1
|
Alsaied T, Li R, Christopher AB, Fogel MA, Slesnick TC, Krishnamurthy R, Muthurangu V, Dorfman AL, Lam CZ, Weigand JD, Robinson JD, Cordina R, Olivieri LJ, Rathod RH. High-Performing Fontan Patients: A Fontan Outcome Registry by Cardiac Magnetic Resonance Imaging Study. JACC. ADVANCES 2024; 3:101254. [PMID: 39309667 PMCID: PMC11414658 DOI: 10.1016/j.jacadv.2024.101254] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/29/2024] [Revised: 08/12/2024] [Accepted: 08/12/2024] [Indexed: 09/25/2024]
Abstract
Background Fontan patients exhibit decreased exercise capacity. However, there is a subset of high-performing Fontan (HPF) patients with excellent exercise capacity. Objectives This study aims to: 1) create a Fontan-specific percent predicted peak VO2 tool using exercise data; 2) examine clinical factors associated with HPF patients; and 3) examine late outcomes in HPF patients. Methods Patients in the multi-institutional Fontan Outcomes Registry Using CMR Examination above the age of 8 years who had a maximal exercise test were included. An HPF patient was defined as a patient in the upper Fontan-specific percent predicted peak VO2 quartile. Multivariable logistic regression was employed to investigate factors associated with the HPF and Cox regression was used to examine the association between HPF patients and late outcomes (composite of death or listing for cardiac transplant). Results The study included 813 patients (mean age: 20.2 ± 8.7 years). An HPF patient was associated with left ventricular morphology (OR: 1.50, P = 0.04), mixed morphology (OR: 2.23, P < 0.001), and a higher ejection fraction (OR: 1.31 for 10% increase, P = 0.01). Patients with at least moderate atrioventricular valve regurgitation, protein-losing enteropathy, or who were using psychiatric medications, were less likely to be an HPF patient. After a mean follow-up of 3.7 years, 46 (5.7%) patients developed a composite endpoint. HPF had a lower risk of death or listing for cardiac transplant (HR: 0.06 [95% CI: 0.01-0.25]). Conclusions Patients with HPF have more favorable outcomes when compared to patients with lower exercise capacity. This large registry data highlights the role of exercise testing in providing personalized care and surveillance post-Fontan.
Collapse
Affiliation(s)
- Tarek Alsaied
- The Heart and Vascular Institute, UPMC Children’s Hospital of Pittsburgh, University of Pittsburgh School of Medicine, Pennsylvania, USA
| | - Runjia Li
- Department of Biostatistics, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Adam B. Christopher
- The Heart and Vascular Institute, UPMC Children’s Hospital of Pittsburgh, University of Pittsburgh School of Medicine, Pennsylvania, USA
| | - Mark A. Fogel
- Division of Cardiology, Department of Pediatrics, The Children’s Hospital of Philadelphia, Perelman School of Medicine, University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania, USA
| | - Timothy C. Slesnick
- Departments of Pediatrics, Emory University School of Medicine, Children’s Healthcare of Atlanta, Atlanta, Georgia, USA
| | - Rajesh Krishnamurthy
- The Department of Radiology, Nationwide Children’s Hospital, Columbus, Ohio, USA
| | - Vivek Muthurangu
- UCL Centre for Cardiovascular Imaging, Institute of Cardiovascular Science, University College London, London, United Kingdom
| | - Adam L. Dorfman
- Department of Pediatrics, University of Michigan Medical School, Ann Arbor, Michigan, USA
| | - Christopher Z. Lam
- Department of Diagnostic Imaging, The Hospital for Sick Children and Department of Medical Imaging, University of Toronto, Toronto, Canada
| | - Justin D. Weigand
- Division of Pediatric Cardiology, Department of Pediatrics, Baylor College of Medicine, Texas Children’s Hospital, Houston, Texas, USA
| | - Joshua D. Robinson
- Department of Pediatrics, Ann & Robert H. Lurie’s Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Rachael Cordina
- Department of Cardiology, Royal Prince Alfred Hospital, Sydney, NSW, Australia
| | - Laura J. Olivieri
- The Heart and Vascular Institute, UPMC Children’s Hospital of Pittsburgh, University of Pittsburgh School of Medicine, Pennsylvania, USA
| | - Rahul H. Rathod
- Department of Pediatrics, Boston Children’s Hospital, Harvard Medical School, Boston, Massachusetts, USA
| |
Collapse
|
2
|
Miwa K, Tsumura S, Kanaya T, Kido T, Tominaga Y, Kawai S, Teguri Y. Impact of the Rudimentary Chamber on Outcomes in Fontan Patients. World J Pediatr Congenit Heart Surg 2024; 15:270-276. [PMID: 38404011 DOI: 10.1177/21501351241227882] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/27/2024]
Abstract
Background: We sought to evaluate the influence of the rudimentary ventricle on long-term outcomes after the Fontan operation, focusing on exercise capacity and cardiac performance. Methods: Between 1995 and 2021, 290 patients underwent a total cavopulmonary connection. "Two-ventricle" Fontan circulation was defined as a rudimentary ventricle >30% of the dominant ventricle or >50% of its predicted normal value. This cohort was compared with patients with single-ventricle Fontan circulation. The primary endpoint was Fontan failure, and the secondary endpoints were VO2 and cardiac catheterization data at ten years postoperatively. Results: The median follow-up after the Fontan operation was 7.9 years (interquartile range: 1.9-13.9). No significant difference was found in Fontan failure-free survival between the "two-ventricle" Fontan circulation group and the single-ventricle Fontan circulation group (83/91, 93% vs 156/199, 78%), respectively at 20 years; P = .11). No significant difference was found in VO2 or cardiac performance except cardiac index, with 2.9 (2.3-4.8) versus 2.5 (2.3-4.3) L/min/m2 (P = .047). Fifty-one patients in the "two-ventricle" Fontan circulation group were followed up for over ten years after the Fontan operation. In the subgroup analysis of this cohort, the rudimentary ventricular end-diastolic volume/dominant ventricular end-diastolic volume ratio showed a significant positive correlation with dominant ventricular end-diastolic pressure (r = 0.58 [95% CI 0.35-0.74], P = .002) and a significant negative correlation with VO2 (r = -0.61 [95% CI -0.80 to -0.28], P = .001). Conclusions: The rudimentary ventricle was not significantly associated with any clinical disadvantages regarding Fontan failure. However, a large rudimentary ventricle was significantly associated with higher end-diastolic pressure and lower exercise capacity.
Collapse
Affiliation(s)
- Koji Miwa
- Department of Cardiovascular Surgery, Osaka Women's and Children's Hospital, Izumi, Osaka, Japan
| | - Sanae Tsumura
- Department of Cardiovascular Surgery, Osaka Women's and Children's Hospital, Izumi, Osaka, Japan
| | - Tomomitsu Kanaya
- Department of Cardiovascular Surgery, Osaka Women's and Children's Hospital, Izumi, Osaka, Japan
| | - Takashi Kido
- Department of Cardiovascular Surgery, Osaka Women's and Children's Hospital, Izumi, Osaka, Japan
| | - Yuji Tominaga
- Department of Cardiovascular Surgery, Osaka Women's and Children's Hospital, Izumi, Osaka, Japan
| | - Shota Kawai
- Department of Cardiovascular Surgery, Osaka Women's and Children's Hospital, Izumi, Osaka, Japan
| | - Yuta Teguri
- Department of Cardiovascular Surgery, Osaka Women's and Children's Hospital, Izumi, Osaka, Japan
| |
Collapse
|
3
|
Patel ND. Risk Factors for Adverse Events in the Fontan Population: Does Ventricular Morphology Play a Role? JACC. ADVANCES 2024; 3:100870. [PMID: 38939670 PMCID: PMC11198674 DOI: 10.1016/j.jacadv.2024.100870] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Indexed: 06/29/2024]
Affiliation(s)
- Neil D. Patel
- Division of Pediatric Cardiology, Children’s Hospital Los Angeles, Keck School of Medicine, University of Southern California, Los Angeles, California, USA
| |
Collapse
|
4
|
Krzywda K, Teson KM, Watson JS, Goudar S, Forsha D, Wagner JB, White DA. Peak Oxygen Consumption (V̇O 2peak ) Recovery Delay in a Pediatric Fontan Population. Med Sci Sports Exerc 2023; 55:1961-1967. [PMID: 37418236 DOI: 10.1249/mss.0000000000003247] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/08/2023]
Abstract
PURPOSE The purpose of this study is to identify predictors and correlates of VO2RD in youth with Fontan. METHODS Cardiopulmonary exercise test data was used from a single center, cross-sectional study of children and adolescents (age, 8-21 yr) with Fontan physiology. The VO2RD was determined using time (s) to <90% of V̇O 2peak and categorized as "low" (≤10 s) or "high" (≥10 s). t Tests and χ 2 analysis were used to compare continuous and categorical variables, respectively. RESULTS The analysis sample included 30 adolescents with Fontan physiology (age, 14.2 ± 2.4 yr; 67% male) with either right ventricular (RV) dominant (40%) or co/left ventricular (Co/LV) dominant (60%) systemic ventricular morphology. There were no differences in V̇O 2peak between the high and low VO2RD groups (high = 1.3 ± 0.4 L·min -1 ; low = 1.3 ± 0.3 L·min -1 ; P = 0.97). VO2RD in participants with RV dominance was significantly greater than in patients with Co/LV dominance (RV = 23.8 ± 15.8 s; Co/LV = 11.8 ± 16.1 s; P = 0.03). CONCLUSIONS V̇O 2peak was not correlated with VO2RD when analyzed as high/low VO2RD groups. However, morphology of the systemic single ventricle (RV vs Co/LV) may be related to rate of recovery in V̇O 2 after a peak cardiopulmonary exercise test.
Collapse
Affiliation(s)
| | | | - Jessica S Watson
- Ward Family Heart Center, Children's Mercy Kansas City, Kansas City, MO
| | - Suma Goudar
- Children's National Heart Institute, Department of Pediatrics, Washington, DC
| | | | | | | |
Collapse
|
5
|
Ohuchi H, Mori A, Kurosaki K, Shiraishi I, Nakai M. Prevalence and clinical correlates and characteristics of "Super Fontan". Am Heart J 2023; 263:93-103. [PMID: 37211285 DOI: 10.1016/j.ahj.2023.05.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/17/2022] [Revised: 04/21/2023] [Accepted: 05/15/2023] [Indexed: 05/23/2023]
Abstract
BACKGROUND Super-Fontan (SF) is an excellent phenotype of patients with Fontan circulation and normal exercise capacity. This study aimed to clarify the prevalence and clinical correlates and characteristics of SF. METHODS We reviewed 404 Fontan patients who had undergone cardiopulmonary exercise testing, and the results were compared with clinical profiles. RESULTS Seventy-seven (19%) patients had SF, and the postoperative prevalence at 5, 10, 15, 20, and ≥ 25 years was 16 (35%), 30 (39%), 18 (19%), 13 (14%), and 0 (0%), respectively. Compared with non-SF, SF patients were younger (P < .001) and were mostly men (P < .05). SF was characterized by a current high arterial blood pressure and oxygen saturation (SaO2), low systemic ventricle (SV) end-diastolic pressure, favorable body composition, superior pulmonary function, preserved hepatorenal and hemostatic functions, and better glucose tolerance (P < .05-.001). Pre-Fontan better SV function, low pulmonary artery resistance, and high SaO2 were associated with current SF (P < .05-.01). Furthermore, positive trajectory of exercise capacity and high daily activity during childhood were associated with current adult SF (P < .05). During the follow-up, 25 patients died, and 74 patients were unexpectedly hospitalized. There was no death in the SF group, and the rate of hospitalization was 67% lower than that of the non-SF group (P < .01-.001). CONCLUSIONS The prevalence of SF gradually decreased over time. SF was characterized by preserved multi-end-organ function and an excellent prognosis. Pre-Fontan hemodynamics and post-Fontan childhood daily activity were associated with being adult SF.
Collapse
Affiliation(s)
- Hideo Ohuchi
- Department of Pediatric Cardiology, National Cerebral and Cardiovascular Center, Osaka, Japan; Adult Congenital Heart Disease Center, National Cerebral and Cardiovascular Center, Osaka, Japan
| | - Aki Mori
- Department of Pediatric Cardiology, National Cerebral and Cardiovascular Center, Osaka, Japan; Adult Congenital Heart Disease Center, National Cerebral and Cardiovascular Center, Osaka, Japan
| | - Kenichi Kurosaki
- Department of Pediatric Cardiology, National Cerebral and Cardiovascular Center, Osaka, Japan
| | - Isao Shiraishi
- Department of Pediatric Cardiology, National Cerebral and Cardiovascular Center, Osaka, Japan
| | - Michikazu Nakai
- Department of Medical and Health Information Management, National Cerebral and Cardiovascular Center, Osaka, Japan
| |
Collapse
|
6
|
Ladrón-Abia R, Cejudo Ramos P, Valverde Pérez I, Camacho Fernández De Liger R, Wals-Rodríguez AJ, Rodríguez Puras MJ, Manso García B, Gallego P. Respiratory Muscle Function and Exercise Performance in Adult Patients with Fontan Circulation. J Clin Med 2023; 12:4593. [PMID: 37510707 PMCID: PMC10380466 DOI: 10.3390/jcm12144593] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2023] [Revised: 07/06/2023] [Accepted: 07/08/2023] [Indexed: 07/30/2023] Open
Abstract
At rest, a good Fontan circulation can provide a normal cardiac output (CO). However, as a consequence of its unique hemodynamic nature, the limitations of the Fontan circuit are exposed during exercise. We aimed to provide a comprehensive assessment of the pathophysiology of exercise in adult Fontan patients (FPs) and identify factors limiting their functional capacity (FC). In a single-center study conducted in 37 FPs aged ≥16 years and 19 healthy-controls (HCs) who underwent CPET on a cycle ergometer in February and March 2022, the mean peakVO2 was 21 ± 5.4 mL/kg/min, which was 55% of the predicted value. Morphologically, the left single ventricle showed a higher peakVO2% predicted value (57.4 ± 14.4% vs. 43.4 ± 8.1%, p = 0.045). The factors associated with low peakVO2 values were an early flattened or descending O2 pulse at maximal exertion (52 ± 14% vs. 62 ± 12.5, p = 0.04 and 47.6 ± 9% vs. 60 ± 14, p = 0.018, respectively) and chronotropic insufficiency (53 ± 12% vs. 69.8 ± 20%, p = 0.008). The OUES was found to be a useful parameter to assess the FC in FPs in maximal and submaximal exercise testing. A strong positive correlation was observed between the %OUES and peakVO2%predicted (r = 0.726, p > 0.001). The lung function was impaired in the FPs, mostly with a mild restrictive pattern (56.8%). The FPs showed lower inspiratory muscle strength compared to the HCs but it was not statistically associated with either the peakVO2 or VE/VCO2 slope. Regular intense physical activity improves one's FC. Although FPs have inspiratory muscle weakness, its impact on their FC is unclear. The peakVO2% predicted grew progressively higher as the level of physical activity increased (low level 49.5 ± 14%, moderate level 55 ± 12%, intense level 69 ± 20%).
Collapse
Affiliation(s)
- Raquel Ladrón-Abia
- Adult Congenital Heart Disease Unit, Hospital Universitario Virgen del Rocío, Instituto de BioMedicina de Sevilla (IBIS), Avenida Manuel Siurot s/n, 41013 Sevilla, Spain
| | - Pilar Cejudo Ramos
- Medical-Surgical Service of Respiratory Diseases, Hospital Universitario Virgen del Rocío, Instituto de BioMedicina de Sevilla (IBIS), 41013 Sevilla, Spain
| | - Israel Valverde Pérez
- Paediatric Cardiology Unit, Hospital Infantil Virgen del Rocío, Instituto de BioMedicina de Sevilla (IBIS), 41013 Sevilla, Spain
| | - Rocío Camacho Fernández De Liger
- Adult Congenital Heart Disease Unit, Hospital Universitario Virgen del Rocío, Instituto de BioMedicina de Sevilla (IBIS), Avenida Manuel Siurot s/n, 41013 Sevilla, Spain
| | - Amadeo-José Wals-Rodríguez
- Adult Congenital Heart Disease Unit, Hospital Universitario Virgen del Rocío, Instituto de BioMedicina de Sevilla (IBIS), Avenida Manuel Siurot s/n, 41013 Sevilla, Spain
| | - María José Rodríguez Puras
- Adult Congenital Heart Disease Unit, Hospital Universitario Virgen del Rocío, Instituto de BioMedicina de Sevilla (IBIS), Avenida Manuel Siurot s/n, 41013 Sevilla, Spain
| | - Begoña Manso García
- Adult Congenital Heart Disease Unit, Hospital Universitario Virgen del Rocío, Instituto de BioMedicina de Sevilla (IBIS), Avenida Manuel Siurot s/n, 41013 Sevilla, Spain
- Paediatric Cardiology Unit, Hospital Infantil Virgen del Rocío, Instituto de BioMedicina de Sevilla (IBIS), 41013 Sevilla, Spain
| | - Pastora Gallego
- Adult Congenital Heart Disease Unit, Hospital Universitario Virgen del Rocío, Instituto de BioMedicina de Sevilla (IBIS), Avenida Manuel Siurot s/n, 41013 Sevilla, Spain
| |
Collapse
|
7
|
Mahendran AK, Katz D, Opotowsky AR, Lubert AM. Exercise Pathophysiology and Testing in Individuals With a Fontan Circulation. CJC PEDIATRIC AND CONGENITAL HEART DISEASE 2023; 2:112-123. [PMID: 37969357 PMCID: PMC10642126 DOI: 10.1016/j.cjcpc.2023.01.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/03/2022] [Accepted: 01/07/2023] [Indexed: 11/17/2023]
Abstract
The Fontan circulation, a surgical palliation for single-ventricle congenital heart disease, profoundly impacts the cardiopulmonary response to exercise. Reliant on passive pulmonary blood flow, the Fontan circulation has limited capacity to augment cardiac output as necessary to supply working muscles during exercise. Cardiopulmonary exercise testing (CPET) objectively assesses cardiorespiratory fitness and provides insight into the etiology of exercise intolerance. Furthermore, CPET variables, such as peak oxygen consumption and submaximal variables, have prognostic value and may be used as meaningful endpoints in research studies. CPET is also useful in clinical research applications to assess the effect of pharmacologic or other interventions. Medical therapies to improve exercise tolerance in individuals with a Fontan circulation, such as pulmonary vasodilators, may modestly improve peak oxygen consumption. Exercise training focused on aerobic fitness and lower extremity strength may have a more consistent and larger impact on these measures of aerobic fitness. CPET is a valuable diagnostic and prognostic tool for those with a Fontan circulation. Newer ancillary assessments, such as noninvasive peripheral venous pressure monitoring and cardiac output measurements, hold promise to provide a more nuanced insight into the underlying pathophysiology.
Collapse
Affiliation(s)
- Arjun K. Mahendran
- Department of Pediatrics, Heart Institute, Cincinnati Children’s Hospital, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
| | - David Katz
- Department of Pediatrics, Heart Institute, Cincinnati Children’s Hospital, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
| | - Alexander R. Opotowsky
- Department of Pediatrics, Heart Institute, Cincinnati Children’s Hospital, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
| | - Adam M. Lubert
- Department of Pediatrics, Heart Institute, Cincinnati Children’s Hospital, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
| |
Collapse
|
8
|
Pollak U, Abarbanel I, Salem Y, Serraf AE, Mishaly D. Dominant Ventricular Morphology and Early Postoperative Course After the Fontan Procedure. World J Pediatr Congenit Heart Surg 2022; 13:346-352. [PMID: 35446208 PMCID: PMC9024023 DOI: 10.1177/21501351221081246] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background Single ventricle heart disease comprises a wide variety of critical heart defects that lead to the provision of systemic cardiac output by one dominant ventricle. It requires staged surgical palliation that culminates in Fontan circulation. Dominant ventricular morphology in single ventricle patients reportedly has an impact on postoperative morbidity and mortality with varying results. The objectives of this study were to examine the association between ventricular morphology and the early postoperative course after the Fontan procedure. Methods A retrospective cohort study in a tertiary referral pediatric medical center that included 98 consecutive patients who underwent Fontan procedure between October 2009 and May 2016. Postoperative outcomes were compared between patients with left ventricular morphology and those with right ventricular morphology (crude effect and regression analysis). Results Patients with right ventricular morphology had longer postoperative hospitalizations compared to patients with left ventricular morphology (26.5 days vs 18.2 days, respectively, P = .028), higher postoperative maximal vasoactive-inotropic scores (25.6 vs 12.4, P = .02), higher serum lactate levels (7.7 mmol/L vs 6.4 mmol/L, P = .03), higher proportions of ventilation throughout 24 h or more (16 patients [38%] vs 8 patients [14%], P = .009), higher proportions of ventricular dysfunction (12 patients [29%] vs 5 patients [9%], P = .0001), and lower blood oxygen saturation levels at discharge (87% vs 92%, P = .03). Conclusions The Fontan procedure in patients with right ventricular morphology is associated with longer postoperative hospitalization and worse early postoperative characteristics (ventricular dysfunction and atrioventricular valve regurgitation) as well as higher rates of early, transient signs of sub-optimal postoperative hemodynamics compared to those with left ventricular morphology.
Collapse
Affiliation(s)
- Uri Pollak
- Pediatric Cardiac Critical Care Unit, Hadassah University Medical Center, Jerusalem, Israel.,Pediatric Cardiology, Hadassah University Medical Center, Jerusalem, Israel.,Pediatric Extracorporeal Support Program, Hadassah University Medical Center, Jerusalem, Israel.,58884The Hebrew University Hadassah Medical School, Jerusalem, Israel
| | - Inbar Abarbanel
- The Sackler Faculty of Medicine, 58408Tel Aviv University, Tel Aviv, Israel
| | - Yishay Salem
- The Sackler Faculty of Medicine, 58408Tel Aviv University, Tel Aviv, Israel.,Pediatric Cardiology, Edmond J. Safra International Congenital Heart Center, 146925The Edmond and Lily Safra Children's Hospital, The Chaim Sheba Medical Center, Tel Hashomer, Israel
| | - Alain E Serraf
- The Sackler Faculty of Medicine, 58408Tel Aviv University, Tel Aviv, Israel.,Pediatric and Congenital Cardiac Surgery, Edmond J. Safra International Congenital Heart Center, The Edmond and Lily Safra Children's Hospital, 26744The Chaim Sheba Medical Center, Tel Hashomer, Israel
| | - David Mishaly
- The Sackler Faculty of Medicine, 58408Tel Aviv University, Tel Aviv, Israel.,Pediatric and Congenital Cardiac Surgery, Edmond J. Safra International Congenital Heart Center, The Edmond and Lily Safra Children's Hospital, 26744The Chaim Sheba Medical Center, Tel Hashomer, Israel
| |
Collapse
|
9
|
Laohachai K, Ayer J. Impairments in Pulmonary Function in Fontan Patients: Their Causes and Consequences. Front Pediatr 2022; 10:825841. [PMID: 35498782 PMCID: PMC9051243 DOI: 10.3389/fped.2022.825841] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/30/2021] [Accepted: 02/23/2022] [Indexed: 11/26/2022] Open
Abstract
Patients with a Fontan circulation lack a sub-pulmonary ventricle with pulmonary blood flow passively redirected to the lungs. In the Fontan circulation, ventilation has a significant influence on pulmonary blood flow and cardiac output both at rest and with exercise. Children and adults with a Fontan circulation have abnormalities in lung function. In particular, restrictive ventilatory patterns, as measured by spirometry, and impaired gas transfer, as measured by the diffusing capacity of carbon monoxide, have been frequently observed. These abnormalities in lung function are associated with reduced exercise capacity and quality of life. Moderate to severe impairment in lung volumes is independently associated with reduced survival in adults with congenital heart disease. Skeletal and inspiratory muscle weakness has also been reported in patients with a Fontan circulation, with the prospect of improving respiratory muscle function through exercise training programs. In this review, we will present data on cardiopulmonary interactions in the Fontan circulation, the prevalence and severity of impaired lung function, and respiratory muscle function in this population. We will discuss potential causes for and consequence of respiratory impairments, and their impact on exercise capacity and longer-term Fontan outcome. We aim to shed light on possible strategies to reduce morbidity by improving respiratory function in this growing population of patients.
Collapse
Affiliation(s)
- Karina Laohachai
- Cardiology Department, Women's and Children's Hospital, Adelaide, SA, Australia.,Faculty of Medicine and Health, The University of Sydney, Sydney, NSW, Australia
| | - Julian Ayer
- Faculty of Medicine and Health, The University of Sydney, Sydney, NSW, Australia.,The Heart Centre for Children, Children's Hospital at Westmead, Sydney, NSW, Australia
| |
Collapse
|
10
|
Tran DL, Celermajer DS, Ayer J, Grigg L, Clendenning C, Hornung T, Justo R, Davis GM, d'Udekem Y, Cordina R. The "Super-Fontan" Phenotype: Characterizing Factors Associated With High Physical Performance. Front Cardiovasc Med 2021; 8:764273. [PMID: 34950712 PMCID: PMC8688538 DOI: 10.3389/fcvm.2021.764273] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2021] [Accepted: 11/09/2021] [Indexed: 12/28/2022] Open
Abstract
Background: People with a Fontan circulation usually have moderately impaired exercise performance, although a subset have high physical performance ("Super-Fontan"), which may represent a low-risk phenotype. Methods: People with a "Super-Fontan" phenotype were defined as achieving normal exercise performance [≥80% predicted peak oxygen uptake (VO2) and work rate] during cardiopulmonary exercise testing (CPET) and were identified from the Australian and New Zealand Fontan Registry. A Fontan control group that included people with impaired exercise performance (<80% predicted VO2 or work rate) was also identified based on a 1:3 allocation ratio. A subset of participants were prospectively recruited and completed a series of physical activity, exercise self-efficacy, and health-related quality of life questionnaires. Results: Sixty CPETs ("Super-Fontan", n = 15; control, n = 45) were included. A subset ("Super-Fontan", n = 10; control, n = 13) completed a series of questionnaires. Average age was 29 ± 8 years; 48% were males. Exercise capacity reflected by percent predicted VO2 was 67 ± 17% in the entire cohort. Compared to the "Super-Fontan" phenotype, age at Fontan completion was higher in controls (4.0 ± 2.9 vs. 7.2 ± 5.3 years, p = 0.002). Only one (7%) person in the "Super-Fontan" group had a dominant right ventricle compared to 15 (33%) controls (p = 0.043). None of those in the "Super-Fontan" group were obese, while almost a quarter (22%) of controls were obese based on body mass index (p = 0.046). Lung function abnormalities were less prevalent in the "Super-Fontan" group (20 vs. 70%, p = 0.006). Exercise self-efficacy was greater in the "Super-Fontan" group (34.2 ± 3.6 vs. 27.9 ± 7.2, p = 0.02). Self-reported sports participation and physical activity levels during childhood and early adulthood were higher in the "Super-Fontan" group (p < 0.05). The total average time spent participating in structured sports and physical activity was 4.3 ± 2.6 h/wk in the "Super-Fontan" group compared to 2.0 ± 3.0 h/wk in controls, p = 0.003. There were no differences in self-reported current total physical activity score or health-related quality of life between groups (p ≥ 0.05). Conclusions: The "Super-Fontan" phenotype is associated with a healthy weight, lower age at Fontan completion, better exercise self-efficacy, and higher overall levels of sport and physical activity participation during physical development.
Collapse
Affiliation(s)
- Derek L Tran
- Department of Cardiology, Royal Prince Alfred Hospital, Sydney, NSW, Australia.,Central Clinical School, The University of Sydney School of Medicine, Sydney, NSW, Australia.,Charles Perkins Centre, Heart Research Institute, Sydney, NSW, Australia
| | - David S Celermajer
- Department of Cardiology, Royal Prince Alfred Hospital, Sydney, NSW, Australia.,Central Clinical School, The University of Sydney School of Medicine, Sydney, NSW, Australia.,Charles Perkins Centre, Heart Research Institute, Sydney, NSW, Australia
| | - Julian Ayer
- Heart Centre for Children, The Sydney Children's Hospital Network, Sydney, NSW, Australia.,The Children's Hospital at Westmead Clinical School, Sydney, NSW, Australia
| | - Leeanne Grigg
- Department of Cardiology, The Royal Melbourne Hospital, Melbourne, VIC, Australia.,The University of Melbourne School of Medicine, Melbourne, VIC, Australia
| | | | - Tim Hornung
- Green Lane Paediatric and Congenital Cardiac Service, Starship Hospital, Auckland, New Zealand
| | - Robert Justo
- Paediatric Cardiac Service, Queensland Children's Hospital, Brisbane, QLD, Australia.,The University of Queensland School of Medicine, Brisbane, QLD, Australia
| | - Glen M Davis
- Discipline of Exercise and Sports Science, Sydney School of Health Sciences, Faculty of Medicine and Health, The University of Sydney, Sydney, NSW, Australia
| | - Yves d'Udekem
- The George Washington University School of Medicine and Health Sciences, Washington, DC, United States.,Division of Cardiovascular Surgery, Children's National Hospital, Washington, DC, United States
| | - Rachael Cordina
- Department of Cardiology, Royal Prince Alfred Hospital, Sydney, NSW, Australia.,Central Clinical School, The University of Sydney School of Medicine, Sydney, NSW, Australia.,Charles Perkins Centre, Heart Research Institute, Sydney, NSW, Australia.,Murdoch Children's Research Institute, Melbourne, VIC, Australia
| |
Collapse
|
11
|
Serial Cardiopulmonary Exercise Testing in Patients after Extracardiac Conduit Total Cavopulmonary Connection for Single-Ventricle Hearts: An Observational Study. J Pediatr 2021; 238:233-240.e1. [PMID: 34228986 DOI: 10.1016/j.jpeds.2021.06.078] [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: 12/23/2020] [Revised: 06/26/2021] [Accepted: 06/29/2021] [Indexed: 01/21/2023]
Abstract
OBJECTIVE To analyze the aerobic fitness and evolution of exercise tolerance in patients with single-ventricle physiology after total cavopulmonary connection (TCPC) with an extracardiac conduit (ECC). STUDY DESIGN This retrospective cohort study included patients with previous ECC-TCPC who underwent cardiopulmonary exercise testing (CPET) between September 2010 and September 2019. Patients who completed at least 2 tests (≥6 months apart) with adequate levels of effort were recruited for the serial CPET evaluation. RESULTS We identified 70 patients (50% male) with a mean age of 6.45 ± 5.14 years at ECC-TCPC and 15.67 ± 5.03 years at the initial CPET. The peak oxygen consumption (peak VO2) to predicted value (peak PD) was 55.90 ± 16.81%. Twenty of the 70 identified patients (50% male) were recruited for serial analysis. The average number of CPETs was 2.6 per patient. The average duration from the first CPET to the last CPET was 3.64 years. The peak VO2 and PD increased slowly, with mean rates of 38.77 ± 129.01 mL/min and 1.66 ± 6.40%, respectively, during the study period. CONCLUSIONS Although the patients had lower exercise tolerance after ECC-TCPC compared with their normal peers, exercise tolerance appears to have been preserved over the adolescent period in those who underwent serial testing after ECC-TCPC.
Collapse
|
12
|
Yamazaki S, Akazawa Y, Obinata H, Motoki N, Takei K, Yasukochi S, Takigiku K. Ventricular myocardial response to exercise in patients with Fontan circulation. J Echocardiogr 2021; 19:212-221. [PMID: 33840066 DOI: 10.1007/s12574-021-00525-w] [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: 09/09/2020] [Revised: 03/13/2021] [Accepted: 03/31/2021] [Indexed: 11/24/2022]
Abstract
BACKGROUND Exercise stress echocardiography has been used to assess myocardial reserve in various heart diseases. This study examined the ventricular myocardial response to exercise in Fontan patients using exercise stress echocardiography. METHODS Twenty-five Fontan patients and 19 control subjects underwent semi-supine bicycle exercise stress echocardiography in this prospective, single-center, cross-sectional study. Pulsed-wave Doppler tissue imaging peak systolic (s') and diastolic (e') velocities, longitudinal strain and systolic strain rate, and early diastolic strain rate data at rest and at peak exercise were obtained for the systemic ventricle. The myocardial reserve of functional parameters was calculated as the difference between peak exercise and rest. RESULTS Inter- and intra-observer reliability were both high for exercise stress echocardiography measurements. Compared with controls, Fontan patients had significantly lower s', e', longitudinal systolic strain and strain rate, and early diastolic longitudinal strain rate at rest and at peak exercise as well as reduced myocardial reserve. CONCLUSIONS Fontan patients have markedly reduced myocardial reserve during exercise. The use of exercise stress echocardiography assessment may improve the clinical management of Fontan patients.
Collapse
Affiliation(s)
- Shoko Yamazaki
- Department of Pediatrics, Shinshu University School of Medicine, 3-1-1 Asahi, Matsumoto, Nagano, 390-8621, Japan
| | - Yohei Akazawa
- Department of Pediatrics, Shinshu University School of Medicine, 3-1-1 Asahi, Matsumoto, Nagano, 390-8621, Japan. .,Division of Cardiology, Nagano Children's Hospital, 3100, Azumino, Nagano, Japan.
| | - Haruka Obinata
- Division of Cardiology, Nagano Children's Hospital, 3100, Azumino, Nagano, Japan
| | - Noriko Motoki
- Department of Pediatrics, Shinshu University School of Medicine, 3-1-1 Asahi, Matsumoto, Nagano, 390-8621, Japan
| | - Kohta Takei
- Division of Cardiology, Nagano Children's Hospital, 3100, Azumino, Nagano, Japan
| | - Satoshi Yasukochi
- Division of Cardiology, Nagano Children's Hospital, 3100, Azumino, Nagano, Japan
| | - Kiyohiro Takigiku
- Division of Cardiology, Nagano Children's Hospital, 3100, Azumino, Nagano, Japan
| |
Collapse
|
13
|
Decline Is Not Inevitable: Exercise Capacity Trajectory in an Australian and New Zealand Fontan Cohort. Heart Lung Circ 2021; 30:1356-1363. [PMID: 33745814 DOI: 10.1016/j.hlc.2021.01.004] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2020] [Accepted: 01/13/2021] [Indexed: 12/19/2022]
Abstract
BACKGROUND In people with a Fontan circulation, serial cardiopulmonary exercise testing (CPET) to evaluate change in peak exercise capacity has been increasingly recognised as a useful prognostic tool; a decline is associated with adverse clinical outcomes. The aim of this study is to describe the "natural" history of exercise capacity in the Australian and New Zealand (ANZ) Fontan cohort and to identify factors associated with a decline. METHODS The ANZ Fontan registry was retrospectively reviewed for adolescent and adult patients (≥16 years) with serial CPET results performed on a cycle ergometer ≥6 months apart. Patients were excluded if they underwent a surgical procedure or fenestration closure in-between tests or if the tests were considered as submaximal effort. Exercise capacity trajectory was defined as the change in percentage of predicted peak oxygen uptake (% pred VO2peak) points per year. RESULTS Thirty-seven (37) patients (59.5% male, mean age 24±7 years) were eligible. Average duration between CPET was 5.3±3.9 years. At baseline, % pred VO2peak was 61.3±14.5%. Thirteen (13) (35%) had a systemic right ventricle, and 14 (38%) had an atriopulmonary type Fontan circulation. Average change in % pred VO2peak overall was +1.3±6.4 percentage points per year. Sixteen (16) had a negative exercise capacity trajectory, and the average decline in that group was -2.7±3.4 percentage points per year. There was no association between exercise capacity trajectory and clinical characteristics. Of the 18 patients with physical activity levels recorded, 12 (67%) were physically active and % pred VO2peak in that group increased by 2.7±4.0 percentage points per year compared with the physically inactive group who fell by 0.5±0.8 percentage points per year. CONCLUSIONS In this ANZ series of Fontan patients, over half of our cohort had stable, or an increase, in peak exercise capacity. Regular participation in physical activity was common in patients with a positive exercise capacity trajectory. Clinical characteristics were not associated with exercise capacity trajectory.
Collapse
|
14
|
Turquetto ALR, Dos Santos MR, Agostinho DR, Sayegh ALC, de Souza FR, Amato LP, Barnabe MSR, de Oliveira PA, Liberato G, Binotto MA, Negrão CE, Canêo LF, Trindade E, Jatene FB, Jatene MB. Aerobic exercise and inspiratory muscle training increase functional capacity in patients with univentricular physiology after Fontan operation: A randomized controlled trial. Int J Cardiol 2021; 330:50-58. [PMID: 33571562 DOI: 10.1016/j.ijcard.2021.01.058] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/08/2020] [Revised: 01/02/2021] [Accepted: 01/11/2021] [Indexed: 11/30/2022]
Abstract
BACKGROUND The effect of exercise training and its mechanisms on the functional capacity improvement in Fontan patients (FP) are virtually unknown. This trial evaluated four-month aerobic exercise training and inspiratory muscle training on functional capacity, pulmonary function, and autonomic control in patients after Fontan operation. METHODS A randomized controlled clinical trial with 42 FP aged 12 to 30 years and, at least, five years of Fontan completion. Twenty-seven were referred to a four-months supervised and personalized aerobic exercise training (AET) or an inspiratory muscle training (IMT). A group of non-exercise (NET) was used as control. The effects of the exercise training in peak VO2; pulmonary volumes and capacities, maximal inspiratory pressure (MIP); muscle sympathetic nerve activity (MSNA); forearm blood flow (FBF); handgrip strength and cross-sectional area of the thigh were analyzed. RESULTS The AET decreased MSNA (p = 0.042), increased FBF (p = 0.012) and handgrip strength (p = 0.017). No significant changes in autonomic control were found in IMT and NET groups. Both AET and IMT increased peak VO2, but the increase was higher in the AET group compared to IMT (23% vs. 9%). No difference was found in the NET group. IMT group showed a 58% increase in MIP (p = 0.008) in forced vital capacity (p = 0.011) and forced expiratory volume in the first second (p = 0.011). No difference in pulmonary function was found in the AET group. CONCLUSIONS Both aerobic exercise and inspiratory muscle training improved functional capacity. The AET group developed autonomic control, and handgrip strength, and the IMT increased inspiratory muscle strength and spirometry. CLINICAL TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT02283255.
Collapse
Affiliation(s)
| | | | | | | | | | | | | | | | - Gabriela Liberato
- Heart Institute, University of São Paulo Medical School, São Paulo, Brazil
| | | | - Carlos Eduardo Negrão
- Heart Institute, University of São Paulo Medical School, São Paulo, Brazil; School of Physical Education and Sport, University of São Paulo, São Paulo, Brazil
| | | | - Evelinda Trindade
- Heart Institute, University of São Paulo Medical School, São Paulo, Brazil
| | | | | |
Collapse
|
15
|
Tran DL, Gibson H, Maiorana AJ, Verrall CE, Baker DW, Clode M, Lubans DR, Zannino D, Bullock A, Ferrie S, Briody J, Simm P, Wijesekera V, D'Almeida M, Gosbell SE, Davis GM, Weintraub R, Keech AC, Puranik R, Ugander M, Justo R, Zentner D, Majumdar A, Grigg L, Coombes JS, d'Udekem Y, Morris NR, Ayer J, Celermajer DS, Cordina R. Exercise Intolerance, Benefits, and Prescription for People Living With a Fontan Circulation: The Fontan Fitness Intervention Trial (F-FIT)-Rationale and Design. Front Pediatr 2021; 9:799125. [PMID: 35071139 PMCID: PMC8771702 DOI: 10.3389/fped.2021.799125] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/21/2021] [Accepted: 12/07/2021] [Indexed: 12/16/2022] Open
Abstract
Background: Despite developments in surgical techniques and medical care, people with a Fontan circulation still experience long-term complications; non-invasive therapies to optimize the circulation have not been established. Exercise intolerance affects the majority of the population and is associated with worse prognosis. Historically, people living with a Fontan circulation were advised to avoid physical activity, but a small number of heterogenous, predominantly uncontrolled studies have shown that exercise training is safe-and for unique reasons, may even be of heightened importance in the setting of Fontan physiology. The mechanisms underlying improvements in aerobic exercise capacity and the effects of exercise training on circulatory and end-organ function remain incompletely understood. Furthermore, the optimal methods of exercise prescription are poorly characterized. This highlights the need for large, well-designed, multi-center, randomized, controlled trials. Aims and Methods: The Fontan Fitness Intervention Trial (F-FIT)-a phase III clinical trial-aims to optimize exercise prescription and delivery in people with a Fontan circulation. In this multi-center, randomized, controlled study, eligible Fontan participants will be randomized to either a 4-month supervised aerobic and resistance exercise training program of moderate-to-vigorous intensity followed by an 8-month maintenance phase; or usual care (control group). Adolescent and adult (≥16 years) Fontan participants will be randomized to either traditional face-to-face exercise training, telehealth exercise training, or usual care in a three-arm trial with an allocation of 2:2:1 (traditional:telehealth:control). Children (<16 years) will be randomized to either a physical activity and exercise program of moderate-to-vigorous intensity or usual care in a two-arm trial with a 1:1 allocation. The primary outcome is a change in aerobic exercise capacity (peak oxygen uptake) at 4-months. Secondary outcomes include safety, and changes in cardiopulmonary exercise testing measures, peripheral venous pressure, respiratory muscle and lung function, body composition, liver stiffness, neuropsychological and neurocognitive function, physical activity levels, dietary and nutritional status, vascular function, neurohormonal activation, metabolites, cardiac function, quality of life, musculoskeletal fitness, and health care utilization. Outcome measures will be assessed at baseline, 4-months, and 12-months. This manuscript will describe the pathophysiology of exercise intolerance in the Fontan circulation and the rationale and protocol for the F-FIT.
Collapse
Affiliation(s)
- Derek L Tran
- Department of Cardiology, Royal Prince Alfred Hospital, Sydney, NSW, Australia.,Central Clinical School, The University of Sydney School of Medicine, Sydney, NSW, Australia.,Charles Perkins Centre, Heart Research Institute, Sydney, NSW, Australia.,Faculty of Medicine and Health, The University of Sydney, Sydney, NSW, Australia
| | - Hannah Gibson
- Charles Perkins Centre, Heart Research Institute, Sydney, NSW, Australia
| | - Andrew J Maiorana
- School of Allied Health, Curtin University, Perth, WA, Australia.,Allied Health Department, Fiona Stanley Hospital, Perth, WA, Australia
| | - Charlotte E Verrall
- The University of Sydney Westmead Clinical School, Sydney, NSW, Australia.,Heart Centre for Children, The Children's Hospital at Westmead, Sydney, NSW, Australia
| | - David W Baker
- Department of Cardiology, Royal Prince Alfred Hospital, Sydney, NSW, Australia.,Central Clinical School, The University of Sydney School of Medicine, Sydney, NSW, Australia
| | - Melanie Clode
- Heart Research Group, Murdoch Children's Research Institute, Melbourne, VIC, Australia
| | - David R Lubans
- School of Education, Priority Research Centre for Physical Activity and Nutrition, The University of Newcastle, Newcastle, NSW, Australia
| | - Diana Zannino
- Heart Research Group, Murdoch Children's Research Institute, Melbourne, VIC, Australia
| | - Andrew Bullock
- Paediatric and Adult Congenital Cardiology, Perth Children's Hospital, Perth, WA, Australia
| | - Suzie Ferrie
- Department of Nutrition and Dietetics, Royal Prince Alfred Hospital, Sydney, NSW, Australia
| | - Julie Briody
- Department of Nuclear Medicine, The Children's Hospital at Westmead, Sydney, NSW, Australia
| | - Peter Simm
- Heart Research Group, Murdoch Children's Research Institute, Melbourne, VIC, Australia
| | - Vishva Wijesekera
- Department of Cardiology, The Prince Charles Hospital, Brisbane, QLD, Australia
| | - Michelle D'Almeida
- Charles Perkins Centre, Heart Research Institute, Sydney, NSW, Australia
| | - Sally E Gosbell
- Central Clinical School, The University of Sydney School of Medicine, Sydney, NSW, Australia.,Charles Perkins Centre, Heart Research Institute, Sydney, NSW, Australia.,Heart Centre for Children, The Children's Hospital at Westmead, Sydney, NSW, Australia
| | - Glen M Davis
- Faculty of Medicine and Health, The University of Sydney, Sydney, NSW, Australia
| | - Robert Weintraub
- Heart Research Group, Murdoch Children's Research Institute, Melbourne, VIC, Australia.,Department of Cardiology, The Royal Children's Hospital, Melbourne, VIC, Australia
| | - Anthony C Keech
- Department of Cardiology, Royal Prince Alfred Hospital, Sydney, NSW, Australia.,Central Clinical School, The University of Sydney School of Medicine, Sydney, NSW, Australia.,NHMRC Clinical Trials Centre, The University of Sydney, Sydney, NSW, Australia
| | - Rajesh Puranik
- Department of Cardiology, Royal Prince Alfred Hospital, Sydney, NSW, Australia.,Central Clinical School, The University of Sydney School of Medicine, Sydney, NSW, Australia
| | - Martin Ugander
- Royal North Shore Hospital, The Kolling Institute, Sydney, NSW, Australia
| | - Robert Justo
- Paediatric Cardiac Service, Queensland Children's Hospital, Brisbane, QLD, Australia
| | - Dominica Zentner
- The University of Melbourne Medical School, Melbourne, VIC, Australia.,Department of Cardiology, The Royal Melbourne Hospital, Melbourne, VIC, Australia
| | - Avik Majumdar
- Central Clinical School, The University of Sydney School of Medicine, Sydney, NSW, Australia.,Australian National Liver Transplant Unit, AW Morrow Gastroenterology and Liver Centre, Royal Prince Alfred Hospital, Camperdown, NSW, Australia
| | - Leeanne Grigg
- The University of Melbourne Medical School, Melbourne, VIC, Australia.,Department of Cardiology, The Royal Melbourne Hospital, Melbourne, VIC, Australia
| | - Jeff S Coombes
- School of Human Movement and Nutrition Sciences, Centre for Research on Exercise, Physical Activity, and Health, The University of Queensland, Brisbane, QLD, Australia
| | - Yves d'Udekem
- Division of Cardiac Surgery, Children's National Hospital, Washington, DC, United States
| | - Norman R Morris
- Allied Health Collaborative and Queensland Lung Transplant Service, The Prince Charles Hospital, Brisbane, QLD, Australia.,School of Health Sciences and Social Work, Griffith University, Gold Coast, QLD, Australia
| | - Julian Ayer
- The University of Sydney Westmead Clinical School, Sydney, NSW, Australia.,Heart Centre for Children, The Children's Hospital at Westmead, Sydney, NSW, Australia
| | - David S Celermajer
- Department of Cardiology, Royal Prince Alfred Hospital, Sydney, NSW, Australia.,Central Clinical School, The University of Sydney School of Medicine, Sydney, NSW, Australia.,Charles Perkins Centre, Heart Research Institute, Sydney, NSW, Australia
| | - Rachael Cordina
- Department of Cardiology, Royal Prince Alfred Hospital, Sydney, NSW, Australia.,Central Clinical School, The University of Sydney School of Medicine, Sydney, NSW, Australia.,Charles Perkins Centre, Heart Research Institute, Sydney, NSW, Australia.,Heart Research Group, Murdoch Children's Research Institute, Melbourne, VIC, Australia
| |
Collapse
|
16
|
Powell AW, Veldtman G. Heart Rate Responses During Exercise by Dominant Ventricle in Pediatric and Young Adult Patients With a Fontan Circulation. Can J Cardiol 2020; 36:1508-1515. [DOI: 10.1016/j.cjca.2019.10.042] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2019] [Revised: 10/17/2019] [Accepted: 10/30/2019] [Indexed: 02/07/2023] Open
|
17
|
Hayama Y, Shimizu S, Kawada T, Negishi J, Sakaguchi H, Miyazaki A, Ohuchi H, Yamada O, Kurosaki K, Sugimachi M. Impact of delayed ventricular wall area ratio on pathophysiology of mechanical dyssynchrony: implication from single-ventricle physiology and 0D modeling. J Physiol Sci 2020; 70:38. [PMID: 32762655 PMCID: PMC10716988 DOI: 10.1186/s12576-020-00765-y] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2020] [Accepted: 07/18/2020] [Indexed: 11/10/2022]
Abstract
Electrical disparity can induce inefficient cardiac performance, representing an uncoordinated wall motion at an earlier activated ventricular wall: an early shortening followed by a systolic rebound stretch. Although regional contractility and distensibility modulate this pathological motion, the effect of a morphological factor has not been emphasized. Our strain analysis in 62 patients with single ventricle revealed that those with an activation delay in 60-70% of ventricular wall area suffered from cardiac dysfunction and mechanical discoordination along with prolonged QRS duration. A computational simulation with a two-compartment ventricular model also suggested that the ventricle with an activation delay in 70% of the total volume was most vulnerable to a large activation delay, accompanied by an uncoordinated motion at an earlier activated wall. Taken together, the ratio of the delayed ventricular wall has a significant impact on the pathophysiology due to an activation delay, potentially highlighting an indicator of cardiac dysfunction.
Collapse
Affiliation(s)
- Yohsuke Hayama
- Department of Cardiovascular Dynamics, National Cerebral and Cardiovascular Center, 6-1, Kishibe-shimmachi, Suita, Osaka, 564-8565, Japan
- Department of Cardiovascular Science, Faculty of Medicine, Osaka University Graduate School of Medicine, 2-2, Yamada-oka, Suita, Osaka, 565-0871, Japan
| | - Shuji Shimizu
- Department of Cardiovascular Dynamics, National Cerebral and Cardiovascular Center, 6-1, Kishibe-shimmachi, Suita, Osaka, 564-8565, Japan
| | - Toru Kawada
- Department of Cardiovascular Dynamics, National Cerebral and Cardiovascular Center, 6-1, Kishibe-shimmachi, Suita, Osaka, 564-8565, Japan
| | - Jun Negishi
- Department of Pediatric Cardiology, National Cerebral and Cardiovascular Center, 6-1, Kishibe-shimmachi, Suita, Osaka, 564-8565, Japan
| | - Heima Sakaguchi
- Department of Pediatric Cardiology, National Cerebral and Cardiovascular Center, 6-1, Kishibe-shimmachi, Suita, Osaka, 564-8565, Japan
| | - Aya Miyazaki
- Department of Cardiology, Shizuoka Children's Hospital, 860, Urushiyama, Aoi-ku, Shizuoka, Shizuoka, 420-8660, Japan
| | - Hideo Ohuchi
- Department of Pediatric Cardiology, National Cerebral and Cardiovascular Center, 6-1, Kishibe-shimmachi, Suita, Osaka, 564-8565, Japan
| | - Osamu Yamada
- Department of Pediatric Cardiology, National Cerebral and Cardiovascular Center, 6-1, Kishibe-shimmachi, Suita, Osaka, 564-8565, Japan
| | - Kenichi Kurosaki
- Department of Pediatric Cardiology, National Cerebral and Cardiovascular Center, 6-1, Kishibe-shimmachi, Suita, Osaka, 564-8565, Japan
| | - Masaru Sugimachi
- Department of Cardiovascular Dynamics, National Cerebral and Cardiovascular Center, 6-1, Kishibe-shimmachi, Suita, Osaka, 564-8565, Japan.
- Department of Cardiovascular Science, Faculty of Medicine, Osaka University Graduate School of Medicine, 2-2, Yamada-oka, Suita, Osaka, 565-0871, Japan.
| |
Collapse
|
18
|
Härtel JA, Müller N, Herberg U, Breuer J, Bizjak DA, Bloch W, Grau M. Altered Hemorheology in Fontan Patients in Normoxia and After Acute Hypoxic Exercise. Front Physiol 2019; 10:1443. [PMID: 31824342 PMCID: PMC6883377 DOI: 10.3389/fphys.2019.01443] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2019] [Accepted: 11/08/2019] [Indexed: 12/02/2022] Open
Abstract
Background The Fontan circulation is a unique palliation procedure for several congenital heart defects. Impaired exercise capacity has previously been demonstrated in these patients and also a higher risk for cardiopulmonary mortality. Hemorheology was shown to affect cardiopulmonary capacity and in turn to be affected by regular exercise and hypoxia but none of these have been investigated in Fontan patients so far. The aim of this study was to detect general differences in hemorheology in normoxia as well as possible altered hemorheological responses to hypoxia exposure and hypoxic exercise between Fontan patients and healthy controls. Methods and Findings 26 Fontan patients and 20 healthy controls performed an acute exercise test (AET) on a bicycle ergometer under hypoxia with ambient 15.2% oxygen saturation (sO2). Blood samples were taken at rest in normoxia (T0), at rest in hypoxia (T1), after maximum exhaustion in hypoxia (T2), and after 50 min recovery in normoxia (T3). Hemorheological and blood parameters were investigated. Additionally, arterial stiffness was tested at T0. Red blood cell (RBC) deformability, NOx, erythropoietin (EPO) concentration, RBC count, hemoglobin (Hb) concentration and hematocrit (hct) were significantly increased in Fontan patients compared to controls. Same was observed for arterial stiffness. No changes were observed for RBC aggregation, fibrinogen concentration, free radical levels and vascular endothelial growth factor (VEGF). Hypoxia exposure did not change parameters, whereas exercise in hypoxia increased aggregation and hct significantly in both groups. Fontan patients showed significantly increased aggregation-disaggregation balance compared to controls. Conclusion Acute hypoxia exposure and exercise under hypoxia might have similar impact on hemorheology in Fontan patients and controls and was clinically well tolerated. Nevertheless, exercise alters aggregation and possibly hemodynamics which requires special attention in Fontan patients.
Collapse
Affiliation(s)
- Julian Alexander Härtel
- Department of Molecular and Cellular Sports Medicine, German Sport University Cologne, Cologne, Germany.,Department for Pediatric Cardiology, University Hospital Bonn, Bonn, Germany
| | - Nicole Müller
- Department for Pediatric Cardiology, University Hospital Bonn, Bonn, Germany
| | - Ulrike Herberg
- Department for Pediatric Cardiology, University Hospital Bonn, Bonn, Germany
| | - Johannes Breuer
- Department for Pediatric Cardiology, University Hospital Bonn, Bonn, Germany
| | - Daniel Alexander Bizjak
- Department of Molecular and Cellular Sports Medicine, German Sport University Cologne, Cologne, Germany
| | - Wilhelm Bloch
- Department of Molecular and Cellular Sports Medicine, German Sport University Cologne, Cologne, Germany
| | - Marijke Grau
- Department of Molecular and Cellular Sports Medicine, German Sport University Cologne, Cologne, Germany
| |
Collapse
|
19
|
Fontan with lateral tunnel is associated with improved survival compared with extracardiac conduit. J Thorac Cardiovasc Surg 2019; 159:1480-1491.e2. [PMID: 31928823 DOI: 10.1016/j.jtcvs.2019.11.048] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/07/2019] [Revised: 11/07/2019] [Accepted: 11/08/2019] [Indexed: 11/22/2022]
Abstract
OBJECTIVES The study aim was to compare Fontan patients undergoing lateral tunnel (LT) versus extracardiac conduit (ECC) technique. METHODS Fontan patients (LT vs ECC) from January 2000 to December 2017 were analyzed retrospectively. Baseline characteristics were analyzed as covariates. Primary outcomes (ie, mortality, Fontan failure, thrombosis, and pacemaker implantation) were compared using time-to-event models. Subgroup analysis including only initially fenestrated cases and propensity score matching were performed. RESULTS Eight hundred one Fontan patients: LT (n = 638) versus ECC (n = 163) were included. Median follow-up time was 4.8 years (range, 1.1-10.8 years). Baseline characteristics were similar except for age: LT versus ECC: 2.6 years (range, 2.2-3.2 years) versus 3.1 years (range, 2.6-4.7 years) (P < .01) and mean pulmonary artery pressure: LT versus ECC: 12 mm Hg (11-15 mm Hg) versus 11 mm Hg (10-13 mm Hg) (P < .05). Early mortality was significantly higher in ECC versus LT group (3.1%; vs 0.5%; P < .05). Freedom from death, heart transplantation and Fontan failure were significantly longer in LT vs ECC (P < .01). After correcting for age, diagnosis, surgical technique, surgeon, mean pulmonary artery pressure, and fenestration, the ECC group showed worse freedom from death (hazard ratio, 2.8; P < .01) and Fontan failure (hazard ratio, 3.0; P < .01). No difference in pacemaker implantation rate was demonstrated (P = .25). Early fenestration closure was associated with higher risk of early (hazard ratio, 30.5) and late mortality (hazard ratio, 3.5). After matching, log-rank tests showed significant differences between the 2 groups for Fontan failure at 5 and 10 years (P < .01) and mortality at 5 years (P = .02). CONCLUSIONS When compared with ECC, LT Fontan is associated with better short and midterm outcomes. Spontaneous fenestration closure is an independent risk factor for early/late mortality.
Collapse
|
20
|
Positive pediatric exercise capacity trajectory predicts better adult Fontan physiology rationale for early establishment of exercise habits. Int J Cardiol 2019; 274:80-87. [DOI: 10.1016/j.ijcard.2018.06.067] [Citation(s) in RCA: 27] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/09/2018] [Revised: 05/14/2018] [Accepted: 06/18/2018] [Indexed: 11/20/2022]
|
21
|
Anesthetic Considerations for Pediatric Patients With Fontan Physiology Undergoing Noncardiac Surgery. Int Anesthesiol Clin 2019; 57:42-60. [DOI: 10.1097/aia.0000000000000250] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
|
22
|
Kodama Y, Koga K, Kuraoka A, Ishikawa Y, Nakamura M, Sagawa K, Ishikawa S. Efficacy of Sports Club Activities on Exercise Tolerance Among Japanese Middle and High School Children and Adolescents After Fontan Procedure. Pediatr Cardiol 2018; 39:1339-1345. [PMID: 29785512 DOI: 10.1007/s00246-018-1900-1] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/24/2017] [Accepted: 05/08/2018] [Indexed: 11/28/2022]
Abstract
The exercise tolerance of Fontan patients is poorer than that of healthy people. Some previous studies reported that exercise tolerance can be improved in this population by cardiac rehabilitation. This study aimed to determine the factors associated with peak oxygen uptake (VO2) and to subsequently clarify the correlation between participation in sports club activities and variables related to exercise tolerance. Cardiopulmonary exercise tests were performed by 115 Fontan patients aged between 6 and 20 years. The patients completed questionnaires on their daily physical activities including participation in extracurricular sports clubs in middle (junior high school) and high school. Peak VO2 had a significant negative correlation with age and a positive correlation with hemoglobin, stroke volume, and resting tidal volume in the entire study group. Additionally, the sports club participants who were middle and high school students had significantly higher peak VO2 and resting tidal volume. Exercise habits including participation in sports club activities may promote exercise tolerance by improving respiratory function in Fontan adolescents.
Collapse
Affiliation(s)
- Yoshihiko Kodama
- Department of Pediatric Cardiology, Fukuoka Children's Hospital, 5-1-1 Kashiiteriha, Higashi-ku, Fukuoka, 813-0017, Japan.
| | - Kyoko Koga
- Department of Clinical Laboratory, Fukuoka Children's Hospital, 5-1-1 Kashiiteriha, Higashi-ku, Fukuoka, 813-0017, Japan
| | - Ayako Kuraoka
- Department of Pediatric Cardiology, Fukuoka Children's Hospital, 5-1-1 Kashiiteriha, Higashi-ku, Fukuoka, 813-0017, Japan
| | - Yuichi Ishikawa
- Department of Pediatric Cardiology, Fukuoka Children's Hospital, 5-1-1 Kashiiteriha, Higashi-ku, Fukuoka, 813-0017, Japan
| | - Makoto Nakamura
- Department of Pediatric Cardiology, Fukuoka Children's Hospital, 5-1-1 Kashiiteriha, Higashi-ku, Fukuoka, 813-0017, Japan
| | - Koichi Sagawa
- Department of Pediatric Cardiology, Fukuoka Children's Hospital, 5-1-1 Kashiiteriha, Higashi-ku, Fukuoka, 813-0017, Japan
| | - Shiro Ishikawa
- Department of Pediatric Cardiology, Fukuoka Children's Hospital, 5-1-1 Kashiiteriha, Higashi-ku, Fukuoka, 813-0017, Japan
| |
Collapse
|
23
|
Udholm S, Aldweib N, Hjortdal VE, Veldtman GR. Prognostic power of cardiopulmonary exercise testing in Fontan patients: a systematic review. Open Heart 2018; 5:e000812. [PMID: 30057765 PMCID: PMC6059270 DOI: 10.1136/openhrt-2018-000812] [Citation(s) in RCA: 43] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/23/2018] [Revised: 04/03/2018] [Accepted: 04/24/2018] [Indexed: 11/04/2022] Open
Abstract
Objective Exercise impairment is common in Fontan patients. Our aim is to systematically review previous literature to determine the prognostic value of exercise capacity in older adolescent and adult Fontan patients with respect to late outcome. Additionally, we reviewed the determinants of exercise capacity in Fontan patients and changes in exercise capacity over time. Methods PubMed, CINAHL, Embase, The Cochrane Library and Scopus were searched systematically for studies reporting exercise capacity and late outcome such as mortality, cardiac transplantation and hospitalisation. Studies were eligible for inclusion if more than 30 patients were included and mean age was ≥16 years. Results Four thousand and seven hundred and twenty-two studies were identified by the systematic search. Seven studies fulfilled the inclusion and exclusion criteria. The total number of patients was 1664 adult Fontan patients. There were 149 deaths and 35 heart transplantations. All eligible studies were retrospective cohort studies. The correlation between exercise capacity and late outcome was identified, and HRs were reported. Conclusion In Fontan patients, the best predictors of death and transplantation were a decline in peak VO2, heart rate variables and exercise oscillatory ventilation. Peak VO2 was not strongly predictive of mortality or hospitalisation in Fontan patients. Several variables were strong and independent predictors of hospitalisation and morbidity.
Collapse
Affiliation(s)
- Sebastian Udholm
- Department of Cardiothoracic and Vascular Surgery, Aarhus University Hospital, Aarhus, Denmark
| | - Nael Aldweib
- Cardiovascular Medicine Department, Allegheny General Hospital, Pittsburgh, Pennsylvania, USA
| | | | - Gruschen R Veldtman
- Adult Congenital Heart Disease Program, Heart Institute, Cincinnati Children's Hospital Medical Centre, Cincinnati, Ohio, USA
| |
Collapse
|
24
|
Kuhn M, Hornung A, Ulmer H, Schlensak C, Hofbeck M, Wiegand G. Comparative Noninvasive Measurement of Cardiac Output Based on the Inert Gas Rebreathing Method (Innocor®) and MRI in Patients with Univentricular Hearts. Pediatr Cardiol 2018; 39:810-817. [PMID: 29396582 DOI: 10.1007/s00246-018-1824-9] [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: 08/06/2017] [Accepted: 01/20/2018] [Indexed: 11/28/2022]
Abstract
There are many complex cardiac malformations that are characterized by a functionally univentricular physiology. Staged surgical repair according to the Fontan principle separates the systemic and pulmonary circulations by connecting the systemic venous return to the pulmonary arteries. However, long-term follow-up studies demonstrate a gradual deterioration of cardiac function, particularly from the second or third decade. Noninvasive evaluation of the cardiac function is, therefore, important in the follow-up of these patients. The cardiac index (CI) is a reliable hemodynamic parameter and represents an important marker of cardiac function. We compared CI values determined by cardiac MRI (CMRI) with values obtained by noninvasive inert gas rebreathing (IGR; Innocor® system). Sixteen patients (age range: 7.2-32.7 years) with functionally univentricular hearts (UVH) following total cavopulmonary connection (TCPC) were compared with 12 healthy subjects (age range: 8.5-18.6 years). The standard treadmill protocol of the German Society of Pediatric Cardiology was used for exercise testing. CI was determined at rest and at two standardized submaximal exercise levels. In all subjects, CI increased under exercise conditions, but the values were significantly lower in patients with UVH. There was no significant difference between patients with UVH and predominantly right- or left-ventricular morphology. In comparison with CMRI measurements, the CI values obtained by the IGR method tended to be lower, with a mean difference of 1.02 l/min/m2. Noninvasive measurement of CI with the IGR method is feasible at rest and during exercise, and appears to be suited for routine determination of CI in patients with UVH following TCPC.
Collapse
Affiliation(s)
- Miriam Kuhn
- Department of Pediatric Cardiology, University Children's Hospital, Hoppe-Seyler-Str. 1, 72076, Tuebingen, Germany
| | - Andreas Hornung
- Department of Pediatric Cardiology, University Children's Hospital, Hoppe-Seyler-Str. 1, 72076, Tuebingen, Germany
| | - Heidi Ulmer
- Department of Pediatric Cardiology, University Children's Hospital, Hoppe-Seyler-Str. 1, 72076, Tuebingen, Germany
| | - Christian Schlensak
- Department of Thoracic and Cardiovascular Surgery, University Hospital Tuebingen, Tuebingen, Germany
| | - Michael Hofbeck
- Department of Pediatric Cardiology, University Children's Hospital, Hoppe-Seyler-Str. 1, 72076, Tuebingen, Germany
| | - Gesa Wiegand
- Department of Pediatric Cardiology, University Children's Hospital, Hoppe-Seyler-Str. 1, 72076, Tuebingen, Germany.
| |
Collapse
|
25
|
Atrioventricular valve regurgitation in patients undergoing total cavopulmonary connection: Impact of valve morphology and underlying mechanisms on survival and reintervention. J Thorac Cardiovasc Surg 2018; 155:701-709.e6. [DOI: 10.1016/j.jtcvs.2017.08.122] [Citation(s) in RCA: 26] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/05/2017] [Revised: 06/30/2017] [Accepted: 08/26/2017] [Indexed: 12/13/2022]
|
26
|
Wong J, Chabiniok R, Tibby SM, Pushparajah K, Sammut E, Celermajer D, Giese D, Hussain T, Greil GF, Schaeffter T, Razavi R. Exploring kinetic energy as a new marker of cardiac function in the single ventricle circulation. J Appl Physiol (1985) 2018; 125:889-900. [PMID: 29369740 DOI: 10.1152/japplphysiol.00580.2017] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
Ventricular volumetric ejection fraction (VV EF) is often normal in patients with single ventricle circulations despite them experiencing symptoms related to circulatory failure. We sought to determine if kinetic energy (KE) could be a better marker of ventricular performance. KE was prospectively quantified using four-dimensional flow MRI in 41 patients with a single ventricle circulation (aged 0.5-28 yr) and compared with 43 healthy volunteers (aged 1.5-62 yr) and 14 patients with left ventricular (LV) dysfunction (aged 28-79 yr). Intraventricular end-diastolic blood was tracked through systole and divided into ejected and residual blood components. Two ejection fraction (EF) metrics were devised based on the KE of the ejected component over the total of both the ejected and residual components using 1) instantaneous peak KE to assess KE EF or 2) summating individual peak particle energy (PE) to assess PE EF. KE EF and PE EF had a smaller range than VV EF in healthy subjects (97.9 ± 0.8 vs. 97.3 ± 0.8 vs. 60.1 ± 5.2%). LV dysfunction caused a fall in KE EF ( P = 0.01) and PE EF ( P = 0.0001). VV EF in healthy LVs and single ventricle hearts was equivalent; however, KE EF and PE EF were lower ( P < 0.001) with a wider range indicating a spectrum of severity. Those reporting the greatest symptomatic impairment (New York Heart Association II) had lower PE EF than asymptomatic subjects ( P = 0.0067). KE metrics are markers of healthy cardiac function. PE EF may be useful in grading dysfunction. NEW & NOTEWORTHY Kinetic energy (KE) represents the useful work of the heart in ejecting blood. This article details the utilization of KE indexes to assess cardiac function in health and a variety of pathophysiological conditions. KE ejection fraction and particle energy ejection fraction (PE EF) showed a narrow range in health and a lower wider range in disease representing a spectrum of severity. PE EF was altered by functional status potentially offering the opportunity to grade dysfunction.
Collapse
Affiliation(s)
- James Wong
- Division of Imaging Sciences and Biomedical Engineering, King's College London, The Rayne Institute, St. Thomas' Hospital , London , United Kingdom
| | - Radomir Chabiniok
- Division of Imaging Sciences and Biomedical Engineering, King's College London, The Rayne Institute, St. Thomas' Hospital , London , United Kingdom.,Inria, Paris-Saclay University, Palaiseau, France.,LMS, Ecole Polytechnique, CNRS, Paris-Saclay University, Palaiseau, France
| | - Shane M Tibby
- Division of Imaging Sciences and Biomedical Engineering, King's College London, The Rayne Institute, St. Thomas' Hospital , London , United Kingdom
| | - Kuberan Pushparajah
- Division of Imaging Sciences and Biomedical Engineering, King's College London, The Rayne Institute, St. Thomas' Hospital , London , United Kingdom
| | - Eva Sammut
- Division of Imaging Sciences and Biomedical Engineering, King's College London, The Rayne Institute, St. Thomas' Hospital , London , United Kingdom
| | - David Celermajer
- Division of Imaging Sciences and Biomedical Engineering, King's College London, The Rayne Institute, St. Thomas' Hospital , London , United Kingdom
| | - Daniel Giese
- Division of Imaging Sciences and Biomedical Engineering, King's College London, The Rayne Institute, St. Thomas' Hospital , London , United Kingdom
| | - Tarique Hussain
- Division of Imaging Sciences and Biomedical Engineering, King's College London, The Rayne Institute, St. Thomas' Hospital , London , United Kingdom
| | - Gerald F Greil
- Division of Imaging Sciences and Biomedical Engineering, King's College London, The Rayne Institute, St. Thomas' Hospital , London , United Kingdom
| | - Tobias Schaeffter
- Division of Imaging Sciences and Biomedical Engineering, King's College London, The Rayne Institute, St. Thomas' Hospital , London , United Kingdom
| | - Reza Razavi
- Division of Imaging Sciences and Biomedical Engineering, King's College London, The Rayne Institute, St. Thomas' Hospital , London , United Kingdom
| |
Collapse
|
27
|
Ohuchi H. Where Is the "Optimal" Fontan Hemodynamics? Korean Circ J 2017; 47:842-857. [PMID: 29035429 PMCID: PMC5711675 DOI: 10.4070/kcj.2017.0105] [Citation(s) in RCA: 40] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2017] [Accepted: 06/23/2017] [Indexed: 12/25/2022] Open
Abstract
Fontan circulation is generally characterized by high central venous pressure, low cardiac output, and slightly low arterial oxygen saturation, and it is quite different from normal biventricular physiology. Therefore, when a patient with congenital heart disease is selected as a candidate for this type of circulation, the ultimate goals of therapy consist of 2 components. One is a smooth adjustment to the new circulation, and the other is long-term circulatory stabilization after adjustment. When either of these goals is not achieved, the patient is categorized as having "failed" Fontan circulation, and the prognosis is dismal. For the first goal of smooth adjustment, a lot of effort has been made to establish criteria for patient selection and intensive management immediately after the Fontan operation. For the second goal of long-term circulatory stabilization, there is limited evidence of successful strategies for long-term hemodynamic stabilization. Furthermore, there have been no data on optimal hemodynamics in Fontan circulation that could be used as a reference for patient management. Although small clinical trials and case reports are available, the results cannot be generalized to the majority of Fontan survivors. We recently reported the clinical and hemodynamic characteristics of early and late failing Fontan survivors and their association with all-cause mortality. This knowledge could provide insight into the complex Fontan pathophysiology and might help establish a management strategy for long-term hemodynamic stabilization.
Collapse
Affiliation(s)
- Hideo Ohuchi
- Departments of Pediatric Cardiology and Adult Congenital Heart Disease, National Cerebral and Cardiovascular Center, Suita, Japan.
| |
Collapse
|
28
|
Cutrì E, Meoli A, Dubini G, Migliavacca F, Hsia TY, Pennati G. Patient-specific biomechanical model of hypoplastic left heart to predict post-operative cardio-circulatory behaviour. Med Eng Phys 2017; 47:85-92. [DOI: 10.1016/j.medengphy.2017.06.024] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2017] [Revised: 05/02/2017] [Accepted: 06/01/2017] [Indexed: 10/19/2022]
|
29
|
Higashida A, Hoashi T, Kagisaki K, Shimada M, Ohuchi H, Shiraishi I, Ichikawa H. Can Fontan Conversion for Patients Without Late Fontan Complications be Justified? Ann Thorac Surg 2017; 103:1963-1968. [DOI: 10.1016/j.athoracsur.2016.11.062] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/20/2016] [Revised: 11/19/2016] [Accepted: 11/21/2016] [Indexed: 02/05/2023]
|
30
|
Ono M, Burri M, Cleuziou J, Pabst von Ohain J, Beran E, Strbad M, Hager A, Hörer J, Schreiber C, Lange R. Impact of early Fontan completion on postoperative outcomes in patients with a functional single ventricle†. Eur J Cardiothorac Surg 2017; 51:995-1002. [DOI: 10.1093/ejcts/ezx019] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/07/2016] [Accepted: 01/10/2017] [Indexed: 11/12/2022] Open
|
31
|
Ohuchi H, Hayama Y, Negishi J, Noritake K, Miyazaki A, Yamada O, Shiraishi I. Determinants of Aortic Size and Stiffness and the Impact on Exercise Physiology in Patients After the Fontan Operation. Int Heart J 2017; 58:73-80. [DOI: 10.1536/ihj.16-183] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Affiliation(s)
- Hideo Ohuchi
- Department of Pediatric Cardiology, National Cerebral and Cardiovascular Center
- Department of Adult Congenital Heart Disease, National Cerebral and Cardiovascular Center
| | - Yosuke Hayama
- Department of Pediatric Cardiology, National Cerebral and Cardiovascular Center
| | - Jun Negishi
- Department of Pediatric Cardiology, National Cerebral and Cardiovascular Center
| | - Kanae Noritake
- Department of Pediatric Cardiology, National Cerebral and Cardiovascular Center
| | - Aya Miyazaki
- Department of Pediatric Cardiology, National Cerebral and Cardiovascular Center
| | - Osamu Yamada
- Department of Pediatric Cardiology, National Cerebral and Cardiovascular Center
| | - Isao Shiraishi
- Department of Pediatric Cardiology, National Cerebral and Cardiovascular Center
| |
Collapse
|
32
|
Kamata M, Stiver C, Naguib A, Tumin D, Tobias JD. A Retrospective Analysis of the Influence of Ventricular Morphology on the Perioperative Outcomes After Fontan Surgery. J Cardiothorac Vasc Anesth 2016; 31:128-133. [PMID: 27720490 DOI: 10.1053/j.jvca.2016.07.024] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/25/2016] [Indexed: 11/11/2022]
Abstract
OBJECTIVES The objectives of this study were to evaluate the effect of ventricular morphology on perioperative outcomes during Fontan surgery. DESIGN Retrospective cohort study. SETTING Single standing, not-for-profit pediatric hospital. PARTICIPANTS A total of 72 patients who underwent Fontan surgery using cardiopulmonary bypass without aortic cross-clamp between January 1, 2009 and December 31, 2014. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS The patients were divided into 3 categories depending on their single-ventricle lesions: (1) LV group (n = 20): left dominant and hypoplastic right ventricle; (2) RV group (n = 37): right dominant and hypoplastic left ventricle; and (3) BV group (n = 15): biventricular or indeterminate dominance. Perioperative major adverse events were collected based on the Society of Thoracic Surgeons database. The need for perioperative allogeneic blood transfusions also was determined. The mean age was 3.3±1.7 years and the mean weight was 13.6±4.0 kg. All patients had extracardiac lateral tunnel or conduit Fontan procedures. Sixty-nine of the patients (96%) underwent tracheal extubation in the operating room. Anesthesia, surgery, and CPB times were 326±68, 239±73, and 70±41 minutes, respectively. Eleven patients (15%) required allogeneic blood products intraoperatively, while 30 patients (42%) required allogeneic blood products during the perioperative period. Length of cardiac intensive care unit stay and hospital stay (median [IQR]) were 1 [1,2] and 12 [9,18] days, respectively. There was no mortality and no significant differences between groups in major postoperative complications, anesthetic or surgical variables. CONCLUSIONS No difference in the immediate perioperative outcomes was noted based on ventricular morphology.
Collapse
Affiliation(s)
- Mineto Kamata
- Department of Anesthesiology & Pain Medicine, Nationwide Children's Hospital, Columbus, OH.
| | - Corey Stiver
- Division of Pediatric Cardiology, Department of Pediatrics, Nationwide Children's Hospital and The Ohio State University, Columbus, OH
| | - Aymen Naguib
- Department of Anesthesiology & Pain Medicine, Nationwide Children's Hospital, Columbus, OH; Department of Anesthesiology & Pain Medicine, The Ohio State University College of Medicine, Columbus, OH
| | - Dmitry Tumin
- Department of Anesthesiology & Pain Medicine, Nationwide Children's Hospital, Columbus, OH
| | - Joseph D Tobias
- Department of Anesthesiology & Pain Medicine, Nationwide Children's Hospital, Columbus, OH; Department of Anesthesiology & Pain Medicine, The Ohio State University College of Medicine, Columbus, OH
| |
Collapse
|
33
|
Ohuchi H. Seeking a Better Quality of Life for Patients after the Fontan Operation: Lessons Learned from Serial Assessment of Fontan Pathophysiology. ACTA ACUST UNITED AC 2016. [DOI: 10.9794/jspccs.32.141] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Affiliation(s)
- Hideo Ohuchi
- Departments of Pediatric Cardiology and Adult Congenital Heart Disease,
National Cerebral and Cardiovascular Center
| |
Collapse
|
34
|
Bolin EH, Maskatia SA, Tate AL, Petit CJ. Older Age at Completion of Fontan Procedure Is Associated with Improved Percentage of Predicted Maximum Oxygen Uptake. Tex Heart Inst J 2015; 42:333-40. [PMID: 26413015 DOI: 10.14503/thij-14-4178] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
We tested the hypothesis that later completion of the Fontan procedure is associated with improved exercise capacity in the current period of staged single-ventricle palliation. We performed a retrospective study, in Fontan patients, of exercise stress test data from April 2003 through March 2011. Patients were included if they had received staged palliations in accordance with current surgical strategy, defined as the performance of a superior cavopulmonary connection at ≤1 year of age, followed in subsequent years by Fontan completion. Patients with a pacemaker or respiratory exchange ratio <1 were excluded. Early and late Fontan groups were created on the basis of whether Fontan completion had been performed at <4 or ≥ 4 years of age. The primary predictor variable was age at Fontan completion, and the primary marker of exercise performance was the percentage of predicted maximum oxygen consumption. During the study period, 55 patients were identified (mean age, 11.7 ± 2.8 yr). Older age at Fontan completion correlated positively with higher percentages of predicted maximum oxygen consumption (R=0.286, P=0.034). Patients in whom Fontan completion was performed at ≥4 years of age had higher percentages of predicted maximum oxygen consumption than did those in whom completion was at <4 years of age (84.4 ± 21.5 vs 72.9 ± 18.1; P=0.041). Later Fontan completion might be associated with improved exercise capacity in patients palliated in accordance with contemporary surgical strategy.
Collapse
|
35
|
Abstract
A biomarker is a characteristic that can be used as an indicator of a biological state. A biomarker can be a clinical observation, laboratory test or an imaging parameter. In this review, we discuss the use of biomarkers in differentiating cardiac from noncardiac disease; predicting the prognosis of patients with heart failure, pulmonary hypertension and dilated cardiomyopathy; diagnosing subclinical cardiac involvement in muscular dystrophy and postchemotherapy cancer patients; detecting acute rejection following heart transplantation; diagnosing Kawasaki disease; aiding the management of postoperative cardiac patients; and managing both common (tetralogy of Fallot) and complex (single-ventricle physiology) congenital heart diseases.
Collapse
Affiliation(s)
- Hythem Nawaytou
- Department of Pediatrics, University of California, San Francisco, CA, USA
| | | |
Collapse
|
36
|
Abstract
BACKGROUND The functionally single fetal right ventricle demonstrates reduced longitudinal relative to circumferential contraction velocities and deformation, a pattern similar to the normal fetal left ventricle. Altered diastolic properties are also present, with greater reliance on atrial contraction for right ventricular filling. It is unknown whether the functionally single left ventricle (SLV) demonstrates similar altered deformation patterns and diastolic properties. METHODS Echocardiograms from 29 fetuses with SLVs were retrospectively compared with those from 48 controls with appropriately grown left ventricles. Ventricular function was assessed using Velocity Vector Imaging velocity, tissue deformation, two-dimensional, and Doppler flow parameters. RESULTS Fetuses with functionally SLVs showed no difference in peak global left ventricular longitudinal velocity or displacement or strain, while global radial displacement was increased (P < .001). The ratio of longitudinal to circumferential deformation was also no different from that in controls. The SLVs showed increased diameters (P < .001) with normal lengths. Mitral inflow peak E-wave (P < .05) and A-wave (P < .0001) velocities were increased, with a reduced E/A ratio (P < .001). A-wave inflow fraction was also increased (P < .05), with no change in A duration. Although ejection time was no different, inflow duration was increased (P < .01) and there was a trend toward reduction of the Tei index (P = .07). CONCLUSIONS The functionally single fetal left ventricle shows comparable changes to the single right ventricle, with a more spherical morphology and greater reliance on atrial contraction for ventricular filling than in controls. However, in contrast to the single right ventricle, the SLV had a normal longitudinal to circumferential deformation ratio with enhanced early diastolic filling.
Collapse
|
37
|
Hyperuricemia reflects global Fontan pathophysiology and associates with morbidity and mortality in patients after the Fontan operation. Int J Cardiol 2015; 184:623-630. [DOI: 10.1016/j.ijcard.2015.02.026] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/09/2014] [Revised: 02/15/2015] [Accepted: 02/21/2015] [Indexed: 01/23/2023]
|
38
|
Ohuchi H, Negishi J, Noritake K, Hayama Y, Sakaguchi H, Miyazaki A, Kagisaki K, Yamada O. Prognostic Value of Exercise Variables in 335 Patients after the Fontan Operation: A 23-year Single-center Experience of Cardiopulmonary Exercise Testing. CONGENIT HEART DIS 2014; 10:105-16. [DOI: 10.1111/chd.12222] [Citation(s) in RCA: 75] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 08/11/2014] [Indexed: 11/27/2022]
Affiliation(s)
- Hideo Ohuchi
- Department of Pediatric Cardiology; National Cerebral and Cardiovascular Center; Osaka Japan
| | - Jun Negishi
- Department of Pediatric Cardiology; National Cerebral and Cardiovascular Center; Osaka Japan
| | - Kanae Noritake
- Department of Pediatric Cardiology; National Cerebral and Cardiovascular Center; Osaka Japan
| | - Yosuke Hayama
- Department of Pediatric Cardiology; National Cerebral and Cardiovascular Center; Osaka Japan
| | - Heima Sakaguchi
- Department of Pediatric Cardiology; National Cerebral and Cardiovascular Center; Osaka Japan
| | - Aya Miyazaki
- Department of Pediatric Cardiology; National Cerebral and Cardiovascular Center; Osaka Japan
| | - Koji Kagisaki
- Department of Thoracic Surgery; National Cerebral and Cardiovascular Center; Osaka Japan
| | - Osamu Yamada
- Department of Pediatric Cardiology; National Cerebral and Cardiovascular Center; Osaka Japan
| |
Collapse
|
39
|
Ohuchi H, Yasuda K, Miyazaki A, Iwasa T, Sakaguchi H, Shin O, Mizuno M, Negishi J, Noritake K, Yamada O. Comparison of prognostic variables in children and adults with Fontan circulation. Int J Cardiol 2014; 173:277-83. [PMID: 24650660 DOI: 10.1016/j.ijcard.2014.03.001] [Citation(s) in RCA: 44] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/15/2013] [Revised: 02/01/2014] [Accepted: 03/02/2014] [Indexed: 10/25/2022]
Abstract
BACKGROUND Non-cardiac complications, such as hepato-renal and metabolic problems, are emerging late after the Fontan operation due to its unique hemodynamics. Consequently, associations between clinical variables and postoperative outcome may change during the prolonged postoperative course. METHODS AND RESULTS To determine if child and adult Fontan patients differ in the impact of cardiac and non-cardiac variables on clinical outcome, we prospectively evaluated associations between hemodynamics, neurohumoral factors, exercise variables, hepato-renal function and metabolic variables and unscheduled hospitalization, including death in 167 consecutive child and 116 adult Fontan patients. When compared with child patients, the adult patients showed higher rates of medications, lower cardiac index, higher values of natriuretic peptides, greater renal dysfunction, more cholestatic livers, and more impaired responses to exercise (p<0.05-0.0001). During the follow-up of 3.7 ± 2.1 years, 64 clinical events (37 in adults), including 13 deaths, occurred. A high CVP and low arterial oxygen satutration strongly predicted the child events (p<0.001), whereas these prognostic parameters were marginal in the adults. Instead, renal dysfunction and metabolic abnormality predicted adult events (p<0.05). Neurohumoral activation, low albumin, hyponatremia, and impaired exercise variables equally predicted clinical events in child and adult Fontan patients. CONCLUSIONS Distinctive differences in predictive value of clinical variables exist between child and adult Fontan patients. In addition to cardiac issues, we should consider non-cardiac determinents of clinical outcome to maximize our efforts to improve prognosis for adult Fontan survivors.
Collapse
Affiliation(s)
- Hideo Ohuchi
- Department of Pediatric Cardiology, National Cerebral and Cardiovascular Center, 5-7-1, Fujishiro-dai, Suita, Osaka 565-8565, Japan.
| | - Kenji Yasuda
- Department of Pediatric Cardiology, National Cerebral and Cardiovascular Center, 5-7-1, Fujishiro-dai, Suita, Osaka 565-8565, Japan
| | - Aya Miyazaki
- Department of Pediatric Cardiology, National Cerebral and Cardiovascular Center, 5-7-1, Fujishiro-dai, Suita, Osaka 565-8565, Japan
| | - Toru Iwasa
- Department of Pediatric Cardiology, National Cerebral and Cardiovascular Center, 5-7-1, Fujishiro-dai, Suita, Osaka 565-8565, Japan
| | - Heima Sakaguchi
- Department of Pediatric Cardiology, National Cerebral and Cardiovascular Center, 5-7-1, Fujishiro-dai, Suita, Osaka 565-8565, Japan
| | - Ono Shin
- Department of Pediatric Cardiology, National Cerebral and Cardiovascular Center, 5-7-1, Fujishiro-dai, Suita, Osaka 565-8565, Japan
| | - Masanori Mizuno
- Department of Pediatric Cardiology, National Cerebral and Cardiovascular Center, 5-7-1, Fujishiro-dai, Suita, Osaka 565-8565, Japan
| | - Jun Negishi
- Department of Pediatric Cardiology, National Cerebral and Cardiovascular Center, 5-7-1, Fujishiro-dai, Suita, Osaka 565-8565, Japan
| | - Kanae Noritake
- Department of Pediatric Cardiology, National Cerebral and Cardiovascular Center, 5-7-1, Fujishiro-dai, Suita, Osaka 565-8565, Japan
| | - Osamu Yamada
- Department of Pediatric Cardiology, National Cerebral and Cardiovascular Center, 5-7-1, Fujishiro-dai, Suita, Osaka 565-8565, Japan
| |
Collapse
|
40
|
Ohuchi H, Yasuda K, Miyazaki A, Kitano M, Sakaguchi H, Yazaki S, Tsuda E, Yamada O. Haemodynamic characteristics before and after the onset of protein losing enteropathy in patients after the Fontan operation. Eur J Cardiothorac Surg 2013; 43:e49-57. [PMID: 23396878 DOI: 10.1093/ejcts/ezs714] [Citation(s) in RCA: 52] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
OBJECTIVES Determinant risk factors for developing protein losing enteropathy (PLE), including haemodynamics, remain unclear in patients after the Fontan operation. METHODS Our purpose was to characterize the serial PLE haemodynamics before and after the onset and to determine the risk factors based on the cardiac catheterization-based analysis. RESULTS Of 354 Fontan survivors who had undergone postoperative cardiac catheterizations, we experienced 26 PLE patients during the follow-up. Non-left ventricular morphology systemic ventricle, functional one-lung pulmonary circulation and an early postoperative high central venous pressure (CVP) were associated with the PLE onset and the high CVP (odds ratio (OR) = 1.19 per 1 mmHg, 95% confidence interval (CI) 1.04-1.37, especially ≥12 mmHg, OR = 3.09, 95% CI 1.25-7.64, P < 0.05 for both) and one-lung pulmonary circulation (OR = 10.0-10.5, P < 0.001) independently predicted the onset. At the time of the PLE onset, a Fontan route stenosis/obstruction, arrhythmias, ventricular dysfunction/heart failure and pulmonary arterio-venous fistulae were demonstrated in 10 (38%), 8 (31%), 4 (15%) and 3 (12%) patients, respectively. When compared with 56 excellent Fontan survivors, the high CVP, ventricular end-diastolic pressure, and pulmonary artery resistance, and the low arterial oxygen saturation, systemic artery pressure, and ventricular ejection fraction characterized the pre-PLE Fontan haemodynamics (P < 0.05-0.0001). However, the following intensive treatments reduced the CVP, systemic artery pressure and cardiac output (P < 0.05-0.01), resulting in haemodynamics no different from those of the excellent survivors, except for the low systemic pressure (P < 0.0001). CONCLUSIONS The pre-PLE haemodynamics was characterized by several impaired haemodynamics, while those after PLE only by a low systemic pressure. A high early postoperative CVP was the only haemodynamic predictor for a new onset of PLE. Strict selective criteria for the operation and strategies to eliminate CVP-raising factors are mandatory to prevent a new onset of PLE.
Collapse
Affiliation(s)
- Hideo Ohuchi
- Departments of Pediatric Cardiology, National Cerebral and Cardiovascular Center, Osaka, Japan.
| | | | | | | | | | | | | | | |
Collapse
|
41
|
Only slow decline in exercise capacity in the natural history of patients with congenital heart disease: A longitudinal study in 522 patients. Eur J Prev Cardiol 2013; 22:113-8. [DOI: 10.1177/2047487313505242] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
|
42
|
Overgaard D, Schrader AM, Lisby KH, King C, Christensen RF, Jensen HF, Moons P. Substance use, dental hygiene, and physical activity in adult patients with single ventricle physiology. CONGENIT HEART DIS 2013; 9:75-82. [PMID: 23663529 DOI: 10.1111/chd.12086] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/19/2013] [Indexed: 11/30/2022]
Abstract
OBJECTIVES The study aims to describe substance use, dental hygiene, and physical activity in adult survivors with single ventricle physiology (SVP) and to compare the behaviors with matched controls, while the patients are particularly at risk for general health problems. DESIGN The present study is part of a larger research project on long-term outcomes in adult patients with SVP. A cross-sectional, case-control study including 59 patients out of 83 eligible patients participated in the study (response rate 71%). The patients were matched to 172 healthy controls. A questionnaire was mailed to the patients. Nonresponders did not differ significantly from the included participants on age, gender, or physical function. SETTING The study was conducted at the Heart Center of Copenhagen University Hospital or the Department of Cardiology, Aarhus University Hospital. RESULTS In these patients, 85% report alcohol consumption (92% in controls; odds ratio [OR] = 0.91; P = 0.575); 26% admit "binge drinking" (41% in controls; OR = 0.56; P = 0.041); 20% are cigarette smokers (36% in controls; OR = 0.59; P = 0.100); 12% have used cannabis over the past year (15% in controls; OR = 0.80; P = 0.596); 20% have had no dental visits during the last year (25% in controls; OR = 1.07; P = 0.684); 46% are not flossing their teeth (32% in controls; OR = 1.32; P = 0.239); and 39% are not physically active (24% in controls; OR = 1.63; P = 0.069). CONCLUSIONS While in general there was no significant differences in overall health behaviors between SVP patients and controls, SVP patients are less physically active and are less likely to binge drink.
Collapse
Affiliation(s)
- Dorthe Overgaard
- The Heart Center, Rigshospitalet, Copenhagen University Hospital, Skejby, Denmark
| | | | | | | | | | | | | |
Collapse
|
43
|
O'Byrne ML, Mercer-Rosa L, Ingall E, McBride MG, Paridon S, Goldmuntz E. Habitual exercise correlates with exercise performance in patients with conotruncal abnormalities. Pediatr Cardiol 2013; 34:853-60. [PMID: 23104594 DOI: 10.1007/s00246-012-0556-5] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/19/2012] [Accepted: 10/04/2012] [Indexed: 12/25/2022]
Abstract
Cardiopulmonary exercise testing (CPET), particularly maximal oxygen consumption (VO2max), has been used to assess the outcome for patients with palliated congenital heart disease (CHD). Small studies correlating VO2max with noninvasive imaging measures of ventricular function have led to the hypothesis that VO2max reflects cardiac performance. In other settings, physical training is associated with increased VO2max. The authors hypothesized that habitual exercise correlates with VO2max to a greater degree than ventricular function in a relatively healthy cohort of patients with palliated CHD. The habitual exercise behavior of 208 subjects with conotruncal abnormalities (tetralogy of Fallot, truncus arteriosus, and interrupted aortic arch) at the time of previously performed, study-based CPET and cardiac magnetic resonance imaging (CMR) were retrospectively assessed via questionnaire. The association of VO2max with habitual exercise duration and CMR measures of ventricular function was tested. Of 208 subjects, 89 (43 %) completed questionnaires, and 78 % of the 89 patients had a concurrent CMR. The mean VO2max was 76 ± 21 % of that predicted. The CMR-assessed left ventricular ejection fraction was 67.6 ± 7.4 %. The hours of habitual exercise per week correlated with VO2max (p < 0.001; r (2) = 0.14). No association was found between right and left ventricular ejection fraction, cardiac index, or right ventricular end-diastolic volume and VO2max. In this study, VO2max correlated with habitual exercise to a greater degree than CMR measurements of ventricular function. These findings highlight the importance of considering the contribution of noncardiac factors when exercise data in both clinical and research settings are interpreted. The contribution of these factors to clinical outcomes deserves further study.
Collapse
Affiliation(s)
- Michael L O'Byrne
- Division of Pediatric Cardiology, Children's Hospital of Philadelphia, 34th Street and Civic Center Boulevard, Philadelphia, PA 19147, USA.
| | | | | | | | | | | |
Collapse
|
44
|
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.
Collapse
Affiliation(s)
- Jeffrey A Feinstein
- Department of Pediatrics, Stanford University School of Medicine, Lucile Salter Packard Children's Hospital, Palo Alto, California 94304, USA.
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
45
|
Petko C, Hansen JH, Scheewe J, Rickers C, Kramer HH. Comparison of Longitudinal Myocardial Deformation and Dyssynchrony in Children with Left and Right Ventricular Morphology after the Fontan Operation Using Two-dimensional Speckle Tracking. CONGENIT HEART DIS 2011; 7:16-23. [DOI: 10.1111/j.1747-0803.2011.00607.x] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
|
46
|
Ohuchi H, Kagisaki K, Miyazaki A, Kitano M, Yazaki S, Sakaguchi H, Ichikawa H, Yamada O, Yagihara T. Impact of the evolution of the Fontan operation on early and late mortality: a single-center experience of 405 patients over 3 decades. Ann Thorac Surg 2011; 92:1457-66. [PMID: 21958797 DOI: 10.1016/j.athoracsur.2011.05.055] [Citation(s) in RCA: 46] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/23/2011] [Revised: 05/04/2011] [Accepted: 05/09/2011] [Indexed: 10/17/2022]
Abstract
BACKGROUND Postoperative mortality has decreased in patients undergoing the Fontan operation, and the determinants of such mortality may also have changed significantly. METHODS We conducted a study intended to focus on clarifying the determinants of mortality in 405 consecutive patients who had undergone a Fontan operation (62 patients after an atriopulmonary connection, 105 after an intra-atrial rerouting, and 238 patients after an extracardiac rerouting) between 1979 and 2010. RESULTS The overall 1-year, 5-year, 10-year, and 15-year rates of survival were 87.1%, 84.6%, 83.4%, and 81.6%, respectively, and the type of procedure as well as heterotaxy syndrome, ventricular ejection fraction, and atrioventricular valve repair at the time of the Fontan operation were independent predictors of overall mortality (p < 0.05 for all). Heterotaxy syndrome and atrioventricular (AV) valve repair were independent predictors of early (less than 6 months postoperative) mortality and the type of procedure was an independent predictor of late (6 or more months postoperative) mortality (p < 0.05 to 0.01). In the era of intra-atrial rerouting, heterotaxy syndrome was the only independent predictor of total, early, and late mortality (p < 0.05 for all), whereas a low ejection fraction, AV valve repair, and repair of a total anomalous pulmonary vein connection, rather than heterotaxy syndrome, were independent predictors of total or early mortality or both (p < 0.05 for all) in the era of extracardiac rerouting. CONCLUSIONS Even in the modern era of extracardiac rerouting in the Fontan operation, a low ventricular ejection fraction, AV valve dysfunction, or a total anomalous pulmonary vein connection remain significant risk factors for mortality in patients with a single-ventricle physiology.
Collapse
Affiliation(s)
- Hideo Ohuchi
- Department of Pediatric Cardiology, National Cerebral and Cardiovascular Center, Osaka, Japan.
| | | | | | | | | | | | | | | | | |
Collapse
|
47
|
Caval flow reflects Fontan hemodynamics: quantification by magnetic resonance imaging. Clin Res Cardiol 2011; 101:133-8. [DOI: 10.1007/s00392-011-0374-4] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/08/2011] [Accepted: 10/21/2011] [Indexed: 10/15/2022]
|
48
|
Miyazaki A, Sakaguchi H, Ohuchi H, Yamamoto T, Igarashi T, Negishi J, Toyota N, Kagisaki K, Yagihara T, Yamada O. The incidence and characteristics of supraventricular tachycardia in left atrial isomerism: a high incidence of atrial fibrillation in young patients. Int J Cardiol 2011; 166:375-80. [PMID: 22082714 DOI: 10.1016/j.ijcard.2011.10.118] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/26/2011] [Revised: 08/29/2011] [Accepted: 10/22/2011] [Indexed: 02/07/2023]
Abstract
BACKGROUND In left atrial isomerism (LAI), both atria show left atrial morphology. Although bradyarrhythmias are frequent and highly complex in LAI patients, previous studies have reported a low incidence of supraventricular tachycardia (SVT). METHODS To evaluate the incidence and characteristics of SVT in LAI, we retrospectively evaluated the clinical characteristics of SVTs in 83 patients with LAI (age at last follow-up, 15.3±10.5 years). RESULTS There were 27 SVTs in 19 patients (23%), including nine episodes of atrial fibrillation (AF) and eight non-reentrant SVTs. Sixteen of the 19 patients with SVT had histories of atriotomy, but the three patients with AF or non-reentrant tachycardia had no history of atriotomy. The rates of freedom from SVT were 66% and 59% at ages of 20 and 30 years, respectively; the corresponding rates for freedom from AF were 89% and 74%. In multivariate analysis, the predictors of SVT were age (OR, 1.14; 95% CI, 1.06-1.26; p=0.003) and sinus node dysfunction (SND) (OR, 3.88; 95% CI, 1.57-13.34; p=0.01). CONCLUSIONS In patients with LAI, SVTs are common, and AF and non-reentrant SVTs are the major type of SVTs. The incidence of AF was high in young patients with LAI. The lack of anatomical barriers in the atria that allow the formation of macro-reentrant circuits may account for the higher incidence of AF and non-reentrant SVT than macro-reentrant tachycardia. Moreover, the increasing prevalence of SND with age should contribute to a higher incidence of SVT.
Collapse
Affiliation(s)
- Aya Miyazaki
- Department of Pediatric Cardiology, National Cerebral and Cardiovascular Center, Osaka, Japan.
| | | | | | | | | | | | | | | | | | | |
Collapse
|
49
|
Ohuchi H, Ono S, Tanabe Y, Fujimoto K, Yagi H, Sakaguchi H, Miyazaki A, Yamada O. Long-term serial aerobic exercise capacity and hemodynamic properties in clinically and hemodynamically good, "excellent", Fontan survivors. Circ J 2011; 76:195-203. [PMID: 22008316 DOI: 10.1253/circj.cj-11-0540] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
BACKGROUND The serial hemodynamics and predictors of long-term, good Fontan survivors remain unknown. METHODS AND RESULTS Two hundred one patients who had undergone a Fontan operation before September 1998 were reviewed to compare their long-term clinical status with serial hemodynamics. During a mean follow-up of 18.7 years, 47 (30.1%) of the 156 survivors had no clinical events that required an unscheduled hospitalization. Of those, 18 survivors exhibited good serial hemodynamics and the respective mean values of central venous pressure (CVP, mmHg), cardiac index (CI, L·min(-1)·m(2)), and ventricular ejection fraction (EF, %) before and 1, 5, 10, and 15 years after the operation were as follows: 3.8, 9.0, 11.3, 10.6, and 10.1 (CVP); 3.6, 3.1, 2.8, 2.6, and 2.6, and 69 (CI); 57, 56, 58, 54, and 53 (EF). Serial values of CVP, ventricular end-diastolic pressure (EDP) and the grade of atrioventricular valve regurgitation (AVVR) were lower and the peak oxygen uptake was greater in the good patients (P<0.05 for all). A 1-year postoperative lower CVP and no history of AVVR repair during the Fontan operation independently predicted the good patients (P<0.05). CONCLUSIONS A lower CVP and EDP, better atrioventricular valvular function, and greater exercise capacity characterize good Fontan survivors and an early postoperative low CVP without an AVVR repair predicts good survivors.
Collapse
Affiliation(s)
- Hideo Ohuchi
- Department of Pediatric Cardiology, National Cerebral and Cardiovascular Center, Suita, Japan.
| | | | | | | | | | | | | | | |
Collapse
|
50
|
Adachi I, Ueno T, Ichikawa H, Kagisaki K, Ide H, Hoashi T, Kogaki S, Ohuchi H, Yagihara T, Sawa Y. Effect of ventricular volume before unloading in a systemic ventricle supporting the Fontan circulation. Am J Cardiol 2011; 107:459-65. [PMID: 21257015 DOI: 10.1016/j.amjcard.2010.09.046] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/18/2010] [Revised: 09/22/2010] [Accepted: 09/22/2010] [Indexed: 10/18/2022]
Abstract
The influence of volume overload on ventricular performance has been previously investigated but primarily with respect to the duration of overload. The aim of the present study was to elucidate whether the magnitude of the preoperative volume overload, represented by the ventricular volume, has any effect on ventricular performance long after the Fontan operation in patients with tricuspid atresia. We evaluated consecutive changes in hemodynamic catheterization data obtained at 1, 5, and 10 years after primary Fontan repair. The variables were compared between patients with larger (n = 20) and smaller (n = 21) ventricles (preoperative end-diastolic volume [percentage of predicted] 262 ± 33%, maximum 320% vs 182 ± 22%, minimum 133%, respectively). In a subgroup of patients (n = 33) who underwent symptom-limited exercise at 10.7 ± 3.0 postoperative years, the peak oxygen uptake was measured, and the potential predictors were interrogated. The difference in ventricular contractility between the groups tended to increase with time, with those with a larger ventricle showing poorer contraction, irrespective of whether it was assessed in a load-dependent (ejection fraction) or load-independent (end-systolic elastance) manner. The differences in these variables reached statistical significance at 10 years (p = 0.028 and p = 0.032). Multivariate analysis indicated a larger ventricle was an independent risk factor of poorer aerobic capacity (p = 0.047). In conclusion, ventricular performance was less preserved in those with a larger ventricle, which might result in suboptimal aerobic capacity. Our findings suggest not only early unloading, but also avoidance of excessive volume overload is of importance to minimize the deleterious effect of volume overload on an inherently susceptible ventricle.
Collapse
|