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Kearney K, McDonald M, Roche L. Collaborative care models in adult congenital heart disease transplant. Curr Opin Organ Transplant 2024; 29:420-427. [PMID: 39498851 DOI: 10.1097/mot.0000000000001173] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2024]
Abstract
PURPOSE OF REVIEW While multidisciplinary collaboration is a tenant of quality heart failure care and critical to the success of transplant programs, this essay challenges the temptation to shoehorn adult congenital heart disease (ACHD) patients into preexisting processes and paradigms. We explore the development of more relevant models, purposefully designed to improve ACHD transplant volumes and outcomes. RECENT FINDINGS Globally, the rapid acceleration of ACHD patients living with and dying from HF stands in stark contrast to their access to transplant. Inferior early outcomes after ACHD transplant remain an undeniable barrier. And yet while all large registry datasets attest to this statistic, a few centers have achieved results comparable to those in acquired heart disease. This despite increases in both ACHD candidate complexity and referrals for Fontan Circulatory Failure. Perhaps something in their approach to care delivery is key?. SUMMARY Alone, neither ACHD nor transplant programs can provide optimal management of HF in ACHD. A siloed approach is similarly inadequate. Building new ACHD-HF-Transplant teams, centered on the patient and supplemented by ad hoc expert partnerships, is an exciting approach that can improve outcomes, create a high-quality training environment, and in our experience, is a truly rewarding way of working together.
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Affiliation(s)
- Katherine Kearney
- University Health Network, Peter Munk Cardiac Centre, Toronto ACHD Program
- Temertry Faculty of Medicine, University of Toronto
| | - Michael McDonald
- Temertry Faculty of Medicine, University of Toronto
- University Health Network, Peter Munk Cardiac Centre, Ajmera Transplant Centre, Heart Transplant Program, Toronto, Ontario, Canada
| | - Lucy Roche
- University Health Network, Peter Munk Cardiac Centre, Toronto ACHD Program
- Temertry Faculty of Medicine, University of Toronto
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Navaratnam M, Li EX, Chen S, Margetson T, Wolke O, Ma M, Ebel NH, Bonham CA, Ramamoorthy C. Perioperative Management of Pediatric Combined Heart and Liver Transplantation: A 17 year single center experience. Paediatr Anaesth 2024; 34:1130-1138. [PMID: 39115452 DOI: 10.1111/pan.14977] [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: 05/31/2024] [Revised: 07/16/2024] [Accepted: 07/23/2024] [Indexed: 10/06/2024]
Abstract
BACKGROUND An increasing number of centers are undertaking combined heart and liver transplantation in adult and pediatric patients with congenital heart disease. AIM The primary aim of this study was to describe the perioperative management of a single center cohort, identifying challenges and potential solutions. METHODS We conducted a retrospective review of all patients undergoing combined heart and liver transplantation at Stanford Children's Hospital from 2006 to 2022. Preoperative information included cardiac diagnosis, hemodynamics, and severity of liver disease. Intraoperative data included length of surgery, cardiopulmonary bypass time, and blood products transfused. Postoperative data included blood products transfused in the intensive care unit, time to extubation, length of intensive care unit stay, survival outcomes and 30-day adverse events. RESULTS Eighteen patients underwent en bloc combined heart and liver transplantation at Stanford Children's Hospital from 2006 to 2022, and the majority 15 (83%) were transplanted for failing Fontan circulation with Fontan Associated Liver Disease. Median surgical procedure time was 13.4 [11.5, 14.5] h with a cardiopulmonary bypass time of 4.3 [3.9, 5.8] h. Median total blood products transfused in the operating room post cardiopulmonary bypass was 89.4 [63.9, 127.0] mLs/kg. Nine patients (50%) had vasoplegia during cardiopulmonary bypass. Activated prothrombin complex concentrates were used post cardiopulmonary bypass in 15 (83%) patients with a 30-day thromboembolism rate of 22%. Median time to extubation was 4.0 [2.8, 6.5] days, median intensive care unit length of stay 20.0 [7.8, 48.3] days and median hospital length of stay 54.0 [30.5, 68.3] days. Incidence of renal replacement therapy was 11%; however, none required renal replacement therapy by the time of hospital discharge. Neurological events within 30 days were 17% and the 30 day and 1 year survival was 89%. CONCLUSIONS Perioperative challenges include major perioperative bleeding, unstable hemodynamics, and end organ injury including acute kidney injury and neurological events. Successful outcomes for en bloc combined heart and liver transplantation are possible with careful multidisciplinary planning, communication, patient selection, and integrated peri-operative management.
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Affiliation(s)
- Manchula Navaratnam
- Department of Anesthesiology, Perioperative and Pain Medicine, Stanford Children's Hospital, Stanford University Medical Center, Palo Alto, California, USA
| | - Emma Xi Li
- Department of Anesthesiology, Perioperative and Pain Medicine, Stanford Children's Hospital, Stanford University Medical Center, Palo Alto, California, USA
| | - Sharon Chen
- Department of Pediatrics, Division of Cardiology, Stanford Children's Hospital, Stanford University Medical Center, Palo Alto, California, USA
| | - Tristan Margetson
- Department of Cardiovascular Perfusion, Stanford Hospital and Clinic, Stanford Children's Hospital, Palo Alto, California, USA
| | - Olga Wolke
- Department of Anesthesiology, Perioperative and Pain Medicine, Stanford Children's Hospital, Stanford University Medical Center, Palo Alto, California, USA
| | - Michael Ma
- Department of Cardiothoracic Surgery, Stanford Children's Hospital, Stanford University Medical Center, Palo Alto, California, USA
| | - Noelle H Ebel
- Department of Pediatric Gastroenterology, Hepatology and Nutrition, Stanford Children's Hospital, Stanford University Medical Center, Palo Alto, California, USA
| | - C Andrew Bonham
- Department of Abdominal Transplantation Surgery, Stanford Children's Hospital, Stanford University Medical Center, Palo Alto, California, USA
| | - Chandra Ramamoorthy
- Department of Anesthesiology, Perioperative and Pain Medicine, Stanford Children's Hospital, Stanford University Medical Center, Palo Alto, California, USA
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Hilscher M, Venkatesh S. From Fragmented Data to Actionable Insights: Predicting HCC in Fontan Patients-A Call for Collaboration. Dig Dis Sci 2024:10.1007/s10620-024-08678-1. [PMID: 39466492 DOI: 10.1007/s10620-024-08678-1] [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: 07/05/2024] [Accepted: 09/30/2024] [Indexed: 10/30/2024]
Affiliation(s)
- Moira Hilscher
- , Rochester, USA.
- Division of Gastroenterology and Hepatology, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA.
| | - Sudhakar Venkatesh
- Department of Radiology, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA.
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Peled Y, Ducharme A, Kittleson M, Bansal N, Stehlik J, Amdani S, Saeed D, Cheng R, Clarke B, Dobbels F, Farr M, Lindenfeld J, Nikolaidis L, Patel J, Acharya D, Albert D, Aslam S, Bertolotti A, Chan M, Chih S, Colvin M, Crespo-Leiro M, D'Alessandro D, Daly K, Diez-Lopez C, Dipchand A, Ensminger S, Everitt M, Fardman A, Farrero M, Feldman D, Gjelaj C, Goodwin M, Harrison K, Hsich E, Joyce E, Kato T, Kim D, Luong ML, Lyster H, Masetti M, Matos LN, Nilsson J, Noly PE, Rao V, Rolid K, Schlendorf K, Schweiger M, Spinner J, Townsend M, Tremblay-Gravel M, Urschel S, Vachiery JL, Velleca A, Waldman G, Walsh J. International Society for Heart and Lung Transplantation Guidelines for the Evaluation and Care of Cardiac Transplant Candidates-2024. J Heart Lung Transplant 2024; 43:1529-1628.e54. [PMID: 39115488 DOI: 10.1016/j.healun.2024.05.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2024] [Accepted: 05/14/2024] [Indexed: 08/18/2024] Open
Abstract
The "International Society for Heart and Lung Transplantation Guidelines for the Evaluation and Care of Cardiac Transplant Candidates-2024" updates and replaces the "Listing Criteria for Heart Transplantation: International Society for Heart and Lung Transplantation Guidelines for the Care of Cardiac Transplant Candidates-2006" and the "2016 International Society for Heart Lung Transplantation Listing Criteria for Heart Transplantation: A 10-year Update." The document aims to provide tools to help integrate the numerous variables involved in evaluating patients for transplantation, emphasizing updating the collaborative treatment while waiting for a transplant. There have been significant practice-changing developments in the care of heart transplant recipients since the publication of the International Society for Heart and Lung Transplantation (ISHLT) guidelines in 2006 and the 10-year update in 2016. The changes pertain to 3 aspects of heart transplantation: (1) patient selection criteria, (2) care of selected patient populations, and (3) durable mechanical support. To address these issues, 3 task forces were assembled. Each task force was cochaired by a pediatric heart transplant physician with the specific mandate to highlight issues unique to the pediatric heart transplant population and ensure their adequate representation. This guideline was harmonized with other ISHLT guidelines published through November 2023. The 2024 ISHLT guidelines for the evaluation and care of cardiac transplant candidates provide recommendations based on contemporary scientific evidence and patient management flow diagrams. The American College of Cardiology and American Heart Association modular knowledge chunk format has been implemented, allowing guideline information to be grouped into discrete packages (or modules) of information on a disease-specific topic or management issue. Aiming to improve the quality of care for heart transplant candidates, the recommendations present an evidence-based approach.
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Affiliation(s)
- Yael Peled
- Leviev Heart & Vascular Center, Sheba Medical Center, Tel Hashomer, Ramat Gan, Israel; Faculty of Medical & Health Sciences, Tel Aviv University, Tel Aviv, Israel.
| | - Anique Ducharme
- Deparment of Medicine, Montreal Heart Institute, Université de Montréal, Montreal, Quebec, Canada.
| | - Michelle Kittleson
- Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, California, USA
| | - Neha Bansal
- Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Josef Stehlik
- Division of Cardiovascular Medicine, Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City, Utah, USA
| | - Shahnawaz Amdani
- Department of Pediatric Cardiology, Cleveland Clinic Children's, Cleveland, Ohio, USA
| | - Diyar Saeed
- Heart Center Niederrhein, Helios Hospital Krefeld, Krefeld, Germany
| | - Richard Cheng
- Division of Cardiology, University of Washington, Seattle, WA, USA
| | - Brian Clarke
- Division of Cardiology, University of British Columbia, St Paul's Hospital, Vancouver, British Columbia, Canada
| | - Fabienne Dobbels
- Academic Centre for Nursing and Midwifery, Department of Public Health and Primary Care, KU Leuven, Leuven, Belgium
| | - Maryjane Farr
- Division of Cardiology, Department of Internal Medicine, UT Southwestern Medical Center, Dallas, TX; Parkland Health System, Dallas, TX, USA
| | - JoAnn Lindenfeld
- Division of Cardiovascular Medicine, Vanderbilt University, Nashville, TN, USA
| | | | - Jignesh Patel
- Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, California, USA
| | - Deepak Acharya
- Division of Cardiovascular Diseases, University of Arizona Sarver Heart Center, Tucson, Arizona, USA
| | - Dimpna Albert
- Department of Paediatric Cardiology, Paediatric Heart Failure and Cardiac Transplant, Heart Center, King Faisal Specialist Hospital and Research Center, Riyadh, Saudi Arabia
| | - Saima Aslam
- Division of Infectious Diseases and Global Public Health, Department of Medicine, University of California San Diego, La Jolla, California, USA
| | - Alejandro Bertolotti
- Heart and Lung Transplant Service, Favaloro Foundation University Hospital, Buenos Aires, Argentina
| | - Michael Chan
- University of Alberta Hospital, Edmonton, Alberta, Canada
| | - Sharon Chih
- Heart Failure and Transplantation, Division of Cardiology, University of Ottawa Heart Institute, Ottawa, Ontario, Canada
| | - Monica Colvin
- Department of Cardiology, University of Michigan, Ann Arbor, MI; Scientific Registry of Transplant Recipients, Hennepin Healthcare Research Institute, Minneapolis, MN, USA
| | - Maria Crespo-Leiro
- Cardiology Department Complexo Hospitalario Universitario A Coruna (CHUAC), CIBERCV, INIBIC, UDC, La Coruna, Spain
| | - David D'Alessandro
- Massachusetts General Hospital, Boston; Harvard School of Medicine, Boston, MA, USA
| | - Kevin Daly
- Boston Children's Hospital & Harvard Medical School, Boston, MA, USA
| | - Carles Diez-Lopez
- Advanced Heart Failure and Heart Transplant Unit, Department of Cardiology, Hospital Universitari de Bellvitge, L'Hospitalet de Llobregat, Barcelona, Spain
| | - Anne Dipchand
- Division of Cardiology, Department of Paediatrics, Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
| | | | - Melanie Everitt
- Department of Pediatrics, University of Colorado School of Medicine, Aurora, CO, USA
| | - Alexander Fardman
- Leviev Heart & Vascular Center, Sheba Medical Center, Tel Hashomer, Ramat Gan, Israel; Faculty of Medical & Health Sciences, Tel Aviv University, Tel Aviv, Israel
| | - Marta Farrero
- Department of Cardiology, Hospital Clínic, Barcelona, Spain
| | - David Feldman
- Newark Beth Israel Hospital & Rutgers University, Newark, NJ, USA
| | - Christiana Gjelaj
- Department of Cardiovascular and Thoracic Surgery, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY, USA
| | - Matthew Goodwin
- Division of Cardiothoracic Surgery, University of Utah, Salt Lake City, UT, USA
| | - Kimberly Harrison
- Department of Pharmaceutical Services, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Eileen Hsich
- Cleveland Clinic Foundation, Division of Cardiovascular Medicine, Cleveland, OH, USA
| | - Emer Joyce
- Department of Cardiology, Mater University Hospital, Dublin, Ireland; School of Medicine, University College Dublin, Dublin, Ireland
| | - Tomoko Kato
- Department of Cardiology, International University of Health and Welfare School of Medicine, Narita, Chiba, Japan
| | - Daniel Kim
- University of Alberta & Mazankowski Alberta Heart Institute, Edmonton, Alberta, Canada
| | - Me-Linh Luong
- Division of Infectious Disease, Department of Medicine, University of Montreal Hospital Center, Montreal, Quebec, Canada
| | - Haifa Lyster
- Department of Heart and Lung Transplantation, The Royal Brompton and Harefield NHS Foundation Trust, Harefield Hospital, Harefield, Middlesex, UK
| | - Marco Masetti
- Heart Failure and Transplant Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | | | - Johan Nilsson
- Department of Cardiothoracic and Vascular Surgery, Skane University Hospital, Lund, Sweden
| | | | - Vivek Rao
- Division of Cardiac Surgery, University of Toronto, Toronto, Ontario, Canada
| | - Katrine Rolid
- Department of Cardiology, Oslo University Hospital, Rikshospitalet, Oslo, Norway
| | - Kelly Schlendorf
- Division of Cardiology, Vanderbilt University Medical Center, Nashville, TN, USA
| | | | - Joseph Spinner
- Section of Pediatric Cardiology, Texas Children's Hospital, Baylor College of Medicine, Houston, TX, USA
| | - Madeleine Townsend
- Division of Pediatric Cardiology, Stollery Children's Hospital, Edmonton, Alberta, Canada
| | - Maxime Tremblay-Gravel
- Deparment of Medicine, Montreal Heart Institute, Université?de Montréal, Montreal, Quebec, Canada
| | - Simon Urschel
- Stollery Children's Hospital, University of Alberta, Edmonton, Alberta, Canada
| | - Jean-Luc Vachiery
- Department of Cardiology, Cliniques Universitaires de Bruxelles, Hôpital Académique Erasme, Bruxelles, Belgium
| | - Angela Velleca
- Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, California, USA
| | - Georgina Waldman
- Department of Pharmacy, Massachusetts General Hospital, Boston, MA, USA
| | - James Walsh
- Allied Health Research Collaborative, The Prince Charles Hospital, Brisbane; Heart Lung Institute, The Prince Charles Hospital, Brisbane, Australia
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Lewis MJ, Schlendorf KH, Reardon LC. Integrating risks and benefits: pretransplant assessment and patient selection for heart transplantation in adult congenital heart disease. Curr Opin Organ Transplant 2024; 29:305-309. [PMID: 39082967 DOI: 10.1097/mot.0000000000001170] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/04/2024]
Abstract
PURPOSE OF REVIEW The number of adult congenital heart disease (ACHD) patients presenting for consideration of heart transplantation continues to grow. Comprehensive pretransplant assessment and thoughtful patient selection are of critical importance to mitigate perioperative and posttransplant morbidity and mortality in this population. RECENT FINDINGS There is increasing evidence that patient outcomes after the onset of heart failure in the ACHD population are poor while overall transplant outcomes for ACHD patients have improved over time. Delineation of factors associated with better versus worse posttransplant outcomes is an area of ongoing research. Several studies have found that delayed patient referral, anatomic complexity and the presence of noncardiac organ dysfunction may increase peri-transplant and posttransplant risk. SUMMARY Pretransplant assessment and patient selection in ACHD patients should focus on mitigating perioperative and early posttransplant risk. Anatomic complexity, noncardiac organ dysfunction, and referral timing after the onset of heart failure can contribute to poor posttransplant outcomes and should inform patient selection.
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Affiliation(s)
- Matthew J Lewis
- Division of Cardiology, Department of Medicine, Columbia University Medical Center, New York, New York
| | - Kelly H Schlendorf
- Division of Cardiology, Department of Medicine, Vanderbilt University, Nashville, Tennessee
| | - Leigh C Reardon
- Department of Medicine, Division of Cardiology, Ahmason/UCLA Adult Congenital Heart Disease Center, University of California Los Angeles, Los Angeles, California, USA
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Téllez L, Rincón D, Payancé A, Jaillais A, Lebray P, Rodríguez de Santiago E, Clemente A, Paradis V, Lefort B, Garrido-Lestache E, Prieto R, Iserin L, Tallegas M, Garrido E, Torres M, Muriel A, Perna C, Jesús Del Cerro M, d'Alteroche L, Rautou PE, Bañares R, Albillos A. Non-invasive assessment of severe liver fibrosis in patients with Fontan-associated liver disease: The VALDIG-EASL FONLIVER cohort. J Hepatol 2024:S0168-8278(24)02542-X. [PMID: 39260705 DOI: 10.1016/j.jhep.2024.09.005] [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: 04/21/2024] [Revised: 08/06/2024] [Accepted: 09/02/2024] [Indexed: 09/13/2024]
Abstract
BACKGROUND & AIMS Fontan-type surgery is used as a palliation for congenital heart disease with univentricular physiology but may, in the long term, lead to advanced chronic liver disease. This study assessed the accuracy of conventional non-invasive models in assessing liver fibrosis and introduces a new risk score employing non-invasive tools. METHODS A prospective, cross-sectional, observational study was conducted across five European centers and encompassing all consecutive adult patients with Fontan circulation, liver biopsy and non-invasive tests (elastography, APRI, FIB-4, Fibrosis score, Doha, GUCI, and AAR). The primary outcome was the identification of severe liver fibrosis on biopsy. Multivariable logistic regression identified non-invasive predictors of severe fibrosis, leading to the development and internal validation of a new scoring model named the FonLiver risk score. RESULTS In total, 217 patients (mean [standard deviation] age, 27.9 [8.9] years; 50.7% males) were included. Severe liver fibrosis was present in 47.9% (95% CI 41.2%-54.5%) and correlated with a lower functional class, protein-losing enteropathy, and compromised cardiopulmonary and systemic hemodynamics. The final FonLiver risk score incorporated liver stiffness measurement using transient elastography and platelet count and demonstrated strong discrimination and calibration (area under the receiver operating curve [AUROC] of 0.81). The FonLiver risk score outperformed conventional prediction models (APRI, FIB-4, Fibrosis score, Doha, GUCI, and AAR), which all exhibited worse performance in our cohort (AUROC < 0.70 for all). CONCLUSION Severe liver fibrosis is prevalent in adults following Fontan-type palliation and can be effectively estimated using with the novel FonLiver risk score. This scoring system can be easily incorporated into the routine assessment of patients with Fontan circulation.
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Affiliation(s)
- Luis Téllez
- Gastroenterology and Hepatology Department, Hospital Universitario Ramón y Cajal, IRYCIS, CIBERehd, Universidad de Alcalá, Madrid, Spain
| | - Diego Rincón
- Liver Unit, Hospital General Universitario Gregorio Marañón, Instituto de Investigación Sanitaria Gregorio Marañón, CIBERehd, Universidad Complutense, Madrid, Spain
| | - Audrey Payancé
- AP-HP, Hôpital Beaujon, Service d'Hépatologie, DMU DIGEST, Centre de Référence des Maladies Vasculaires du Foie, FILFOIE, ERN RARE-LIVER, Clichy, France.Gastroenterology Department, CHRU de Tours, Tours, France; Université Paris-Cité, Inserm, Centre de recherche sur l'inflammation, UMR 1149, Paris, France
| | - Anaïs Jaillais
- Service d'Hépato-gastroentérologie, Centre de référence constitutifs des maladies vasculaires du foie, ERN RARE LIVER, CHU de Tours, France Hepatology Unit, UPMC, Pitié Salpetriere Hospital, Paris, France
| | - Pascal Lebray
- Sorbonne Université, Service d'Hépatologie, Hôpitaux Universitaires Pitié Salpêtrière - Charles Foix, AP-HP, Paris, France
| | - Enrique Rodríguez de Santiago
- Gastroenterology and Hepatology Department, Hospital Universitario Ramón y Cajal, IRYCIS, CIBERehd, Universidad de Alcalá, Madrid, Spain
| | - Ana Clemente
- Liver Unit, Hospital General Universitario Gregorio Marañón, Instituto de Investigación Sanitaria Gregorio Marañón, CIBERehd, Universidad Complutense, Madrid, Spain
| | - Valerie Paradis
- Service de Phathologie, Hôpital Beaujon, AP-HP, Clichy, France
| | - Bruno Lefort
- Institut des Cardiopathies Congénitales de Tours, CHU de Tours, et INSERM UMR1069 N2C, Tours, France
| | - Elvira Garrido-Lestache
- Pediatric Cardiology Department and ACHD, Hospital Universitario Ramón y Cajal, IRYCIS, Universidad de Alcalá, Madrid, Spain
| | - Raquel Prieto
- Cardiology Unit, Hospital General Universitario Gregorio Marañón, Instituto de Investigación Sanitaria Gregorio Marañón, CIBERCV, Universidad Complutense, Madrid, Spain
| | - Laurence Iserin
- Adult Congenital Heart Disease Unit, Cardiology departement, European George Pompidou Hospital, APHP, France
| | | | - Elena Garrido
- Gastroenterology and Hepatology Department, Hospital Universitario Ramón y Cajal, IRYCIS, CIBERehd, Universidad de Alcalá, Madrid, Spain
| | - María Torres
- Gastroenterology and Hepatology Department, Hospital Universitario Ramón y Cajal, IRYCIS, CIBERehd, Universidad de Alcalá, Madrid, Spain
| | - Alfonso Muriel
- Unidad de Bioestadística Clínica, Hospital Universitario Ramón y Cajal, IRYCIS), CIBERESP, Universidad de Alcalá, Madrid, Spain
| | - Cristian Perna
- Pathology Department, Hospital Universitario Ramón y Cajal, Universidad de Alcalá, Madrid, Spain
| | - María Jesús Del Cerro
- Pediatric Cardiology Department and ACHD, Hospital Universitario Ramón y Cajal, IRYCIS, Universidad de Alcalá, Madrid, Spain
| | - Louis d'Alteroche
- Service d'Hépato-gastroentérologie, Centre de référence constitutifs des maladies vasculaires du foie, ERN RARE LIVER, CHU de Tours, France Hepatology Unit, UPMC, Pitié Salpetriere Hospital, Paris, France
| | - Pierre-Emmanuel Rautou
- AP-HP, Hôpital Beaujon, Service d'Hépatologie, DMU DIGEST, Centre de Référence des Maladies Vasculaires du Foie, FILFOIE, ERN RARE-LIVER, Clichy, France.Gastroenterology Department, CHRU de Tours, Tours, France; Université Paris-Cité, Inserm, Centre de recherche sur l'inflammation, UMR 1149, Paris, France
| | - Rafael Bañares
- Liver Unit, Hospital General Universitario Gregorio Marañón, Instituto de Investigación Sanitaria Gregorio Marañón, CIBERehd, Universidad Complutense, Madrid, Spain
| | - Agustín Albillos
- Gastroenterology and Hepatology Department, Hospital Universitario Ramón y Cajal, IRYCIS, CIBERehd, Universidad de Alcalá, Madrid, Spain.
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7
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Levitte S, Nilkant R, Chen S, Beadles A, Lee J, Bonham CA, Rosenthal D, Gallo A, Hollander S, Esquivel C, Ma M, Zhang KY. Pediatric Combined Heart-liver Transplantation: A Single-center Long-term Experience. Transplant Direct 2024; 10:e1696. [PMID: 39165490 PMCID: PMC11335332 DOI: 10.1097/txd.0000000000001696] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2024] [Accepted: 06/30/2024] [Indexed: 08/22/2024] Open
Abstract
Background Combined heart liver transplant (CHLT) continues to gain attention as a surgical treatment for patients with end-stage heart and liver disease but remains rare. We present our institutional longitudinal experience with up to 14 y of follow-up, focused on long-term outcomes in CHLT recipients. Methods We conducted a single-institutional, retrospective review from January 1, 2010, to December 31, 2023, including 7 patients ages 7-17 y who underwent CHLT. Results Most patients were surgically palliated via Fontan procedure pretransplant (n = 6), and all had evidence of advanced fibrosis or cirrhosis before transplant. The 30-d mortality was 14.3% (n = 1, multiorgan failure). During the follow-up period, 1 patient developed acute heart rejection which required treatment and 2 developed acute liver rejection. In all cases, rejection was successfully treated. Two patients developed acute heart rejection which did not require treatment (grade 1R). No patients developed chronic or refractory rejection. No patients developed allograft coronary artery vasculopathy. Conclusions CHLT remains a rarely performed treatment for pediatric patients with end-stage heart and liver disease, but our long-term data suggest that this treatment strategy should be considered more frequently.
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Affiliation(s)
- Steven Levitte
- Division of Pediatric Gastroenterology, Hepatology, and Nutrition, Stanford University, Palo Alto, CA
| | - Riya Nilkant
- Department of Cardiothoracic Surgery, Stanford University, Palo Alto, CA
| | - Sharon Chen
- Division of Pediatric Cardiology, Stanford University, Palo Alto, CA
| | - Angela Beadles
- Department of Pharmacy, Lucile Packard Children’s Hospital, Palo Alto, CA
| | - Joanne Lee
- Department of Pharmacy, Lucile Packard Children’s Hospital, Palo Alto, CA
| | - Clark A. Bonham
- Division of Abdominal Transplantation, Department of Surgery, Stanford University, Palo Alto, CA
| | - David Rosenthal
- Division of Pediatric Cardiology, Stanford University, Palo Alto, CA
| | - Amy Gallo
- Division of Abdominal Transplantation, Department of Surgery, Stanford University, Palo Alto, CA
| | - Seth Hollander
- Division of Pediatric Cardiology, Stanford University, Palo Alto, CA
| | - Carlos Esquivel
- Division of Abdominal Transplantation, Department of Surgery, Stanford University, Palo Alto, CA
| | - Michael Ma
- Department of Cardiothoracic Surgery, Stanford University, Palo Alto, CA
| | - Ke-You Zhang
- Division of Pediatric Gastroenterology, Hepatology, and Nutrition, Stanford University, Palo Alto, CA
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8
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Spahic H, Wasuwanich P, Modanloo B, Rajborirug S, Kutty S, Cedars A, Karnsakul W. Prognostic Indicators of Morbidity and Mortality in Children with Congestive Hepatopathy Presenting with Ascites. Diagnostics (Basel) 2024; 14:1618. [PMID: 39125494 PMCID: PMC11311675 DOI: 10.3390/diagnostics14151618] [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: 04/17/2024] [Revised: 07/16/2024] [Accepted: 07/24/2024] [Indexed: 08/12/2024] Open
Abstract
Objectives: Congestive hepatopathy is a significant complication for children suffering from right-sided heart disease (RHD). We hypothesize that hospitalized pediatric patients with ascites will have congestive hepatopathy leading to advanced liver disease if their cardiac condition is RHD versus non-right-sided heart disease (NRHD). Methods: This is a retrospective cohort study of pediatric patients who presented with an ascites diagnosis (ICD-10 R18) and at least one cardiac diagnosis. Patient demographics, past medical history, laboratory values, imaging results, calculated clinical scores (e.g., APRI, FIB-4), treatment, length of stay (LOS), and death at hospital discharge were analyzed. Results: Of the 136 patients with ascites, 21 patients presented with a primary cardiac disease (12 in RHD and 9 in NRHD). Of these patients, eight (38%) were female, and nine (43%) were White, seven (33%) were Black, and five (24%) were unknown. The RHD group had a mean age of 5.1 Y (vs. 9.5 Y in NRHD). The mean APRI score in RHD patients was 2.87, and it was 0.85 in NRDH. Treatments were similar, with most patients requiring diuretics (11 RHD (92%) vs. 8 NRDH (89%)); 5 RHD (42%) vs. 4 NRDH (44%) required inotropic support. RHD patients had a longer LOS, with an average of 92 days vs. 52 days for NRDH patients. Overall, each group had one death at discharge (8% RHD vs. 11% NRDH). Conclusions: In the realm of children with ascites, the subset grappling with congestive heart disease paints a unique picture. In this context, ascites stands as an elusive predictor of liver decompensation, defying conventional diagnostic pathways.
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Affiliation(s)
- Harisa Spahic
- Department of Pediatrics, University of Colorado, Aurora, CO 80045, USA
| | - Paul Wasuwanich
- Department of Internal Medicine, University of Florida College of Medicine, Gainesville, FL 32610, USA
| | - Bahareh Modanloo
- Biostatistics, Epidemiology, and Data Management (BEAD) Core, Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, MD 21205, USA
| | - Songyos Rajborirug
- Department of Epidemiology, Johns Hopkins University Bloomberg School of Public Health, Baltimore, MD 21205, USA
| | - Shelby Kutty
- Division of Pediatric Cardiology, Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, MD 21205, USA
| | - Ari Cedars
- Division of Pediatric Cardiology, Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, MD 21205, USA
| | - Wikrom Karnsakul
- Division of Pediatric Gastroenterology, Hepatology, and Nutrition, Department of Pediatrics, Johns Hopkins University School of Medicine, 550 N. Broadway, 10th Floor Suite 1003, Baltimore, MD 21205, USA
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9
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Liu X, Han L, Zhou Z, Tu J, Ma J, Chen J. Effect of liver abnormalities on mortality in Fontan patients: a systematic review and meta-analysis. BMC Cardiovasc Disord 2024; 24:385. [PMID: 39054422 PMCID: PMC11270789 DOI: 10.1186/s12872-024-04042-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2023] [Accepted: 07/10/2024] [Indexed: 07/27/2024] Open
Abstract
BACKGROUND Fontan-associated liver disease (FALD) is one of the most common complications following Fontan procedure, but the impact of FALD on survival outcomes remains controversial. The aim of this systematic review and meta-analysis was to examine and quantify the influence of liver disease on the survival of Fontan patients. METHODS The Preferred Reporting Items for Systematic reviews and Meta-Analyses guidelines were followed, and relevant human studies published from inception up to 12 August 2022 were searched. Stata (version 17.0) was applied to perform the meta-analysis, using random effects (Mantel-Haenszel) models. The I2 statistic was used to assess the heterogeneity. Subgroup analysis and meta-regression were employed to explore the potential sources of heterogeneity and sensitivity analysis was performed to determine the potential influence of each study on the overall pooled results. RESULTS A total of 312 records were initially identified and 8 studies involving 2,466 patients were selected for inclusion. Results revealed a significant association between the severity of liver disease following Fontan procedure and mortality, which was confirmed by sensitivity analysis and subgroup analysis assessing post-HT mortality. Meta-regression showed that diagnostic methods for liver disease may be a source of heterogeneity. After removal of the FALD patients identified by international classification of disease codes, heterogeneity was markedly reduced, and the positive association between all-cause mortality and the severity of liver disease became significant. CONCLUSIONS This meta-analysis showed the severity of liver disease following the Fontan procedure has a significant association with mortality. Lifelong follow-up is necessary and imaging examinations are recommended for routine surveillance of liver disease. Among patients with failing Fontan and advanced liver disease, combined heart-liver transplantation may provide additional survival benefits.
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Affiliation(s)
- Xiang Liu
- Department of Cardiac Surgery, Guangdong Provincial People's Hospital (Guangdong Academy of Medical Sciences), Guangdong Cardiovascular Institute, Southern Medical University, No. 106, Zhongshan 2nd Road, Guangzhou, 510080, PR China
- Guangdong Provincial Key Laboratory of South China Structural Heart Disease, Guangzhou, 510080, China
| | - Linjiang Han
- Department of Cardiac Surgery, Guangdong Provincial People's Hospital (Guangdong Academy of Medical Sciences), Guangdong Cardiovascular Institute, Southern Medical University, No. 106, Zhongshan 2nd Road, Guangzhou, 510080, PR China
- Guangdong Provincial Key Laboratory of South China Structural Heart Disease, Guangzhou, 510080, China
| | - Ziqin Zhou
- Department of Cardiac Surgery, Guangdong Provincial People's Hospital (Guangdong Academy of Medical Sciences), Guangdong Cardiovascular Institute, Southern Medical University, No. 106, Zhongshan 2nd Road, Guangzhou, 510080, PR China
- Guangdong Provincial Key Laboratory of South China Structural Heart Disease, Guangzhou, 510080, China
| | - Jiazichao Tu
- Department of Cardiac Surgery, Guangdong Provincial People's Hospital (Guangdong Academy of Medical Sciences), Guangdong Cardiovascular Institute, Southern Medical University, No. 106, Zhongshan 2nd Road, Guangzhou, 510080, PR China
- Guangdong Provincial Key Laboratory of South China Structural Heart Disease, Guangzhou, 510080, China
| | - Jianrui Ma
- Department of Cardiac Surgery, Guangdong Provincial People's Hospital (Guangdong Academy of Medical Sciences), Guangdong Cardiovascular Institute, Southern Medical University, No. 106, Zhongshan 2nd Road, Guangzhou, 510080, PR China
- Guangdong Provincial Key Laboratory of South China Structural Heart Disease, Guangzhou, 510080, China
| | - Jimei Chen
- Department of Cardiac Surgery, Guangdong Provincial People's Hospital (Guangdong Academy of Medical Sciences), Guangdong Cardiovascular Institute, Southern Medical University, No. 106, Zhongshan 2nd Road, Guangzhou, 510080, PR China.
- Guangdong Provincial Key Laboratory of South China Structural Heart Disease, Guangzhou, 510080, China.
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10
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Vinogradsky AV, Nguyen SN, Patel K, Regan M, Axsom KM, Lewis MJ, Sayer G, Uriel N, Naka Y, Goldstone AB, Takeda K. Long-term outcomes of heart transplantation in adults with congenital heart disease: The impact of single-ventricle versus biventricular physiology. JTCVS OPEN 2024; 19:257-274. [PMID: 39015448 PMCID: PMC11247235 DOI: 10.1016/j.xjon.2024.04.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/18/2024] [Revised: 03/11/2024] [Accepted: 04/02/2024] [Indexed: 07/18/2024]
Abstract
Objective Congenital heart disease is a risk factor for mortality after orthotopic heart transplantation; however, the impact of preoperative circulation type and primary congenital heart disease diagnosis remains poorly delineated. Methods We retrospectively reviewed patients with adult congenital heart disease aged 16 years or more who underwent orthotopic heart transplantation at our institution between 2008 and 2022. Patients were categorized as having single-ventricle or biventricular circulation. The primary end point was 5-year post-transplant survival. Results Sixty-one patients with adult congenital heart disease (single-ventricle: n = 26 [42.6%], biventricular: n = 35 [57.4%]) underwent orthotopic heart transplantation at 33.7 [interquartile range, 19.1-48.7] years. The most common congenital heart disease diagnosis was hypoplastic left heart syndrome (n = 11, 42.3%) in the single-ventricle group and congenitally corrected transposition of the great arteries (n = 7, 20.0%) in the biventricular group. Twenty-four patients previously underwent Fontan palliation. At transplant, patients in the single-ventricle group were younger (18.5 [interquartile range, 17.6-32.3] years vs 45.0 [interquartile range, 33.0-52.2] years, P < .001) and more likely to have biopsy-proven cirrhosis (46.2% vs 14.3%, P = .01) and protein-losing enteropathy (42.3% vs 2.9%, P < .001). Patients in the single-ventricle group also had longer bypass times (223.4 ± 65.3 minutes vs 187.4 ± 59.5 minutes, P = .03) and longer durations of mechanical ventilatory support (3.5 [interquartile range, 2.0-6.0] days vs 1.0 [interquartile range, 1.0-2.0] days, P < .001). Operative mortality was comparable (11.5% vs 8.6%, P = 1). Median follow-up was 6.0 [interquartile range, 2.4-10.0] years. Five-year survival was worse in the single-ventricle group (66.0% ± 10.0% vs 91.3% ± 4.8%, P = .03), as was freedom from major rejection (58.3% ± 10.2% vs 84.0% ± 6.6%, P = .02). In univariable analysis, hypoplastic left heart syndrome and Fontan circulation were risk factors for post-transplant mortality (hypoplastic left heart syndrome: hazard ratio, 5.0, P < .001; Fontan: hazard ratio, 3.5, P = .03). Conclusions Adult patients with congenital heart disease undergoing heart transplant with single-ventricle physiology experienced a more complicated post-transplant course, with worse long-term survival and freedom from rejection. Multicenter studies are required to guide orthotopic heart transplantation decision-making in this complex cohort.
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Affiliation(s)
- Alice V. Vinogradsky
- Division of Cardiac, Thoracic & Vascular Surgery, Department of Surgery, Columbia University Irving Medical Center, New York, NY
| | - Stephanie N. Nguyen
- Division of Cardiac, Thoracic & Vascular Surgery, Department of Surgery, Columbia University Irving Medical Center, New York, NY
| | - Krushang Patel
- Division of Cardiac, Thoracic & Vascular Surgery, Department of Surgery, Columbia University Irving Medical Center, New York, NY
| | - Matthew Regan
- Heart Transplant Program, NewYork-Presbyterian Hospital, New York, NY
| | - Kelly M. Axsom
- Division of Cardiology, Department of Medicine, Columbia University Irving Medical Center, New York, NY
| | - Matthew J. Lewis
- Division of Cardiology, Department of Medicine, Columbia University Irving Medical Center, New York, NY
| | - Gabriel Sayer
- Division of Cardiology, Department of Medicine, Columbia University Irving Medical Center, New York, NY
| | - Nir Uriel
- Division of Cardiology, Department of Medicine, Columbia University Irving Medical Center, New York, NY
| | - Yoshifumi Naka
- Division of Cardiac, Thoracic & Vascular Surgery, Department of Surgery, Columbia University Irving Medical Center, New York, NY
| | - Andrew B. Goldstone
- Division of Cardiac, Thoracic & Vascular Surgery, Department of Surgery, Columbia University Irving Medical Center, New York, NY
| | - Koji Takeda
- Division of Cardiac, Thoracic & Vascular Surgery, Department of Surgery, Columbia University Irving Medical Center, New York, NY
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11
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Ahmed MH, Miranda WR, Kamath PS, Sugrue MH, Jain CC, Jokhadar M, Burchill LJ, Connolly HM, Egbe AC. Outcomes of Esophageal Varices in Adults With Fontan Palliation and Liver Cirrhosis. CJC PEDIATRIC AND CONGENITAL HEART DISEASE 2024; 3:107-114. [PMID: 39070956 PMCID: PMC11282881 DOI: 10.1016/j.cjcpc.2024.01.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 11/28/2023] [Accepted: 01/26/2024] [Indexed: 07/30/2024]
Abstract
Background The purpose of this study was to define the risk and outcomes of esophageal varices in adults with Fontan palliation and liver cirrhosis undergoing esophagogastroduodenoscopy (EGD). Method The results of EGD, abdominal ultrasound, and liver biopsy, as well as clinic notes from the hepatologist, were reviewed to determine the diagnosis of cirrhosis and esophageal varices. The incidence of acute gastrointestinal bleeding complication was assessed among patients with esophageal varices using the time of EGD as the baseline. Results Of 149 patients with Fontan palliation and liver cirrhosis, the prevalence of esophageal varices at baseline EGD was 34% (51 of 149). Of 98 patients without esophageal varices at baseline EGD, 27 (27%) underwent subsequent EGD, of whom 11 showed a new diagnosis of esophageal varices. The incidence of a new diagnosis of esophageal varices was 9% per year. Of 62 patients with esophageal varices, 9 (15%) had acute gastrointestinal bleeding complications during 45 (37-62) months of follow-up, yielding an incidence of 5% per year. Of the 9 patients, 8 underwent EGD and variceal banding during the hospitalization for bleeding and 1 patient died of septicaemia. Of the 8 patients who survived to hospital discharge, 2 patients were readmitted for esophageal bleeding within 12 months from the index hospitalization. Higher hepatic vein wedge pressure and hepatic vein pressure gradient were associated with esophageal varices and bleeding complications. Conclusions In this selected sample of adults with Fontan palliation and liver cirrhosis, esophageal varices were relatively common, and patients with esophageal varices had risk of bleeding complications.
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Affiliation(s)
- Marwan H. Ahmed
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - William R. Miranda
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Patrick S. Kamath
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota, USA
| | - Moira H. Sugrue
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota, USA
| | - C. Charles Jain
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Maan Jokhadar
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Luke J. Burchill
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Heidi M. Connolly
- 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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12
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Bulut OP, Bailey SS, Bhat DP. Accuracy of elastography versus biopsy in assessing severity of liver fibrosis in young Fontan patients. Cardiol Young 2024:1-7. [PMID: 38804649 DOI: 10.1017/s1047951124025241] [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: 05/29/2024]
Abstract
OBJECTIVES We performed a single-centre retrospective study comparing the accuracy of non-invasive elastography with liver biopsy in accurate assessment of Fontan-associated liver disease. METHODS Fontan patients who underwent combined assessment with a percutaneous liver biopsy and non-invasive elastography between January 2015 and December 2023 at our Children's hospital were included. Liver biopsies were classified using the Congestive Hepatic Fibrosis Score as early Fontan-associated liver disease (scores 1, 2) and advanced Fontan-associated liver disease (score 3/bridging fibrosis and score 4/cirrhosis). Elastography values were categorised as advanced Fontan-associated liver disease for liver elasticity >2.1 m/s by ultrasound and liver stiffness >5 KPa on magnetic resonance elastography. RESULTS We included 130 patients (116 children, 89%, mean age at biopsy: 14.6 years ± 3.6) who underwent liver biopsy at a mean duration of 11.1 years (±0.3) following Fontan surgery. Advanced Fontan-associated liver disease was noted in 41 (31.5%) patients with 13 (10%) showing frank cirrhosis. Pre-biopsy ultrasound showed advanced liver fibrosis in 18/125 (14%), with low sensitivity (23%), high specificity (90%), and low accuracy (68%, k = 0.1) in diagnosing advanced Fontan-associated liver disease. Similarly, pre-biopsy magnetic resonance elastography showed advanced fibrosis in 23/86 (27%) of patients, with low sensitivity (30%), fair specificity (75%), and low accuracy (63%, k = 0.1). Interestingly, advanced Fontan-associated liver disease was missed by ultrasound in 29% and by magnetic resonance elastography in 25% of patients. Advanced Fontan-associated liver disease was associated with lower platelet count (p = 0.02) and higher Gamma-glutamyl Transferase levels (p = 0.02). CONCLUSION Advanced hepatic fibrosis is common among paediatric Fontan patients. Non-invasive elastography may overestimate and underestimate the degree of liver fibrosis, and therefore, liver biopsy may be required for confirming disease severity.
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Affiliation(s)
- Ozlem P Bulut
- Division of Gastroenterology, Phoenix Children's Hospital, University of Arizona Phoenix, Phoenix, AZ, USA
| | - Smita S Bailey
- Division of Radiology, Phoenix Children's Hospital, University of Arizona Phoenix, Phoenix, AZ, USA
| | - Deepti P Bhat
- Division of Cardiology, Phoenix Children's Hospital, University of Arizona Phoenix, Phoenix, AZ, USA
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13
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Vaikunth SS, Ortega-Legaspi JM, Conrad DR, Chen S, Daugherty T, Haeffele CL, Teuteberg J, Mclean R, MacArthur JW, Woo YJ, Maeda K, Ma M, Nasirov T, Hoteit M, Hilscher MB, Wald J, Mandelbaum T, Olthoff KM, Abt PL, Atluri P, Cevasco M, Mavroudis CD, Fuller S, Lui GK, Kim YY. Mortality and morbidity after combined heart and liver transplantation in the failing Fontan: An updated dual center retrospective study. Clin Transplant 2024; 38:e15302. [PMID: 38567883 DOI: 10.1111/ctr.15302] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2023] [Revised: 03/12/2024] [Accepted: 03/15/2024] [Indexed: 04/05/2024]
Abstract
INTRODUCTION As the adult Fontan population with Fontan associated liver disease continues to increase, more patients are being referred for transplantation, including combined heart and liver transplantation. METHODS We report updated mortality and morbidity outcomes after combined heart and liver transplant in a retrospective cohort series of 40 patients (age 14 to 49 years) with Fontan circulation across two centers from 2006-2022. RESULTS The 30-day, 1-year, 5-year and 10-year survival rate was 90%, 80%, 73% and 73% respectively. Sixty percent of patients met a composite comorbidity of needing either post-transplant mechanical circulatory support, renal replacement therapy or tracheostomy. Cardiopulmonary bypass time > 283 min (4.7 h) and meeting the composite comorbidity were associated with mortality by Kaplan Meier analysis. CONCLUSION Further study to mitigate early mortality and the above comorbidities as well as the high risk of bleeding and vasoplegia in this patient population is warranted.
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Affiliation(s)
- Sumeet S Vaikunth
- Division of Cardiovascular Medicine, Department of Medicine, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA
- Division of Cardiology, Department of Pediatrics, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Juan M Ortega-Legaspi
- Division of Cardiovascular Medicine, Department of Medicine, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Desiree R Conrad
- Division of Cardiovascular Medicine, Department of Medicine, Stanford University School of Medicine, Palo Alto, California, USA
| | - Sharon Chen
- Division of Pediatric Cardiology, Department of Pediatrics, Stanford University School of Medicine, Palo Alto, California, USA
| | - Tami Daugherty
- Division of Gastroenterology and Hepatology, Department of Medicine, Stanford University School of Medicine, Palo Alto, California, USA
| | - Christiane L Haeffele
- Division of Cardiovascular Medicine, Department of Medicine, Stanford University School of Medicine, Palo Alto, California, USA
- Division of Pediatric Cardiology, Department of Pediatrics, Stanford University School of Medicine, Palo Alto, California, USA
| | - Jeffrey Teuteberg
- Division of Cardiovascular Medicine, Department of Medicine, Stanford University School of Medicine, Palo Alto, California, USA
| | - Rhondalynn Mclean
- Division of Cardiovascular Medicine, Department of Medicine, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - John W MacArthur
- Department of Cardiothoracic Surgery, Stanford University School of Medicine, Palo Alto, California, USA
| | - Y Joseph Woo
- Department of Cardiothoracic Surgery, Stanford University School of Medicine, Palo Alto, California, USA
| | - Katsuhide Maeda
- Division of Cardiac Surgery, Department of Surgery, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Michael Ma
- Department of Cardiothoracic Surgery, Stanford University School of Medicine, Palo Alto, California, USA
| | - Teimour Nasirov
- Department of Cardiothoracic Surgery, Stanford University School of Medicine, Palo Alto, California, USA
| | - Marrouf Hoteit
- Division of Gastroenterology and Hepatology, Department of Medicine, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Moira B Hilscher
- Division of Gastroenterology and Hepatology, Department of Medicine, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Joyce Wald
- Division of Cardiovascular Medicine, Department of Medicine, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Tal Mandelbaum
- Department of Anesthesiology and Critical Care, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Kim M Olthoff
- Division of Transplant Surgery, Department of Surgery, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Peter L Abt
- Division of Transplant Surgery, Department of Surgery, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Pavan Atluri
- Division of Cardiovascular Surgery, Department of Surgery, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Marisa Cevasco
- Division of Cardiovascular Surgery, Department of Surgery, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Constantine D Mavroudis
- Division of Cardiac Surgery, Department of Surgery, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Stephanie Fuller
- Division of Cardiac Surgery, Department of Surgery, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - George K Lui
- Division of Cardiovascular Medicine, Department of Medicine, Stanford University School of Medicine, Palo Alto, California, USA
- Division of Pediatric Cardiology, Department of Pediatrics, Stanford University School of Medicine, Palo Alto, California, USA
| | - Yuli Y Kim
- Division of Cardiovascular Medicine, Department of Medicine, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA
- Division of Cardiology, Department of Pediatrics, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
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Fuster V. Editor-in-Chief's Top Picks From 2023. J Am Coll Cardiol 2024; 83:961-1026. [PMID: 38448128 DOI: 10.1016/j.jacc.2024.01.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/08/2024]
Abstract
Each week, I record audio summaries for every paper in JACC, as well as an issue summary. This process has become a true labor of love due to the time they require, but I am motivated by the sheer number of listeners (16M+), and it has allowed me to familiarize myself with every paper that we publish. Thus, I have selected the top 100 papers (Original Investigations, Review Articles, Society Documents, and the Global Burden of Diseases) from 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∗ and podcasts. The highlights comprise the following sections: Aorta; Basic and Translational Science; Cardiac Failure, Myocarditis, and Pericarditis; Cardiomyopathies and Genetics; Congenital Heart Disease; Coronary, Peripheral, and Structural Interventions; Coronavirus; Health Promotion and Preventive Cardiology; Imaging; Metabolic and Lipid Disorders; Neurovascular Disease and Dementia; Rhythm Disorders and Thromboembolism; and Valvular Heart Disease.1-104 ∗ To view the full manuscript, including the full-sized Central Illustration, please refer to the original publication in JACC.
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15
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Lee JTC, Sarode D, Emamaullee JA. Review of pediatric combined heart-liver transplantation: A roadmap to success. Pediatr Transplant 2023; 27:e14633. [PMID: 37899638 PMCID: PMC10842164 DOI: 10.1111/petr.14633] [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: 08/06/2023] [Revised: 10/06/2023] [Accepted: 10/18/2023] [Indexed: 10/31/2023]
Abstract
BACKGROUND Combined heart-liver transplantation (CHLT) is a promising technique to address end stage organ failure in patients with concomitant heart failure and chronic liver disease. While most experience with CHLT has involved adult patients, the expanding population of children born with univentricular congenital heart disease who underwent the Fontan procedure and develop Fontan-associated liver disease (FALD) has emerged as a growing indication for pediatric CHLT. METHODS Currently, CHLT is performed at a select subset of experienced transplant centers, especially in the pediatric population. RESULTS While technically demanding, CHLT may offer survival benefit when compared to heart transplant alone with decreased rejection of both synchronous allografts and equivalent outcomes with respect to waitlist time and post-operative complications. Limitations in the technique can be attributed to need for an appropriate multidisciplinary care center, challenges with donor organ availability and allocation, and the complexity associated with patient selection and peri-operative management. CONCLUSION In this review, we summarize the history of CHLT, discuss patient selection, and highlight key facets of peri-operative care in the pediatric population.
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Affiliation(s)
- Jason T C Lee
- Division of Abdominal Organ Transplantation and Hepatobiliary Surgery, Department of Surgery, Keck School of Medicine, University of Southern California, Los Angeles, California, USA
| | - Deepika Sarode
- Division of Abdominal Organ Transplantation and Hepatobiliary Surgery, Department of Surgery, Keck School of Medicine, University of Southern California, Los Angeles, California, USA
| | - Juliet A Emamaullee
- Division of Abdominal Organ Transplantation and Hepatobiliary Surgery, Department of Surgery, Keck School of Medicine, University of Southern California, Los Angeles, California, USA
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Shibbani K, Ashfaq A, Alsaied T, Diab KA. From Other Journals: A Review of Recent Articles by Our Editorial Team. Pediatr Cardiol 2023; 44:1864-1867. [PMID: 37552245 DOI: 10.1007/s00246-023-03254-2] [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: 06/22/2023] [Accepted: 07/25/2023] [Indexed: 08/09/2023]
Abstract
In this review, we provide a brief description of recently published articles addressing topics relevant to pediatric cardiologists. This review includes (1) Fetal diagnosis, associated anomalies, and factors affecting outcomes in fetal congenitally corrected transposition of the great arteries (ccTGA), (2) The impact of Fontan-associated liver disease on heart and heart/liver transplant, (3) 1-year outcomes of the Harmony transcatheter pulmonary valve, (4) Risk factors associated with major adverse cardiac events in patients with pulmonary atresia and intact ventricular septum undergoing intervention, and (5) Benefits of pulmonary valve replacement in tetralogy of Fallot patients.
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Affiliation(s)
- Kamel Shibbani
- Department of Pediatrics, Stead Family Children's Hospital, University of Iowa, Iowa City, IA, USA
- Department of Pediatrics, University of California San Diego, Rady Children's Hospital, San Diego, CA, USA
| | - Awais Ashfaq
- Department of Cardiothoracic Surgery, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - Tarek Alsaied
- Heart Institute, Pittsburgh Children's Hospital Medical Center, 3333 Burnet Avenue, Pittsburgh, PA, 45215, USA.
- Department of Pediatrics, University of Pittsburgh, Pittsburgh, PA, USA.
| | - Karim A Diab
- Ann & Robert H Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
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Peled Y, Kittleson MM. Two negatives make a positive: Maximizing heart procurement in adult congenital heart disease. J Heart Lung Transplant 2023; 42:1489-1492. [PMID: 37579830 DOI: 10.1016/j.healun.2023.08.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2023] [Revised: 08/03/2023] [Accepted: 08/05/2023] [Indexed: 08/16/2023] Open
Affiliation(s)
- Yael Peled
- Leviev Cardiothoracic and Vascular Center, Sheba Medical Center, and Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel.
| | - Michelle M Kittleson
- Department of Cardiology, Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, California
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Haeffele C, McElhinney DB. Fontan Associated Liver Disease: Canary in the Coal Mine or Silent Killer? J Am Heart Assoc 2023; 12:e031597. [PMID: 37776191 PMCID: PMC10727260 DOI: 10.1161/jaha.123.031597] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/02/2023]
Affiliation(s)
- Christiane Haeffele
- Departments of Medicine, Cardiothoracic Surgery, and PediatricsStanford University School of MedicinePalo AltoCAUSA
| | - Doff B. McElhinney
- Departments of Medicine, Cardiothoracic Surgery, and PediatricsStanford University School of MedicinePalo AltoCAUSA
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Vaikunth S, Sundaravel S, Saef J, Ortega-Legaspi J. Novel Therapeutic Strategies in Heart Failure in Adult Congenital Heart Disease: of Medicines and Devices. Curr Heart Fail Rep 2023; 20:401-416. [PMID: 37582901 DOI: 10.1007/s11897-023-00621-1] [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] [Accepted: 07/18/2023] [Indexed: 08/17/2023]
Abstract
PURPOSE OF REVIEW This paper reviews the latest literature on the growing field of heart failure in the adult congenital heart disease population. RECENT FINDINGS After highlighting the increasing prevalence and a few of the unique potential causes, including the concept of early senescence, this review begins with novel medical management strategies such as the angiotensin II receptor blocker and neprilysin inhibitors and sodium glucose cotransporter-2 inhibitors. Then, it addresses the latest applications of percutaneous techniques like implantable hemodynamic monitoring, transcatheter pulmonary and aortic valve replacement, and mitral clips. Cardiac resynchronization therapy and novel lymphatic system imaging and intervention are then described. Finally, the use of mechanical support devices, temporary and durable, is discussed as well as heart and combined heart and liver transplantation. There have been recent exciting advances in the strategies used to manage adult congenital heart disease patients with heart failure. As this population continues to grow, it is likely we will see further rapid evolution in this field.
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Affiliation(s)
- Sumeet Vaikunth
- Philadelphia Adult Congenital Heart Center, Penn Medicine & Children's Hospital of Philadelphia, University of Pennsylvania, Philadelphia, PA, USA.
| | - Swethika Sundaravel
- Advanced Heart Failure Section, Cardiovascular Medicine Division, Hospital of the University of Pennsylvania, Philadelphia, PA, USA
| | - Joshua Saef
- Philadelphia Adult Congenital Heart Center, Penn Medicine & Children's Hospital of Philadelphia, University of Pennsylvania, Philadelphia, PA, USA
| | - Juan Ortega-Legaspi
- Advanced Heart Failure Section, Cardiovascular Medicine Division, Hospital of the University of Pennsylvania, Philadelphia, PA, USA
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Hsu DT, Lui GK. Transplant in Single Ventricle Physiology: The Fourth Stage? J Am Coll Cardiol 2023; 82:1242-1244. [PMID: 37704314 DOI: 10.1016/j.jacc.2023.06.038] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/09/2023] [Revised: 06/15/2023] [Accepted: 06/26/2023] [Indexed: 09/15/2023]
Affiliation(s)
- Daphne T Hsu
- Departments of Pediatrics and Medicine, Albert Einstein College of Medicine, Bronx, New York, USA.
| | - George K Lui
- Departments of Medicine and Pediatrics, Stanford University School of Medicine, Palo Alto, California, USA
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21
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Stout K, Buber J. The Last Stage of the Fontan Operation? J Am Coll Cardiol 2023; 81:2172-2174. [PMID: 37257952 DOI: 10.1016/j.jacc.2023.04.023] [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: 04/19/2023] [Accepted: 04/21/2023] [Indexed: 06/02/2023]
Affiliation(s)
- Karen Stout
- Division of Cardiology, Department of Medicine, University of Washington and Seattle Children's Hospital, Seattle, Washington, USA.
| | - Jonathan Buber
- Division of Cardiology, Department of Medicine, University of Washington and Seattle Children's Hospital, Seattle, Washington, USA
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