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Rahm AL, Razzouk JA, Foster CS, Voleti SL, Razzouk AJ, Fortuna RS. Does the External Pericardial Lateral Tunnel Fontan Pathway Enlarge to Accommodate Somatic Growth? A Preliminary Analysis. World J Pediatr Congenit Heart Surg 2024; 15:44-51. [PMID: 37525504 DOI: 10.1177/21501351231183975] [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] [Indexed: 08/02/2023]
Abstract
Objectives: An ideal Fontan pathway should be capable of adapting to changes in circulatory demands. The external pericardial lateral tunnel Fontan (EPLTF) is constructed of viable, autologous tissue and may be capable of changing in size. We investigated the ability of the EPLTF to enlarge with increasing physiologic demands of somatic growth. Methods: Retrospective review of echocardiographic images for patients with a minimum of five years follow-up after EPLTF. Serial echocardiographic measurements of the EPLTF pathway were obtained at three distinct locations: the inferior vena cava junction with the EPLTF, midsection of the EPLTF, and cross-sectional area of the EPLTF visualized in a four-chamber view. Body surface area (BSA) was calculated at the time of each echocardiographic measurement. Changes in echocardiographic measurements over time were analyzed and compared with changes in BSA. Results: A total of 332 echocardiographic studies from 38 patients were reviewed. Significant enlargement of the EPLTF pathway is observed at the inferior vena caval junction (P < .001), midsection (P < .01), and cross-sectional area (P < .001). Repeated measures correlation between pathway measurements and BSA is highly significant (P < .001). Conclusions: The EPLTF pathway enlarges over time in correlation with increasing BSA. Further research is needed to define ideal pathway size, differentiate normal physiologic growth from pathologic enlargement, and correlate changes with clinical outcomes.
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Affiliation(s)
- Amy L Rahm
- Department of Cardiothoracic Surgery, Loma Linda University Children's Hospital, Loma Linda, CA, USA
| | - Jacob A Razzouk
- Department of Cardiothoracic Surgery, Loma Linda University Children's Hospital, Loma Linda, CA, USA
| | - Carter S Foster
- Department of Cardiothoracic Surgery, Loma Linda University Children's Hospital, Loma Linda, CA, USA
| | - Sonia L Voleti
- Department of Pediatric Cardiology, Loma Linda University Children's Hospital, Loma Linda, CA, USA
| | - Anees J Razzouk
- Department of Cardiothoracic Surgery, Loma Linda University Children's Hospital, Loma Linda, CA, USA
| | - Randall S Fortuna
- Department of Cardiothoracic Surgery, Loma Linda University Children's Hospital, Loma Linda, CA, USA
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2
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Kelly JM, Mirhaidari GJM, Chang YC, Shinoka T, Breuer CK, Yates AR, Hor KN. Evaluating the Longevity of the Fontan Pathway. Pediatr Cardiol 2020; 41:1539-1547. [PMID: 33161457 PMCID: PMC10017017 DOI: 10.1007/s00246-020-02452-6] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/07/2020] [Accepted: 09/02/2020] [Indexed: 11/25/2022]
Abstract
Children born with single ventricle physiology who undergo Fontan palliation face a diverse set of long-term complications. However, patient follow-up has in large part been limited to single institutional experiences without uniform application of diagnostic modalities to screen for relevant outcomes. Additionally, the use of different graft materials and variable surgical technique as part of the Fontan procedure has further complicated the evaluation of single ventricle patients. The purpose of this review is to define the changes in the Fontan pathway specific to the graft material used and its relationship to patient outcomes. As a means of introduction, we briefly review the historical evolution of the Fontan procedure with a focus on the intent behind design changes and incorporation of different biomaterials. We further delineate changes to the Fontan pathway which include the development of stenosis, differential growth, thrombosis, and calcification. Ultimately, the recognition of the changes noted within the Fontan pathway need to be assessed relative to their impact on patient hemodynamics, functional capacity, and Fontan-associated comorbidities.
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Affiliation(s)
- John M Kelly
- Center for Regenerative Medicine, Abigail Wexner Research Institute At Nationwide Children's Hospital, Columbus, OH, USA.
- Department of Pediatrics, The Ohio State University College of Medicine, Columbus, OH, USA.
- The Heart Center, Nationwide Children's Hospital, Columbus, OH, USA.
| | - Gabriel J M Mirhaidari
- Center for Regenerative Medicine, Abigail Wexner Research Institute At Nationwide Children's Hospital, Columbus, OH, USA
- Biomedical Sciences Graduate Program, The Ohio State University College of Medicine, Columbus, OH, USA
| | - Yu-Chun Chang
- Center for Regenerative Medicine, Abigail Wexner Research Institute At Nationwide Children's Hospital, Columbus, OH, USA
- Biomedical Sciences Graduate Program, The Ohio State University College of Medicine, Columbus, OH, USA
| | - Toshiharu Shinoka
- Center for Regenerative Medicine, Abigail Wexner Research Institute At Nationwide Children's Hospital, Columbus, OH, USA
- The Heart Center, Nationwide Children's Hospital, Columbus, OH, USA
- Department of Cardiothoracic Surgery, Nationwide Children's Hospital, Columbus, OH, USA
| | - Christopher K Breuer
- Center for Regenerative Medicine, Abigail Wexner Research Institute At Nationwide Children's Hospital, Columbus, OH, USA
- Department of Surgery, The Ohio State University Wexner Medical Center, Columbus, OH, USA
- Department of Surgery, Nationwide Children's Hospital, Columbus, OH, USA
| | - Andrew R Yates
- Department of Pediatrics, The Ohio State University College of Medicine, Columbus, OH, USA
- The Heart Center, Nationwide Children's Hospital, Columbus, OH, USA
- Department of Critical Care Medicine, Nationwide Children's Hospital, Columbus, OH, USA
| | - Kan N Hor
- Department of Pediatrics, The Ohio State University College of Medicine, Columbus, OH, USA
- The Heart Center, Nationwide Children's Hospital, Columbus, OH, USA
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Liu X, Yuan H, Chen J, Cen J, Nie Z, Xu G, Wen S, Zhuang J. Outcomes following modified extracardiac Fontan procedure of direct total cavopulmonary connection with autologous vessels: a single-centre 10-year experience. Eur J Cardiothorac Surg 2020; 57:628-634. [PMID: 31740945 DOI: 10.1093/ejcts/ezz310] [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: 06/19/2019] [Revised: 09/14/2019] [Accepted: 10/16/2019] [Indexed: 11/12/2022] Open
Abstract
OBJECTIVES The modified extracardiac Fontan of direct total cavopulmonary connection (dTCPC) with entirely autologous vessels is a better solution in selected patients with functionally univentricular hearts because it combines the advantages of a tubular connection and of full growth potential. We investigated the mid-term to long-term outcomes of the physical condition of patients who had the dTCPC and assessed the growth potential of the autologous dTCPC pathway. METHODS From July 2005 to June 2014, 31 patients, aged 1.8-14.0 years, underwent a modified extracardiac Fontan with dTCPC at our institution. Twenty-two patients underwent a 1-stage dTCPC and 9 patients underwent a 2-stage dTCPC. The preoperative and postoperative data were reviewed retrospectively. RESULTS There were 17 (54.8%) boys and 14 (45.2%) girls, with a median age of 6.4 years (range 1.8-14.0 years) and a mean weight of 17.8 kg (range 9-41 kg). The mean follow-up period was 6.0 years (range 2.1-10.2 years). There was 1 early death and 2 late deaths. The event-free survival rate for the 31 patients was 88.9% at 10 years during the follow-up period. Late protein-losing enteropathy, thromboembolism, arrhythmia or heart failure were not observed. There was a significant difference between the preoperative and postoperative data for body mass index and the diameters of the autologous dTCPC pathway and pulmonary artery branches, confirming that the growth potential of the autologous dTCPC pathway was realized. CONCLUSIONS The dTCPC procedure could be performed with satisfactory midterm to long-term outcomes in selected patients. It has the potential of retaining the advantage of the extracardiac Fontan operation together with the potential for growth and the avoidance of prosthetic materials.
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Affiliation(s)
- Xiaobing Liu
- Department of Cardiovascular Surgery, Guangdong Cardiovascular Institute, Guangdong Provincial Key Laboratory of South China Structural Heart Disease, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangzhou, China
| | - Haiyun Yuan
- Department of Cardiovascular Surgery, Guangdong Cardiovascular Institute, Guangdong Provincial Key Laboratory of South China Structural Heart Disease, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangzhou, China
| | - Jimei Chen
- Department of Cardiovascular Surgery, Guangdong Cardiovascular Institute, Guangdong Provincial Key Laboratory of South China Structural Heart Disease, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangzhou, China
| | - Jianzheng Cen
- Department of Cardiovascular Surgery, Guangdong Cardiovascular Institute, Guangdong Provincial Key Laboratory of South China Structural Heart Disease, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangzhou, China
| | - Zhiqiang Nie
- Department of Epidemiology, Guangdong Cardiovascular Institute, WHO Collaborating Center for Research and Training in Cardiovascular Diseases, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangzhou, China
| | - Gang Xu
- Department of Cardiovascular Surgery, Guangdong Cardiovascular Institute, Guangdong Provincial Key Laboratory of South China Structural Heart Disease, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangzhou, China
| | - Shusheng Wen
- Department of Cardiovascular Surgery, Guangdong Cardiovascular Institute, Guangdong Provincial Key Laboratory of South China Structural Heart Disease, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangzhou, China
| | - Jian Zhuang
- Department of Cardiovascular Surgery, Guangdong Cardiovascular Institute, Guangdong Provincial Key Laboratory of South China Structural Heart Disease, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangzhou, China
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Talwar S, Marathe SP, Choudhary SK, Airan B. Where are we after 50 years of the Fontan operation? Indian J Thorac Cardiovasc Surg 2020; 37:42-53. [PMID: 33584026 DOI: 10.1007/s12055-019-00906-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2019] [Revised: 11/02/2019] [Accepted: 11/08/2019] [Indexed: 01/11/2023] Open
Abstract
First introduced in 1971, the Fontan procedure is the final common destination for all patients with a functional single ventricle. The procedure itself has evolved tremendously over the last five decades. This review traces this journey and presents the importance, outcomes and future outlook of the procedure in the current era.
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Affiliation(s)
- Sachin Talwar
- Cardiothoracic Centre, All India Institute of Medical Sciences, New Delhi, India
- Department of Cardiothoracic and Vascular Surgery, All India Institute of Medical Sciences, Ansari Nagar, New Delhi, 110029 India
| | | | - Shiv Kumar Choudhary
- Cardiothoracic Centre, All India Institute of Medical Sciences, New Delhi, India
| | - Balram Airan
- Mahatma Gandhi Hospital, Mahatma Gandhi University of Medical Sciences Technology, Jaipur, India
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5
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Extracardiac Versus Lateral Tunnel Fontan: A Meta-Analysis of Long-Term Results. Ann Thorac Surg 2019; 107:837-843. [DOI: 10.1016/j.athoracsur.2018.08.041] [Citation(s) in RCA: 26] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/15/2018] [Revised: 07/20/2018] [Accepted: 08/20/2018] [Indexed: 11/22/2022]
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6
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Konieczny A, Jędrzejczyk-Patej E, Kozielski J, Kowalska W, Bugajski M, Litwin L, Kalarus Z, Średniawa B, Kowalski O. The first successful implantation of an intravenous AAIR pacemaker into autologous extracardiac lateral tunnel Fontan in the child. J Electrocardiol 2018; 51:1015-1018. [PMID: 30497722 DOI: 10.1016/j.jelectrocard.2018.07.019] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2018] [Revised: 07/20/2018] [Accepted: 07/26/2018] [Indexed: 10/28/2022]
Abstract
Patients with a single ventricle have complex anatomy that requires staged palliation which is usually the Fontan procedure. This procedure has undergone a lot of modifications to improve hemodynamics. Despite these efforts, sinus node dysfunction (SND) and bradyarrythmias are still common complications after Fontan operation, therefore there is a need of pacemakers implantation. Unfortunately, the most frequent technique of creating Fontan cannale - the extracardiac lateral tunnel makes the transvenous access to the atrium difficult or impossible to achieve. We report a case of successful implantation of an endocardial atrial lead for SND in patient with an extracardiac autologous Fontan tunnel.
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Affiliation(s)
- Aleksandra Konieczny
- Student Scientific Circle at the Department of Cardiology, Congenital Heart Diseases and Electrotherapy, Silesian Center of Heart Diseases, Zabrze, Poland.
| | - Ewa Jędrzejczyk-Patej
- Department of Cardiology, Congenital Heart Diseases and Electrotherapy, Silesian Center for Heart Diseases, Zabrze, Poland
| | - Jonasz Kozielski
- Student Scientific Circle at the Department of Cardiology, Congenital Heart Diseases and Electrotherapy, Silesian Center of Heart Diseases, Zabrze, Poland
| | - Wiktoria Kowalska
- Student Scientific Circle at the Department of Cardiology, Congenital Heart Diseases and Electrotherapy, Silesian Center of Heart Diseases, Zabrze, Poland
| | - Maciej Bugajski
- Student Scientific Circle at the Department of Cardiology, Congenital Heart Diseases and Electrotherapy, Silesian Center of Heart Diseases, Zabrze, Poland
| | - Linda Litwin
- Department of Congenital Heart Diseases and Pediatric Cardiology, Silesian Center for Heart Diseases, Zabrze, Poland
| | - Zbigniew Kalarus
- Department of Cardiology, Congenital Heart Diseases and Electrotherapy, Silesian Center for Heart Diseases, Zabrze, Poland; Department of Cardiology, School of Medicine with the Division of Dentistry in Zabrze, Medical University of Silesia, Katowice, Poland
| | - Beata Średniawa
- Department of Cardiology, Congenital Heart Diseases and Electrotherapy, Silesian Center for Heart Diseases, Zabrze, Poland; Department of Cardiology, School of Medicine with the Division of Dentistry in Zabrze, Medical University of Silesia, Katowice, Poland
| | - Oskar Kowalski
- Department of Cardiology, Congenital Heart Diseases and Electrotherapy, Silesian Center for Heart Diseases, Zabrze, Poland; Department of Dietetics, School of Public Health in Bytom, Medical University of Silesia, Katowice, Poland
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7
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Attard C, Huang J, Monagle P, Ignjatovic V. Pathophysiology of thrombosis and anticoagulation post Fontan surgery. Thromb Res 2018; 172:204-213. [PMID: 29685556 DOI: 10.1016/j.thromres.2018.04.011] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2017] [Revised: 04/05/2018] [Accepted: 04/11/2018] [Indexed: 01/19/2023]
Abstract
The Fontan procedure has transformed the lives of children born with single-ventricle physiology, previously deemed inoperable. Worldwide, there are an increasing number of children with Fontan circulation, with the potential for survival into adulthood. Due to the abnormal circulation, Fontan patients have an increased risk of thromboembolic (TE) events, with up to 25% of events leading to death. Despite the importance of preventing TE events in this patient population, there is currently no clinical consensus on the optimal monitoring, thromboprophylaxis therapies, and treatment of these events. This paper reviews the available literature regarding anticoagulation in the pediatric and adult Fontan population, including the mechanisms for thrombosis and current antithrombotic therapies.
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Affiliation(s)
- Chantal Attard
- Murdoch Children's Research Institute, Haematology Research Group, Parkville, Victoria, Australia; Royal Children's Hospital, Department of Clinical Haematology, Parkville, Victoria, Australia; The University of Melbourne, Department of Paediatrics, Parkville, Victoria, Australia.
| | - Joanna Huang
- Murdoch Children's Research Institute, Haematology Research Group, Parkville, Victoria, Australia; Royal Children's Hospital, Department of Clinical Haematology, Parkville, Victoria, Australia; Monash University, School of Clinical Sciences, Clayton, Victoria, Australia
| | - Paul Monagle
- Murdoch Children's Research Institute, Haematology Research Group, Parkville, Victoria, Australia; Royal Children's Hospital, Department of Clinical Haematology, Parkville, Victoria, Australia; The University of Melbourne, Department of Paediatrics, Parkville, Victoria, Australia
| | - Vera Ignjatovic
- Murdoch Children's Research Institute, Haematology Research Group, Parkville, Victoria, Australia; Royal Children's Hospital, Department of Clinical Haematology, Parkville, Victoria, Australia
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8
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Schwartz I, McCracken CE, Petit CJ, Sachdeva R. Late outcomes after the Fontan procedure in patients with single ventricle: a meta-analysis. Heart 2018. [PMID: 29535229 DOI: 10.1136/heartjnl-2017-312807] [Citation(s) in RCA: 46] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/22/2022] Open
Abstract
OBJECTIVE More patients with Fontan physiology are reaching adulthood. The purpose of this meta-analysis was to evaluate the late outcomes of patients palliated with Fontan procedure and to assess the risk factors for mortality. METHODS PubMed, Embase and Web of Science were queried to retrieve observational studies of survival in patients following the Fontan procedure with ≥5 years of follow-up. A random-effects model was used to determine pooled survival estimates at 5, 10 and 15 years. Meta-regression was used to assess potential moderators for death. RESULTS Nineteen articles with a total of 5859 patients were included. The weighted mean follow-up time was 8.94±2.64 years with overall 8.3% deaths and 1.5% transplants. Pooled survival estimates at 5, 10 and 15 years were 90.7%, 87.2% and 87.5%, respectively; and 88.4%, 85.7% and 84.1%, respectively, for studies that included all three time intervals (n=4). Earliest surgical year included in the study, proportion of atriopulmonary connections versus extracardiac conduit or lateral tunnel, and older age at Fontan were associated with higher rates of death, but ventricular morphology was not. Protein-losing enteropathy, reoperation and pacemaker insertion were reported in 2.1%, 5.6% and 6.8% patients, respectively. CONCLUSIONS Survival following the Fontan procedure has improved with time and is influenced by Fontan type and age at the time of Fontan. At a mean follow-up of 8.9 years, there was no significant association between survival and ventricular morphology, not taking into account the mortality prior to Fontan.
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Affiliation(s)
- Ilana Schwartz
- School of Medicine, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Courtney E McCracken
- Department of Pediatrics, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Christopher J Petit
- Department of Pediatrics, Emory University School of Medicine, Atlanta, Georgia, USA.,Children's Healthcare of Atlanta, Sibley Heart Center Cardiology, Atlanta, Georgia, USA
| | - Ritu Sachdeva
- Department of Pediatrics, Emory University School of Medicine, Atlanta, Georgia, USA.,Children's Healthcare of Atlanta, Sibley Heart Center Cardiology, Atlanta, Georgia, USA
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9
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Kverneland LS, Kramer P, Ovroutski S. Five decades of the Fontan operation: A systematic review of international reports on outcomes after univentricular palliation. CONGENIT HEART DIS 2018; 13:181-193. [DOI: 10.1111/chd.12570] [Citation(s) in RCA: 61] [Impact Index Per Article: 10.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/28/2017] [Revised: 11/08/2017] [Accepted: 12/08/2017] [Indexed: 11/28/2022]
Affiliation(s)
- Laura S. Kverneland
- Department of Internal Medicine; Herlev Hospital; Copenhagen Denmark
- Department of Congenital Heart Disease/Pediatric Cardiology; German Heart Center Berlin; Berlin Germany
| | - Peter Kramer
- Department of Congenital Heart Disease/Pediatric Cardiology; German Heart Center Berlin; Berlin Germany
| | - Stanislav Ovroutski
- Department of Congenital Heart Disease/Pediatric Cardiology; German Heart Center Berlin; Berlin Germany
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10
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The Long-Term Management of Children and Adults with a Fontan Circulation: A Systematic Review and Survey of Current Practice in Australia and New Zealand. Pediatr Cardiol 2017; 38:56-69. [PMID: 27787594 DOI: 10.1007/s00246-016-1484-6] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/03/2016] [Accepted: 10/15/2016] [Indexed: 01/28/2023]
Abstract
Although long-term survival is now the norm, Fontan patients face significant morbidity and premature mortality. Wide variation exists in long-term Fontan management. With an aim of improving their long-term management, we conducted a systematic review to identify best available evidence and gaps in knowledge for future research focus. We also surveyed cardiologists in Australia and New Zealand managing Fontan patients, to determine the alignment of current local practice with best available evidence. A systematic review was conducted using strict search criteria (PRISMA guidelines), pertaining to long-term Fontan management. All adult congenital and paediatric cardiologists registered with The Australia and New Zealand Fontan Registry were invited to respond to an online survey. Reasonable quality evidence exists for non-inferiority of aspirin over warfarin for thromboprophylaxis in standard-risk Fontan patients. No strong evidence is currently available for the routine use of ACE inhibitors, beta blockers or pulmonary vasodilators. Little evidence exists regarding optimal arrhythmia treatment, exercise restriction/prescription, routine fenestration closure, elective Fontan conversion and screening/management of liver abnormalities. Although pregnancy is generally well tolerated, there are high rates of miscarriage and premature delivery. Thirty-nine out of 78 (50 %) cardiologists responded to the survey. Heterogeneity in response was demonstrated with regard to long-term anti-coagulation, other medication use, fenestration closure and pregnancy and contraception counselling. Substantial gaps in our knowledge remain with regard to the long-term management of Fontan patients. This is reflected in the survey of cardiologists managing these patients. We have identified a number of key areas for future research.
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O’Leary E, Alexander ME, Fynn-Thompson F, Mah D. Transvenous approach to pacemaker lead implantation for sinus node dysfunction after extracardiac lateral tunnel Fontan conduit placement. HeartRhythm Case Rep 2016; 2:495-498. [PMID: 28491745 PMCID: PMC5419993 DOI: 10.1016/j.hrcr.2016.07.006] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022] Open
Affiliation(s)
- Edward O’Leary
- Department of Pediatrics, Boston Children’s Hospital, Boston, Massachusetts
- Address reprint requests and correspondence: Dr Edward O’Leary, Department of Cardiology, Boston Children’s Hospital, 300 Longwood Avenue, Boston, MA 02115.Department of Cardiology, Boston Children’s Hospital, 300 Longwood AvenueBostonMA02115
| | - Mark E. Alexander
- Department of Cardiology, Boston Children’s Hospital, Boston, Massachusetts
| | | | - Douglas Mah
- Department of Cardiology, Boston Children’s Hospital, Boston, Massachusetts
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12
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Hallbergson A, Mascio CE, Rome JJ. Transcatheter fontan takedown. Catheter Cardiovasc Interv 2015; 86:849-54. [DOI: 10.1002/ccd.25963] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/31/2015] [Revised: 03/19/2015] [Accepted: 03/23/2015] [Indexed: 11/11/2022]
Affiliation(s)
- Anna Hallbergson
- Division of Cardiology; the Children's Hospital of Philadelphia, Perelman School of Medicine and the University of Pennsylvania; Philadelphia Pennsylvania
- Children's Heart Center, Skane University Hospital; Lund Sweden
| | - Christopher E. Mascio
- Division of Cardiothoracic Surgery; the Children's Hospital of Philadelphia, Perelman School of Medicine and the University of Pennsylvania; Philadelphia Pennsylvania
| | - Jonathan J. Rome
- Division of Cardiology; the Children's Hospital of Philadelphia, Perelman School of Medicine and the University of Pennsylvania; Philadelphia Pennsylvania
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13
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Davies RR, Pizarro C. Decision-Making for Surgery in the Management of Patients with Univentricular Heart. Front Pediatr 2015; 3:61. [PMID: 26284226 PMCID: PMC4515559 DOI: 10.3389/fped.2015.00061] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/31/2015] [Accepted: 06/21/2015] [Indexed: 12/24/2022] Open
Abstract
A series of technical refinements over the past 30 years, in combination with advances in perioperative management, have resulted in dramatic improvements in the survival of patients with univentricular heart. While the goal of single-ventricle palliation remains unchanged - normalization of the pressure and volume loads on the systemic ventricle, the strategies to achieve that goal have become more diverse. Optimal palliation relies on a thorough understanding of the changing physiology over the first years of life and the risks and consequences of each palliative strategy. This review describes how to optimize surgical decision-making in univentricular patients based on a current understanding of anatomy, physiology, and surgical palliation.
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Affiliation(s)
- Ryan Robert Davies
- Nemours Cardiac Center, A. I. duPont Hospital for Children , Wilmington, DE , USA ; Thomas Jefferson University , Philadelphia, PA , USA
| | - Christian Pizarro
- Nemours Cardiac Center, A. I. duPont Hospital for Children , Wilmington, DE , USA ; Thomas Jefferson University , Philadelphia, PA , USA
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Newcombe J, Gordon B, Razzouk A, Bailey L, Mandapati R. Extracardiac Autologous Pericardial Tunnel Fontan Allows Implantation of an Endocardial Atrial Lead for Sinus Node Dysfunction. Ann Thorac Surg 2014; 98:1094-6. [DOI: 10.1016/j.athoracsur.2013.09.115] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/24/2013] [Revised: 08/26/2013] [Accepted: 09/23/2013] [Indexed: 11/28/2022]
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15
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Lasa JJ, Glatz AC, Daga A, Shah M. Prevalence of arrhythmias late after the Fontan operation. Am J Cardiol 2014; 113:1184-8. [PMID: 24513470 DOI: 10.1016/j.amjcard.2013.12.025] [Citation(s) in RCA: 47] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/19/2013] [Revised: 12/18/2013] [Accepted: 12/18/2013] [Indexed: 10/25/2022]
Abstract
The extracardiac conduit (ECC) modification of the Fontan procedure has been theorized to reduce the risk of sinus node dysfunction and atrial arrhythmia compared with the intra-atrial lateral tunnel (ILT) Fontan. This study aimed to compare the prevalence of early and late arrhythmias in patients who underwent ECC and ILT Fontan from a similar era with long-term follow-up at a single institution. A retrospective cohort study was conducted of all patients who underwent ECC or ILT Fontan from 1995 to 2005 at The Children's Hospital of Philadelphia. Bradyarrhythmias (including sinus node dysfunction), tachyarrhythmias, and pacemaker burden prevalence was determined throughout early (<30 days) and late (>30 days) postoperative periods. Of 434 patients undergoing the Fontan procedure during the study period, a total of 87 and 106 patients who underwent ECC and ILT Fontan, respectively, met the inclusion criteria. There were no significant differences in risk of sinus node dysfunction or tachyarrhythmia in both early and late postoperative periods. Although the overall risk of late postoperative pacemaker therapy was lower for the ECC cohort (4.9% vs 15.7%, p=0.03), when adjusting for follow-up time, no significant difference was observed (odds ratio 3.1, 95% confidence interval 0.6 to 15.2, p=0.16). In conclusion, the overall prevalence of late postoperative arrhythmias observed after contemporary Fontan modifications is low. Intra-atrial reentrant tachycardia, a potentially fatal complication of the atriopulmonary Fontan operation was infrequently encountered in both ECC and ILT Fontan cohorts. Pacemaker use was higher in the ILT group, although this difference may be explained by differences in follow-up time. Despite the low prevalence of arrhythmias after contemporary Fontan modifications, ongoing surveillance is warranted as the onset of arrhythmias may emerge after longer follow-up time.
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Murphy MO, Glatz AC, Goldberg DJ, Rogers LS, Ravishankar C, Nicolson SC, Steven JM, Fuller S, Spray TL, Gaynor JW. Management of early Fontan failure: a single-institution experience. Eur J Cardiothorac Surg 2014; 46:458-64; discussion 464. [DOI: 10.1093/ejcts/ezu022] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
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Firdouse M, Agarwal A, Chan AK, Mondal T. Thrombosis and Thromboembolic Complications in Fontan Patients. Clin Appl Thromb Hemost 2014; 20:484-92. [DOI: 10.1177/1076029613520464] [Citation(s) in RCA: 46] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023] Open
Abstract
Hemodynamic fluctuations and thromboembolic complications are significant areas of concern during the postoperative management of patients with univentricular hearts. The objective of this study is to review the incidence and risk factors associated with thrombosis and thromboembolic complications following total cavopulmonary anastomosis, the third stage of the palliative surgical procedure. A literature search of published evidence was conducted on OvidSP MEDLINE(R) and Embase followed by paired title, abstract, and full-text screening based on specific inclusion criteria. High risks of thromboembolic outcomes were identified across studies, with variable incidences between 3% and 20%, high mortality rates up to 38%, and an inverse relationship with prophylaxis treatment administration. Several risk factors for thrombotic complications, including chronic systemic venous hypertension, protein-losing enteropathy, passive blood flow, atrial arrhythmias, conduit stenosis, prosthetic material use, coagulation factor abnormalities, and several patient characteristics were identified. Based on these findings, a prophylactic anticoagulation algorithm has been proposed.
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Affiliation(s)
| | - Arnav Agarwal
- Faculty of Health Sciences, McMaster University, Hamilton, Canada
| | - Anthony K. Chan
- Department of Pediatrics, McMaster Children’s Hospital, McMaster University, Hamilton, Canada
| | - Tapas Mondal
- Department of Pediatrics, McMaster Children’s Hospital, McMaster University, Hamilton, Canada
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Voges I, Jerosch-Herold M, Hart C, Scheewe J, Gabbert DD, Pardun E, Kramer HH, Rickers C. Anatomical and functional assessment of the intra-atrial lateral tunnel in the Fontan circulation. Eur J Cardiothorac Surg 2013; 44:462-7. [PMID: 23447475 DOI: 10.1093/ejcts/ezt066] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
OBJECTIVES In patients after completion of the total cavopulmonary connection (TCPC) with an intra-atrial lateral tunnel, deviations of the tunnel from an ideal straight tubular shape were observed. However, little is known about frequency and adverse effects of such shape deviations. We sought to analyse tunnel anatomy, dimensions and blood flow using cardiac magnetic resonance imaging (CMR). METHODS Fifty-four patients with hypoplastic left heart syndrome (HLHS; mean age 6.0 ± 2.4 years) underwent CMR with gradient-echo cine sequences, 2D- and 3D-phase-contrast imaging. We analysed anatomy, diameters, cross-sectional areas, volumes and blood flow of the tunnel. RESULTS Twenty-five patients had a tubular tunnel. In 29 patients, bulging and/or narrowing of the tunnel were present. Cross-sectional areas and volumes of the tunnel were not significantly different between the two groups. There were also no differences for the mean blood flow and the mean and maximal flow velocity (P = 0.05-0.6). In all the patients, the normalized tunnel volume was related to age (r = 0.44; P = 0.002) and body surface area (BSA; r = 0.42; P = 0.005). The mean tunnel blood flow correlated with age (r = 0.73; P = 0.001) and BSA (r = 0.83; P < 0.0001). CONCLUSIONS A considerable percentage of patients with an intra-atrial lateral tunnel develop mild deviations of the tunnel from ideal tubular shape. The correlation between tunnel volume and mean blood flow with age and BSA suggests that the capacity of the tunnel adjusts to body growth, independent of tunnel shapes that deviate from a fluid-dynamically favourable shape. Follow-up CMRs are needed to detect long-term effects of irregular tunnel shapes on flow dynamics.
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Affiliation(s)
- Inga Voges
- Department of Congenital Heart Disease and Pediatric Cardiology, University Hospital of Schleswig-Holstein, Kiel, Germany
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Michielon G, Carotti A, Pongiglione G, Cogo P, Parisi F. Orthotopic heart transplantation in patients with univentricular physiology. Curr Cardiol Rev 2013; 7:85-91. [PMID: 22548031 PMCID: PMC3197093 DOI: 10.2174/157340311797484259] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/01/2011] [Revised: 04/28/2011] [Accepted: 06/24/2011] [Indexed: 11/23/2022] Open
Abstract
Parallel advancements in surgical technique, preoperative and postoperative care, as well as a better understanding of physiology in patients with duct-dependent pulmonary or systemic circulation and a functional single ventricle, have led to superb results in staged palliation of most complex congenital heart disease (CHD) [1]. The Fontan procedure and its technical modifications have resulted in markedly improved outcomes of patients with single ventricle anatomy [2,3,4]. The improved early survival has led to an exponential increase of the proportion of Fontan patients surviving long into adolescence and young adulthood [5]. Improved early and late survival has not yet abolished late mortality secondary to myocardial failure, therefore increasing the referrals for cardiac transplantation [6]. Interstage attrition [7] is moreover expected in staged palliation towards completion of a Fontan-type circulation, while Fontan failure represents a growing indication for heart transplantation [8]. Heart transplantation has therefore become the potential “fourth stage” [9] or a possible alternative to a high-risk Fontan operation [10] in a strategy of staged palliation for single ventricle physiology. Heart transplant barely accounts for 16% of pediatric solid organ transplants [11]. The thirteenth official pediatric heart transplantation report- 2010 [11] indicates that pediatric recipients received only 12.5% of the total reported heart transplants worldwide. Congenital heart disease is not only the most common recipient diagnosis, but also the most powerful predictor of 1-year mortality after OHT. Results of orthotopic heart transplantations (OHT) for failing single ventricle physiology are mixed. Some authors advocate excellent early and mid-term survival after OHT for failing Fontan [9], while others suggest that rescue-OHT after failing Fontan seems unwarranted [10]. Moreover, OHT outcome appears to be different according to the surgical staging towards the Fontan operation and surgical technique of Fontan completion [12]. The focus of this report is a complete review of the recent literature on OHT for failing single ventricles, outlining the clinical issues affecting Fontan failure, OHT listing and OHT outcome. These data are endorsed reporting our experience with OHT for failing single ventricle physiology in recent years.
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Affiliation(s)
- Guido Michielon
- Dipartimento Medico-Chirurgico di Cardiologia Pediatrica Ospedale Pediatrico Bambino Gesù Roma, Italy
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20
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Gordon BM, Hasaniya NW, Newcombe JB, Daher NS, Jodhka U, Razzouk AJ, Bailey LL. Blake Drains: A Novel Method of Chest Drainage After Extracardiac Fontan Operation With Autologous Pericardium. Ann Thorac Surg 2012; 94:1289-94. [DOI: 10.1016/j.athoracsur.2012.03.077] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/07/2012] [Revised: 03/24/2012] [Accepted: 03/29/2012] [Indexed: 10/27/2022]
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21
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Todd Tzanetos DR, Yu C, Hernanz-Schulman M, Barr FE, Brown NJ. Prospective study of the incidence and predictors of thrombus in children undergoing palliative surgery for single ventricle physiology. Intensive Care Med 2012; 38:105-12. [PMID: 21979273 PMCID: PMC4747610 DOI: 10.1007/s00134-011-2378-y] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2011] [Accepted: 08/17/2011] [Indexed: 01/19/2023]
Abstract
PURPOSE To determine the incidence and clinical and biomarker predictors of perioperative thrombosis in children with single ventricle physiology undergoing staged palliation. METHODS Nineteen patients were enrolled and 16 completed the study. Serial ultrasounds of the central venous system were performed to evaluate for thrombus. Plasma antithrombin III, thrombin-antithrombin complex, protein C, protein S, tissue factor pathway inhibitor, plasminogen activator inhibitor-1, tissue plasminogen activator antigen, D-dimer, soluble CD40 ligand, and urinary thromboxane were measured serially before and after surgery. Cardiopulmonary bypass time, aortic cross clamp time, blood product administration, inotrope score, chest tube output, cardiac function by echocardiography, intensive care unit and hospital lengths of stay, and central venous catheter days were recorded. RESULTS The incidence of perioperative thrombus was 31%. Patients who developed a thrombus had poorer preoperative ventricular function (p = 0.03) and longer cardiopulmonary bypass times (p = 0.03) than those who did not develop a thrombus. Preoperative plasma antithrombin III was lower (p = 0.01) and tissue plasminogen activator antigen concentrations were higher (p = 0.02) in patients with a thrombus compared with patients without a thrombus. When measured over time, antithrombin III remained lower (p = 0.002) and tissue plasminogen activator antigen higher (p = 0.005) in those who developed a thrombus compared with those who did not. There were no other statistically significant differences in biomarkers of coagulation between patients with and without thrombosis. CONCLUSION One-third of patients undergoing palliative surgery for single ventricle physiology develop thrombosis. Decreased ventricular function, low antithrombin III, and increased tissue plasminogen activator may predict those most suitable for randomized clinical trials of anticoagulation.
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Affiliation(s)
- Deanna R Todd Tzanetos
- Department of Pediatrics, Division of Critical Care, University of Kentucky School of Medicine, Lexington, KY, USA.
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Outcomes in adult congenital heart surgery: analysis of the Society of Thoracic Surgeons database. J Thorac Cardiovasc Surg 2011; 142:1090-7. [PMID: 21911232 DOI: 10.1016/j.jtcvs.2011.07.028] [Citation(s) in RCA: 60] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/05/2011] [Revised: 07/11/2011] [Accepted: 07/19/2011] [Indexed: 02/02/2023]
Abstract
OBJECTIVE Outcomes data for adults undergoing congenital heart surgery are limited. Previous analyses used administrative data or focused on single-center outcomes. We describe the most common operations, patient characteristics, and postoperative outcomes using a multicenter clinical database. METHODS The study included adults (aged ≥ 18 years) listed in the Society of Thoracic Surgeons Congenital Heart Surgery Database (2000-2009). We describe patient characteristics and morbidity and mortality, and examine congenital procedures in the Society of Thoracic Surgeons Adult Cardiac Surgery Database to permit consideration of the primary dataset within a broader context. RESULTS A total of 5265 patients (68 centers) from the Society of Thoracic Surgeons Congenital Heart Surgery Database were included. Patients' median age was 25 years (interquartile range, 20-35). Common preoperative risk factors included noncardiac abnormalities (17%) and arrhythmia (14%). Overall, in-hospital mortality was 2.1%, 27% had 1 or more complication, and median length of stay was 5 days. Common operations included right ventricular outflow tract procedures (21%) and pacemaker/arrhythmia procedures (20%). We further evaluated cardiopulmonary bypass procedures in more than 100 patients. Mortality ranged from 0% (atrial septal defect repair) to 11% (Fontan revision/conversion). Separate evaluation of the Society of Thoracic Surgeons Adult Cardiac Surgery Database revealed 39,872 adults undergoing congenital heart operations. CONCLUSIONS Most adult congenital heart operations listed in the Society of Thoracic Surgeons Congenital Heart Surgery Database are performed in the third to fourth decades of life; approximately half are for right heart pathology or arrhythmia. Many patients have complications, but mortality is low with the exception of those undergoing Fontan revision/conversion. Many more adults undergoing congenital heart surgery are entered into the Society of Thoracic Surgeons Adult Cardiac Surgery Database.
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Chinnock RE, Bailey LL. Heart transplantation for congenital heart disease in the first year of life. Curr Cardiol Rev 2011; 7:72-84. [PMID: 22548030 PMCID: PMC3197092 DOI: 10.2174/157340311797484231] [Citation(s) in RCA: 38] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/26/2011] [Revised: 06/13/2011] [Accepted: 06/30/2011] [Indexed: 01/24/2023] Open
Abstract
Successful infant heart transplantation has now been performed for over 25 years. Assessment of long term outcomes is now possible. We report clinical outcomes for322 patients who received their heart transplant during infancy. Actuarial graft survival for newborn recipients is 59% at 25 years. Survival has improved in the most recent era. Cardiac allograft vasculopathy is the most important late cause of death with an actuarial incidence at 25 years of 35%. Post-transplant lymphoma is estimated to occur in 20% of infant recipients by25 years. Chronic kidney disease grade 3 or worse is present in 31% of survivors. The epidemiology of infant heart transplantation has changed through the years as the results for staged repair improved and donor resources remained stagnant. Most centers now employ staged repair for hypoplastic left heart syndrome and similar extreme forms of congenital heart disease. Techniques for staged repair, including the hybrid procedure, are described. The lack of donors is described with particular note regarding decreased donors due to newer programs for appropriate infant sleep positioning and infant car seats. ABO incompatible donors are a newer resource for maximizing donor resources, as is donation after circulatory determination of death and techniques to properly utilize more donors by expanding the criteria for what is an acceptable donor. An immunological advantage for the youngest recipients has long been postulated, and evaluation of this phenomenon may provide clues to the development of accommodation and/or tolerance.
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Affiliation(s)
- Richard E Chinnock
- Departments of Pediatrics, Loma Linda University School of Medicine Pediatric Heart Transplant Program Loma Linda University Children's Hospital Loma Linda, CA, USA.
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