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Oğuzhan Ş, Sakamoto K, Tamura K, Honjo M, Nishi Y, Funamizu N, Ogawa K, Takada Y. Robot assisted anatomical liver resection is safe for patient with hepatocellular carcinoma underlying Fontan-associated liver disease. Hepatobiliary Pancreat Dis Int 2024:S1499-3872(24)00103-6. [PMID: 39084965 DOI: 10.1016/j.hbpd.2024.07.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/06/2024] [Accepted: 07/10/2024] [Indexed: 08/02/2024]
Affiliation(s)
- Şal Oğuzhan
- Department of Hepato-Biliary-Pancreatic and Breast Surgery,Ehime University, Ehime University Graduate School of Medicine, 454 Kou, Shitsukawa, Toon, Ehime 791-0295, Japan; Department of General Surgery, Istanbul University, Istanbul Faculty of Medicine, İstanbul, Türkiye
| | - Katsunori Sakamoto
- Department of Hepato-Biliary-Pancreatic and Breast Surgery,Ehime University, Ehime University Graduate School of Medicine, 454 Kou, Shitsukawa, Toon, Ehime 791-0295, Japan.
| | - Kei Tamura
- Department of Hepato-Biliary-Pancreatic and Breast Surgery,Ehime University, Ehime University Graduate School of Medicine, 454 Kou, Shitsukawa, Toon, Ehime 791-0295, Japan
| | - Masahiko Honjo
- Department of Hepato-Biliary-Pancreatic and Breast Surgery,Ehime University, Ehime University Graduate School of Medicine, 454 Kou, Shitsukawa, Toon, Ehime 791-0295, Japan
| | - Yusuke Nishi
- Department of Hepato-Biliary-Pancreatic and Breast Surgery,Ehime University, Ehime University Graduate School of Medicine, 454 Kou, Shitsukawa, Toon, Ehime 791-0295, Japan
| | - Naotake Funamizu
- Department of Hepato-Biliary-Pancreatic and Breast Surgery,Ehime University, Ehime University Graduate School of Medicine, 454 Kou, Shitsukawa, Toon, Ehime 791-0295, Japan
| | - Kohei Ogawa
- Department of Hepato-Biliary-Pancreatic and Breast Surgery,Ehime University, Ehime University Graduate School of Medicine, 454 Kou, Shitsukawa, Toon, Ehime 791-0295, Japan
| | - Yasutsugu Takada
- Department of Hepato-Biliary-Pancreatic and Breast Surgery,Ehime University, Ehime University Graduate School of Medicine, 454 Kou, Shitsukawa, Toon, Ehime 791-0295, Japan
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Kogiso T, Takayanagi K, Ishizuka T, Otsuka M, Inai K, Ogasawara Y, Horiuchi K, Taniai M, Tokushige K. Serum level of full-length connective tissue growth factor reflects liver fibrosis stage in patients with Fontan-associated liver disease. PLoS One 2024; 19:e0296375. [PMID: 38166061 PMCID: PMC10760884 DOI: 10.1371/journal.pone.0296375] [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] [Received: 07/26/2023] [Accepted: 12/11/2023] [Indexed: 01/04/2024] Open
Abstract
BACKGROUND Chronic liver disease leads to liver fibrosis, and an accurate diagnosis of the fibrosis stage is crucial for medical management. Connective tissue growth factor (CTGF) is produced by endothelial cells and platelets and plays a central role in inducing fibrosis in various organs. In the present study, we tested the validity of measuring the serum levels of two types of CTGF to estimate the biopsy-confirmed liver fibrosis stage. METHODS We used two detection antibodies targeting the N- and C-terminal of CTGF to measure the serum levels of two forms of CTGF consisting of its full length and its N-terminal fragment. We analyzed the level of CTGF (via enzyme-linked immunosorbent assay) and the liver fibrosis stage in 38 patients with Fontan-associated liver disease (FALD) (26 cases of which were diagnosed pathologically). Correlations were determined by multivariate analysis and the area under the receiver operating characteristic curve. The 65 patients with nonalcoholic fatty liver disease (NAFLD) were included as a disease control group for examination. RESULTS Full-length CTGF was significantly inversely correlated with liver fibrosis in patients with FALD. Although the platelet count was also associated with the liver fibrosis stage, full-length CTGF was more closely correlated with the fibrosis stage. Furthermore, the level of full-length CTGF was inversely associated with high central venous pressure. Conversely, the serum level of CTGF was not correlated with the fibrosis stage in NAFLD. CONCLUSION The serum level of full-length CTGF may be useful for estimating the liver fibrosis stage in patients with FALD.
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Affiliation(s)
- Tomomi Kogiso
- Institute of Gastroenterology, Department of Internal Medicine, Tokyo Women’s Medical University, Tokyo, Japan
| | - Kayo Takayanagi
- Division of Transplant Immunology, Central Clinical Laboratories, Tokyo Women’s Medical University, Tokyo, Japan
| | - Tsutomu Ishizuka
- Division of Transplant Immunology, Central Clinical Laboratories, Tokyo Women’s Medical University, Tokyo, Japan
| | - Motoyuki Otsuka
- Department of Gastroenterology and Hepatology, Okayama University Graduate School of Medicine, Dentistry, and Pharmaceutical Sciences, Okayama, Japan
| | - Kei Inai
- Department of Pediatric Cardiology and Adult Congenital Cardiology, Tokyo Women’s Medical University, Tokyo, Japan
| | - Yuri Ogasawara
- Institute of Gastroenterology, Department of Internal Medicine, Tokyo Women’s Medical University, Tokyo, Japan
| | - Kentaro Horiuchi
- Institute of Gastroenterology, Department of Internal Medicine, Tokyo Women’s Medical University, Tokyo, Japan
| | - Makiko Taniai
- Institute of Gastroenterology, Department of Internal Medicine, Tokyo Women’s Medical University, Tokyo, Japan
| | - Katsutoshi Tokushige
- Institute of Gastroenterology, Department of Internal Medicine, Tokyo Women’s Medical University, Tokyo, Japan
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Greidanus PG, Pagano JJ, Escudero CA, Thompson R, Tham EB. Regional Elevation of Liver T1 in Fontan Patients. CJC PEDIATRIC AND CONGENITAL HEART DISEASE 2023; 2:134-142. [PMID: 37969352 PMCID: PMC10642140 DOI: 10.1016/j.cjcpc.2023.03.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/08/2022] [Accepted: 03/08/2023] [Indexed: 11/17/2023]
Abstract
Background Fontan-associated liver disease (FALD) is characterized by hepatic congestion and progressive hepatic fibrosis in patients with the Fontan operation. This condition is generally clinically silent until late, necessitating techniques for early detection. Liver T1 mapping has been used to screen for FALD, but without consideration of regional variations in T1 values. Methods Liver T1 measured with a liver-specific T1 mapping sequence (PROFIT1) in Fontan patients was compared with cohorts of patients with biventricular congenital heart disease (BiV-CHD) and controls with normal cardiac function and anatomy. Results Liver T1 was significantly elevated in the Fontan cohort (n = 20) compared with patients with BiV-CHD (n = 12) and controls (n = 9) (781, 678, and 675 milliseconds, respectively; P < 0.001), with a consistent pattern of significantly elevated T1 values in the peripheral compared with central liver regions (ΔT1 = 54, 2, and 11 milliseconds; P < 0.001). PROFIT1 also yielded simultaneous T2∗ maps and fat fraction values that were similar in all groups. Fontan liver T1 values were also significantly elevated as compared with BiV-CHD and controls as measured with the cardiac (modified Look-Locker inversion) acquisitions (728, 583, and 583 milliseconds, respectively; P < 0.001) and values correlated with PROFIT1 liver T1 (R = 0.87, P < 0.001). Conclusions Fontan patients have globally increased liver T1 values and consistent spatial variations, with higher values in the peripheral liver regions as compared with spatially uniform values in BiV-CHD and controls. The spatial patterns may provide insight into the progression of FALD. Liver T1 mapping studies should include uniform spatial coverage to avoid bias based on slice locations in this population.
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Affiliation(s)
- Paul G. Greidanus
- Division of Pediatric Cardiology, Stollery Children’s Hospital & Mazankowski Alberta Heart Institute, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Alberta, Canada
| | - Joseph J. Pagano
- Division of Pediatric Cardiology, Stollery Children’s Hospital & Mazankowski Alberta Heart Institute, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Alberta, Canada
| | - Carolina A. Escudero
- Division of Pediatric Cardiology, Stollery Children’s Hospital & Mazankowski Alberta Heart Institute, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Alberta, Canada
| | - Richard Thompson
- Department of Biomedical Engineering, University of Alberta, Edmonton, Alberta, Canada
| | - Edythe B. Tham
- Division of Pediatric Cardiology, Stollery Children’s Hospital & Mazankowski Alberta Heart Institute, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Alberta, Canada
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FUKUNAGA HIDEO, SUZUKI MITSUYOSHI, SATO KEIYA, MIYAZAKI SAKIKO, UCHIYAMA AKIRA, YAMASHINA SHUNPEI, MIYASHITA MAMIKO, TAKAHASHI KEN, SHIMIZU TOSHIAKI. Young Adult Case of Fontan-associated Liver Disease with Hepatocellular Carcinoma During the Transition from Pediatric to Internal Medicine Care and Follow-up. JUNTENDO IJI ZASSHI = JUNTENDO MEDICAL JOURNAL 2023; 69:246-251. [PMID: 38855435 PMCID: PMC11153059 DOI: 10.14789/jmj.jmj22-0037-cr] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 11/16/2022] [Accepted: 02/20/2023] [Indexed: 06/11/2024]
Abstract
In recent years, the outcomes of the Fontan procedure have been good, but Fontan-associated liver disease (FALD), which causes congestive hepatopathy due to elevated central venous pressure (CVP), has become a serious problem when considering patients' long-term prognosis. A 28-year-old woman with Emanuel syndrome was admitted to our hospital for the treatment of hepatocellular carcinoma (HCC). She was diagnosed with pulmonary atresia and underwent a bidirectional pulmonary artery shunt at the age of 1 year and 10 months and the Fontan procedure at 4 years of age. Blood tests showed an increase in γ-glutamyltransferase in her early 20s and a marked increase in alfa-fetoprotein levels at age 27 years. She was diagnosed as having HCC in the S7 region by contrast-enhanced computed tomography and underwent hepatectomy. There were no serious adverse events, and the patient has survived 18 months after surgery without recurrence. In this report, the optimal time for the transition from the pediatrics department to adult healthcare units is also discussed, along with the management system for FALD in our hospital.
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Affiliation(s)
| | - MITSUYOSHI SUZUKI
- Corresponding author: Mitsuyoshi Suzuki, Department of Pediatrics, Juntendo University Faculty of Medicine, 2-1-1 Hongo, Bunkyo-ku, Tokyo 113-8421, Japan, TEL: +81-3-3813-3111 FAX: +81-3-3812-7560 E-mail:
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Shiina Y, Inai K, Sakai R, Tokushige K, Nagao M. Hepatocellular carcinoma and focal nodular hyperplasia in patients with Fontan-associated liver disease: characterisation using dynamic gadolinium ethoxybenzyl diethylenetriamine pentaacetic acid-enhanced MRI. Clin Radiol 2023; 78:e197-e203. [PMID: 36481111 DOI: 10.1016/j.crad.2022.10.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2022] [Revised: 08/24/2022] [Accepted: 10/31/2022] [Indexed: 12/12/2022]
Abstract
AIM To identify the characteristic diagnostic features of hepatocellular carcinoma (HCC) and focal nodular hyperplasia (FNH) in Fontan-associated liver disease (FALD) patients using dynamic gadolinium ethoxybenzyl diethylenetriamine pentaacetic acid (Gd-EOB-DTPA)-enhanced magnetic resonance imaging (MRI). MATERIALS AND METHODS Thirty-one FALD patients (mean age, 28.3 ± 7.2 years) with liver nodules who underwent dynamic Gd-EOB-DTPA-enhanced MRI were enrolled prospectively. Twenty-five patients (mean age, 72.8 ± 11.4 years) with hepatitis C virus (HCV)-related HCC constituted the control group. The tumour-to-liver signal intensity (SI) ratio was measured at 30, 60, 100, 180 seconds and 15 minutes, and the SI ratio was compared among FALD-HCC, FALD-FNH, and HCV-HCC. RESULTS FALD-HCC exhibited weak early enhancement with mild washout in late phases. FALD-FNH exhibited marked early enhancement that continued until the late phases. The SI ratio was significantly lower for FALD-HCC than for FALD-FNH in all phases. The SI ratio was significantly lower for FALD-HCC than for HCV-HCC only at 30 seconds (p<0.05), whereas poorer washout was seen in FALD-HCC than HCV-HCC in other phases. In 15 minutes, FALD-HCC had a significantly lower SI ratio compared to FALD-FNH (p<0.001). CONCLUSIONS The time course of Gd-EOB-DTPA-enhanced MRI signal intensity in FALD-HCC was different from that in FALD-FNH or HCV-HCC. This imaging finding may be useful adjunctive information to distinguish FALD-HCC from FALD-FNH.
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Affiliation(s)
- Y Shiina
- Department of Pediatric Cardiology and Adult Congenital Cardiology, Tokyo Women's Medical University, Tokyo, Japan; Cardiovascular Center, St Luke's International Hospital, Tokyo, Japan
| | - K Inai
- Department of Pediatric Cardiology and Adult Congenital Cardiology, Tokyo Women's Medical University, Tokyo, Japan
| | - R Sakai
- Department of Diagnostic Imaging & Nuclear Medicine, Tokyo Women's Medical University, Tokyo, Japan
| | - K Tokushige
- Department of Gastroenterology, Tokyo Women's Medical University, Tokyo, Japan
| | - M Nagao
- Department of Diagnostic Imaging & Nuclear Medicine, Tokyo Women's Medical University, Tokyo, Japan.
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Hur MH, Kim H, Lee JH. Hepatocellular carcinoma diagnosed in a patient who had Fontan operation 30 years ago: a case report. JOURNAL OF LIVER CANCER 2022; 22:188-193. [PMID: 37383407 PMCID: PMC10035737 DOI: 10.17998/jlc.2022.08.17] [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: 05/26/2022] [Revised: 08/11/2022] [Accepted: 08/17/2022] [Indexed: 06/30/2023]
Abstract
The Fontan operation is performed in patients with a single ventricle. As the systemic venous return is directly connected to the pulmonary circulation during this procedure, chronic hepatic congestion is induced, leading to Fontan-associated liver disease (FALD) including liver cirrhosis and hepatocellular carcinoma (HCC). In this report, we present a case of HCC diagnosed in a patient who underwent the Fontan operation 30 years ago. The patient underwent regular surveillance for FALD, which revealed a 4 cm-sized hepatic mass with elevated serum alpha-fetoprotein. After surgical treatment, there was no evidence of HCC recurrence during 3 years of follow-up. As the risk of HCC and Fontan-associated liver cirrhosis increases with the duration elapsed since the operation, regular surveillance should be emphasized. Serial follow-up of serum alpha-fetoprotein levels and abdominal imaging are necessary to achieve early and accurate diagnosis of HCC in post-Fontan patients.
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Affiliation(s)
- Moon Haeng Hur
- Department of Internal Medicine and Liver Research Institute, Seoul National University College of Medicine, Seoul, Korea
| | - Haeryoung Kim
- Department of Pathology, Seoul National University College of Medicine, Seoul, Korea
| | - Jeong-Hoon Lee
- Department of Internal Medicine and Liver Research Institute, Seoul National University College of Medicine, Seoul, Korea
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Emamaullee J, Martin S, Goldbeck C, Rocque B, Barbetta A, Kohli R, Starnes V. Evaluation of Fontan-associated Liver Disease and Ethnic Disparities in Long-term Survivors of the Fontan Procedure: A Population-based Study. Ann Surg 2022; 276:482-490. [PMID: 35766375 PMCID: PMC9388565 DOI: 10.1097/sla.0000000000005581] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVES Fontan-associated liver disease (FALD) has emerged as a nearly universal chronic comorbidity in patients with univentricular congenital heart disease who undergo the Fontan procedure. There is a paucity of data reporting long-term outcomes and the impact of FALD in this population. METHODS Patients who underwent the Fontan procedure between 1992 and 2018 were identified using California registry data. Presumed FALD was assessed by a composite of liver disease codes. Primary outcomes were mortality and transplant. Multivariable regression and survival analyses were performed. RESULTS Among 1436 patients post-Fontan, 75.9% studied were adults, with a median follow-up of 12.6 (8.4, 17.3) years. The population was 46.3% Hispanic. Overall survival at 20 years was >80%, but Hispanic patients had higher mortality risk compared with White patients [hazard ratio: 1.49 (1.09-2.03), P =0.012]. Only 225 patients (15.7%) had presumed FALD, although >54% of patients had liver disease by age 25. FALD was associated with later deaths [median: 9.6 (6.4-13.2) years post-Fontan] compared with patients who died without liver disease [4.1 (1.4-10.4) years, P =0.02]. Patients with FALD who underwent combined heart liver transplant had 100% survival at 5 years, compared with only 70.7% of patients who underwent heart transplant alone. CONCLUSIONS In this population-based analysis of long-term outcomes post-Fontan, Hispanic ethnicity was associated with increased all-cause mortality. Further, the prevalence of FALD is underrecognized, but our data confirms that its incidence increases with age. FALD is associated with late mortality but excellent posttransplant survival. This emphasizes the need for FALD-specific liver surveillance strategies in patients post-Fontan.
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Affiliation(s)
- Juliet Emamaullee
- Keck School of Medicine, University of Southern California, Los Angeles, CA
- Department of Surgery, University of Southern California, Los Angeles, CA
| | - Sean Martin
- Keck School of Medicine, University of Southern California, Los Angeles, CA
- Department of Surgery, University of Southern California, Los Angeles, CA
| | - Cameron Goldbeck
- Keck School of Medicine, University of Southern California, Los Angeles, CA
- Department of Surgery, University of Southern California, Los Angeles, CA
| | - Brittany Rocque
- Keck School of Medicine, University of Southern California, Los Angeles, CA
- Department of Surgery, University of Southern California, Los Angeles, CA
| | - Arianna Barbetta
- Keck School of Medicine, University of Southern California, Los Angeles, CA
- Department of Surgery, University of Southern California, Los Angeles, CA
| | - Rohit Kohli
- Keck School of Medicine, University of Southern California, Los Angeles, CA
- Department of Pediatrics, University of Southern California, Los Angeles, CA
- Division of Gastroenterology, Children’s Hospital Los Angeles, Los Angeles, CA
| | - Vaughn Starnes
- Keck School of Medicine, University of Southern California, Los Angeles, CA
- Department of Surgery, University of Southern California, Los Angeles, CA
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Nagasawa T, Kuroda H, Abe T, Saiki H, Takikawa Y. Shear wave dispersion to assess liver disease progression in Fontan-associated liver disease. PLoS One 2022; 17:e0271223. [PMID: 35802664 PMCID: PMC9269959 DOI: 10.1371/journal.pone.0271223] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2022] [Accepted: 06/25/2022] [Indexed: 11/18/2022] Open
Abstract
Aim
We aimed to analyze the dispersion slope (DS) using shear wave dispersion (SWD) in patients with Fontan-associated liver disease (FALD) and to investigate its utility as a biomarker of disease progression.
Methods
This cross-sectional study enrolled 27 adults with FALD who underwent SWD, two-dimensional shear wave elastography (2D-SWE), transthoracic echocardiography, cardiac catheterization, or abdominal computed tomography (CT) from April 2019 to April 2021. According to CT findings, patients were divided into two groups: significant fibrosis and non-significant fibrosis.
Results
The median DS in the control (n = 10), non-significant fibrosis (n = 12), and significant fibrosis (n = 15) was 9.35, 12.55, and 17.64 (m/s)/kHz, respectively. The significant fibrosis group showed a significantly higher DS than non-significant fibrosis group (P = 0.003). DS showed a significant correlation with central venous pressure (r = 0.532, P = 0.017) and liver stiffness measurements using 2D-SWE (r = 0.581, P = 0.002). The areas under the receiver operating characteristic curve for the diagnosis of significant fibrosis were 0.903 and 0.734 for SWD and 2D-SWE, respectively (P = 0.043).
Conclusions
DS measured by SWD reflects the severity of liver damage in patients with FALD. SWE may be valuable for the therapeutic management of patients with FALD.
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Affiliation(s)
- Tomoaki Nagasawa
- Division of Hepatology, Department of Internal Medicine, Iwate Medical University, Yahaba-cho, Shiwa-gun, Iwate, Japan
| | - Hidekatsu Kuroda
- Division of Hepatology, Department of Internal Medicine, Iwate Medical University, Yahaba-cho, Shiwa-gun, Iwate, Japan
- * E-mail:
| | - Tamami Abe
- Division of Hepatology, Department of Internal Medicine, Iwate Medical University, Yahaba-cho, Shiwa-gun, Iwate, Japan
| | - Hirofumi Saiki
- Department of Pediatrics, Iwate Medical University, Yahaba-cho, Shiwa-gun, Iwate, Japan
| | - Yasuhiro Takikawa
- Division of Hepatology, Department of Internal Medicine, Iwate Medical University, Yahaba-cho, Shiwa-gun, Iwate, Japan
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Kogiso T, Sagawa T, Taniai M, Shimada E, Inai K, Shinohara T, Tokushige K. Risk factors for Fontan-associated hepatocellular carcinoma. PLoS One 2022; 17:e0270230. [PMID: 35714161 PMCID: PMC9205474 DOI: 10.1371/journal.pone.0270230] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2021] [Accepted: 06/07/2022] [Indexed: 11/18/2022] Open
Abstract
Aims The incidence of hepatocellular carcinoma (HCC) in patients with Fontan-associated liver disease (i.e., FALD-HCC) has increased over time. However, the risk factors for HCC development remain unclear. Here, we compared the levels of non-invasive markers to the survival rate of FALD-HCC patients. Methods From 2003 to 2021, 154 patients (66 men, 42.9%) developed liver disease after undergoing Fontan procedures. HCC was diagnosed in 15 (9.7%) (8 men, 53.3%) at a median age of 34 years (range, 21–45 years). We compared FALD-HCC and non-HCC cases; we generated marker level cutoffs using receiver operating characteristic curves. We sought to identify risk factors for HCC and mortality. Results The incidence of HCC was 4.9% in FALD patients within 20 years after the Fontan procedure. Compared with non-HCC patients, FALD-HCC patients exhibited higher incidences of polysplenia and esophageal varices. At the time of HCC development, the hyaluronic acid (HA) level (p = 0.04) and the fibrosis-4 index (p = 0.02) were significantly higher in FALD-HCC patients than in non-HCC patients; the total bilirubin (T-BIL) level (p = 0.07) and the model for end-stage liver disease score [excluding the international normalized ratio (MELD-XI)] (p = 0.06) tended to be higher in FALD-HCC patients. Within approximately 20 years of the Fontan procedure, 10 patients died (survival rate, 96.9%). Kaplan–Meier curve analysis indicated that patients with T-BIL levels ≥ 2.2 mg/dL, HA levels ≥ 55.5 ng/mL, and MELD-XI scores ≥ 18.7 were at high risk of HCC, a generally poor prognosis, and both polysplenia and esophageal varices. Multivariate Cox regression analyses indicated that the complication of polysplenia [Hazard ratio (HR): 10.915] and a higher MELD-XI score (HR: 1.148, both p < 0.01) were independent risk factors for FALD-HCC. Conclusions The complication of polysplenia and a MELD-XI score may predict HCC development and mortality in FALD patients.
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Affiliation(s)
- Tomomi Kogiso
- Department of Internal Medicine, Institute of Gastroenterology, Tokyo Women’s Medical University, Shinjuku-ku, Tokyo, Japan
- * E-mail:
| | - Takaomi Sagawa
- Department of Internal Medicine, Institute of Gastroenterology, Tokyo Women’s Medical University, Shinjuku-ku, Tokyo, Japan
| | - Makiko Taniai
- Department of Internal Medicine, Institute of Gastroenterology, Tokyo Women’s Medical University, Shinjuku-ku, Tokyo, Japan
| | - Eriko Shimada
- Pediatric Cardiology and Adult Congenital Cardiology, Tokyo Women’s Medical University, Shinjuku-ku, Tokyo, Japan
| | - Kei Inai
- Pediatric Cardiology and Adult Congenital Cardiology, Tokyo Women’s Medical University, Shinjuku-ku, Tokyo, Japan
| | - Tokuko Shinohara
- Pediatric Cardiology and Adult Congenital Cardiology, Tokyo Women’s Medical University, Shinjuku-ku, Tokyo, Japan
| | - Katsutoshi Tokushige
- Department of Internal Medicine, Institute of Gastroenterology, Tokyo Women’s Medical University, Shinjuku-ku, Tokyo, Japan
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Neethling E, Heggie JE. Considerations in Critical Care and Anesthetic Management of Adult Patients Living with Fontan Circulation. Can J Cardiol 2022; 38:1100-1110. [PMID: 35490923 DOI: 10.1016/j.cjca.2022.04.017] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2021] [Revised: 04/21/2022] [Accepted: 04/21/2022] [Indexed: 11/02/2022] Open
Abstract
The Fontan procedure is a staged palliation for various complex congenital cardiac lesions, including tricuspid atresia (TA), pulmonary atresia (PA), hypoplastic left heart syndrome (HLHS), and double inlet left ventricle (DILV), all of which involve a functional single-ventricle physiology. The complexity of the patients' original anatomy combined with the anatomical and physiological consequences of the Fontan circulation creates challenges. Teens and adults living with Fontan palliation will need perioperative support for non-cardiac surgery, peripartum management for labor and delivery, interventions related to their structural heart disease, electrophysiology procedures, pacemakers, cardioversions, cardiac surgery, transplant, and advanced mechanical support. This review focuses on the anesthetic and ICU management of these patients during their perioperative journey, with an emphasis on the continuity of pre-intervention planning, referral pathways, and post-intervention intensive care unit (ICU) management. Requests for recipes and doses of medications are frequent; however, as in normal anesthesia and ICU practice, the method of anesthesia and dosing are dependent on the presenting medical/surgical conditions and the underlying anatomy and physiological reserve. A patient with Fontan palliation in their early 20s attending school full-time with a cavopulmonary connection is likely to have more reserve than a patient in their late 40s with an atrio- pulmonary (AP) Fontan at home waiting for a heart transplant. Each case will require an anesthetic and critical care plan tailored to their situation. The critical care environment is a natural extension of the anesthetic management of a patient, with complex considerations for a patient with Fontan palliation.
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Affiliation(s)
| | - Jane E Heggie
- Toronto General Hospital, University Health Network, Toronto.
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Suzuki H, Niizeki T, Shirono T, Koteda Y, Kinjyo Y, Mizukami N, Koda M, Ota S, Nakano M, Okamura S, Iwamoto H, Shimose S, Noda Y, Kamachi N, Kajiwara A, Suda K, Akiba J, Yano H, Kuromatsu R, Koga H, Torimura T. Robust Effect of Hepatic Arterial Infusion Chemotherapy and Radiation Therapy on Hepatocellular Carcinoma Arising from Fontan-associated Liver Disease. Intern Med 2022; 61:1145-1150. [PMID: 34565776 PMCID: PMC9107970 DOI: 10.2169/internalmedicine.8154-21] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/15/2021] [Accepted: 08/01/2021] [Indexed: 11/06/2022] Open
Abstract
Fontan-associated liver disease (FALD) caused by long-term systemic venous congestion following the Fontan procedure may eventually lead to hepatocellular carcinoma (HCC). Treatment strategies for HCC due to FALD (FALD-HCC) remain unclear. We herein report a 35-year-old man with FALD-HCC that was well controlled by 3 cycles of continuous infusion of 5-fluorouracil and low-dose cisplatin (low-dose FP therapy) combined with 60 Gy of radiation therapy. However, the patient ultimately died of extrahepatic metastases. A pathological autopsy revealed more than 90% necrosis in the primary HCC lesion. This case suggests that low-dose FP therapy might be effective in FALD-HCC.
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Affiliation(s)
- Hiroyuki Suzuki
- Division of Gastroenterology, Department of Medicine, Kurume University School of Medicine, Japan
| | - Takashi Niizeki
- Division of Gastroenterology, Department of Medicine, Kurume University School of Medicine, Japan
| | - Tomotake Shirono
- Division of Gastroenterology, Department of Medicine, Kurume University School of Medicine, Japan
| | - Yusuke Koteda
- Department of Pediatrics and Child Health, Kurume University School of Medicine, Japan
| | - Yoshinao Kinjyo
- Department of Pathology, Kurume University School of Medicine, Japan
| | | | - Makoto Koda
- Division of Gastroenterology, Department of Medicine, Kurume University School of Medicine, Japan
| | - Satoshi Ota
- Division of Gastroenterology, Department of Medicine, Kurume University School of Medicine, Japan
| | - Masahito Nakano
- Division of Gastroenterology, Department of Medicine, Kurume University School of Medicine, Japan
| | - Shusuke Okamura
- Division of Gastroenterology, Department of Medicine, Kurume University School of Medicine, Japan
| | - Hideki Iwamoto
- Division of Gastroenterology, Department of Medicine, Kurume University School of Medicine, Japan
- Iwamoto Internal Medicine Clinic, Japan
| | - Shigeo Shimose
- Division of Gastroenterology, Department of Medicine, Kurume University School of Medicine, Japan
| | - Yu Noda
- Division of Gastroenterology, Department of Medicine, Kurume University School of Medicine, Japan
| | - Naoki Kamachi
- Division of Gastroenterology, Department of Medicine, Kurume University School of Medicine, Japan
| | - Akira Kajiwara
- Division of Gastroenterology, Department of Medicine, Kurume University School of Medicine, Japan
| | - Kenji Suda
- Department of Pediatrics and Child Health, Kurume University School of Medicine, Japan
| | - Jun Akiba
- Department of Pathology, Kurume University School of Medicine, Japan
| | - Hirohisa Yano
- Department of Pathology, Kurume University School of Medicine, Japan
| | - Ryoko Kuromatsu
- Division of Gastroenterology, Department of Medicine, Kurume University School of Medicine, Japan
| | - Hironori Koga
- Division of Gastroenterology, Department of Medicine, Kurume University School of Medicine, Japan
| | - Takuji Torimura
- Division of Gastroenterology, Department of Medicine, Kurume University School of Medicine, Japan
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12
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Karunakaran KB, Gabriel GC, Balakrishnan N, Lo CW, Ganapathiraju MK. Novel Protein-Protein Interactions Highlighting the Crosstalk between Hypoplastic Left Heart Syndrome, Ciliopathies and Neurodevelopmental Delays. Genes (Basel) 2022; 13:genes13040627. [PMID: 35456433 PMCID: PMC9032108 DOI: 10.3390/genes13040627] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2022] [Revised: 03/08/2022] [Accepted: 03/08/2022] [Indexed: 02/06/2023] Open
Abstract
Hypoplastic left heart syndrome (HLHS) is a severe congenital heart disease (CHD) affecting 1 in 5000 newborns. We constructed the interactome of 74 HLHS-associated genes identified from a large-scale mouse mutagenesis screen, augmenting it with 408 novel protein-protein interactions (PPIs) using our High-Precision Protein-Protein Interaction Prediction (HiPPIP) model. The interactome is available on a webserver with advanced search capabilities. A total of 364 genes including 73 novel interactors were differentially regulated in tissue/iPSC-derived cardiomyocytes of HLHS patients. Novel PPIs facilitated the identification of TOR signaling and endoplasmic reticulum stress modules. We found that 60.5% of the interactome consisted of housekeeping genes that may harbor large-effect mutations and drive HLHS etiology but show limited transmission. Network proximity of diabetes, Alzheimer's disease, and liver carcinoma-associated genes to HLHS genes suggested a mechanistic basis for their comorbidity with HLHS. Interactome genes showed tissue-specificity for sites of extracardiac anomalies (placenta, liver and brain). The HLHS interactome shared significant overlaps with the interactomes of ciliopathy- and microcephaly-associated genes, with the shared genes enriched for genes involved in intellectual disability and/or developmental delay, and neuronal death pathways, respectively. This supported the increased burden of ciliopathy variants and prevalence of neurological abnormalities observed among HLHS patients with developmental delay and microcephaly, respectively.
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Affiliation(s)
- Kalyani B. Karunakaran
- Supercomputer Education and Research Centre, Indian Institute of Science, Bangalore 560012, India; (K.B.K.); (N.B.)
| | - George C. Gabriel
- Department of Developmental Biology, School of Medicine, University of Pittsburgh, Pittsburgh, PA 15201, USA; (G.C.G.); (C.W.L.)
| | - Narayanaswamy Balakrishnan
- Supercomputer Education and Research Centre, Indian Institute of Science, Bangalore 560012, India; (K.B.K.); (N.B.)
| | - Cecilia W. Lo
- Department of Developmental Biology, School of Medicine, University of Pittsburgh, Pittsburgh, PA 15201, USA; (G.C.G.); (C.W.L.)
| | - Madhavi K. Ganapathiraju
- Department of Biomedical Informatics, School of Medicine, University of Pittsburgh, Pittsburgh, PA 15206, USA
- Intelligent Systems Program, School of Computing and Information, University of Pittsburgh, Pittsburgh, PA 15260, USA
- Correspondence:
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13
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Naganuma A, Suzuki Y, Hoshino T, Yasuoka H, Tamura Y, Naruse H, Tanaka H, Hirai K, Sakamoto I, Ogawa T, Hatanaka T, Kakizaki S. A case of conversion hepatectomy for huge ruptured hepatocellular carcinoma after transarterial embolization and lenvatinib therapy. Clin J Gastroenterol 2021; 15:177-184. [PMID: 34811701 DOI: 10.1007/s12328-021-01558-5] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/05/2021] [Accepted: 11/10/2021] [Indexed: 12/09/2022]
Abstract
We herein report a successfully treated case of huge ruptured hepatocellular carcinoma (HCC) by conversion hepatectomy after transarterial embolization (TAE) and lenvatinib therapy. A 33-year-old male patient with right hypochondralgia and liver tumor was referred to our hospital. He had a history of surgery for heart malformation. The tumor at the right lobe was 15 cm in diameter with bloody ascites. Right atrial thrombus 4.5 cm in diameter and marked cardiac dilatation were observed. TAE with ethanol suspended in lipiodol and gelatin sponge achieved hemostasis of the ruptured HCC. Although viable HCC remained after TAE, surgical treatment was abandoned because of abdominal wall invasion and his heart function. Lenvatinib and rivaroxaban were then initiated for HCC and atrial thrombus, respectively. Lenvatinib treatment resulted in a reduction in tumor marker levels and the tumor size. First, we planned conversion hepatectomy after 5 months of lenvatinib. However, recurrence of atrial thrombus prompted us to put off the surgery, and lenvatinib was re-administered. After improvement of atrial thrombus, we finally performed conversion hepatectomy 10 months after starting lenvatinib administration. The tumor was completely removed by combined resection of the diaphragm, and the patient has been doing well without any signs of recurrence.
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Affiliation(s)
- Atsushi Naganuma
- Department of Gastroenterology, National Hospital Organization Takasaki General Medical Center, 36 Takamatsu-cho, Takasaki, Gunma, 370-0829, Japan
| | - Yuhei Suzuki
- Department of Gastroenterology, National Hospital Organization Takasaki General Medical Center, 36 Takamatsu-cho, Takasaki, Gunma, 370-0829, Japan
| | - Takashi Hoshino
- Department of Gastroenterology, National Hospital Organization Takasaki General Medical Center, 36 Takamatsu-cho, Takasaki, Gunma, 370-0829, Japan
| | - Hidetoshi Yasuoka
- Department of Gastroenterology, National Hospital Organization Takasaki General Medical Center, 36 Takamatsu-cho, Takasaki, Gunma, 370-0829, Japan
| | - Yuki Tamura
- Department of Gastroenterology, National Hospital Organization Takasaki General Medical Center, 36 Takamatsu-cho, Takasaki, Gunma, 370-0829, Japan
| | - Hiroaki Naruse
- Department of Gastroenterology, National Hospital Organization Takasaki General Medical Center, 36 Takamatsu-cho, Takasaki, Gunma, 370-0829, Japan
| | - Hiroshi Tanaka
- Department of Surgery, National Hospital Organization Takasaki General Medical Center, 36 Takamatsu-cho, Takasaki, Gunma, 370-0829, Japan
| | - Keitaro Hirai
- Department of Surgery, National Hospital Organization Takasaki General Medical Center, 36 Takamatsu-cho, Takasaki, Gunma, 370-0829, Japan
| | - Ichiro Sakamoto
- Department of Surgery, National Hospital Organization Takasaki General Medical Center, 36 Takamatsu-cho, Takasaki, Gunma, 370-0829, Japan
| | - Tetsushi Ogawa
- Department of Surgery, National Hospital Organization Takasaki General Medical Center, 36 Takamatsu-cho, Takasaki, Gunma, 370-0829, Japan
| | - Takeshi Hatanaka
- Department of Gastroenterology, Gunma Saiseikai Maebashi Hospital, 564-1 Kamishindenmachi, Maebashi, Gunma, 371-0821, Japan
| | - Satoru Kakizaki
- Department of Gastroenterology, National Hospital Organization Takasaki General Medical Center, 36 Takamatsu-cho, Takasaki, Gunma, 370-0829, Japan. .,Department of Clinical Research, National Hospital Organization Takasaki General Medical Center, 36 Takamatsu-cho, Takasaki, Gunma, 370-0829, Japan.
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14
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Isoura Y, Yamamoto A, Cho Y, Ehara E, Jogo A, Suzuki T, Amano-Teranishi Y, Kioka K, Hamazaki T, Murakami Y, Tokuhara D. Platelet count and abdominal dynamic CT are useful in predicting and screening for gastroesophageal varices after Fontan surgery. PLoS One 2021; 16:e0257441. [PMID: 34618830 PMCID: PMC8496823 DOI: 10.1371/journal.pone.0257441] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2021] [Accepted: 09/02/2021] [Indexed: 12/12/2022] Open
Abstract
OBJECTIVE Patients who undergo Fontan surgery for complex cardiac anomalies are prone to developing liver and gastrointestinal complications. In particular, gastroesophageal varices (GEVs) can occur, but their prevalence is unknown. We aimed to elucidate the occurrence of GEVs and the predicting parameters of GEVs in these patients. MATERIALS AND METHODS Twenty-seven patients (median age, 14.8 years; median time since surgery, 12.9 years) who had undergone the Fontan surgery and were examined by abdominal dynamic computed tomography (CT) for the routine follow-up were included in the study. Radiological findings including GEVs and extraintestinal complications were retrospectively evaluated by experienced radiologists in a blinded manner. Relationships between blood-biochemical and demographic parameters and the presence of GEVs were statistically analyzed. RESULTS Dynamic CT revealed gastric varices (n = 3, 11.1%), esophageal varices (n = 1, 3.7%), and gastrorenal shunts (n = 5, 18.5%). All patients with gastric varices had gastrorenal shunts. All gastric varices were endoscopically confirmed as being isolated and enlarged, with indications for preventive interventional therapy. A platelet count lower than 119 × 109 /L was identified as a predictor of GEV (area under the receiver operating curve, 0.946; sensitivity, 100%; and specificity, 87%). CONCLUSIONS GEVs are important complications that should not be ignored in patients who have undergone a Fontan procedure. Platelet counts lower than 119 × 109 /L may help to prompt patient screening by using abdominal dynamic CT to identify GEVs and their draining collateral veins in these patients.
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Affiliation(s)
- Yoshiharu Isoura
- Department of Pediatrics, Osaka City University Graduate School of Medicine, Osaka, Japan
| | - Akira Yamamoto
- Department of Diagnostic and Interventional Radiology, Osaka City University Graduate School of Medicine, Osaka, Japan
| | - Yuki Cho
- Department of Pediatrics, Osaka City University Graduate School of Medicine, Osaka, Japan
| | - Eiji Ehara
- Department of Pediatric Cardiology, Osaka City General Hospital, Osaka, Japan
| | - Atsushi Jogo
- Department of Diagnostic and Interventional Radiology, Osaka City University Graduate School of Medicine, Osaka, Japan
| | - Tsugutoshi Suzuki
- Department of Pediatric Electrophysiology, Osaka City General Hospital, Osaka, Japan
| | | | - Kiyohide Kioka
- Department of Hepatology, Osaka City General Hospital, Osaka, Japan
| | - Takashi Hamazaki
- Department of Pediatrics, Osaka City University Graduate School of Medicine, Osaka, Japan
| | - Yosuke Murakami
- Department of Pediatrics, Osaka City University Graduate School of Medicine, Osaka, Japan
- Department of Pediatric Cardiology, Osaka City General Hospital, Osaka, Japan
| | - Daisuke Tokuhara
- Department of Pediatrics, Osaka City University Graduate School of Medicine, Osaka, Japan
- * E-mail:
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15
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Kakizaki S, Uehara D, Tojima H, Suga T, Yamazaki Y, Sato K, Kubo N, Shirabe K, Yokota T, Shibuya K, Maehara T, Yokoo H, Naganuma A, Uraoka T. The first reported case of Noonan syndrome complicated with hepatocellular carcinoma. Clin Case Rep 2021; 9:e04317. [PMID: 34267897 PMCID: PMC8271263 DOI: 10.1002/ccr3.4317] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2021] [Revised: 04/11/2021] [Accepted: 04/26/2021] [Indexed: 11/20/2022] Open
Abstract
Noonan syndrome is a genetic multisystem disorder and is associated with mutation of genes encoding the proteins in the RAS-MAPK pathway. We reported the first case of Noonan syndrome complicated with hepatocellular carcinoma.
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Affiliation(s)
- Satoru Kakizaki
- Department of Gastroenterology and HepatologyGunma University Graduate School of MedicineMaebashiJapan
- Department of Clinical ResearchNational Hospital Organization Takasaki General Medical CenterTakasakiJapan
| | - Daisuke Uehara
- Department of Gastroenterology and HepatologyGunma University Graduate School of MedicineMaebashiJapan
| | - Hiroki Tojima
- Department of Gastroenterology and HepatologyGunma University Graduate School of MedicineMaebashiJapan
| | - Takayoshi Suga
- Department of Gastroenterology and HepatologyGunma University Graduate School of MedicineMaebashiJapan
| | - Yuichi Yamazaki
- Department of Gastroenterology and HepatologyGunma University Graduate School of MedicineMaebashiJapan
| | - Ken Sato
- Department of Gastroenterology and HepatologyGunma University Graduate School of MedicineMaebashiJapan
| | - Norio Kubo
- Department of General Surgical ScienceGunma University Graduate School of MedicineMaebashiJapan
| | - Ken Shirabe
- Department of General Surgical ScienceGunma University Graduate School of MedicineMaebashiJapan
| | - Takayuki Yokota
- Department of Diagnostic Radiology and Nuclear MedicineGunma University Graduate School of MedicineMaebashiJapan
| | - Kei Shibuya
- Gunma University Heavy Ion Medical CenterMaebashiJapan
| | - Tatsurou Maehara
- Department of Human PathologyGunma University Graduate School of MedicineMaebashiJapan
| | - Hideaki Yokoo
- Department of Human PathologyGunma University Graduate School of MedicineMaebashiJapan
| | - Atsushi Naganuma
- Department of GastroenterologyNational Hospital Organization Takasaki General Medical CenterTakasakiJapan
| | - Toshio Uraoka
- Department of Gastroenterology and HepatologyGunma University Graduate School of MedicineMaebashiJapan
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16
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Cho Y, Kabata D, Ehara E, Yamamoto A, Mizuochi T, Mushiake S, Kusano H, Kuwae Y, Suzuki T, Uchida-Kobayashi S, Morikawa H, Amano-Teranishi Y, Kioka K, Jogo A, Isoura Y, Hamazaki T, Murakami Y, Tokuhara D. Assessing liver stiffness with conventional cut-off values overestimates liver fibrosis staging in patients who received the Fontan procedure. Hepatol Res 2021; 51:593-602. [PMID: 33677839 DOI: 10.1111/hepr.13627] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/24/2020] [Revised: 02/07/2021] [Accepted: 02/08/2021] [Indexed: 12/19/2022]
Abstract
AIM Patients who undergo the Fontan procedure for complex congenital heart disease are prone to liver cirrhosis. Liver stiffness (LS) reflects liver fibrosis stage in patients with chronic viral hepatitis; however, its accuracy in predicting liver fibrosis stage in Fontan patients is controversial. We aimed to clarify the correlation between LS and liver fibrosis stage in Fontan patients. METHODS Fifty-eight Fontan patients were prospectively measured for LS with transient elastography. We undertook liver biopsy, cardiac catheterization, and laboratory tests in 22 of these patients (median age, 14.7 years; range, 9.9-32.1 years) with LS > 11.0 kPa (median, 19.2 kPa; range, 12.2-39.8 kPa); these elevated LS values suggest liver cirrhosis. RESULTS Histologically, all patients showed mild-to-severe portal and sinusoidal fibrosis but no cirrhosis. Statistically, LS did not predict histological liver fibrosis scores (p = 0.175). Liver stiffness was not correlated with central venous pressure (p = 0.456) or with the hepatic venous pressure gradient (HVPG; p = 0.062), although the p value for HVPG was only slightly above the threshold for significance. CONCLUSIONS Fontan patients are prone to developing both portal and sinusoidal fibrosis. Liver stiffness could be influenced by HVPG, and using the conventional cut-off values for LS overestimates and overtreats liver fibrosis in these patients.
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Affiliation(s)
- Yuki Cho
- Department of Pediatrics, Osaka City University Graduate School of Medicine, Osaka, Japan
| | - Daijiro Kabata
- Department of Medical Statistics, Osaka City University Graduate School of Medicine, Osaka, Japan
| | - Eiji Ehara
- Department of Pediatric Cardiology, Osaka City General Hospital, Osaka, Japan
| | - Akira Yamamoto
- Department of Diagnostic and Interventional Radiology, Osaka City University Graduate School of Medicine, Osaka, Japan
| | - Tatsuki Mizuochi
- Department of Pediatrics and Child Health, Kurume University School of Medicine, Kurume, Japan
| | - Sotaro Mushiake
- Department of Pediatrics, Kinki University Nara Hospital, Ikoma, Japan
| | - Hironori Kusano
- Department of Pathology, Kurume University School of Medicine, Kurume, Japan
| | - Yuko Kuwae
- Department of Pathology, Osaka City University Gradute School of Medicine, Osaka, Japan
| | - Tsugutoshi Suzuki
- Department of Pediatric Electrophysiology, Osaka City General Hospital, Osaka, Japan
| | | | | | | | - Kiyohide Kioka
- Department of Hepatology, Osaka City General Hospital, Osaka, Japan
| | - Atsushi Jogo
- Department of Diagnostic and Interventional Radiology, Osaka City University Graduate School of Medicine, Osaka, Japan
| | - Yoshiharu Isoura
- Department of Pediatrics, Osaka City University Graduate School of Medicine, Osaka, Japan
| | - Takashi Hamazaki
- Department of Pediatrics, Osaka City University Graduate School of Medicine, Osaka, Japan
| | - Yosuke Murakami
- Department of Pediatrics, Osaka City University Graduate School of Medicine, Osaka, Japan.,Department of Pediatric Cardiology, Osaka City General Hospital, Osaka, Japan
| | - Daisuke Tokuhara
- Department of Pediatrics, Osaka City University Graduate School of Medicine, Osaka, Japan
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