Late complications associated with the Fontan circulation

Anesthetic considerations for combined heart--liver transplantation in patients with Fontan-associated liver disease

PURPOSE OF REVIEW

The success of the Fontan procedure has led to increased survival of patients born with certain congenital heart disease to the point that new sequlae, as a result of Fontan circulation, are being discovered. Included among these is Fontan-associated liver disease (FALD). The purpose of this review is to present available literature on the perioperative management of the combined heart--liver transplantation (CHLT) in patients with FALD.

RECENT FINDINGS

The perioperative management of a combined heart-liver transplant in a patient with Fontan circulation is complex. The patient is at risk for hemodynamic disturbances, significant blood loss, coagulopathies, and metabolic derangements. The maintenance of an appropriate transpulmonary pressure gradient is paramount to success. Postoperative management should be accomplished by a multidisciplinary care team. Limited series have demonstrated good outcomes in patients who have undergone CHLT.

SUMMARY

The perioperative management of CHLT in patients with FALD is complex and available literature is limited. Future studies are needed to further assess proper perioperative management of patients with FALD who undergo CHLT.

Anaesthetic management of a patient with Fontan physiology for electrophysiology study and catheter ablation

The success of the Fontan procedure for congenital single ventricle anatomy has resulted in adult patients with Fontan physiology requiring anaesthesia for cardiac and non-cardiac procedures. We present the perioperative management of a patient with Fontan physiology who underwent electrophysiological study with radiofrequency ablation for atrial tachycardia under general anaesthesia. Good communication between the multidisciplinary teams, a detailed understanding of the patient's complex cardiac anatomy and physiology, as well as the ability to recognise and manage perioperative complications all play a vital role for a successful outcome.

Eponymous cardiovascular surgeries for congenital heart diseases--imaging review and historical perspectives

Advances in pediatric cardiology and cardiac surgical techniques over the past few decades have revolutionized the management of the patients with congenital heart disease, and many now survive into adulthood. Several eponymous surgical procedures performed for congenital heart disease have been named after eminent surgeons. In this article, we provide a short biography of the surgeons associated with these eponymous surgical procedures along with their other important scientific contributions. This is followed by a review of these surgical procedures and their most common complications. Imaging appearances of these surgical procedures along with common complications are described and illustrated, with particular emphasis on magnetic resonance imaging. The surgical procedures described in this review include Blalock-Taussig, Potts, Waterston, Glenn, Fontan, Kawashima, Norwood, Sano, Damus-Kaye-Stansel, Mustard, Senning, Jatene, LeCompte, Rastelli, Rashkind, Ross, and Waldenhausen.

Pictorial review of the role of multidetector computed tomography imaging in the postoperative evaluation of congenital heart disease

Echocardiography and cardiac magnetic resonance imaging are the methods of choice for preoperative and postoperative assessments of most congenital heart diseases. However, multidetector computed tomographic angiography of the chest is a complementary imaging technique especially in postoperative evaluations. To accurately interpret those computed tomography examinations, an appropriate study protocol, knowledge of the details of surgical procedures, and their complications are essential. In this pictorial review, we discuss our computed tomography technique with a number of illustrative cases with varied postoperative appearances and complications after some of the commonly performed surgical procedures.

Common acquired causes of thrombosis in children

Compared to adults, venous thromboembolism in the pediatric population is a rare event. Cancer, cardiac disease, antiphospholipid antibodies, and indwelling catheters are established risk factors for thromboembolism in children. We examined the literature related to thrombophilia in children, childhood cancer and thrombosis, cardiac disease and thrombosis, and antiphospholipid antibody syndrome in children. Citations in identified articles yielded additional articles for review. We found that studies of acquired thrombophilia in children are limited. Current treatment for thromboembolism in children is based on adult data therefore optimal treatment in this population remains unclear.

Application of Computer Modeling in Systemic VAD Support of Failing Fontan Physiology

Although the Fontan procedure has been enormously successful in palliation of single-ventricle patients, many seem to experience progressive failure of the Fontan circulation over time. Ventricular assist devices (VADs) have developed into stable platforms for long-term support of adult patients with heart failure. Given the success of axial flow devices, it was hypothesized that the technology could provide clinical benefit to failing Fontan patients. The aim of this study was to use a computer model to evaluate VAD support in failing Fontan physiology. A computer model of Fontan circulation with heart failure was developed and the HeartMate II (HM II) (Thoratec Corp) axial flow ventricular assist device was connected to this model in a systemic configuration to examine its impact. Cardiac catheterization data from 7 patients (8 catheterization studies) with failing Fontan physiology were applied to this model to evaluate the impact of using the HM II in this manner. When the HM II was used in a systemic configuration at 8000 rpm, there was a 35% decrease in the systemic venous pressure in the Fontan circuit and a 63% decrease in pulmonary capillary wedge pressure with a resultant 41% increase in CI. The model also predicted patient-specific parameters where the VAD may not benefit the patient, such as fixed elevated pulmonary vascular resistance, low systemic ventricular end-diastolic pressure, and high unresponsive systemic vascular resistance. These data suggest a potential benefit from application of axial flow VAD technology in the management of failing Fontan physiology. Clinical correlation will allow for refinement of this model as a predictive tool in discerning which patients may benefit from placement of a VAD and what issues must be addressed prior to implanting the device.

Extracardiac complications of the Fontan circuit

The Fontan operation is the primary surgical procedure used in the palliation of patients with univentricular cardiac physiology. With improved survival of children with congenital heart disease, long-term complications of the Fontan circuit are being encountered more frequently. Radiologists are more likely to see both the cardiac and extracardiac complications of the Fontan circuit. Awareness of the common extracardiac complications in children with failing Fontan circuits will aid the radiologist in making the appropriate diagnosis and guide the cardiologist caring for these patients.

Post-operative cardiac lesions after cardiac surgery in childhood

A new population of patients in cardiology has been growing steadily so that the number of grown-ups with congenital heart disease (GUCH) is almost equal to those under paediatric care. The dramatic improvement in survival should lead to a larger number of GUCH patients than children with CHD in the new millennium. Although echocardiography remains the imaging modality of choice, cross-sectional imaging techniques have a decision-aiding function for the postoperative evaluation of surgical reconstructions as well as in the preparation of complex interventional procedures. Cardiovascular CT and MRI are often complementary in providing comprehensive complex anatomical evaluation, haemodynamic assessment of residual postoperative lesions and complications of surgery. A thorough understanding of postsurgical corrections is a prerequisite for choosing the optimal imaging techniques and achieving an accurate evaluation.

Effects of transcatheter closure of Fontan fenestration on exercise tolerance. kidecho@yahoo.com

Baffle fenestration is associated with a significantly better outcome in standard and high-risk patients undergoing completion of Fontan. We report the effects of subsequent transcatheter closure of fenestration on exercise capacity and oxygen saturation. Sixteen patients with a mean age of 10.3 years underwent Amplatzer septal occluder (ASO) device transcatheter closure of Fontan fenestration. All had a fenestrated Fontan operation 6 month to 8 years prior to the procedure. A stress test was performed before and after device closure of fenestration in 14 patients (2 patients did not tolerate stress test before the procedure). The fenestrations in all patients were successfully occluded with the use of the Amplatzer device occluder. No complications occurred during or after the procedure. O2 saturation increased from a mean 85.1 +/- 7.89% to 94.5 +/- 3.63% (p < 0.01) at rest and from 66.2 +/- 12.86% to 87.2 +/- 8.64% (p < 0.01) following exercise. Exercise duration has also increased from 8.22 +/- 2.74 min to 10.29 +/- 1.91 min (p < 0.05). Transcatheter closure of Fontan fenestration increases the duration of exercise capacity and increases O2 saturation at rest and after exercise.

Update in adult congenital cardiac surgery

The number of grown-up patients with congenital heart disease (GUCH) is constantly increasing and will equal the number of children requiring surgery for congenital heart disease (CHD). Specialized centers dealing with the medical and paramedical problems of these patients are required. GUCH patients can be divided into the following groups: (1) patients with minor cardiac malformations presenting at adult age for first treatment; (2) patients presenting for correction as adults because they are either naturally balanced or were surgically palliated; (3) patients presenting for expected reoperations after correction in childhood; (4) patients requiring repair of residual defects after correction; (5) patients developing heart failure after correction or palliation of CHD requiring thoracic transplantation; and (6) patients developing acquired heart disease in addition to CHD. Special aspects of malformations frequently occurring in GUCH patients are discussed in detail. Acquired heart disease in this patient population is expected to increase in the coming decades as survivors of CHD grow old.