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Venkatesh P, Gao H, Abudayyeh I, Pai RG, Varadarajan P. Contemporary Management of the Failing Fontan. J Clin Med 2024; 13:3049. [PMID: 38892760 PMCID: PMC11172880 DOI: 10.3390/jcm13113049] [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: 05/19/2024] [Accepted: 05/21/2024] [Indexed: 06/21/2024] Open
Abstract
Adult patients with congenital heart disease have now surpassed the pediatric population due to advances in surgery and improved survival. One such complex congenital heart disease seen in adult patients is the Fontan circulation. These patients have complex physiology and are at risk for several complications, including thrombosis of the Fontan pathway, pulmonary vascular disease, heart failure, atrial arrhythmias, atrioventricular valve regurgitation, and protein-losing enteropathy. This review discusses the commonly encountered phenotypes of Fontan circulatory failure and their contemporary management.
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Affiliation(s)
- Prashanth Venkatesh
- Smidt Heart Institute, Department of Cardiology, Cedars-Sinai Medical Center, Los Angeles, CA 90048, USA; (P.V.); (H.G.)
| | - Hans Gao
- Smidt Heart Institute, Department of Cardiology, Cedars-Sinai Medical Center, Los Angeles, CA 90048, USA; (P.V.); (H.G.)
| | | | - Ramdas G. Pai
- California University of Science and Medicine, Colton, CA 92324, USA;
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2
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Yang EL, Evers PD, Long MJ, Mostafavifar M, Balaji S. Impact of Atrial Pacing in Fontan Patients with Junctional Rhythm: A Prospective Echocardiographic Study. Pediatr Cardiol 2024; 45:361-367. [PMID: 38062259 DOI: 10.1007/s00246-023-03345-0] [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: 06/28/2023] [Accepted: 11/03/2023] [Indexed: 01/28/2024]
Abstract
Sinus node dysfunction (SND) with junctional rhythm (JR) is common after the Fontan operation. Atrial pacing (AP) restores atrioventricular (AV) synchrony, but the placement of a pacemaker carries significant morbidity. To study the impact of AP on echocardiographic parameters of function in Fontan patients with SND and JR. Nine Fontan patients with AP for SND and JR were prospectively studied with echocardiography in the following conditions-baseline paced rhythm, underlying JR and, if possible, slow-paced rhythm below their baseline paced rate (~ 10 bpm faster than their JR rate). Cardiac index was significantly lower in JR (3 ± 1.1 L/min/m2) vs AP (4.2 ± 1.4 L/min/m2; p = 0.002). Diastolic function also significantly worsened with increased ratio of early diastolic systemic AV valve inflow velocity to early diastolic systemic AV valve annulus velocity (E/e' ratio) by tissue Doppler imaging (TDI) in JR (11.6 ± 4.6) vs AP (8.8 ± 2.2, p = 0.016). Pulmonary venous flow reversal was present in 7/9 patients in JR vs 0/9 in AP (p = 0.016). There were no significant differences in these echocardiographic measurements between the paced and slow-paced conditions. When compared to AP, JR was associated with a significant reduction in cardiac output and diastolic function, and an increased prevalence of pulmonary vein flow reversal. There were no differences between paced and slow-paced conditions, suggesting that AV synchrony rather than heart rate was primarily contributing to cardiac output. Further studies are needed to understand the chronic impact of JR on Fontan outcomes.
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Affiliation(s)
- Emily L Yang
- Division of Pediatric Cardiology, Oregon Health and Science University, 707 SW Gaines Street, Mail code: CDRC-P, Portland, OR, 97239, USA.
| | - Patrick D Evers
- Division of Pediatric Cardiology, Oregon Health and Science University, 707 SW Gaines Street, Mail code: CDRC-P, Portland, OR, 97239, USA
| | - Mia J Long
- Division of Pediatric Cardiology, Oregon Health and Science University, 707 SW Gaines Street, Mail code: CDRC-P, Portland, OR, 97239, USA
| | - Mina Mostafavifar
- Division of Pediatric Cardiology, Oregon Health and Science University, 707 SW Gaines Street, Mail code: CDRC-P, Portland, OR, 97239, USA
| | - Seshadri Balaji
- Division of Pediatric Cardiology, Oregon Health and Science University, 707 SW Gaines Street, Mail code: CDRC-P, Portland, OR, 97239, USA
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3
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Datta S, Cao W, Skillman M, Wu M. Hypoplastic Left Heart Syndrome: Signaling & Molecular Perspectives, and the Road Ahead. Int J Mol Sci 2023; 24:15249. [PMID: 37894928 PMCID: PMC10607600 DOI: 10.3390/ijms242015249] [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: 09/13/2023] [Revised: 10/07/2023] [Accepted: 10/12/2023] [Indexed: 10/29/2023] Open
Abstract
Hypoplastic left heart syndrome (HLHS) is a lethal congenital heart disease (CHD) affecting 8-25 per 100,000 neonates globally. Clinical interventions, primarily surgical, have improved the life expectancy of the affected subjects substantially over the years. However, the etiological basis of HLHS remains fundamentally unclear to this day. Based upon the existing paradigm of studies, HLHS exhibits a multifactorial mode of etiology mediated by a complicated course of genetic and signaling cascade. This review presents a detailed outline of the HLHS phenotype, the prenatal and postnatal risks, and the signaling and molecular mechanisms driving HLHS pathogenesis. The review discusses the potential limitations and future perspectives of studies that can be undertaken to address the existing scientific gap. Mechanistic studies to explain HLHS etiology will potentially elucidate novel druggable targets and empower the development of therapeutic regimens against HLHS in the future.
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Affiliation(s)
| | | | | | - Mingfu Wu
- Department of Pharmacological and Pharmaceutical Sciences, College of Pharmacy, University of Houston, Houston, TX 77204, USA; (S.D.); (W.C.); (M.S.)
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4
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Kamsheh AM, O'Connor MJ, Rossano JW. Management of circulatory failure after Fontan surgery. Front Pediatr 2022; 10:1020984. [PMID: 36425396 PMCID: PMC9679629 DOI: 10.3389/fped.2022.1020984] [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: 08/16/2022] [Accepted: 10/18/2022] [Indexed: 11/11/2022] Open
Abstract
With improvement in survival after Fontan surgery resulting in an increasing number of older survivors, there are more patients with a Fontan circulation experiencing circulatory failure each year. Fontan circulatory failure may have a number of underlying etiologies. Once Fontan failure manifests, prognosis is poor, with patient freedom from death or transplant at 10 years of only about 40%. Medical treatments used include traditional heart failure medications such as renin-angiotensin-aldosterone system blockers and beta-blockers, diuretics for symptomatic management, antiarrhythmics for rhythm control, and phosphodiesterase-5 inhibitors to decrease PVR and improve preload. These oral medical therapies are typically not very effective and have little data demonstrating benefit; if there are no surgical or catheter-based interventions to improve the Fontan circulation, patients with severe symptoms often require inotropic medications or mechanical circulatory support. Mechanical circulatory support benefits patients with ventricular dysfunction but may not be as useful in patients with other forms of Fontan failure. Transplant remains the definitive treatment for circulatory failure after Fontan, but patients with a Fontan circulation face many challenges both before and after transplant. There remains significant room and urgent need for improvement in the management and outcomes of patients with circulatory failure after Fontan surgery.
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Affiliation(s)
- Alicia M Kamsheh
- Division of Cardiology, Children's Hospital of Philadelphia, United States
| | - Matthew J O'Connor
- Division of Cardiology, Children's Hospital of Philadelphia, United States
| | - Joseph W Rossano
- Division of Cardiology, Children's Hospital of Philadelphia, United States
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Hoyt WJ, Moore JP, Shannon KM, Kannankeril PJ, Fish FA. Epicardial atrial pacing after the extracardiac Fontan operation: Feasibility of an entirely transvenous approach. J Cardiovasc Electrophysiol 2021; 33:128-133. [PMID: 34716972 DOI: 10.1111/jce.15285] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/09/2021] [Revised: 10/02/2021] [Accepted: 10/20/2021] [Indexed: 11/28/2022]
Abstract
This series describes an innovative technique for pacing in patients with sinus node dysfunction after extracardiac Fontan surgery. This transpulmonary approach to the left atrial epi-myocardium has been successfully applied to three patients at two centers and resulted in excellent acute and midterm pacing characteristics without known complications. The principal advantage of this procedure in comparison to prior iterations is the absence of pacing material within the pulmonary venous atrium, so that future systemic thromboembolism risk is minimized. The transpulmonary approach for permanent atrial pacing offers a novel solution to the unique challenges for patients after extracardiac Fontan operation.
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Affiliation(s)
- Walter J Hoyt
- Division of Pediatric Cardiology, Department of Pediatrics, Ochsner Health System, New Orleans, Louisiana, USA
| | - Jeremy P Moore
- Department of Pediatrics, Division of Pediatric Cardiology, UCLA Health System, Los Angeles, California, USA.,Division of Cardiology, Department of Medicine, Ahmanson/UCLA Adult Congenital Heart Disease Center, UCLA Health System, Los Angeles, California, USA.,Division of Cardiology, Department of Medicine, UCLA Cardiac Arrhythmia Center, UCLA Health System, Los Angeles, California, USA
| | - Kevin M Shannon
- Department of Pediatrics, Division of Pediatric Cardiology, UCLA Health System, Los Angeles, California, USA.,Division of Cardiology, Department of Medicine, Ahmanson/UCLA Adult Congenital Heart Disease Center, UCLA Health System, Los Angeles, California, USA.,Division of Cardiology, Department of Medicine, UCLA Cardiac Arrhythmia Center, UCLA Health System, Los Angeles, California, USA
| | - Prince J Kannankeril
- Division of Pediatric Cardiology, Department of Pediatrics, Vanderbilt University, Nashville, Tennessee, USA
| | - Frank A Fish
- Division of Pediatric Cardiology, Department of Pediatrics, Vanderbilt University, Nashville, Tennessee, USA
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Rychik J. What “FUEL”s the Fontan circulation—solvitur ambulando! J Thorac Cardiovasc Surg 2021; 162:1234-1238. [DOI: 10.1016/j.jtcvs.2020.08.114] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/03/2020] [Revised: 08/10/2020] [Accepted: 08/11/2020] [Indexed: 01/01/2023]
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Ferrero P, Piazza I, Sadou Y, Ciuffreda M. Reversible acute Fontan circulation failure secondary to retrogradely conducted junctional rhythm: clinical echocardiographic correlation. JOURNAL OF CONGENITAL CARDIOLOGY 2021. [DOI: 10.1186/s40949-021-00063-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
Abstract
Background
Sequential atrioventricular activation plays a critical role in the physiology of Fontan circulation. Although bradycardia is usually well tolerated, retrogradely conducted junctional rhythm may acutely increase atrial pressure impairing cardiac output. Echocardiographic evaluation can reveal clues of this hemodynamic condition. The clinical impact of arrhythmic disturbance on the follow up of patients who had undergone total cavo-pulmonary connection is well recognized but the role of, transient periods of retrogradely conducted junctional rhythm on the immediate post-operative course is less defined.
Case presentation
We describe two cases of acute Fontan circulatory failure due to postoperative retrogradely conducted junctional escape rhythm despite an adequate heart rate and circadian variation. The patients rapidly improved after atrial pacing, allowing discharge with a minimal dose of diuretic.
Conclusion
In the absence of any hemodynamic target, hearth rhythm should be systematically checked after TCPC irrespective of adequacy of heart rate. Likewise, efficiency of temporary atrial pacing should be granted and surgeons should have a low threshold for epicardial lead implantation.
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Abstract
Hypoplastic left heart syndrome (HLHS) is a complex form of congenital heart disease defined by anatomic and functional inadequacy of the left side of the heart with nonviability of the left ventricle to perform systemic perfusion. Lethal if not treated, a strategy for survival currently is well established, with continuing improvement in outcomes over the past 30 years. Prenatal diagnosis, good newborn care, improved surgical skills, specialized postoperative care, and unique strategies for interstage monitoring all have contributed to increasing likelihood of survival. The unique life with a single right ventricle and a Fontan circulation is a focused area of investigation.
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Abstract
The aim of this study was to describe serial changes in echocardiographic Doppler pulmonary vein flow (PVF) patterns in infants with single right ventricle (RV) anomalies enrolled in the Single Ventricle Reconstruction trial. Measurement of PVF peak systolic (S) and diastolic (D) velocities, velocity time integrals (VTI), S/D peak velocity and VTI ratios, and frequency of atrial reversal (Ar) waves were made at three postoperative time points in 261 infants: early post-Norwood, pre-stage II surgery, and 14 months. Indices were compared over time, between initial shunt type [modified Blalock-Taussig shunt (MBTS) and right ventricle-to-pulmonary artery shunt (RVPAS)] and in relation to clinical outcomes. S velocities and VTI increased over time while D wave was stable, resulting in increasing S/D peak velocity and VTI ratios, with a median post-Norwood S/D VTI ratio of 1.14 versus 1.38 at pre-stage II and 1.89 at 14 months (P < 0.0001 between intervals). MBTS subjects had significantly higher S/D peak velocity and VTI ratios compared to RVPAS at the post-Norwood and pre-stage II time points (P < 0.0001) but not by 14 months. PVF patterns did not correlate with survival or hospitalization course at 1 year. PVF patterns after Norwood palliation differ from normal infants by having a dominant systolic pattern throughout infancy. PVF differences based upon shunt type resolve by 14 months and did not correlate with clinical outcomes. This study describes normative values and variations in PVF for infants with a single RV from shunt-dependent pulmonary blood flow to cavopulmonary blood flow.
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Kirklin JK, Pearce FB, Dabal RJ, Carlo WF, Mauchley DC. Challenges of Cardiac Transplantation Following the Fontan Procedure. World J Pediatr Congenit Heart Surg 2017; 8:480-486. [DOI: 10.1177/2150135117714460] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- James K. Kirklin
- Division of Cardiothoracic Surgery, Department of Surgery, University of Alabama at Birmingham, Birmingham, AL, USA
| | - F. Bennett Pearce
- Division of Pediatric Cardiology, Department of Pediatrics, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Robert J. Dabal
- Division of Cardiothoracic Surgery, Department of Surgery, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Waldemar F. Carlo
- Division of Pediatric Cardiology, Department of Pediatrics, University of Alabama at Birmingham, Birmingham, AL, USA
| | - David C. Mauchley
- Division of Cardiothoracic Surgery, Department of Surgery, University of Alabama at Birmingham, Birmingham, AL, USA
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Januszewska K, Schuh A, Lehner A, Dalla-Pozza R, Malec E. Lateral Atrial Tunnel Fontan Operation Predisposes to the Junctional Rhythm. Pediatr Cardiol 2017; 38:712-718. [PMID: 28184977 DOI: 10.1007/s00246-017-1571-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/19/2016] [Accepted: 01/19/2017] [Indexed: 11/30/2022]
Abstract
The goal of the study was to compare the early postoperative course after fenestrated lateral atrial tunnel (LT) and non-fenestrated extracardiac conduit (EC) Fontan operation (FO) in a single center where both techniques were parallelly used. Between 2004 and 2012, 56(32.7%) children underwent LT and 113(66.1%) EC FO. The mean age was 3.7 ± 2.9 years and mean weight was 14.6 ± 7.3 kg. The most common malformation was hypoplastic left heart syndrome (50.9%). The general approach was to perform LT in children after hemi-Fontan operation and EC in patients after Glenn anastomosis. Medical records were retrospectively reviewed. The hospital survival was 100%. In EC group, cardiopulmonary bypass time (CPB) was shorter (p = 0.004) and less patients needed aortic cross-clamping (p < 0.001). Children after EC stayed longer in the hospital (p = 0.016) and manifested more often prolonged effusions (p = 0.038). The incidence of all forms of junctional rhythm was higher in the LT group, early postoperatively (p < 0.001), during hospitalization (p = 0.004) and at discharge (p < 0.001). Children after LT required more often temporary pacemaker stimulation (p < 0.001). Patients without postoperative normofrequent sinus rhythm had longer CPB time (p = 0.008) and were more often operated on with aortic cross-clamping (p = 0.028). Lateral atrial tunnel Fontan operation with fenestration facilitates early adaptation to the total passive pulmonary flow, but predisposes the patients to the loss of sinus rhythm. The crucial role in the preservation of sinus rhythm plays the last step of the multistage surgery of the single ventricle malformations, probably not only the surgical technique but also factors associated with the cardiopulmonary bypass.
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Affiliation(s)
- Katarzyna Januszewska
- Division of Pediatric Cardiac Surgery, Department of Cardiothoracic Surgery, University Hospital Muenster, Albert-Schweitzer-Campus 1, Geb. A1, 48149, Muenster, Germany.
| | - Anna Schuh
- Department of Pediatric Cardiology and Pediatric Intensive Care, Ludwig-Maximilian-University, Klinikum Großhadern, Marchioninistr.15, 81377, Munich, Germany
| | - Anja Lehner
- Department of Pediatric Cardiology and Pediatric Intensive Care, Ludwig-Maximilian-University, Klinikum Großhadern, Marchioninistr.15, 81377, Munich, Germany
| | - Robert Dalla-Pozza
- Department of Pediatric Cardiology and Pediatric Intensive Care, Ludwig-Maximilian-University, Klinikum Großhadern, Marchioninistr.15, 81377, Munich, Germany
| | - Edward Malec
- Division of Pediatric Cardiac Surgery, Department of Cardiothoracic Surgery, University Hospital Muenster, Albert-Schweitzer-Campus 1, Geb. A1, 48149, Muenster, Germany
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Schiavazzi DE, Baretta A, Pennati G, Hsia TY, Marsden AL. Patient-specific parameter estimation in single-ventricle lumped circulation models under uncertainty. INTERNATIONAL JOURNAL FOR NUMERICAL METHODS IN BIOMEDICAL ENGINEERING 2017; 33:10.1002/cnm.2799. [PMID: 27155892 PMCID: PMC5499984 DOI: 10.1002/cnm.2799] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/30/2015] [Revised: 03/05/2016] [Accepted: 04/21/2016] [Indexed: 05/08/2023]
Abstract
Computational models of cardiovascular physiology can inform clinical decision-making, providing a physically consistent framework to assess vascular pressures and flow distributions, and aiding in treatment planning. In particular, lumped parameter network (LPN) models that make an analogy to electrical circuits offer a fast and surprisingly realistic method to reproduce the circulatory physiology. The complexity of LPN models can vary significantly to account, for example, for cardiac and valve function, respiration, autoregulation, and time-dependent hemodynamics. More complex models provide insight into detailed physiological mechanisms, but their utility is maximized if one can quickly identify patient specific parameters. The clinical utility of LPN models with many parameters will be greatly enhanced by automated parameter identification, particularly if parameter tuning can match non-invasively obtained clinical data. We present a framework for automated tuning of 0D lumped model parameters to match clinical data. We demonstrate the utility of this framework through application to single ventricle pediatric patients with Norwood physiology. Through a combination of local identifiability, Bayesian estimation and maximum a posteriori simplex optimization, we show the ability to automatically determine physiologically consistent point estimates of the parameters and to quantify uncertainty induced by errors and assumptions in the collected clinical data. We show that multi-level estimation, that is, updating the parameter prior information through sub-model analysis, can lead to a significant reduction in the parameter marginal posterior variance. We first consider virtual patient conditions, with clinical targets generated through model solutions, and second application to a cohort of four single-ventricle patients with Norwood physiology. Copyright © 2016 John Wiley & Sons, Ltd.
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Affiliation(s)
| | - Alessia Baretta
- Department of Chemistry, Materials and Chemical Engineering, Politecnico di Milano, Milano, Italy
| | - Giancarlo Pennati
- Department of Chemistry, Materials and Chemical Engineering, Politecnico di Milano, Milano, Italy
| | - Tain-Yen Hsia
- Great Ormond Street Hospital for Children and UCL Institute of Cardiovascular Science, London, UK
| | - Alison L Marsden
- Department of Pediatrics, Bioengineering and ICME, Stanford University, Stanford, CA, USA
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Rychik J. The Relentless Effects of the Fontan Paradox. Semin Thorac Cardiovasc Surg Pediatr Card Surg Annu 2016; 19:37-43. [PMID: 27060041 DOI: 10.1053/j.pcsu.2015.11.006] [Citation(s) in RCA: 113] [Impact Index Per Article: 14.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2015] [Accepted: 11/25/2015] [Indexed: 06/05/2023]
Abstract
The Fontan operation is the anticipated palliative strategy for children born with single-ventricle type of congenital heart disease. As a result of important circulatory limitations, a series of end-organ complications are now increasingly recognized. Elevated central venous pressure and impaired cardiac output are the hallmarks of cavo-pulmonary flow, which result in a cascade of pathophysiological consequences. The Fontan circulation likely impacts all organ systems in an indolent and relentless manner, with progressive decline in functionality likely to occur in many. Liver fibrosis, altered bone density, decreased muscle mass, renal dysfunction, lymphatic insufficiency, and a host of other conditions are present. Standardized screening and evaluation of survivors as they grow through childhood and beyond is indicated and can be facilitated through dedicated multidisciplinary clinical programs. Invasive assessment at specific milestones can provide important actionable information to optimize individual status. More detailed characterization and understanding of these end-organ complications is necessary to contribute to the goal of achieving a normal duration and quality of life for these unique individuals.
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Affiliation(s)
- Jack Rychik
- Single Ventricle Survivorship Program, The Children's Hospital of Philadelphia, Philadelphia, PA.
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End-organ consequences of the Fontan operation: liver fibrosis, protein-losing enteropathy and plastic bronchitis. Cardiol Young 2013; 23:831-40. [PMID: 24401255 DOI: 10.1017/s1047951113001650] [Citation(s) in RCA: 73] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
Abstract
The Fontan operation, although part of a life-saving surgical strategy, manifests a variety of end-organ complications and unique morbidities that are being recognised with increasing frequency as patients survive into their second and third decades of life and beyond. Liver fibrosis, protein-losing enteropathy and plastic bronchitis are consequences of a complex physiology involving circulatory insufficiency, inflammation and lymphatic derangement. These conditions are manifest in a chronic, indolent state. Management strategies are emerging, which shed some light on the origins of these complications. A better characterisation of the end-organ consequences of the Fontan circulation is necessary, which can then allow for development of specific methods for treatment. Ideally, the goal is to establish systematic strategies that might reduce or eliminate the development of these potentially life-threatening challenges.
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Rychik J, Goldberg D, Dodds K. Long-term results and consequences of single ventricle palliation. PROGRESS IN PEDIATRIC CARDIOLOGY 2010. [DOI: 10.1016/j.ppedcard.2010.02.001] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
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17
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Modeling the Fontan circulation: where we are and where we need to go. Pediatr Cardiol 2008; 29:3-12. [PMID: 17917765 DOI: 10.1007/s00246-007-9104-0] [Citation(s) in RCA: 53] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/07/2007] [Revised: 06/30/2007] [Accepted: 07/03/2007] [Indexed: 10/22/2022]
Abstract
The Fontan procedure and its subsequent modifications over the past 30 years can be described as a class of surgical procedures for patients born with complex congenital heart disease exhibiting a single-ventricle physiology. The long-term outcome for children currently undergoing a Fontan procedure remains worrisome because of multiple late morbidities observed. Despite significant modeling efforts spanning three decades, improvements to the Fontan procedure have occurred without comprehensive validation from these modeling studies. Careful examination shows that modeling studies to date offer only a "glimpse through a keyhole" into understanding and modeling a representative range of the variations in anatomy and physiology that exist in Fontan patients. Suggestions for future investigations are provided.
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Selamet Tierney ES, Glickstein JS, Altmann K, Solowiejczyk DE, Mosca RS, Quaegebeur JM, Kleinman CS, Printz BF. Bidirectional cavopulmonary anastomosis: impact on diastolic ventricular function indices. Pediatr Cardiol 2007; 28:372-8. [PMID: 17687592 DOI: 10.1007/s00246-006-0122-0] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/27/2006] [Accepted: 04/18/2007] [Indexed: 11/26/2022]
Abstract
Systolic ventricular function has been demonstrated to remain unchanged following bidirectional cavopulmonary anastomosis (BCPA). The effects of BCPA on diastolic ventricular performance have not been critically assessed. The objective of this study was to evaluate the changes in diastolic ventricular function indices early after BCPA. Nineteen patients were enrolled prospectively. Transthoracic echocardiograms were performed at a median of 4 days prior to and 5 days subsequent to BCPA. Diastolic and systolic echocardiographic indices of ventricular performance were measured for the dominant ventricle. End diastolic volume decreased postoperatively (71.1 +/- 21.1 vs 68.08 +/- 17.9 ml/m2, p = 0.05). Tei index increased postoperatively (0.51 +/- 0.2 vs 0.62 +/- 0.1, p = 0.002), whereas inflow Doppler E velocity (70.3 +/- 13 vs 56.3 +/- 24.7 cm/sec, p = 0.04), E/A ratio (1.18 +/- 0.52 vs 0.84 +/- 0.2, p = 0.02), tissue Doppler E' velocity (9.5 +/- 2.5 vs 6.4 +/- 3.2 cm/sec, p = 0.03) and diastolic flow propagation velocity (56.5 +/- 12 vs 52.8 +/- 11 cm/sec, p = 0.04) all decreased. There was no change in ventricular mass, area change fraction, heart rate, or inflow Doppler A or tissue Doppler A' and S' velocities. This study demonstrated that diastolic indices of ventricular performance are altered indicating decreased diastolic function early following BCPA. Whether this observation is a result of a change in ventricular mass:volume ratio, loading conditions of the ventricle, ventricular geometry, or the effects of cardiopulmonary bypass remains to be determined.
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Affiliation(s)
- E S Selamet Tierney
- Division of Pediatric Cardiology, Morgan Stanley Children's Hospital of New York Presbyterian, Columbia University, College of Physicians & Surgeons, New York, NY, USA.
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Barber BJ, Batra AS, Burch GH, Shen I, Ungerleider RM, Brown JW, Turrentine MW, Mori M, Hsieh YC, Balaji S. Acute Hemodynamic Effects of Pacing in Patients With Fontan Physiology. J Am Coll Cardiol 2005; 46:1937-42. [PMID: 16286183 DOI: 10.1016/j.jacc.2005.07.045] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/05/2005] [Revised: 05/24/2005] [Accepted: 07/05/2005] [Indexed: 10/25/2022]
Abstract
OBJECTIVES The purpose of this research was to assess the hemodynamic response to atrial, ventricular, and dual-chamber pacing in patients with Fontan physiology. BACKGROUND Bradycardia, due to sinus node dysfunction or atrioventricular (AV) block, with need for pacing, is common after the Fontan operation. The optimal pacing mode for Fontan patients is unknown, but is critical, as hemodynamic aberrancies may cause severe clinical deterioration. We hypothesized that AV synchrony is vital for maximizing Fontan hemodynamics. METHODS A cross-over trial was conducted with 21 patients (age 2 to 18 years, median 4 years; male patients = 13) in the intensive care unit after a Fontan operation. Hemodynamic parameters, including mean left atrial pressure (LAP, in mm Hg), mean pulmonary artery pressure (PAP, in mm Hg), mean arterial blood pressure (MAP, in mm Hg), and indexed cardiac output via Fick (Qs, in l/min/m2) were measured with atrial, ventricular, and dual-chamber pacing. Measurements were made after pacing for 10 min in each mode, and a 10-min rest was given between each pacing maneuver. RESULTS Asynchronous ventricular (VOO) pacing resulted in significantly worse hemodynamics when compared to dual-chamber (DOO) and atrial (AOO) pacing with a higher LAP (9.4 VOO; 6.8 DOO; 5.4 AOO) and PAP (15.2 VOO; 13.5 DOO; 12.7 AOO) and lower Qs (3.0 VOO; 3.5 DOO; 3.9 AOO) and MAP (60.1 VOO; 66.5 DOO; 67.2 AOO). CONCLUSIONS Asynchronous ventricular pacing, after the Fontan procedure, has acute, adverse hemodynamic consequences (elevated LAP and PAP and decreased Qs and MAP).
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Affiliation(s)
- Brent J Barber
- Department of Pediatric Cardiology, Oregon Health & Science University, Portland, Oregon, USA.
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Pekkan K, Frakes D, De Zelicourt D, Lucas CW, Parks WJ, Yoganathan AP. Coupling Pediatric Ventricle Assist Devices to the Fontan Circulation: Simulations with a Lumped-Parameter Model. ASAIO J 2005; 51:618-28. [PMID: 16322728 DOI: 10.1097/01.mat.0000176169.73987.0d] [Citation(s) in RCA: 71] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
In pediatric ventricular assist device (VAD) design, the process of matching device characteristics and dimensions to the relevant disease conditions poses a formidable challenge because the disease spectrum is more highly varied than for adult applications. One example arises with single-ventricle congenital defects, which demand palliative surgeries that create elevated systemic venous pressure and altered pulmonary hemodynamics. Substituting a mechanical pump as a right ventricle has long been proposed to eliminate the associated early and postoperative anomalies. A pulsatile lumped-parameter model of the single-ventricle circulation was developed to guide the preliminary design studies. Two special modules, the pump characteristics and the total cavopulmonary connection (TCPC) module, are introduced. The TCPC module incorporates the results of three-dimensional patient-specific computational fluid dynamics calculations, where the pressure drop in the TCPC anastomosis is calculated at the equal vascular lung resistance operating point for different cardiac outputs at a steady 60/40 inferior vena cava/superior vena cava flow split. Preliminary results obtained with the adult parameters are presented with no ventricle remodeling or combined larger-size single ventricle. A detailed literature review of single-ventricle function is provided. Coupling a continuous pump to the single-ventricle circulation brought both the pulmonary and systemic venous pressures back to manageable levels. Selected VADs provided an acceptable cardiac output trace of the single left ventricle, after initial transients. Remodeling of the systemic venous compliance plays a critical role in performance and is included in this study. Pulsatile operation mode with rotational speed regulation highlighted the importance of TCPC and pulmonary artery compliances. Four different pumps and three patient-specific anatomical TCPC pathologies were studied. Magnitudes of the equivalent TCPC resistances were found to be comparable to the vascular resistances of the normal baseline circulation, significantly affecting both the VAD design and hemodynamics.
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Affiliation(s)
- Kerem Pekkan
- Cardiovascular Fluid Mechanics Laboratory, Wallace H. Coulter Department of Biomedical Engineering, Georgia Institute of Technology, Atlanta, GA 30332-0535, USA
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Hasselman T, Schneider D, Madan N, Jacobs M. Reversal of fenestration flow during ventricular systole in Fontan patients in junctional or ventricular paced rhythm. Pediatr Cardiol 2005; 26:638-41. [PMID: 16132285 DOI: 10.1007/s00246-005-0879-6] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
Sinus node dysfunction is relatively common in patients with Fontan palliation for single ventricle congenital heart disease, and such patients often are in junctional rhythm or may have pacemaker systems for bradycardia. Because the physiologic determinants of left atrial pressure play a major role in determining pulmonary blood flow and therefore cardiac output in Fontan patients, the loss of atrioventricular (AV) synchrony in junctional rhythm or demand ventricular pacing in these patients might be expected to influence cardiac output. We report two cases of Fontan patients with the absence of AV synchrony that resulted in reversal of flow through the Fontan fenestration during ventricular systole. In both cases, restoration of AV synchrony by atrial pacing resulted in the elimination of retrograde fenestration flow, increased cardiac output, and improved clinical status.
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Affiliation(s)
- T Hasselman
- University of Illinois at Chicago School of Medicine at Peoria, Children's Hospital of Illinois, 420 NE Glen Oak Avenue, Suite 304, Peoria, IL 61603, USA
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Abstract
BACKGROUND Respiration is known to be a significant contributor to pulmonary flow in patients who have had Glenn or Fontan procedures. OBJECTIVE The purpose of this study was to evaluate the effect of respiration on branch pulmonary artery flow in normal participants, in those with uncomplicated Glenn or Fontan procedures, and in those with uncomplicated biventricular (2V) repairs, and to compare them with similar groups of postoperative patients who had unilateral diaphragm paralysis. METHODS Twenty-one normal infants and children were studied, along with 10 who had undergone uncomplicated bidirectional Glenn or Fontan palliation. Also studied were 10 patients with uncomplicated 2V repairs and 17 patients having ultrasound demonstration of diaphragm paralysis. Nine had undergone Glenn or Fontan procedures and 8 had undergone 2V repair. With the use of conventional pulsed Doppler, branch right and left pulmonary artery waveforms were recorded during spontaneous respiration. The velocity time integral (VTI); heart rate (HR); and systolic, diastolic, and mean velocities were measured at end-expiration and during inspiration. The pulsatility index (PI) (PI = systolic velocity - diastolic velocity/mean velocity) was calculated for each condition. RESULTS In normal participants PI was 1.69 with a 4.7% increase with inspiration; VTI x HR was 1859. In patients who had undergone uncomplicated Glenn/Fontan procedures PI was 1.06 with a 27.5% increase with inspiration; VTI x HR was 1303, all P =.001 versus normal participants. In patients with 2V repairs PI was 1.7 with a 5.6% increase with inspiration; VTI x HR was 1850, all P = ns versus normal participants. Patients with Glenn/Fontan connections and diaphragm paralysis had lower PI (0.81), inspiratory increase (7.9%), and VTI x HR (610) on the affected side, all P =.001 versus the normal side, and versus patients who had undergone uncomplicated Glenn/Fontan procedures. Patients with 2V repair with a pulsatile source of pulmonary flow had a smaller significant difference in the measured indices. Three patients underwent diaphragm plication with improvement in PI, inspiratory increase in PI, and VTI x HR postplication. CONCLUSION In normal participants and patients with uncomplicated 2V repair, inspiration has little effect on PI in branch pulmonary arteries. In patients who have undergone uncomplicated Glenn/Fontan procedures, PI is less than that of normal participants and the effect of inspiration is approximately 5-fold greater. This significant effect of inspiration on pulmonary flow is lost on the affected side in patients with Glenn/Fontan connections and diaphragm paralysis, and is blunted on the affected side in patients with 2V repair and diaphragm paralysis. Loss of diaphragm function is associated with redistribution of pulmonary flow away from the affected side.
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Abstract
BACKGROUND Significant atrioventricular valve (AVV) insufficiency has been associated with increased mortality and morbidity in patients with single ventricle. Although many patients can be managed with valvuloplasty alone, some patients require AVV replacement. The optimal timing, outcome, and risk factors for AVV replacement in this population have not been described. METHODS We retrospectively reviewed our experience with AVV replacement in patients with single ventricle from January 1984 to August 2000. Outcome variables included mortality and valve-related complications. RESULTS Seventeen patients required AVV replacement. Prosthetic valve types included: St. Jude's valve in 14, Bjork-Shiley in 1, Hall-Kaster in 1, and Carpentier-Edwards in 1. Valve size ranged from 17 to 33 mm, Median age at valve replacement was 3.0 years (range 7 days to 17.3 years). Of the 16 subjects with normal atrioventricular conduction preoperatively, 7 (44%) developed postoperative complete heart block. Hospital mortality was 29%. Hospital mortality decreased significantly from 56% in 1984 to 1993 to no deaths from 1994 to 2000 (p = 0.03). Younger age (less than 2 years) at operation was also a risk factor for hospital mortality (p = 0.03). There were four late deaths in this series and 1 patient underwent heart transplantation. Of the surviving patients, none has required replacement of the prosthetic valve. No patients have had cerebrovascular accident subsequent to AVV replacement. Functional status is New York Heart Association functional class I in 5, class II in 1, and Class III in 1. CONCLUSIONS Atrioventricular valve replacement can be performed in patients with single ventricle with acceptable morbidity and mortality. The development of postoperative complete heart block is common. Survival after AVV replacement has improved in recent years, and intervention before patients develop ventricular dysfunction and atrial arrhythmias may further improve outcome.
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Affiliation(s)
- W T Mahle
- Division of Cardiology, Children's Hospital of Philadelphia, University of Pennsylvania School of Medicine, 19104, USA.
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Black MD, Smallhorn JF, Freedom RM. Aortic atresia with a ventricular septal defect: modified single-stage neonatal biventricular repair. Ann Thorac Surg 1999; 67:751-5. [PMID: 10215222 DOI: 10.1016/s0003-4975(98)01271-5] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND The spectrum of hypoplastic left heart disease is diverse but the surgical repair is strictly dichotomous, culminating in either a univentricular or a biventricular surgical repair. Although aortic atresia with a ventricular septal defect historically has been managed by conversion to a univentricular physiology, a biventricular repair occasionally has been attempted in stages or in conjunction with the implantation of multiple allografts or prosthetic conduits. Our repair strategy recently has evolved to the use of a modified single-stage biventricular repair using only autologous tissues without conduits. METHODS Retrospective analysis (1989 to 1997) of neonates with aortic atresia with a ventricular septal defect. RESULTS Five neonates underwent repair of aortic atresia with a ventricular septal defect. One died in the hospital. The mean age and weight of the neonates who underwent repair were 7.8 days (range, 2 to 17 days) and 3.2 kg (range, 3 to 3.6 kg), respectively. Three neonates had a univentricular repair and 2 had a modified biventricular repair. The latter two procedures were successful and the patients were discharged from the hospital. CONCLUSIONS Long-term results are lacking to attest to this surgical modification's superiority over either the standard multistage univentricular operation or the single-stage biventricular repair using multiple conduits. However, we are optimistic that routine use of this modification will enable a greater percentage of neonates to undergo a biventricular repair without the need for serial conduit revisions or future aortoplasty.
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Affiliation(s)
- M D Black
- Division of Cardiovascular Surgery, The Hospital for Sick Children and The University of Toronto, Ontario, Canada.
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