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Ozawa H, Hoashi T, Ohuchi H, Kurosaki K, Ichikawa H. Long-Term Outcomes After Fenestration Closure in High-Risk Fontan Candidates. Pediatr Cardiol 2021; 42:1356-1364. [PMID: 33881601 DOI: 10.1007/s00246-021-02619-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/09/2020] [Accepted: 04/15/2021] [Indexed: 10/21/2022]
Abstract
The study aimed to assess the long-term outcomes after fenestration closure in patients at risk for Fontan failure. Of 119 patients who underwent Fontan operation between 1995 and 2004, fenestration was not created in 89 patients (NF group) and created in 30 patients with hypoplastic left heart syndrome, heterotaxy syndrome, high pulmonary arterial pressure, high systemic ventricular end-diastolic pressure, low ventricular ejection fraction, or atrioventricular valve regurgitation. All fenestrations were closed spontaneously or by catheter/surgical interventions, excepting two patients, and therefore, they were excluded. In fenestration group, patients with pre-Fontan mean pulmonary arterial pressure ≥ 15 mmHg or systemic atrioventricular valve regurgitation ≥ moderate were classified as high-risk Fontan candidates (F-HR group, n = 16), and the remaining patients were as standard-risk (F-SR group, n = 12). Protein-losing enteropathy-free survival rates did not differ among the three groups (p = 0.72). Serial follow-up catheter examinations after Fontan operation were completed in 69 patients in NF group and 11 patients in both F-SR and F-HR groups. Cardiac index and pulmonary vascular resistance significantly and similarly decreased over time in all groups, though the F-HR group showed lowest arterial oxygen saturation, lowest cardiac index, and highest pulmonary vascular resistance. The F-HR group also showed much veno-venous collaterals (p = 0.049), low peak oxygen consumption (p = 0.019), and low anaerobic threshold (p = 0.023) as compared to those in the F-SR group. In F-HR group, cyanosis remained after fenestration closure due to transformation from fenestration to veno-venous collaterals, which resulted in elevation of pulmonary vascular resistance, low cardiac index, and deterioration of exercise tolerance.
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Affiliation(s)
- Hideto Ozawa
- Department of Pediatric Cardiovascular Surgery, National Cerebral and Cardiovascular Center, 6-1 Kishibe-Shimmachi, Suita, Osaka, 564-8565, Japan
| | - Takaya Hoashi
- Department of Pediatric Cardiovascular Surgery, National Cerebral and Cardiovascular Center, 6-1 Kishibe-Shimmachi, Suita, Osaka, 564-8565, Japan.
| | - Hideo Ohuchi
- Department of Pediatric Cardiology, National Cerebral and Cardiovascular Center, Suita, Japan
| | - Kenichi Kurosaki
- Department of Pediatric Cardiology, National Cerebral and Cardiovascular Center, Suita, Japan
| | - Hajime Ichikawa
- Department of Pediatric Cardiovascular Surgery, National Cerebral and Cardiovascular Center, 6-1 Kishibe-Shimmachi, Suita, Osaka, 564-8565, Japan
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Contemporary Outcomes of the Fontan Operation: A Large Single-Institution Cohort. Ann Thorac Surg 2019; 108:1439-1446. [DOI: 10.1016/j.athoracsur.2019.05.039] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/22/2018] [Revised: 05/07/2019] [Accepted: 05/08/2019] [Indexed: 12/31/2022]
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Michel M, Zlamy M, Entenmann A, Pichler K, Scholl-Bürgi S, Karall D, Geiger R, Salvador C, Niederwanger C, Ohuchi H. Impact of the Fontan Operation on Organ Systems. Cardiovasc Hematol Disord Drug Targets 2019; 19:205-214. [PMID: 30747084 DOI: 10.2174/1871529x19666190211165124] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2018] [Revised: 01/09/2019] [Accepted: 01/29/2019] [Indexed: 02/06/2023]
Abstract
In patients having undergone the Fontan operation, besides the well discussed changes in the cardiac, pulmonary and gastrointestinal system, alterations of further organ systems including the hematologic, immunologic, endocrinological and metabolic are reported. As a medical adjunct to Fontan surgery, the systematic study of the central role of the liver as a metabolizing and synthesizing organ should allow for a better understanding of the pathomechanism underlying the typical problems in Fontan patients, and in this context, the profiling of endocrinological and metabolic patterns might offer a tool for the optimization of Fontan follow-up, targeted monitoring and specific adjunct treatment.
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Affiliation(s)
- Miriam Michel
- Department of Pediatrics III, Division of Cardiology, Pulmology, Allergology, and Cystic Fibrosis, Innsbruck Medical University, Anichstraße 35, 6020 Innsbruck, Austria
| | - Manuela Zlamy
- Department of Pediatrics I, Innsbruck Medical University, Anichstraße 35, 6020 Innsbruck, Austria
| | - Andreas Entenmann
- Department of Pediatrics I, Innsbruck Medical University, Anichstraße 35, 6020 Innsbruck, Austria
| | - Karin Pichler
- Department of Pediatrics, Vienna Medical University, Währinger Gürtel 16, 1090 Vienna, Austria
| | - Sabine Scholl-Bürgi
- Department of Pediatrics I, Innsbruck Medical University, Anichstraße 35, 6020 Innsbruck, Austria
| | - Daniela Karall
- Department of Pediatrics I, Innsbruck Medical University, Anichstraße 35, 6020 Innsbruck, Austria
| | - Ralf Geiger
- Department of Pediatrics III, Division of Cardiology, Pulmology, Allergology, and Cystic Fibrosis, Innsbruck Medical University, Anichstraße 35, 6020 Innsbruck, Austria
| | - Christina Salvador
- Department of Pediatrics I, Innsbruck Medical University, Anichstraße 35, 6020 Innsbruck, Austria
| | - Christian Niederwanger
- Department of Pediatrics I, Innsbruck Medical University, Anichstraße 35, 6020 Innsbruck, Austria
| | - Hideo Ohuchi
- Department for Pediatric Cardiology, National Cerebral and Cardiovascular Center, 5-7-1 Fujishiro-dai, Suita, Osaka 565-8565, Japan
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Poh CL, Celermajer DS, Grigg LE, Kalman JM, McGuire MA, Gentles TL, Radford DJ, Bullock A, Disney PJS, Winlaw D, du Plessis K, d'Udekem Y. Pacemakers are associated with a higher risk of late death and transplantation in the Fontan population. Int J Cardiol 2019; 282:33-37. [PMID: 30755335 DOI: 10.1016/j.ijcard.2019.01.088] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/06/2018] [Revised: 01/08/2019] [Accepted: 01/24/2019] [Indexed: 01/26/2023]
Abstract
BACKGROUND The need for permanent pacing has been identified as a predictor of poor outcomes in the late survivors of Fontan surgery. However, it is not clear if the need for a pacemaker is a surrogate marker of a declining Fontan state, or if pacing is deleterious to the Fontan circulation. OBJECTIVES We sought to compare the long-term outcomes of propensity-matched Fontan patients with and without a permanent pacemaker. METHODS Patients who have survived Fontan completion with a documented history of cardiac arrhythmia were identified from the Australia and New Zealand Fontan Registry. Pacemaker insertion details, cardiac function and electrophysiological data were obtained for the patients with a permanent pacemaker. Survival analysis was performed with propensity score matching to compare late survival and outcomes in patients with versus without a pacemaker. RESULTS There was a total of 310 patients with a history of cardiac arrhythmia, of which 126 (41%) had a permanent pacemaker. After propensity-score matching, 99 pairs were generated (n = 198). Patients with a permanent pacemaker had a higher risk of death (HR 3.32 95% CI 1.60-6.90, p = 0.001) and death or transplantation (HR 3.55 95% CI 1.87-6.73, p < 0.001). Patients who were only paced atrially were not at a significantly increased risk of death or transplantation. However, patients who were ventricular paced >50% of the time were much more likely to encounter late death or transplantation (HR 3.82 95% CI 1.64-8.95, p = 0.002). CONCLUSIONS Having a permanent pacemaker and needing ventricular pacing is likely associated with an increased risk of death and transplantation in patients with a Fontan circulation.
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Affiliation(s)
- Chin L Poh
- Department of Paediatrics, University of Melbourne, Melbourne, VIC, Australia; Murdoch Childrens Research Institute, Heart Research Group, Melbourne, VIC, Australia; Department of Cardiac Surgery, Royal Children's Hospital, Melbourne, VIC, Australia
| | - David S Celermajer
- Department of Cardiology, Royal Prince Alfred Hospital, Sydney, NSW, Australia
| | - Leeanne E Grigg
- Department of Cardiology, The Royal Melbourne Hospital, Melbourne, VIC, Australia
| | - Jonathan M Kalman
- Department of Cardiology, The Royal Melbourne Hospital, Melbourne, VIC, Australia
| | - Mark A McGuire
- Department of Cardiology, Royal Prince Alfred Hospital, Sydney, NSW, Australia
| | - Thomas L Gentles
- Department of Paediatric Cardiology, Starship Children's Hospital, Auckland, New Zealand
| | - Dorothy J Radford
- Adult Congenital Heart Unit, The Prince Charles Hospital, Brisbane, QLD, Australia
| | - Andrew Bullock
- Children's Cardiac Centre, Princess Margaret Hospital for Children, Perth, WA, Australia
| | - Patrick J S Disney
- Department of Cardiovascular Services, Royal Adelaide Hospital, Adelaide, SA, Australia
| | - David Winlaw
- Heart Centre for Children, The Children's Hospital at Westmead, Sydney, NSW, Australia
| | - Karin du Plessis
- Murdoch Childrens Research Institute, Heart Research Group, Melbourne, VIC, Australia
| | - Yves d'Udekem
- Department of Paediatrics, University of Melbourne, Melbourne, VIC, Australia; Murdoch Childrens Research Institute, Heart Research Group, Melbourne, VIC, Australia; Department of Cardiac Surgery, Royal Children's Hospital, Melbourne, VIC, Australia.
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Mkrtchyan N, Frank Y, Steinlechner E, Calavrezos L, Meierhofer C, Hager A, Martinoff S, Ewert P, Stern H. Aortopulmonary collateral flow quantification by MR at rest and during continuous submaximal exercise in patients with total cavopulmonary connection. J Magn Reson Imaging 2017; 47:1509-1516. [PMID: 29105891 DOI: 10.1002/jmri.25889] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2017] [Accepted: 10/24/2017] [Indexed: 11/08/2022] Open
Abstract
BACKGROUND Aortopulmonary collateral flow is considered to have significant impact on the outcome of patients with single ventricle circulation and total cavopulmonary connection (TCPC). There is little information on collateral flow during exercise. PURPOSE To quantify aortopulmonary collateral flow at rest and during continuous submaximal exercise in clinical patients doing well with TCPC. STUDY TYPE Prospective, case controlled. POPULATION Thirteen patients with TCPC (17 (11-37) years) and 13 age and sex-matched healthy controls (18 (11-38) years). FIELD STRENGTH 1.5T; free breathing; phase sensitive gradient echo sequence. ASSESSMENT Blood flow in the ascending and descending aorta and superior vena cava were measured at rest and during continuous submaximal physical exercise in patients and controls. Systemic blood flow (Qs ) was assumed to be represented by the sum of flow in the superior caval vein (Qsvc ) and the descending aorta (QAoD ) at the diaphragm level. Aortopulmonary collateral flow (Qcoll ) was calculated by subtracting Qs from flow in the ascending aorta (QAoA ). STATISTICS Mann-Whitney U-test and Wilcoxon test for comparison between groups and between rest and exercise. RESULTS Absolute collateral flow in TCPC patients at rest was 0.4 l/min/m2 (-0.1-1.2), corresponding to 14% (-2-42) of Qs . Collateral flow did not change during exercise (difference -0.01 (-0.7-1.0) l/min/m2 , P = 0.97). TCPC patients had significantly lower Qs at rest (2.5 (1.6-4.1) vs. 3.5 (2.6-4.8) l/min/m2 , P = 0.001) and during submaximal exercise (3.2 (2.0-6.0) vs. 4.8 (3.3-6.9) l/min/m2 , P = 0.001), compared to healthy controls. The increase in Qs with exercise was also significantly lower in patients than in healthy controls (median 0.6 vs. 1.2 l/min/m2 , P < 0.02). DATA CONCLUSION Clinical patients doing well with TCPC have significant aortopulmonary collateral flow at rest (14% of Qs ) compared to healthy controls, which does not change during submaximal exercise. LEVEL OF EVIDENCE 2 Technical Efficacy: Stage 3 J. Magn. Reson. Imaging 2018;47:1509-1516.
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Affiliation(s)
- Naira Mkrtchyan
- Department of Pediatric Cardiology and Congenital Heart Disease, Deutsches Herzzentrum München an der Technischen Universität München, München, Germany
| | - Yvonne Frank
- Department of Pediatric Cardiology and Congenital Heart Disease, Deutsches Herzzentrum München an der Technischen Universität München, München, Germany
| | - Eva Steinlechner
- Department of Pediatric Cardiology and Congenital Heart Disease, Deutsches Herzzentrum München an der Technischen Universität München, München, Germany
| | - Lenika Calavrezos
- Department of Pediatric Cardiology and Congenital Heart Disease, Deutsches Herzzentrum München an der Technischen Universität München, München, Germany
| | - Christian Meierhofer
- Department of Pediatric Cardiology and Congenital Heart Disease, Deutsches Herzzentrum München an der Technischen Universität München, München, Germany
| | - Alfred Hager
- Department of Pediatric Cardiology and Congenital Heart Disease, Deutsches Herzzentrum München an der Technischen Universität München, München, Germany
| | - Stefan Martinoff
- Department of Radiology, Deutsches Herzzentrum München an der Technischen Universität München, München, Germany
| | - Peter Ewert
- Department of Pediatric Cardiology and Congenital Heart Disease, Deutsches Herzzentrum München an der Technischen Universität München, München, Germany
| | - Heiko Stern
- Department of Pediatric Cardiology and Congenital Heart Disease, Deutsches Herzzentrum München an der Technischen Universität München, München, Germany
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Muneuchi J, Okada S, Nagatomo Y, Iida C, Matsuoka R, Shirozu M, Watanabe M. Intravascular Ultrasound-Guided Cardiac Intervention in a Fontan Patient with Allergy to Contrast Media. Tex Heart Inst J 2017; 44:373-375. [PMID: 29259515 DOI: 10.14503/thij-16-6096] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
Allergy to contrast media is hazardous in patients who need multiple cardiac catheterizations. We describe the case of a 16-year-old boy who presented with fatigue and cyanosis. He had undergone a Fontan operation 14 years previously, after which he developed an allergy to iodinated contrast media. Contrast echocardiograms by manual injection of microbubbles suggested the presence of a venovenous collateral vessel from the brachiocephalic vein draining into the pulmonary vein. We used intravascular ultrasound as the sole imaging method to identify the target vessel and to guide deployment of an Amplatzer Vascular Plug II. The patient experienced immediate improvement in his systemic saturation. Our experience shows that intravascular ultrasound may be a feasible alternative to standard imaging methods in patients with congenital heart disease who need cardiac interventional procedures and are allergic to contrast media.
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Clift P, Celermajer D. Managing adult Fontan patients: where do we stand? Eur Respir Rev 2016; 25:438-450. [PMID: 27903666 PMCID: PMC9487559 DOI: 10.1183/16000617.0091-2016] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2016] [Accepted: 10/13/2016] [Indexed: 01/10/2023] Open
Abstract
The Fontan operation is performed as a palliative procedure to improve survival in infants born with a functionally univentricular circulation. The success of the operation is demonstrated by a growing adult Fontan population that exists with this unique physiology. Late follow-up has demonstrated expected and unexpected sequelae, and has shown multisystem effects of this circulation. This review discusses the challenges of managing the late complications in terms of understanding this unique physiology and the innovative therapeutic interventions that are being investigated. The challenge remains to maintain quality of life for adult survivors, as well as extending life expectancy. Innovative solutions are required to meet the challenges of the Fontan circulation faced in adult lifehttp://ow.ly/XTSm305oH8b
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Ajami GH, Mohammadi H, Amirghofran AA, Borzouee M, Amoozgar H, Cheriki S, Edraki MR, Mehdizadegan N, Arabi H, Alvasabi F, Naghshzan A. Noninvasive Assessment of Pulmonary Artery Pressure in Patients with Extracardiac Conduit Total Cavopulmonary Connection. Pediatr Cardiol 2016; 37:1361-9. [PMID: 27377526 DOI: 10.1007/s00246-016-1442-3] [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: 02/23/2016] [Accepted: 06/23/2016] [Indexed: 11/30/2022]
Abstract
To assess quantitative measurement of mean pulmonary artery pressure (PAP) in extracardiac total cavopulmonary connection (TCPC) patients by noninvasive echocardiographic inferior vena cava collapsibility index (IVC-CI) and also correlation between the peripheral vein pressure and mean PAP. In 19 TCPC patients with at least 1-year follow-up after completion of TCPC, complete echocardiography including IVC-CI was recorded. All patients underwent cardiac catheterization for mean PAP pressure, peripheral vein pressure (PVP) and contrast study. Different cutoff points of mean PAP were analyzed, and based on the highest cutoff point, patients were categorized into two groups: mean PAP < 17 mmHg (acceptable) and > = 17 mmHg (high) for comparison analysis. Between 2006 and 2015, from 43 patients who had undergone TCPC, nineteen patients with a mean age 12.9 ± 6.6 years and mean follow-up time of 3.4 ± 1.9 years were included in this study. Mean PAP was 14.6 ± 3.97 (range 8-22 mmHg). Thirteen (68 %) patients had PAP < 17 mmHg. No significant statistical difference was detected with respect to age, sex, type of congenital heart disease and fenestration between these two groups. But, right ventricular dominancy was more prevalent in the high PAP group (50 % vs. 7.7 % P value 0.03). IVC-CI had a correlation with mean PAP (r 0.67, P < 0.001). IVC-CI < 21.8 % can predict PAP > = 17 mmHg with 83 % sensitivity and 100 % specificity. Regression analysis proposed an equation for PAP measurement: PAP (mmHg) = 20.2097-0.1796 × (IVC-CI), (r2 = 0.56). Peripheral vein pressure measurement also showed a good correlation with mean PAP and may be used to estimate PAP with the following equation: PAP (mmHg) = 0. 8675 × PVP, (r 0.90, P < 0.0001). In conclusion, IVC-CI as noninvasive and peripheral vein pressure measurement as a minimal invasive method may be useful for quantitative estimation of PAP in patients with extracardiac TCPC.
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Affiliation(s)
- Gholam Hossein Ajami
- Cardiovascular and Neonatology Research Center, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Hamid Mohammadi
- Cardiovascular and Neonatology Research Center, Shiraz University of Medical Sciences, Shiraz, Iran. .,Department of Pediatrics, Nemazee Hospital, Shiraz University of Medical Sciences, 7193711351, Shiraz, Iran.
| | | | - Mohammad Borzouee
- Cardiovascular and Neonatology Research Center, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Hamid Amoozgar
- Cardiovascular and Neonatology Research Center, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Sirous Cheriki
- Cardiovascular and Neonatology Research Center, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Mohammad Reza Edraki
- Cardiovascular and Neonatology Research Center, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Nima Mehdizadegan
- Cardiovascular and Neonatology Research Center, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Hamid Arabi
- Cardiovascular and Neonatology Research Center, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Fathi Alvasabi
- Cardiovascular and Neonatology Research Center, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Amir Naghshzan
- Cardiovascular and Neonatology Research Center, Shiraz University of Medical Sciences, Shiraz, Iran
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Boe BA, Rectenwald JE, Bocks ML. Severely regurgitant left ventricle to ascending aorta conduit in a failing fontan patient treated with a vascular endograft and melody transcatheter pulmonary valve via hybrid approach. Catheter Cardiovasc Interv 2016; 88:1113-1117. [PMID: 27184689 DOI: 10.1002/ccd.26578] [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: 01/28/2016] [Revised: 04/06/2016] [Accepted: 04/22/2016] [Indexed: 11/09/2022]
Abstract
A 28-year-old male with single ventricular heart disease status post Fontan palliation and subsequent placement of left ventricle to ascending aorta (LV-AAo) valved conduit developed ascites and edema. Diagnostic catheterization revealed elevated ventricular end diastolic pressures (EDP) secondary to severe LV-AAo conduit regurgitation. Given the unique anatomy, surgical access via the right axillary artery provided optimal route for transcatheter valve implantation within the conduit. The procedure resulted in significant hemodynamic improvement with no complications. © 2016 Wiley Periodicals, Inc.
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Affiliation(s)
- Brian A Boe
- Department of Pediatric Cardiology, Nationwide Children's Hospital, Columbus, Ohio
| | - John E Rectenwald
- Division of Vascular & Endovascular Surgery, UT Southwestern Medical Center, Dallas, Texas
| | - Martin L Bocks
- Division of Pediatric Cardiology, Department of Pediatrics and Communicable Diseases, University of Michigan C.S. Mott Children's Hospital Congenital Heart Center, Ann Arbor, Michigan
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Haemodynamic impact of stent implantation for lateral tunnel Fontan stenosis: a patient-specific computational assessment. Cardiol Young 2016; 26:116-26. [PMID: 25712430 DOI: 10.1017/s1047951114002765] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
BACKGROUND The physiological importance of the lateral tunnel stenosis in the Fontan pathway for children with single ventricle physiology can be difficult to determine. The impact of the stenosis and stent implantation on total cavopulmonary connection resistance has not been characterized, and there are no clear guidelines for intervention. Methods and results A computational framework for haemodynamic assessment of stent implantation in patients with lateral tunnel stenosis was developed. Cardiac magnetic resonances images were reconstructed to obtain total cavopulmonary connection anatomies before stent implantation. Stents with 2-mm diameter increments were virtually implanted in each patient to understand the impact of stent diameter. Numerical simulations were performed in all geometries with patient-specific flow rates. Exercise conditions were simulated by doubling and tripling the lateral tunnel flow rate. The resulting total cavopulmonary connection vascular resistances were computed. A total of six patients (age: 14.4 ± 3.1 years) with lateral tunnel stenosis were included for preliminary analysis. The mean baseline resistance was 1.54 ± 1.08 WU · m(2) and dependent on the stenosis diameter. It was further exacerbated during exercise. It was observed that utilising a stent with a larger diameter lowered the resistance, but the resistance reduction diminished at larger diameters. CONCLUSIONS Using a computational framework to assess the severity of lateral tunnel stenosis and the haemodynamic impact of stent implantation, it was observed that stenosis in the lateral tunnel pathway was associated with higher total cavopulmonary connection resistance than unobstructed pathways, which was exacerbated during exercise. Stent implantation could reduce the resistance, but the improvement was specific to the minimum diameter.
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11
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Kutty S, Rathod RH, Danford DA, Celermajer DS. Role of imaging in the evaluation of single ventricle with the Fontan palliation. Heart 2015; 102:174-83. [PMID: 26567230 DOI: 10.1136/heartjnl-2015-308298] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/22/2015] [Accepted: 10/08/2015] [Indexed: 12/29/2022] Open
Abstract
The Fontan operation for single ventricle palliation consists of the creation of a complete cavopulmonary connection, usually by incorporating inferior vena caval flow into a pulmonary arterial circulation already receiving flow from the superior vena cava. In single ventricle palliated in this way, the anatomy is complex, and the pathophysiological complications are frequent; so, cardiac imaging is a key aspect of clinical surveillance. Common problems that echocardiography and MRI may disclose and characterise in the Fontan palliation of single ventricle include obstruction of systemic venous and pulmonary arterial flow, atrioventricular and semilunar valve dysfunction, unintended collateral flow patterns, ventricular dysfunction, aortic arch obstruction, interatrial obstruction, fenestration flow and patch leaks. Despite the broad scope of these modalities for detection of such problems, often no single imaging method is comprehensive in any given patient. Therefore, physicians must recognise the limitations of each modality, and circumvent these by application of suitable alternatives. New imaging tools are becoming available, which may ultimately prove to be of value in the Fontan circulation. Proper application of diverse new technologies such as four dimensional flow, computational fluid dynamics and three-dimensional printing will require critical evaluation in the single ventricle population.
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Affiliation(s)
- Shelby Kutty
- Division of Pediatric Cardiology, University of Nebraska College of Medicine, Children's Hospital & Medical Center, Omaha, Nebraska, USA
| | - Rahul H Rathod
- Department of Cardiology, Boston Children's Hospital, Boston, Massachusetts, USA Department of Pediatrics, Harvard Medical School, Boston, Massachusetts, USA
| | - David A Danford
- Division of Pediatric Cardiology, University of Nebraska College of Medicine, Children's Hospital & Medical Center, Omaha, Nebraska, USA
| | - David S Celermajer
- Faculty of Medicine, Sydney Medical School, University of Sydney, Sydney, Australia Department of Cardiology, Royal Prince Alfred Hospital, Sydney, Australia
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Van Dorn CS, Menon SC, Johnson JT, Day RW, Hoffman JL, Yetman AT. Lifetime cardiac reinterventions following the Fontan procedure. Pediatr Cardiol 2015; 36:329-34. [PMID: 25135603 DOI: 10.1007/s00246-014-1007-2] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/06/2014] [Accepted: 08/07/2014] [Indexed: 11/28/2022]
Abstract
Patients with single ventricle physiology face significant morbidity and mortality following the Fontan procedure resulting in the need for additional cardiac reinterventions. Online patient education resources provide limited information on the reinterventions performed in single ventricle patients following the Fontan procedure. We sought to determine cardiac surgical and percutaneous reintervention rates and factors affecting reinterventions following the Fontan procedure. Databases from a single tertiary care center were retrospectively reviewed for all patients who underwent a Fontan procedure between 1978 and 2002. The number and type of cardiac surgical and percutaneous interventions following the Fontan procedure were determined, and relationships between need for reintervention and clinical variables were sought. A total of 91 patients (55 males) underwent the Fontan procedure at a median age of 5.50 years (IQR: 3.33-9.50 years). Median age at last follow-up, death, or transplant was 21.89 years (IQR: 10.87-25.51 years). Following the Fontan procedure, 60 (66%) patients required an additional 144 median sternotomies and 61 (67%) required 139 percutaneous cardiac interventions. Pacemaker system placement/replacement was the most common intervention following the Fontan procedure. The median time to first cardiac surgery following the Fontan was 1.96 years (IQR: 0.06-8.42 years) while the median time to the first percutaneous intervention was 7.63 years (IQR: 0.65-15.89 years). Families of single ventricle patients should be counseled on the likelihood of requiring additional cardiac interventions following the Fontan procedure.
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Affiliation(s)
- Charlotte S Van Dorn
- Division of Cardiology, Department of Pediatrics, Primary Children's Hospital, University of Utah, 100 N. Mario Capecchi Drive, Salt Lake City, 84113, UT, USA,
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Restrepo M, Mirabella L, Tang E, Haggerty CM, Khiabani RH, Fynn-Thompson F, Valente AM, McElhinney DB, Fogel MA, Yoganathan AP. Fontan pathway growth: a quantitative evaluation of lateral tunnel and extracardiac cavopulmonary connections using serial cardiac magnetic resonance. Ann Thorac Surg 2014; 97:916-22. [PMID: 24444876 DOI: 10.1016/j.athoracsur.2013.11.015] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/11/2013] [Revised: 10/31/2013] [Accepted: 11/11/2013] [Indexed: 11/16/2022]
Abstract
BACKGROUND Typically, a Fontan connection is constructed as either a lateral tunnel (LT) pathway or an extracardiac (EC) conduit. The LT is formed partially by atrial wall and is assumed to have growth potential, but the extent and nature of LT pathway growth have not been well characterized. A quantitative analysis was performed to evaluate this issue. METHODS Retrospective serial cardiac magnetic resonance data were obtained for 16 LT and 9 EC patients at 2 time points (mean time between studies, 4.2 ± 1.6 years). Patient-specific anatomies and flows were reconstructed. Geometric parameters of Fontan pathway vessels and the descending aorta were quantified, normalized to body surface area (BSA), and compared between time points and Fontan pathway types. RESULTS Absolute LT pathway mean diameters increased over time for all but 2 patients; EC pathway size did not change (2.4 ± 2.2 mm vs 0.02 ± 2.1 mm, p < 0.05). Normalized LT and EC diameters decreased, while the size of the descending aorta increased proportionally to BSA. Growth of other cavopulmonary vessels varied. The patterns and extent of LT pathway growth were heterogeneous. Absolute flows for all vessels analyzed, except for the superior vena cava, proportionally to BSA. CONCLUSIONS Fontan pathway vessel diameter changes over time were not proportional to somatic growth but increases in pathway flows were; LT pathway diameter changes were highly variable. These factors may impact Fontan pathway resistance and hemodynamic efficiency. These findings provide further understanding of the different characteristics of LT and EC Fontan connections and set the stage for further investigation.
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Affiliation(s)
- Maria Restrepo
- The Wallace H. Coulter Department of Biomedical Engineering at Georgia Institute of Technology and Emory University, Atlanta, Georgia
| | - Lucia Mirabella
- The Wallace H. Coulter Department of Biomedical Engineering at Georgia Institute of Technology and Emory University, Atlanta, Georgia
| | - Elaine Tang
- School of Chemical and Biomolecular Engineering, Georgia Institute of Technology, Atlanta, Georgia
| | - Christopher M Haggerty
- The Wallace H. Coulter Department of Biomedical Engineering at Georgia Institute of Technology and Emory University, Atlanta, Georgia
| | - Reza H Khiabani
- The Wallace H. Coulter Department of Biomedical Engineering at Georgia Institute of Technology and Emory University, Atlanta, Georgia
| | | | - Anne Marie Valente
- Department of Cardiology, Boston Children's Hospital, Boston, Massachusetts
| | - Doff B McElhinney
- Department of Cardiology, Boston Children's Hospital, Boston, Massachusetts
| | - Mark A Fogel
- Division of Cardiology, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Ajit P Yoganathan
- The Wallace H. Coulter Department of Biomedical Engineering at Georgia Institute of Technology and Emory University, Atlanta, Georgia.
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Sonomura T, Ikoma A, Kawai N, Suenaga T, Takeuchi T, Suzuki H, Uchita S, Nakai M, Minamiguchi H, Kishi K, Sato M. Usefulness of the Guglielmi detachable coil for embolization of a systemic venous collateral after Fontan operation: A case report. World J Radiol 2012; 4:418-20. [PMID: 23024844 PMCID: PMC3460230 DOI: 10.4329/wjr.v4.i9.418] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/11/2012] [Revised: 08/21/2012] [Accepted: 08/28/2012] [Indexed: 02/06/2023] Open
Abstract
Embolization of collateral veins is often treated with rigid coils (Gianturco and interlocking detachable coils type). However, when dealing with tortuous and dilated collateral veins, there is a high risk for technical failure and coil migration due to inflexibility of the coils. To safely and successfully solve this problem, Guglielmi detachable coils (GDC) can be used for embolization. Their flexibility allows for easy navigation in tortuous veins, low risk of unintended coil release or coil migration, and safe deployment. A 12-year-old girl with a single ventricle had severe cyanosis and a low exercise tolerance 5 years after Fontan procedure. The symptoms were caused by a tortuous and dilated collateral from the left phrenic vein into the left pulmonary vein, forming a right-to-left shunt. The collateral, which had a large diameter and high flow, and therefore a high risk of coil migration, was successfully embolized with 8 GDC. There were no complications such as coil migration or cerebral infarction. Transcatheter embolization increased her systemic oxygen saturation from 81%-84% to 94%-95%, and increased her ability to exercise. The embolization procedure using flexible GDC was low risk compared with other rigid coil embolization techniques when performing embolization of tortuous and dilated collateral veins.
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Feinstein JA, Benson DW, Dubin AM, Cohen MS, Maxey DM, Mahle WT, Pahl E, Villafañe J, Bhatt AB, Peng LF, Johnson BA, Marsden AL, Daniels CJ, Rudd NA, Caldarone CA, Mussatto KA, Morales DL, Ivy DD, Gaynor JW, Tweddell JS, Deal BJ, Furck AK, Rosenthal GL, Ohye RG, Ghanayem NS, Cheatham JP, Tworetzky W, Martin GR. Hypoplastic left heart syndrome: current considerations and expectations. J Am Coll Cardiol 2012; 59:S1-42. [PMID: 22192720 PMCID: PMC6110391 DOI: 10.1016/j.jacc.2011.09.022] [Citation(s) in RCA: 349] [Impact Index Per Article: 29.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/19/2011] [Revised: 09/06/2011] [Accepted: 09/20/2011] [Indexed: 01/25/2023]
Abstract
In the recent era, no congenital heart defect has undergone a more dramatic change in diagnostic approach, management, and outcomes than hypoplastic left heart syndrome (HLHS). During this time, survival to the age of 5 years (including Fontan) has ranged from 50% to 69%, but current expectations are that 70% of newborns born today with HLHS may reach adulthood. Although the 3-stage treatment approach to HLHS is now well founded, there is significant variation among centers. In this white paper, we present the current state of the art in our understanding and treatment of HLHS during the stages of care: 1) pre-Stage I: fetal and neonatal assessment and management; 2) Stage I: perioperative care, interstage monitoring, and management strategies; 3) Stage II: surgeries; 4) Stage III: Fontan surgery; and 5) long-term follow-up. Issues surrounding the genetics of HLHS, developmental outcomes, and quality of life are addressed in addition to the many other considerations for caring for this group of complex patients.
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Affiliation(s)
- Jeffrey A Feinstein
- Department of Pediatrics, Stanford University School of Medicine, Lucile Salter Packard Children's Hospital, Palo Alto, California 94304, USA.
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Feltes TF, Bacha E, Beekman RH, Cheatham JP, Feinstein JA, Gomes AS, Hijazi ZM, Ing FF, de Moor M, Morrow WR, Mullins CE, Taubert KA, Zahn EM. Indications for cardiac catheterization and intervention in pediatric cardiac disease: a scientific statement from the American Heart Association. Circulation 2011; 123:2607-52. [PMID: 21536996 DOI: 10.1161/cir.0b013e31821b1f10] [Citation(s) in RCA: 492] [Impact Index Per Article: 37.8] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
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Salazar JD, Zafar F, Siddiqui K, Coleman RD, Morales DLS, Heinle JS, Rossano JW, Mossad EB, Fraser CD. Fenestration during Fontan palliation: now the exception instead of the rule. J Thorac Cardiovasc Surg 2010; 140:129-36. [PMID: 20620378 DOI: 10.1016/j.jtcvs.2010.03.013] [Citation(s) in RCA: 44] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/21/2009] [Revised: 02/21/2010] [Accepted: 03/16/2010] [Indexed: 10/19/2022]
Abstract
OBJECTIVE Fenestration during Fontan palliation has traditionally been used to decrease surgical morbidity and mortality, particularly in high-risk cases. Potential limitations include oxygen desaturation, risk of paradoxic embolism, and need for late intervention. Our practice has evolved away from routine fenestration with increased extracardiac conduit use. We reviewed our experience with Fontan palliation and retrospectively assessed outcomes with decreased fenestration. METHODS Between January 2002 and April 2008, 226 patients underwent primary Fontan palliation. Outcomes were assessed by hospital stay, chest drain duration, short- and long-term survivals, and late interventions. RESULTS Anatomic subtypes were single left ventricle (n = 88, 38.9%), single right ventricle (n = 78, 34.5%), common ventricle (n = 19, 8.4%), and heterotaxy syndrome (n = 41, 18.1%). Lateral tunnel connection was created in 69 patients (30.5%); extracardiac connection was created in 157 (69.5%). Mean age and weight at surgery were 4.3 +/- 3.8 years and 17.2 +/- 9 kg, respectively. In 2002, 14 of 16 patients (87.5%) had fenestrated Fontan circulations, versus 2 of 32 (6.3%) in 2008. Mean hospital stay was 10.8 +/- 8.8 days. Survival to discharge or 30 days was 98.7%. There were 2 (0.9%) late deaths during mean follow-up of 2.0 +/- 1.7 years. Outcomes were equivalent between fenestrated and nonfenestrated procedures across anatomic subtypes. CONCLUSIONS Highly selective use of Fontan fenestration is achievable while maintaining excellent outcomes without increased surgical morbidity or mortality, irrespective of anatomic subtype. Risks of hypoxia, systemic embolism, and late instrumentation can be avoided in most cases.
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Affiliation(s)
- Jorge D Salazar
- Division of Congenital Heart Surgery, Baylor College of Medicine, Houston, Tex, USA.
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Congenitally corrected transposition of the great arteries: a unique case from Iraq. Pediatr Cardiol 2010; 31:120-3. [PMID: 19787386 DOI: 10.1007/s00246-009-9545-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/28/2009] [Accepted: 09/10/2009] [Indexed: 10/20/2022]
Abstract
A severely cyanotic 27-month-old Iraqi child was transferred to the United States for surgical treatment of suspected tetralogy of Fallot. Her diagnostic studies showed dextrocardia, congenitally corrected transposition of the great arteries, hypoplastic left-sided ventricle, interrupted inferior vena cava, and severe pulmonic stenosis. Given the anatomic constraints as well as the absence of long-term medical care, the decision was made to pursue single-ventricle palliation. The patient recovered from a superior cavopulmonary anastomosis without event and has since returned to her native Iraq.
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Koteda Y, Suda K, Kishimoto S, Iemura M. Portal-systemic encephalopathy after Fontan-type operation in patient with polysplenia syndrome. Eur J Cardiothorac Surg 2009; 35:1083-5. [DOI: 10.1016/j.ejcts.2009.02.043] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/22/2008] [Revised: 02/19/2009] [Accepted: 02/24/2009] [Indexed: 10/20/2022] Open
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Motoki N, Ohuchi H, Miyazaki A, Yamada O. Clinical Profiles of Adult Patients With Single Ventricular Physiology. Circ J 2009; 73:1711-6. [DOI: 10.1253/circj.cj-08-1155] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Affiliation(s)
- Noriko Motoki
- Department of Pediatrics, Shinshu University School of Medicine
| | - Hideo Ohuchi
- Department of Pediatrics, National Cardiovascular Center
| | - Aya Miyazaki
- Department of Pediatrics, National Cardiovascular Center
| | - Osamu Yamada
- Department of Pediatrics, National Cardiovascular Center
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Kim SJ, Kim WH, Lim HG, Lee JY. Outcome of 200 patients after an extracardiac Fontan procedure. J Thorac Cardiovasc Surg 2008; 136:108-16. [PMID: 18603062 DOI: 10.1016/j.jtcvs.2007.12.032] [Citation(s) in RCA: 124] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/26/2007] [Revised: 12/18/2007] [Accepted: 12/27/2007] [Indexed: 11/30/2022]
Abstract
OBJECTIVES Despite the known advantages of the extracardiac conduit Fontan procedure, the long-term outcomes related to the longevity of the conduit and anticoagulation therapy have not been determined. The purpose of this study was to evaluate the outcome of hospital survivors with an extracardiac Fontan circulation. METHODS AND RESULTS Between 1996 and 2006, 200 patients had the extracardiac conduit Fontan operation. The median age at operation was 3.4 years. Most patients (89.5%) underwent a bidirectional cavopulmonary shunt. Fenestration was required in 85 patients. Overall, the 10-year survival was 92.4% +/- 2.1%. Multivariate analysis identified severe infection during the early postoperative period and a high pulmonary arterial pressure during the preoperative period as independent risk factors for patient mortality. The Kaplan-Meier estimate for freedom from reoperation was 82.4% +/- 4.1% at 10 years. Arrhythmia occurred in 32 patients after the Fontan operation; freedom from arrhythmia was 85.1% +/- 4.4% at 10 years. The risk factors for arrhythmia were the heterotaxy syndrome, follow-up duration, and age at Fontan operation. Freedom from thromboembolism at 10 years was 92.9% +/- 1.9%. Among all of the patients, 95.2% were classified in New York Heart Association class I. CONCLUSIONS The results of this study showed that during 10 years of follow-up, the overall survival and the functional status of the survivors after an extracardiac Fontan procedure were satisfactory. We might infer that fenestration provided benefit inasmuch as the high-risk Fontan patients fenestrated had similar outcomes to those not fenestrated, who were presumably low risk. The incidence of late death, reoperation, obstruction of the cavopulmonary pathway, arrhythmias, and thromboembolism was low.
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Affiliation(s)
- Soo-Jin Kim
- Department of Pediatric Cardiology, Sejong General Hospital, Sejong Heart Institute, Bucheon, Korea
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Ono M, Boethig D, Goerler H, Lange M, Westhoff-Bleck M, Breymann T. Clinical outcome of patients 20 years after Fontan operation — effect of fenestration on late morbidity. Eur J Cardiothorac Surg 2006; 30:923-9. [PMID: 17074498 DOI: 10.1016/j.ejcts.2006.08.025] [Citation(s) in RCA: 107] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/27/2006] [Revised: 08/06/2006] [Accepted: 08/14/2006] [Indexed: 10/24/2022] Open
Abstract
OBJECTIVE The Fontan operation has been proposed as definitive palliation for an increasing variety of hearts with complex univentricular anatomy, but late morbidity after Fontan operation is still a matter of concern. This retrospective study evaluates the late outcome in patients with Fontan circulation. METHODS We included 121 consecutive patients that underwent Fontan operation between 1984 and 2004. Modifications of the Fontan operation included atriopulmonary anastomosis (APA; n = 28), total cavopulmonary connection (TCPC; n = 63), and fenestrated TCPC (f-TCPC; n = 30). Mean age was 5.8+/-5.5 years. Post operative mortality, morbidity, hemodynamics, and somatic development were analyzed. RESULTS Actuarial survival was 87% at 20 years after Fontan operation. There were 10 early deaths, 5 late deaths, and 2 takedowns followed by successful conversion and heart transplantation. Among 108 early-survivors with Fontan circulation, 19 underwent reoperation, including 3 conversions of APA to TCPC. Freedom from reoperation was 76% at 20 years. Freedom from intervention was 34% at 20 years. Freedom from tachyarrhythmia or pacemaker implantation was 23% and 77%, respectively at 20 years. Heterotaxy and atrioventricular valve anomaly were risk factors for late failure and tachyarrhythmias. Patients with fenestrated TCPC had reduced incidence of late tachyarrhythmias, and patients with APA who developed collaterals showed low incidence of late tachyarrythmia. Postoperative sinus node dysfunction or tachyarrhythmias was associated with significantly lower cardiac index. Somatic development was gradually compensated after Fontan operation. Weight normalized completely 15 years postoperatively. CONCLUSIONS Long-term survival after Fontan procedure is encouraging, but late morbidity remains suboptimal. During follow-up, emerging complications should be managed by surgical and interventional procedures. Fenestration in Fontan circulation provided better cardiac output and lower incidence of late tachyarrhythmias, suggesting a benefit of fenestration for late outcome.
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Affiliation(s)
- Masamichi Ono
- Division of Thoracic and Cardiovascular Surgery, Hannover Medical School, Hannover, Germany.
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Suzuki H, Ohuchi H, Hiraumi Y, Yasuda K, Echigo S. Effects of postural change on oxygen saturation and respiration in patients after the Fontan operation: platypnea and orthodeoxia. Int J Cardiol 2006; 106:211-7. [PMID: 16321694 DOI: 10.1016/j.ijcard.2005.01.044] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/20/2004] [Revised: 01/27/2005] [Accepted: 01/30/2005] [Indexed: 11/16/2022]
Abstract
The aim of this study was to assess whether platypnea and orthodeoxia occur in Fontan patients. We divided 14 Fontan patients into 2 groups: 8 patients who had pulmonary arteriovenous fistulas and/or intra-atrial shunts (group A) and 6 patients who had neither pulmonary arteriovenous fistulas nor intra-atrial shunts (group B). They were compared with 9 controls (group C). Arterial oxygen saturation, minute ventilation per body weight and ventilatory equivalent for carbon dioxide were measured in the supine and then sitting positions. In group A, 1 patient had platypnea and 3 patients had orthodeoxia (changes in the saturation from the supine position to the sitting position were -4% to -7%) accompanied with slight hyperpnea, and all 4 patients had both pulmonary arteriovenous fistulas and intra-atrial shunts. Contrary, patients in group B had neither platypnea nor orthodeoxia. The saturation was significantly lower and the minute ventilation was significantly higher in the sitting position than in the supine position in group A (p < 0.05). The other groups showed no significant difference in the saturation or the minute ventilation between the 2 positions. All groups showed the ventilatory equivalent was significantly higher in the sitting position than in the supine position (p < 0.05 to 0.01). We demonstrated platypnea and orthodeoxia in Fontan patients with pulmonary arteriovenous fistulas and intra-atrial shunts. We believe platypnea and orthodeoxia should be regard as a complication in Fontan patients with pulmonary arteriovenous fistulas and/or intra-atrial shunts.
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Affiliation(s)
- Hiroshi Suzuki
- Department of Pediatrics, National Cardiovascular Center, Suita, Osaka, Japan.
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Suda K, Matsumura M, Sano A, Yoshimura S, Ishii T. Hemoptysis from collateral arteries 12 years after a fontan-type operation. Ann Thorac Surg 2005; 79:e7-8. [PMID: 15620904 DOI: 10.1016/j.athoracsur.2004.08.026] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 08/10/2004] [Indexed: 10/26/2022]
Abstract
A 20-year-old patient who had a single ventricle and pulmonary stenosis presented with recurrent hemoptysis 12 years after a Fontan-type operation. He was referred to us because of unsuccessful treatment with a tentative diagnosis of lung tuberculosis for 3 months. He had been relatively well for the prior 12 years, although he had attacks of paroxysmal supraventricular tachycardia and had underwent successful catheter ablation 3 years ago. Aortography revealed multiple collateral arteries as a cause of hemoptysis and coil embolization of these collateral arteries successfully stopped the hemoptysis. This case illustrates that collateral arteries may stay open or develop, and these collateral arteries can become a source of hemoptysis long after a Fontan-type operation.
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Affiliation(s)
- Kenji Suda
- Division of Pediatric Cardiology, Department of Pediatrics, Tenri Hospital, Tenri, Japan.
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Suda K, Matsumura M, Miyanish S, Uehara K, Sugita T, Matsumoto M. Increased vascular endothelial growth factor in patients with cyanotic congenital heart diseases may not be normalized after a Fontan type operation. Ann Thorac Surg 2005; 78:942-6; discussion 946-7. [PMID: 15337024 DOI: 10.1016/j.athoracsur.2004.03.039] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/16/2004] [Indexed: 10/26/2022]
Abstract
BACKGROUND To determine the change of serum concentration of vascular endothelial growth factor (VEGF) in patients with cyanotic congenital heart disease (C-CHD). METHODS Patients comprised four groups: group A, 19 patients without cyanosis; group B, 24 patients with C-CHD; group C, 17 patients who had C-CHD and underwent biventricular repair; and group D, 15 patients who had single ventricle and underwent a Fontan type operation. Blood samples were obtained from upper arm veins and serum VEGF was determined. We determined correlation between serum VEGF and arterial oxygen saturation and compared levels of serum VEGF among groups. In addition, age and hemodynamic variables derived from cardiac catheterization were analyzed in terms of correlation with serum VEGF. RESULTS Serum VEGF significantly negatively correlated with arterial oxygen saturation (r = -0.62, p < 0.0001). Serum VEGF in B and D were significantly higher than those in A and C (median = 443 pg/mL in B and 302 pg/mL in D vs 180 pg/mL in A and 216 pg/mL in C, respectively). Serum VEGF was significantly negatively correlated with patient's age (p = 0.54, p < 0.04) in D, but significantly positively correlated with systemic venous pressure (p = 0.45, p < 0.01) in pooled data. CONCLUSIONS Patients with C-CHD have increased serum VEGF in parallel with the degree of cyanosis. With biventricular repair, cyanosis and serum VEGF are normalized. However, with a Fontan type operation, cyanosis disappears but serum VEGF may not be normalized because of elevated venous pressure in association with younger age.
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Affiliation(s)
- Kenji Suda
- Department of Pediatrics, Tenri Hospital, Tenri City, Japan.
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Abstract
For more than 30 years Fontan-type procedures have been performed for surgical treatment in patients with functionally univentricular hearts. Advances in proper patient selection, staging of the Fontan palliation, and modifications of the surgical technique resulted in continuous improvement of the surgical results during the past two decades. However, increasing experience with medium term and long term follow-up of the Fontan circulation has drawn attention to a number of sequelae and chronic complications affecting a significant number of patients.
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Affiliation(s)
- R Kaulitz
- Department of Pediatric Cardiology and Pediatric Intensive Care Medicine, Tuebingen University Hospital, Germany
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Ichikawa H, Sawa Y, Fukushima N, Ishizaka T, Iwai S, Kondo H, Matsuda H. Late Assessment After Biventricular Repair for Isomerism Heart. Ann Thorac Surg 2005; 80:50-5. [PMID: 15975338 DOI: 10.1016/j.athoracsur.2005.01.065] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/11/2004] [Revised: 01/12/2005] [Accepted: 01/17/2005] [Indexed: 11/29/2022]
Abstract
BACKGROUND Although biventricular repair is theoretically ideal for the treatment of isomerism heart, the long-term outcome is unknown. We assessed the outcome of biventricular repair for atrial isomerism. METHODS From 1984 to 2002 in our surgical database, 10 of 67 patients with atrial isomerism received biventricular repair. The age at operation was 7.7 +/- 9.1 years. Preoperative ventricular volume was normal in all patients. Left ventricular ejection fraction was 62% +/- 8%. Intra-atrial rerouting was required in 8. The atrioventricular septal defect with double-outlet right ventricle was closed using comma-shaped intraventricular conduit in 8. Other procedures included pulmonary valvotomy and infundibulectomy in 2, transannular patch in 1 and right ventricle to pulmonary artery conduit in 1. RESULTS There was one early death due to hemolytic phagocytic syndrome. The other 9 patients are in New York Heart Association class I at 12.7 +/- 5.3 years postoperatively. There was no atrial baffle stenosis except in 1 patient; it was successfully treated by stent placement 10 years after the operation. There was no incidence of left ventricular outflow obstruction. Mitral replacement (4 months postoperatively) or repair (15 years postoperatively) was done in 2 patients. The other 5 patients with atrioventricular septal defect showed trivial to mild regurgitation in the long-term period. Arrhythmia was observed in 5 (left 4, right 1). Catheter ablation was needed in a patient with atrial flutter. Three of 9 patients require diuretics or digitalization, or both. CONCLUSIONS The long-term outcome of the biventricular repair for atrial isomerism was excellent. Late development of mitral regurgitation and arrhythmia could be managed adequately.
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Affiliation(s)
- Hajime Ichikawa
- Department of Surgery, Osaka University Medical School, Suita, Osaka, Japan
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Hansky B, Blanz U, Peuster M, Gueldner H, Sandica E, Crespo-Martinez E, Mathies W, Meyer H, Koerfer R. Endocardial Pacing After Fontan-Type Procedures. PACING AND CLINICAL ELECTROPHYSIOLOGY: PACE 2005; 28:140-8. [PMID: 15679644 DOI: 10.1111/j.1540-8159.2005.04006.x] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
BACKGROUND Sinus node dysfunction is a frequent complication of Fontan-type procedure. Epicardial pacing is considered as the standard treatment for these patients. METHODS AND RESULTS We evaluated an endocardial approach in seven patients using a 4.1 French bipolar lumenless lead (SelectSecure) that is positioned through a steerable guiding catheter. Either a purely transvenous or an open transatrial approach can be used for lead placement. The smallest child weighed 12 kg. Individual anatomy was assessed preimplantation using magnetic resonance imaging and injection of radiographic contrast agent through the guiding catheter. A pullback pressure recording was used to confirm unimpaired blood flow into the pulmonary artery. Five of our seven patients underwent de novo transvenous atrial lead implantation for AAIR pacing. In the remaining two patients, both atrial and ventricular leads were inserted. One patient with an intraatrial tunnel underwent transvenous-lead placement. The remaining patient with an extracardiac conduit received atrial and ventricular leads implanted through a guiding catheter inserted through an atriotomy. The postoperative management included short- or long-term oral anticoagulation. CONCLUSIONS Transvenous endocardial lead implantation avoids the problem of increasing capture thresholds typically observed with epicardial leads. Due to its high tensile strength and lumenless design, the isodiametric lead is expected to remain extractable for an extended period of time.
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Affiliation(s)
- Bert Hansky
- Department of Thoracic and Cardiovascular Surgery, Heart and Diabetes Center NRW, Ruhr University Bochum, Clinic for Thoracic and Cardiovascular Surgery, Bad Oeynhausen, Germany.
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van den Bosch AE, Roos-Hesselink JW, Van Domburg R, Bogers AJJC, Simoons ML, Meijboom FJ. Long-term outcome and quality of life in adult patients after the Fontan operation. Am J Cardiol 2004; 93:1141-5. [PMID: 15110207 DOI: 10.1016/j.amjcard.2004.01.041] [Citation(s) in RCA: 115] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/16/2003] [Revised: 01/12/2004] [Accepted: 01/12/2004] [Indexed: 11/17/2022]
Abstract
The first successful Fontan operation was performed in 1971, and this first cohort of Fontan patients is reaching adulthood with unclear outcome of this palliative procedure. We studied the mortality, morbidity, and quality of life in our adult Fontan patients. We examined all patients (n = 36) who underwent a Fontan procedure and were being seen in an adult outpatient clinic by using electrocardiography, exercise testing, and echocardiography. Quality of life was assessed by the Short Form 36 questionnaire. The mean follow-up period was 15 years (range 0 to 23). Of the initial 36 patients, 10 died (28%) at a mean of 10 years (range 0 to 21) after the Fontan operation and 1 patient underwent cardiac transplantation. Reoperations were performed in 21 patients (58%), and the most common reason was revision of the Fontan connection. Sustained supraventricular tachycardia was observed in 20 patients (56%) with an increased incidence of arrhythmias with longer follow-up. Thromboembolic events were detected in 9 patients (25%), 5 of whom had adequate anticoagulant levels at the time of event. The thromboembolic event was fatal for 3 patients. A total of 195 hospital admissions (mean 3.8 +/- 2.7, range 1 to 13) was recorded. Quality-of-life assessment showed physical functioning, mental health, and general health perception to be significantly lower for Fontan patients than for the normal Dutch population. Thus, we found high mortality and very high morbidity in adult patients after the Fontan operation. In particular, reoperations, arrhythmias, and thromboembolic events compromised quality of life.
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