a NEW section), Hypertension, Imaging, Metabolic & Lipid Disorders, Neurovascular Disease & Dementia, Promoting Health & Prevention, Rhythm Disorders & Thromboembolism, Valvular Heart Disease, and Vascular Medicine (1-100).
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Gewillig M, Cools B, Van De Bruaene A. Pulmonary Vascular Reserve in Fontan Patients: Looking Upstream for the True Heart of the Matter. J Am Coll Cardiol 2021; 76:2764-2767. [PMID: 33272371 DOI: 10.1016/j.jacc.2020.10.006] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/05/2020] [Accepted: 10/06/2020] [Indexed: 01/17/2023]
Affiliation(s)
- Marc Gewillig
- Pediatric Cardiology, University Hospitals Leuven, Leuven, Belgium.
| | - Bjorn Cools
- Pediatric Cardiology, University Hospitals Leuven, Leuven, Belgium
| | - Alexander Van De Bruaene
- Congenital Cardiology, University Hospitals Leuven, Leuven, Belgium. https://twitter.com/alexvdbruaene
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Latus H, Apitz C. Exercise-Induced Pulmonary Hypertension: The Final Answer to Characterize Pulmonary Vascular Disease in Fontan Patients? J Am Coll Cardiol 2021; 77:1594-1595. [PMID: 33766268 DOI: 10.1016/j.jacc.2020.12.066] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/22/2020] [Accepted: 12/28/2020] [Indexed: 10/21/2022]
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Cedars A, Opotowsky A, Tedford RJ, Burkhoff D. Resist Neglecting Diastolic Dysfunction in Fontan Physiology. J Am Coll Cardiol 2021; 77:1595-1596. [PMID: 33766269 DOI: 10.1016/j.jacc.2021.01.036] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/03/2021] [Accepted: 01/04/2021] [Indexed: 10/21/2022]
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Reply: Abnormal Pulmonary Vascular Reserve in Fontan: Pulmonary Vascular Disease Versus Diastolic Dysfunction. J Am Coll Cardiol 2021; 77:1596-1597. [PMID: 33766270 DOI: 10.1016/j.jacc.2021.01.037] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/15/2021] [Accepted: 01/20/2021] [Indexed: 11/23/2022]
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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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