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Lu CW, Wu CH, Huang MT, Lee CS, Chen HL, Lin MT, Chiu SN, Tseng WC, Chen CA, Wang JK, Wu MH. Liver fibrosis detected by diffusion-weighted magnetic resonance imaging and its functional correlates in Fontan patients. Eur J Cardiothorac Surg 2024; 66:ezae249. [PMID: 38913856 DOI: 10.1093/ejcts/ezae249] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/21/2024] [Revised: 04/17/2024] [Accepted: 06/23/2024] [Indexed: 06/26/2024] Open
Abstract
OBJECTIVES The evaluation of Fontan-associated liver disease is often challenging. Diffusion-weighted magnetic resonance imaging can detect hepatic fibrosis from capillary perfusion and diffusion abnormalities from extracellular matrix accumulation. This study investigated its role in the evaluation of liver disease in Fontan patients and explored possible diagnostic methods for early detection of advanced liver fibrosis. METHODS Stable adult Fontan patients who could safely be examined with magnetic resonance imaging were enrolled, and blood biomarkers, transient elastography were also examined. RESULTS Forty-six patients received diffusion-weighted imaging; and 58.7% were diagnosed with advanced liver fibrosis (severe liver fibrosis, 37.0%, and cirrhosis 21.7%). Two parameters of hepatic dysfunction, platelet counts (Spearman's ρ: -0.456, P = 0.001) and cholesterol levels (Spearman's ρ: -0.383, P = 0.009), decreased with increasing severity of fibrosis. Using transient elastography, a cut-off value of 14.2 kPa predicted the presence of advanced liver fibrosis, but with a low positive predictive value. When we included platelet count, cholesterol, post-Fontan years and transient elastography values as a composite, the capability of predicting advanced liver fibrosis was the most satisfactory (C statistic 0.817 ± 0.071, P < 0.001). A cut-off value of 5.0 revealed a sensitivity of 78% and a specificity of 82%. CONCLUSIONS In Fontan patients, diffusion-weighted imaging was helpful in detecting liver fibrosis that was correlated with hepatic dysfunction. A simple score was proposed for long-term surveillance and early detection of advanced liver disease in adult Fontan patients. For adult Fontan patients with a calculated score > 5.0, we may consider timely diffusion-weight imaging and early management for liver complications.
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Affiliation(s)
- Chun-Wei Lu
- Adult Congenital Heart Center, National Taiwan University Hospital, Taipei, Taiwan
- Department of Pediatrics, National Taiwan University Hospital, Taipei, Taiwan
| | - Chih-Horng Wu
- Department of Medical Imaging, National Taiwan University Hospital, Taipei, Taiwan
| | - Miao-Tzu Huang
- Department of Medical Research, National Taiwan University Hospital, Taipei, Taiwan
| | - Chee-Seng Lee
- Department of Pediatrics, National Taiwan University Hospital Hsin-Chu Biomedical Park Branch, Hsin-Chu, Taiwan
| | - Huey-Ling Chen
- Department of Pediatrics, National Taiwan University Hospital, Taipei, Taiwan
| | - Ming-Tai Lin
- Department of Pediatrics, National Taiwan University Hospital, Taipei, Taiwan
| | - Shuenn-Nan Chiu
- Department of Pediatrics, National Taiwan University Hospital, Taipei, Taiwan
| | - Wei-Chieh Tseng
- Department of Pediatrics, National Taiwan University Hospital, Taipei, Taiwan
| | - Chun-An Chen
- Department of Pediatrics, National Taiwan University Hospital, Taipei, Taiwan
| | - Jou-Kou Wang
- Department of Pediatrics, National Taiwan University Hospital, Taipei, Taiwan
| | - Mei-Hwan Wu
- Adult Congenital Heart Center, National Taiwan University Hospital, Taipei, Taiwan
- Department of Pediatrics, National Taiwan University Hospital, Taipei, Taiwan
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2
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Hitawala AA, Gopalakrishna H, Mironova M, Livinski AA, Wright EC, Downing T, Ito S, Fisher SD, Cedars AM, John AS, Heller T. Meta-analysis: Incidence of cirrhosis and hepatocellular carcinoma in patients with Fontan palliation. Aliment Pharmacol Ther 2024; 59:1020-1032. [PMID: 38497159 DOI: 10.1111/apt.17952] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/10/2023] [Revised: 12/10/2023] [Accepted: 03/03/2024] [Indexed: 03/19/2024]
Abstract
BACKGROUND AND AIMS The Fontan palliation is the final stage of surgery for many children born with univentricular physiology. Almost all Fontan patients develop liver fibrosis which may eventually lead to cirrhosis and hepatocellular carcinoma (HCC). These are important causes of morbidity and mortality in these patients. We performed a systematic review and meta-analysis to assess the incidence of cirrhosis and HCC in Fontan patients and stratify it based on time since surgery. METHODS A literature search of seven databases identified 1158 records. Studies reporting the number of cirrhosis and HCC cases in Fontan patients and time since Fontan surgery were included. In the cirrhosis cohort, we included only those studies where all patients underwent liver biopsy. RESULTS A total of 23 studies were included: 12 and 13 studies in the cirrhosis and HCC cohorts, respectively, with two studies included in both cohorts. The incidence of cirrhosis was 0.97 per 100 patient-years (95% CI 0.57-1.63), with the incidence and cumulative incidence ≥20 years post Fontan surgery being 1.61 per 100 patient-years (95% CI 1.24-2.08) and 32.2% (95% CI 25.8%-39.4%), respectively. The incidence of HCC was 0.12 per 100 patient-years (95% CI 0.07-0.21), with the incidence and cumulative incidence ≥20 years post Fontan surgery being 0.20 per 100 patient-years (95% CI 0.12-0.35) and 3.9% (95% CI 2.2%-6.8%), respectively. Only about 70% of patients with HCC (20/28) had underlying cirrhosis. CONCLUSION The incidence of cirrhosis and HCC increases over time, especially at ≥20 years post Fontan surgery. Studies are needed to further identify at-risk patients in order to streamline surveillance for these highly morbid conditions.
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Affiliation(s)
- Asif A Hitawala
- Liver Disease Branch, National Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health, Bethesda, Maryland, USA
| | - Harish Gopalakrishna
- Liver Disease Branch, National Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health, Bethesda, Maryland, USA
| | - Maria Mironova
- Liver Disease Branch, National Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health, Bethesda, Maryland, USA
| | - Alicia A Livinski
- National Institutes of Health Library, Office of Research Services, Office of the Director, National Institutes of Health, Bethesda, Maryland, USA
| | - Elizabeth C Wright
- Office of the Director, National Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health, Bethesda, Maryland, USA
| | - Tacy Downing
- Division of Pediatric Cardiology, Children's National Hospital, Washington, DC, USA
| | - Seiji Ito
- Division of Pediatric Cardiology, Children's National Hospital, Washington, DC, USA
| | - Stacy D Fisher
- Adult Congenital Heart Disease Center, Johns Hopkins Heart and Vascular Institute, Baltimore, Maryland, USA
| | - Ari M Cedars
- Adult Congenital Heart Disease Center, Johns Hopkins Heart and Vascular Institute, Baltimore, Maryland, USA
| | - Anitha S John
- Division of Pediatric Cardiology, Children's National Hospital, Washington, DC, USA
| | - Theo Heller
- Translational Hepatology Section, Liver Disease Branch, National Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health, Bethesda, Maryland, USA
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3
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Téllez L, Payancé A, Tjwa E, Del Cerro MJ, Idorn L, Ovroutski S, De Bruyne R, Verkade HJ, De Rita F, de Lange C, Angelini A, Paradis V, Rautou PE, García-Pagán JC. EASL-ERN position paper on liver involvement in patients with Fontan-type circulation. J Hepatol 2023; 79:1270-1301. [PMID: 37863545 DOI: 10.1016/j.jhep.2023.07.013] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/06/2023] [Accepted: 07/06/2023] [Indexed: 10/22/2023]
Abstract
Fontan-type surgery is the final step in the sequential palliative surgical treatment of infants born with a univentricular heart. The resulting long-term haemodynamic changes promote liver damage, leading to Fontan-associated liver disease (FALD), in virtually all patients with Fontan circulation. Owing to the lack of a uniform definition of FALD and the competitive risk of other complications developed by Fontan patients, the impact of FALD on the prognosis of these patients is currently debatable. However, based on the increasing number of adult Fontan patients and recent research interest, the European Association for The Study of the Liver and the European Reference Network on Rare Liver Diseases thought a position paper timely. The aims of the current paper are: (1) to provide a clear definition and description of FALD, including clinical, analytical, radiological, haemodynamic, and histological features; (2) to facilitate guidance for staging the liver disease; and (3) to provide evidence- and experience-based recommendations for the management of different clinical scenarios.
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Affiliation(s)
- Luis Téllez
- Gastroenterology and Hepatology Department, Hospital Universitario Ramón y Cajal, Madrid, Spain; Instituto Ramón y Cajal de Investigación Sanitaria (IRYCIS), CIBEREHD (Centro de Investigación Biomédica en Red Enfermedades Hepáticas y Digestivas), University of Alcalá, Madrid, Spain
| | - Audrey Payancé
- DHU Unity, Pôle des Maladies de l'Appareil Digestif, Service d'Hépatologie, Hôpital Beaujon, AP-HP, Clichy, France; Université Denis Diderot-Paris 7, Sorbonne Paris Cité, Paris, France
| | - Eric Tjwa
- Department of Gastroenterology and Hepatology, Radboud University Medical Center, Nijmegen, The Netherlands
| | - María Jesús Del Cerro
- Pediatric Cardiology Department, Hospital Universitario Ramón y Cajal, Madrid, Spain; Instituto Ramón y Cajal de Investigación Sanitaria (IRYCIS), University of Alcalá, Madrid, Spain
| | - Lars Idorn
- Department of Pediatrics, Section of Pediatric Cardiology, Rigshospitalet, Copenhagen, Denmark
| | - Stanislav Ovroutski
- Department of Congenital Heart Disease/Pediatric Cardiology, Deutsches Herzzentrum Berlin, Berlin, Germany
| | - Ruth De Bruyne
- Department of Pediatric Gastroenterology, Hepatology and Nutrition, Ghent University Hospital, Belgium
| | - Henkjan J Verkade
- Department of Pediatrics, Beatrix Children's Hospital/University Medical Center Groningen, The Netherlands
| | - Fabrizio De Rita
- Adult Congenital and Paediatric Heart Unit, Freeman Hospital, Newcastle Upon Tyne Hospitals NHS Foundation Trust, Newcastle Upon Tyne, UK
| | - Charlotte de Lange
- Department of Pediatric Radiology, Queen Silvia Childrens' Hospital, Sahlgrenska University Hospital, Behandlingsvagen 7, 41650 Göteborg, Sweden
| | - Annalisa Angelini
- Pathology of Cardiac Transplantation and Regenerative Medicine Unit, Department of Cardiac, Thoracic and Vascular Sciences and Public Health, University of Padua, Padua, Italy
| | - Valérie Paradis
- Centre de recherche sur l'inflammation, INSERM1149, Université Paris Cité, Paris, France; Pathology Department, Beaujon Hospital, APHP.Nord, Clichy, France
| | - Pierre Emmanuel Rautou
- AP-HP, Service d'Hépatologie, Hôpital Beaujon, DMU DIGEST, Centre de Référence des Maladies Vasculaires du Foie, FILFOIE, Clichy, France; Université Paris-Cité, Inserm, Centre de recherche sur l'inflammation, UMR 1149, Paris, France
| | - Juan Carlos García-Pagán
- Barcelona Hepatic Hemodynamic Laboratory, Liver Unit, Hospital Clínic, Institut de Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Departament de Medicina i Ciències de la Salut, University of Barcelona, Barcelona, Spain; CIBEREHD (Centro de Investigación Biomédica en Red Enfermedades Hepáticas y Digestivas), Health Care Provider of the European Reference Network on Rare Liver Disorders (ERN-Liver), Spain.
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4
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Rathgeber SL. Liver Stiffness vs Vibrosis After Fontan Palliation: Is Transient Elastography the Solution to Early Detection of Progressive Liver Disease? Can J Cardiol 2023; 39:1346-1348. [PMID: 37331621 DOI: 10.1016/j.cjca.2023.06.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2023] [Revised: 06/09/2023] [Accepted: 06/12/2023] [Indexed: 06/20/2023] Open
Affiliation(s)
- Steven L Rathgeber
- Division of Pediatric Cardiology, Department of Pediatrics, Faculty of Medicine University of British Columbia, Vancouver, British Columbia, Canada.
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5
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Evans WN, Acherman RJ, Galindo A, Rothman A, Ciccolo ML, Lehoux J, Restrepo H. Hepatic Fibrosis Risk Factors in Extracardiac-Fontan Patients: Observations From a Single Center. World J Pediatr Congenit Heart Surg 2023; 14:345-349. [PMID: 36883214 DOI: 10.1177/21501351231154216] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/09/2023]
Abstract
Objective: We reviewed our experience with transvenous liver biopsy-derived hepatic fibrosis scores and possible associated risk factors in those postextracardiac Fontan patients. Methods: We identified extracardiac-Fontan patients with postoperative durations <20 years who underwent cardiac catheterizations with transvenous hepatic biopsies between April 2012 and July 2022. If a patient underwent two liver biopsies, we averaged the two total fibrosis scores and concurrent time, pressure, and oxygen saturation data. We grouped patients by the following factors: (1) sex, (2) venovenous collaterals, and (3) type of functionally univentricular heart. We identified potential hepatic fibrosis risk factors as the following: female, presence of venovenous collaterals, and a functional univentricle of right-ventricular type. For statistical analysis, we used Kruskal-Wallis nonparametric testing. Results: We identified 127 patients who underwent 165 transvenous biopsies, with 38 patients undergoing 2 biopsies. We found that females with two additional risk factors had the highest median total fibrosis scores, 4 (1-8); males with <2 risk factors had the lowest median total fibrosis scores, 2 (0-5); and females with <2 additional risk factors and males with two risk factors were in the middle, median total fibrosis score 3 (0-6), P =.002; and there were no statistical differences for the other demographic or hemodynamic variables. Conclusions: For extracardiac-Fontan patients with similar demographic and hemodynamic variables, identifiable risk factors are associated with the degree of hepatic fibrosis.
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Affiliation(s)
- William N Evans
- Congenital 20567Heart Center Nevada, Las Vegas, NV, USA.,Division of Pediatric Cardiology, Department of Pediatrics, 212548Kirk Kerkorian School of Medicine, Las Vegas, NV, USA
| | - Ruben J Acherman
- Congenital 20567Heart Center Nevada, Las Vegas, NV, USA.,Division of Pediatric Cardiology, Department of Pediatrics, 212548Kirk Kerkorian School of Medicine, Las Vegas, NV, USA
| | - Alvaro Galindo
- Congenital 20567Heart Center Nevada, Las Vegas, NV, USA.,Division of Pediatric Cardiology, Department of Pediatrics, 212548Kirk Kerkorian School of Medicine, Las Vegas, NV, USA
| | - Abraham Rothman
- Congenital 20567Heart Center Nevada, Las Vegas, NV, USA.,Division of Pediatric Cardiology, Department of Pediatrics, 212548Kirk Kerkorian School of Medicine, Las Vegas, NV, USA
| | - Michael L Ciccolo
- Congenital 20567Heart Center Nevada, Las Vegas, NV, USA.,Department of Surgery, 212548Kirk Kerkorian School of Medicine at UNLV, Las Vegas, NV, USA
| | - Juan Lehoux
- Congenital 20567Heart Center Nevada, Las Vegas, NV, USA
| | - Humberto Restrepo
- Congenital 20567Heart Center Nevada, Las Vegas, NV, USA.,Division of Pediatric Cardiology, Department of Pediatrics, 212548Kirk Kerkorian School of Medicine, Las Vegas, NV, USA
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6
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Evans WN, Acherman RJ, Restrepo H. Hepatic fibrosis gender differences in extracardiac Fontan patients. J Card Surg 2022; 37:3520-3524. [PMID: 36057990 DOI: 10.1111/jocs.16880] [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: 07/23/2022] [Accepted: 08/11/2022] [Indexed: 11/30/2022]
Abstract
OBJECTIVE We investigated possible gender differences for hepatic fibrosis in extracardiac-Fontan patients. METHODS We identified extracardiac Fontan, performed between 2000 and 2016, who underwent cardiac catheterizations with transvenous hepatic biopsies between April 2012 and June 2022. We divided the patients by gender for analysis. RESULTS We identified 116 patients who underwent 145 transvenous biopsies, with 29 patients undergoing 2 biopsies at an average interval of 5 ± 1 years. We divided the 145 biopsies into two groups: 1) 98/145 (68%) males and 2) 47/145 (32%) females. For the 47 female liver biopsy specimens, the median total fibrosis score was 3 (0-8), and for the 98 male liver biopsy specimens, the median total fibrosis score was 2 (0-6), p = .007. The average age at surgery for females was 3 ± 1 years and for males 3 ± 1 years, p = .99. Average Fontan duration at biopsy for females was 11 ± 5 years and for males, 10 ± 4 years, p = .23. No other demographic, anatomic, echocardiographic, laboratory, or hemodynamic findings demonstrated statistically significant gender differences. CONCLUSIONS Females had statistically significantly higher median total fibrosis scores than males for the similar average age at extracardiac Fontan and average Fontan duration.
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Affiliation(s)
- William N Evans
- Congenital Heart Center Nevada, Las Vegas, Nevada, USA.,Division of Pediatric Cardiology, Department of Pediatrics, Kirk Kerkorian School of Medicine at UNLV, Las Vegas, Nevada, USA
| | - Ruben J Acherman
- Congenital Heart Center Nevada, Las Vegas, Nevada, USA.,Division of Pediatric Cardiology, Department of Pediatrics, Kirk Kerkorian School of Medicine at UNLV, Las Vegas, Nevada, USA
| | - Humberto Restrepo
- Congenital Heart Center Nevada, Las Vegas, Nevada, USA.,Division of Pediatric Cardiology, Department of Pediatrics, Kirk Kerkorian School of Medicine at UNLV, Las Vegas, Nevada, USA
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7
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Liver Disease Assessment in Children with Fontan and Glenn Surgeries for Univentricular Hearts—The Role of Elastography and Biochemical Fibrosis Markers. APPLIED SCIENCES-BASEL 2022. [DOI: 10.3390/app12157481] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
Background: Children born with single-ventricle hearts require surgery in order to survive. Liver fibrosis is a known complication of Fontan surgery for univentricular hearts. Methods: In this study on 13 post-Fontan and 21 post-Glenn patients, we used elastography (shearwave and transient elastography) as well as serum biochemical fibrosis markers to evaluate the degree of liver fibrosis in comparison to 32 controls. Results: The mean Emedian and Vmedian values determined by shear wave elastography in the Fontan Group were significantly higher than the controls (4.85 kPa vs. 3.91 kPa and 1.25 m/s vs. 1.12 m/s, respectively). Fontan patients had significantly increased Fibrotest, Actitest, AST-to-Platelet Ratio index, ALT and GammaGT levels compared to controls. For post-Glenn patients, the mean Emedian and Vmedian values were similar to healthy controls, whereas the Fibrotest, Actitest and AST-to-Platelet Ratio index were significantly increased. Using transient elastography, we found significantly higher values for Emedian and Vmedian in Fontan patients compared to Glenn patients. Conclusions: Elastography and biochemical fibrosis markers are valuable non-invasive tools for screening and monitoring liver fibrosis in patients with Fontan and Glenn interventions.
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8
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Rathgeber SL, Lam C, Harris KC, GrewalMD J. Hepatic and Renal Consequences of Single Ventricle Physiology Palliated with the Fontan Operation. Can J Cardiol 2022; 38:1002-1011. [PMID: 35525398 DOI: 10.1016/j.cjca.2022.04.022] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2021] [Revised: 04/26/2022] [Accepted: 04/26/2022] [Indexed: 12/21/2022] Open
Abstract
Over time the long-term survival has dramatically increased for patients with complex congenital heart disease who undergo the Fontan operation. With this increased survival, it has become apparent that such a circulation has important consequences for other organ systems, particularly the liver and kidney. The adverse milieu created by chronic venous hypertension, low cardiac output and an inflammatory state contribute to the pathologic changes observed in the liver and kidneys over the long-term in Fontan patients. The clinical importance of these hepatic and renal comorbidities have only recently begun to be recognized in the context of increasing life expectancy in this population. The objectives of this review are: i) to provide an overview of the pathophysiology of the Fontan circulation and how liver and kidney disease evolve in this setting; ii) to summarize the current evidence base as it relates to the diagnostic approach to liver and kidney disease in Fontan patients; and, iii) to discuss the therapeutic approaches to Fontan associated liver and kidney disease. Given that this is a very active area of research in congenital heart disease, we have identified knowledge gaps and priority research areas to improve the care of Fontan patients. These include: i) establishing the optimal diagnostic tests to detect and track liver and kidney disease change over time,; ii) determining what treatable risk factors contribute to the development of liver and kidney disease; and, iii) evaluating therapies to prevent or slow progression of liver and kidney disease.
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Affiliation(s)
- Steven L Rathgeber
- Division of Cardiology, British Columbia Children's Hospital, Department of Pediatrics, University of British Columbia, Vancouver, BC, Canada
| | - Charmaine Lam
- Division of Cardiology, Yasmin and Amir Virani Provincial Adult Congenital Heart Program, St.Paul's Hospital, University of British Columbia, Vancouver, BC, Canada
| | - Kevin C Harris
- Division of Cardiology, British Columbia Children's Hospital, Department of Pediatrics, University of British Columbia, Vancouver, BC, Canada
| | - Jasmine GrewalMD
- Division of Cardiology, Yasmin and Amir Virani Provincial Adult Congenital Heart Program, St.Paul's Hospital, University of British Columbia, Vancouver, BC, Canada.
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9
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Driesen BW, Voskuil M, Grotenhuis HB. Current Treatment Options for the Failing Fontan Circulation. Curr Cardiol Rev 2022; 18:e060122200067. [PMID: 34994331 PMCID: PMC9893132 DOI: 10.2174/1573403x18666220106114518] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/21/2020] [Revised: 10/22/2021] [Accepted: 11/16/2021] [Indexed: 11/22/2022] Open
Abstract
The Fontan operation was introduced in 1968. For congenital malformations, where biventricular repair is unsuitable, the Fontan procedure has provided a long-term palliation strategy with improved outcomes compared to the initially developed procedures. Despite these improvements, several complications merely due to a failing Fontan circulation, including myocardial dysfunction, arrhythmias, increased pulmonary vascular resistance, protein-losing enteropathy, hepatic dysfunction, plastic bronchitis, and thrombo-embolism, may occur, thereby limiting the life-expectancy in this patient cohort. This review provides an overview of the most common complications of Fontan circulation and the currently available treatment options.
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Affiliation(s)
- Bart W. Driesen
- Department of Pediatric Cardiology, Wilhelmina Children’s Hospital, University Medical Center, Utrecht, Utrecht, The Netherlands
- Department of Cardiology, University Medical Center Utrecht, Utrecht, The Netherlands
- Department of Cardiology, Laurentius Ziekenhuis, Roermond, The Netherlands
| | - Michiel Voskuil
- Department of Cardiology, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Heynric B. Grotenhuis
- Department of Pediatric Cardiology, Wilhelmina Children’s Hospital, University Medical Center, Utrecht, Utrecht, The Netherlands
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10
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Brayer SW, Zafar F, Lubert AM, Trout AT, Palermo JJ, Opotowsky AR, Anwar N, Dillman JR, Alsaied T. Relation of Magnetic Resonance Elastography to Fontan Circulatory Failure in a Cohort of Pediatric and Adult Patients. Pediatr Cardiol 2021; 42:1871-1878. [PMID: 34448042 DOI: 10.1007/s00246-021-02707-w] [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: 04/28/2021] [Accepted: 08/04/2021] [Indexed: 01/03/2023]
Abstract
Elevated magnetic resonance elastography (MRE)-derived liver stiffness may be associated with worse outcomes in people with Fontan circulation. We sought to evaluate the association between liver stiffness and Fontan failure or portal hypertension. Single center cross-sectional retrospective study of people with Fontan circulation who underwent MRE between 2011 and 2020. The cohort was divided into adult (age ≥ 21 years) and pediatric (< 21 years) groups. Fontan circulatory failure (FF) was defined as any of the following: death, transplantation, ventricular assist device, heart failure symptoms requiring escalation of diuretics. Radiologic portal hypertension was defined as the presence of one or more of the following: splenomegaly, ascites, or gastrointestinal varices. 128 patients were included (average age = 22.6 ± 8.7 years) and 58 (45%) were children. Median liver stiffness was 4.3 kPa (interquartile range (IQR) 3.8-5.8) for the entire cohort. Thirty patients (23%) developed FF (16 adults, 14 children). Liver stiffness was higher in adults with FF compared to those without FF (4.9 (IQR 4.0-6.0) vs. 4.2 (IQR 3.8-4.7) kPa, p = 0.04). There was no difference in liver stiffness between pediatric patients with and without FF (4.4 (IQR 4.1-5.4) vs. 4.4 (IQR 3.8-5.0), p = 0.5). Adults with radiologic portal hypertension and adults with moderate or severe atrioventricular valve regurgitation had higher liver stiffness than adults without. MRE-derived liver stiffness is associated with atrioventricular valve regurgitation, portal hypertension, and poor clinical outcomes in adults with Fontan circulation. There was no association between liver stiffness and FF in pediatric patients. This difference may be due to the progressive nature of Fontan-associated liver disease.
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Affiliation(s)
- Samuel W Brayer
- Pediatric Residency Training Program, Cincinnati Children's Hospital Medical Center, 3333 Burnet Avenue, Cincinnati, OH, USA.
| | - Faizeen Zafar
- Pediatric Residency Training Program, Cincinnati Children's Hospital Medical Center, 3333 Burnet Avenue, Cincinnati, OH, USA
| | - Adam M Lubert
- Department of Pediatrics, Cincinnati Children's Hospital Heart Institute, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Andrew T Trout
- Department of Radiology, Cincinnati Children's Hospital Medical Center, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Joseph J Palermo
- Division of Gastroenterology, Department of Pediatrics, Cincinnati Children's Hospital Medical Center, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Alexander R Opotowsky
- Department of Pediatrics, Cincinnati Children's Hospital Heart Institute, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Nadeem Anwar
- Division of Gastroenterology, Department of Medicine, University of Cincinnati Medical Center, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Jonathan R Dillman
- Department of Radiology, Cincinnati Children's Hospital Medical Center, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Tarek Alsaied
- UPMC Children's Hospital of Pittsburgh Heart and Vascular Institute, Pittsburgh, PA, USA
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11
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Langguth P, Salehi Ravesh M, Moritz JD, Rinne K, Harneit PL, Khodami JK, Graessner J, Uebing A, Jansen O, Both M, Hansen JH. Non-contrast enhanced magnetic resonance imaging for characterization of Fontan associated liver disease. Int J Cardiol 2021; 349:48-54. [PMID: 34808211 DOI: 10.1016/j.ijcard.2021.11.048] [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: 05/24/2021] [Accepted: 11/16/2021] [Indexed: 11/05/2022]
Abstract
OBJECTIVES To evaluate the ability of non-contrast enhanced magnetic resonance imaging (MRI) techniques to characterize Fontan associated liver disease (FALD) in adolescent and adult Fontan patients. METHODS Fontan patients (n = 29) and healthy controls (n = 13) underwent an MRI protocol with T1, T2 and Apparent Diffusion Coefficient (ADC) mapping. Routine FALD screening included abdominal ultrasound and laboratory testing. RESULTS Median follow-up after Fontan operation was 15.1 (IQR 12.0-16.8) years. Distinct differences in tissue characteristics were visualized. T1 and T2 relaxation times were prolonged in Fontan patients, particularly of the right lobe (T1: 745 (IQR 715-784) ms vs. 586 (IQR 555-602) ms, p < 0.001; T2: 63 (IQR 59-64) ms vs. 58 (IQR 56-60) ms, p = 0.002). Left lobe ADC was lower in Fontan patients (1.10 (IQR 1.06-1.18) x 10-3 mm2/s vs. 1.23 (IQR 1.19-1.29) x 10-3 mm2/s, p < 0.001). T2 mapping was able to differentiate between controls and Fontan patients with different FALD severity. Right lobe T2 was higher in patients with moderate or severe in comparison to those with no or mild changes and healthy controls (64 (IQR 61-67) ms vs. 60 (IQR 59-63) ms vs. 58 (IQR 56-60) ms, p = 0.001). CONCLUSIONS Non-contrast enhanced MRI methods are able to visualize regional differences in liver tissue characteristics. T1 and T2 relaxation times were prolonged in Fontan patients suggestive of fibrosis or congestive hepatopathy, while reduced ADC might reflect impaired microperfusion. These methods have promising clinical potential for detection of liver abnormalities in Fontan patients. The usefulness of T2 mapping to grade FALD severity merits further investigation.
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Affiliation(s)
- Patrick Langguth
- Department of Radiology and Neuroradiology, University Hospital Schleswig-Holstein, Campus Kiel, Germany
| | - Mona Salehi Ravesh
- Department of Radiology and Neuroradiology, University Hospital Schleswig-Holstein, Campus Kiel, Germany
| | - Jörg Detlev Moritz
- Department of Radiology and Neuroradiology, University Hospital Schleswig-Holstein, Campus Kiel, Germany
| | - Katy Rinne
- Department of Congenital Heart Disease and Pediatric Cardiology, University Hospital Schleswig-Holstein, Campus Kiel, Germany
| | - Paul Lennard Harneit
- Department of Congenital Heart Disease and Pediatric Cardiology, University Hospital Schleswig-Holstein, Campus Kiel, Germany
| | - Joshua Kian Khodami
- Department of Congenital Heart Disease and Pediatric Cardiology, University Hospital Schleswig-Holstein, Campus Kiel, Germany
| | | | - Anselm Uebing
- Department of Congenital Heart Disease and Pediatric Cardiology, University Hospital Schleswig-Holstein, Campus Kiel, Germany; DZHK (German Center for Cardiovascular Research), Partner Site Hamburg/Kiel/Lübeck, Germany
| | - Olav Jansen
- Department of Radiology and Neuroradiology, University Hospital Schleswig-Holstein, Campus Kiel, Germany
| | - Marcus Both
- Department of Radiology and Neuroradiology, University Hospital Schleswig-Holstein, Campus Kiel, Germany
| | - Jan Hinnerk Hansen
- Department of Congenital Heart Disease and Pediatric Cardiology, University Hospital Schleswig-Holstein, Campus Kiel, Germany; DZHK (German Center for Cardiovascular Research), Partner Site Hamburg/Kiel/Lübeck, Germany.
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12
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Téllez L, Rodríguez de Santiago E, Albillos A. Fontan-Associated Liver Disease: Pathophysiology, Staging, and Management. Semin Liver Dis 2021; 41:538-550. [PMID: 34399435 DOI: 10.1055/s-0041-1732355] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
Fontan-associated liver disease is the term used to encompass the disorders arising from abnormal hemodynamic alterations and systemic venous congestion after the Fontan procedure. The histological changes produced in the liver are similar but not equivalent to those seen in other forms of cardiac liver disease. While the natural history of this form of liver disease is poorly established, many Fontan patients ultimately develop portal hypertension-related complications such as ascites, esophageal varices, malnutrition, and encephalopathy. Fontan survivors also show an elevated risk of hepatocellular carcinoma. Adequate staging of the liver damage is essential to anticipate screening strategies and improve global management.
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Affiliation(s)
- Luis Téllez
- Department of Gastroenterology and Hepatology, Hospital Universitario Ramón y Cajal, Instituto Ramón y Cajal de Investigación Sanitaria (IRYCIS), Centro de Investigación Biomédica en Red (CIBEREHD), Universidad de Alcalá, Madrid, Spain
| | - Enrique Rodríguez de Santiago
- Department of Gastroenterology and Hepatology, Hospital Universitario Ramón y Cajal, Instituto Ramón y Cajal de Investigación Sanitaria (IRYCIS), Centro de Investigación Biomédica en Red (CIBEREHD), Universidad de Alcalá, Madrid, Spain
| | - Agustín Albillos
- Department of Gastroenterology and Hepatology, Hospital Universitario Ramón y Cajal, Instituto Ramón y Cajal de Investigación Sanitaria (IRYCIS), Centro de Investigación Biomédica en Red (CIBEREHD), Universidad de Alcalá, Madrid, Spain
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13
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Hansen JH, Khodami JK, Moritz JD, Rinne K, Voges I, Scheewe J, Kramer HH, Uebing A. Surveillance of Fontan Associated Liver Disease in Childhood and Adolescence. Semin Thorac Cardiovasc Surg 2021; 34:642-650. [PMID: 33979666 DOI: 10.1053/j.semtcvs.2021.04.005] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2021] [Accepted: 04/12/2021] [Indexed: 02/06/2023]
Abstract
Fontan associated liver disease (FALD) has been recognized as a potentially serious sequela of the Fontan circulation. Prevalence of FALD among different age groups and risk factors for advanced changes were assessed. FALD screening included abdominal ultrasound and laboratory tests. A "liver disease score (LDS)" incorporating items from ultrasound and blood testing was calculated to grade FALD severity (5 items each, maximum score 10 points). 240 patients (male: n = 139, female: n = 101, systemic right ventricle: n = 160) underwent FALD screening 10 (IQR 7-15) years after Fontan surgery. Ultrasound was abnormal in 184 (76.6%) patients (surface nodularity / blunted liver edge: n = 133, 55.4%; heterogeneous parenchyma: n = 93, 38.8%; splenomegaly: n = 68, 28.3%; ascites: n = 23, 9.6%). At least one abnormal laboratory test was detected in 218 (90.8%) patients. Gamma-glutamyl-transpeptidase was elevated in the majority of patients (n = 206, 85.8%). Median LDS was 3 (2-4). Scores ≥5 were observed in 32 (13.3%) patients. Longer follow-up (15 (11-20) vs 9 (6-14) years, P <0.001), higher central venous (13 (11-15) vs 10 (9-12) mmHg, P <0.001) and end-diastolic pressure (8 (5-10) vs 6 (5-7) mmHg, P = 0.001), impaired ventricular function and absence of sinus rhythm were associated with LDS ≥5. Longer follow-up (OR 1.2 (1.1-1.3), P <0.001) and higher central venous pressure (OR 1.6 (1.3-2.1), p < 0.001) were the only independent predictors of advanced FALD. Abdominal ultrasound and laboratory abnormalities suggestive of FALD are common during routine follow-up already in childhood and adolescence irrespective of ventricular morphology. More advanced findings are associated with longer follow-up and higher central venous pressure.
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Affiliation(s)
- Jan Hinnerk Hansen
- Department of Congenital Heart Disease and Pediatric Cardiology, University Hospital Schleswig-Holstein, Campus Kiel; DZHK (German Center for Cardiovascular Research), Partner Site Hamburg/Kiel/Lübeck, Germany.
| | - Joshua Kian Khodami
- Department of Congenital Heart Disease and Pediatric Cardiology, University Hospital Schleswig-Holstein, Campus Kiel
| | - Jörg Detlev Moritz
- Department of Radiology and Neuroradiology, University Hospital Schleswig-Holstein, Campus Kiel
| | - Katy Rinne
- Department of Congenital Heart Disease and Pediatric Cardiology, University Hospital Schleswig-Holstein, Campus Kiel
| | - Inga Voges
- Department of Congenital Heart Disease and Pediatric Cardiology, University Hospital Schleswig-Holstein, Campus Kiel; DZHK (German Center for Cardiovascular Research), Partner Site Hamburg/Kiel/Lübeck, Germany
| | - Jens Scheewe
- Department of Cardiovascular Surgery, University Hospital Schleswig-Holstein, Campus Kiel
| | - Hans-Heiner Kramer
- Department of Congenital Heart Disease and Pediatric Cardiology, University Hospital Schleswig-Holstein, Campus Kiel; DZHK (German Center for Cardiovascular Research), Partner Site Hamburg/Kiel/Lübeck, Germany
| | - Anselm Uebing
- Department of Congenital Heart Disease and Pediatric Cardiology, University Hospital Schleswig-Holstein, Campus Kiel; DZHK (German Center for Cardiovascular Research), Partner Site Hamburg/Kiel/Lübeck, Germany
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14
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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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15
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Evans WN, Acherman RJ, Galindo A, Rothman A, Ciccolo ML, Lehoux J, Winn BJ, Yumiaco NS, Restrepo H. Fontan-associated liver disease and total cavopulmonary anatomical flow effectors. J Card Surg 2021; 36:2329-2335. [PMID: 33834526 DOI: 10.1111/jocs.15553] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2021] [Accepted: 03/24/2021] [Indexed: 12/27/2022]
Abstract
OBJECTIVE We investigated a relationship between a composite index comprised of Fontan-circuit anatomical features and hepatic fibrosis scores from biopsy. METHODS We identified living extracardiac Fontan patients, ≥7 years old and ≥5 but <20 years postoperative, that underwent cardiac catheterization and transvenous liver biopsy between March 2012 and September 2020. We divided patients into anatomical groups and applied a risk score to each patient. We compared average anatomical risk scores with average hepatic total fibrosis scores by group. RESULTS We identified 111 patients that met inclusion criteria. After excluding four patients, we assigned 107 to one of 12 anatomical variant groups (n ≥ 3). For the 107, the average age at liver biopsy was 14 ± 6 years old. Of the 107, 105 (98%) were New York Heart Association Class 1. We found average anatomical risk scores by group correlated with average total fibrosis scores by group (R = 0.8; p = .005). An average Fontan duration to biopsy of 10 ± 1 years was similar for all 12 anatomical groups. We found no other clinical variables, laboratory, or hemodynamic values that trended with anatomical risk scores or hepatic total fibrosis scores. CONCLUSIONS In a cohort of relatively young, stable extracardiac Fontan patients, average composite anatomical risk scores strongly correlated with average hepatic total fibrosis scores by anatomical group. These findings suggest that some anatomical variants in extracardiac Fontan patients are associated with higher Fontan-associated liver disease (FALD)-related hepatic total fibrosis scores than others, despite similar Fontan durations.
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Affiliation(s)
- William N Evans
- Children's Heart Center Nevada, Las Vegas, Nevada, USA.,Department of Pediatrics, School of Medicine, Division of Pediatric Cardiology, University of Nevada Las Vegas, Las Vegas, Nevada, USA
| | - Ruben J Acherman
- Children's Heart Center Nevada, Las Vegas, Nevada, USA.,Department of Pediatrics, School of Medicine, Division of Pediatric Cardiology, University of Nevada Las Vegas, Las Vegas, Nevada, USA
| | - Alvaro Galindo
- Children's Heart Center Nevada, Las Vegas, Nevada, USA.,Department of Pediatrics, School of Medicine, Division of Pediatric Cardiology, University of Nevada Las Vegas, Las Vegas, Nevada, USA
| | - Abraham Rothman
- Children's Heart Center Nevada, Las Vegas, Nevada, USA.,Department of Pediatrics, School of Medicine, Division of Pediatric Cardiology, University of Nevada Las Vegas, Las Vegas, Nevada, USA
| | - Michael L Ciccolo
- Children's Heart Center Nevada, Las Vegas, Nevada, USA.,Department of Surgery, School of Medicine, University of Nevada Las Vegas, Las Vegas, Nevada, USA
| | - Juan Lehoux
- Children's Heart Center Nevada, Las Vegas, Nevada, USA
| | - Brody J Winn
- Laboratory Medicine Consultants, Las Vegas, Nevada, USA
| | | | - Humberto Restrepo
- Children's Heart Center Nevada, Las Vegas, Nevada, USA.,Department of Pediatrics, School of Medicine, Division of Pediatric Cardiology, University of Nevada Las Vegas, Las Vegas, Nevada, USA
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16
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Evans WN, Acherman RJ, Mayman GA, Galindo A, Rothman A, Ciccolo ML, Lehoux J, Winn BJ, Yumiaco NS, Restrepo H. Fontan-Associated Anatomical Variants and Hepatic Fibrosis. World J Pediatr Congenit Heart Surg 2021; 12:168-172. [PMID: 33684008 DOI: 10.1177/2150135120969388] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
OBJECTIVE We hypothesized that a relationship between post-Fontan hepatic fibrosis and anatomical variants might exist. METHODS Attempting to limit confounding variables, we analyzed data from living, stable, post-extracardiac Fontan patients who underwent cardiac catheterization and transvenous hepatic biopsy procedures between March 2012 and June 2020. RESULTS We identified 120 patients who met the inclusion criteria. Of the 120, 35 (29%) had pulmonary artery stents. For the 35 with pulmonary artery stents, the average total fibrosis score was 3.2 ± 1.9 and the fibrosis progression rate was 0.36 ± 0.33, and for those with no pulmonary artery stents, the total fibrosis score was 2.6 ± 1.8 and the fibrosis progression rate was 0.27 ± 0.33 (P = .13 and P = .11, respectively). Of the 120, 65 had functional univentricles of right ventricular type. Of these 65, 27 had pulmonary artery stents. For the 27 with pulmonary artery stents, the average total fibrosis score was 3.4 ± 1.8 and the average fibrosis progression rate was 0.39 ± 0.30, and for the 38 without pulmonary artery stents, the average fibrosis score was 2.3 ± 1.5 and the average fibrosis progression rate was 0.23 ± 0.21 (P = .01 for comparison of both values). CONCLUSIONS This study's findings suggest that a post-extracardiac Fontan with a functional univentricle of right ventricular type plus a pulmonary artery stent may have more advanced liver pathology than those without a pulmonary artery stent at similar Fontan duration years and ages at liver biopsy.
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Affiliation(s)
- William N Evans
- 20567Children's Heart Center Nevada, Las Vegas, NV, USA.,Division of Pediatric Cardiology, Department of Pediatrics, University of Nevada, Las Vegas, School of Medicine, Las Vegas, NV, USA
| | - Ruben J Acherman
- 20567Children's Heart Center Nevada, Las Vegas, NV, USA.,Division of Pediatric Cardiology, Department of Pediatrics, University of Nevada, Las Vegas, School of Medicine, Las Vegas, NV, USA
| | - Gary A Mayman
- 20567Children's Heart Center Nevada, Las Vegas, NV, USA.,Division of Pediatric Cardiology, Department of Pediatrics, University of Nevada, Las Vegas, School of Medicine, Las Vegas, NV, USA
| | - Alvaro Galindo
- 20567Children's Heart Center Nevada, Las Vegas, NV, USA.,Division of Pediatric Cardiology, Department of Pediatrics, University of Nevada, Las Vegas, School of Medicine, Las Vegas, NV, USA
| | - Abraham Rothman
- 20567Children's Heart Center Nevada, Las Vegas, NV, USA.,Division of Pediatric Cardiology, Department of Pediatrics, University of Nevada, Las Vegas, School of Medicine, Las Vegas, NV, USA
| | - Michael L Ciccolo
- 20567Children's Heart Center Nevada, Las Vegas, NV, USA.,Department of Surgery, University of Nevada, Las Vegas, School of Medicine, Las Vegas, NV, USA
| | - Juan Lehoux
- 20567Children's Heart Center Nevada, Las Vegas, NV, USA
| | - Brody J Winn
- Laboratory Medicine Consultants, Las Vegas, NV, USA
| | | | - Humberto Restrepo
- 20567Children's Heart Center Nevada, Las Vegas, NV, USA.,Division of Pediatric Cardiology, Department of Pediatrics, University of Nevada, Las Vegas, School of Medicine, Las Vegas, NV, USA
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17
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Evans WN, Acherman RJ, Mayman GA, Galindo A, Rothman A, Ciccolo ML, Lehoux J, Winn BJ, Yumiaco NS, Restrepo H. Fontan venovenous collaterals and hepatic fibrosis. J Card Surg 2020; 35:2974-2978. [DOI: 10.1111/jocs.14951] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Affiliation(s)
- William N. Evans
- Children's Heart Center Nevada Las Vegas Nevada
- Division of Pediatric Cardiology, Department of Pediatrics, School of Medicine University of Nevada Las Vegas Las Vegas Nevada
| | - Ruben J. Acherman
- Children's Heart Center Nevada Las Vegas Nevada
- Division of Pediatric Cardiology, Department of Pediatrics, School of Medicine University of Nevada Las Vegas Las Vegas Nevada
| | - Gary A. Mayman
- Children's Heart Center Nevada Las Vegas Nevada
- Division of Pediatric Cardiology, Department of Pediatrics, School of Medicine University of Nevada Las Vegas Las Vegas Nevada
| | - Alvaro Galindo
- Children's Heart Center Nevada Las Vegas Nevada
- Division of Pediatric Cardiology, Department of Pediatrics, School of Medicine University of Nevada Las Vegas Las Vegas Nevada
| | - Abraham Rothman
- Children's Heart Center Nevada Las Vegas Nevada
- Division of Pediatric Cardiology, Department of Pediatrics, School of Medicine University of Nevada Las Vegas Las Vegas Nevada
| | - Michael L. Ciccolo
- Children's Heart Center Nevada Las Vegas Nevada
- Department of Surgery, School of Medicine University of Nevada Las Vegas Las Vegas Nevada
| | - Juan Lehoux
- Children's Heart Center Nevada Las Vegas Nevada
| | | | | | - Humberto Restrepo
- Children's Heart Center Nevada Las Vegas Nevada
- Division of Pediatric Cardiology, Department of Pediatrics, School of Medicine University of Nevada Las Vegas Las Vegas Nevada
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18
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The Rate of Hepatic Fibrosis Progression in Patients Post-Fontan. Pediatr Cardiol 2020; 41:905-909. [PMID: 32125444 DOI: 10.1007/s00246-020-02331-0] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/09/2019] [Accepted: 02/20/2020] [Indexed: 01/28/2023]
Abstract
This investigation analyzed the rate of hepatic fibrosis progression in post-Fontan patients that underwent hepatic biopsy. The study cohort comprised post-Fontan patients that underwent cardiac catheterization and transvenous liver biopsy between March 2012 and September 2019. We identified 126 patients that met inclusion criteria. Of the 126, 27 (21%) had a lateral tunnel Fontan, and 99 (79%) had an extracardiac Fontan. For the 27 lateral tunnel Fontan patients, age at Fontan was 4 ± 2 years, and for the 99 extracardiac Fontan patients age at Fontan was 4 ± 2 years (p = 0.98). For the 27 lateral tunnel Fontan patients, the average total fibrosis score was 3.0 ± 1.5; and for the 99 extracardiac Fontan patients, the average total fibrosis was 2.7 ± 1.7 (p = 0.48). For the lateral tunnel Fontan patients, the average Fontan duration was 20 ± 6 years; and for the 99 extracardiac Fontan patients, the average Fontan duration was 11 ± 5 years (p < 0.001). For the 27 lateral tunnel Fontan patients, the average rate of fibrosis progression was 0.16 ± 0.10 total fibrosis score/year; and for the 99 extracardiac Fontan patients, the average rate of fibrosis progression was 0.30 ± 0.23 total fibrosis score/year (p < 0.001). In conclusion, our findings suggest that those with extracardiac Fontans have a faster rate of hepatic fibrosis progression than those with lateral tunnel Fontans. More extensive or multi-institutional studies will be needed to confirm these findings and define the clinical significance of discrepant rates of hepatic fibrosis in post-Fontan patients.
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19
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Alsaied T, Possner M, Lubert AM, Trout AT, Szugye C, Palermo JJ, Lorts A, Goldstein BH, Veldtman GR, Anwar N, Dillman JR. Relation of Magnetic Resonance Elastography to Fontan Failure and Portal Hypertension. Am J Cardiol 2019; 124:1454-1459. [PMID: 31474329 DOI: 10.1016/j.amjcard.2019.07.052] [Citation(s) in RCA: 35] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/08/2019] [Revised: 07/24/2019] [Accepted: 07/25/2019] [Indexed: 12/11/2022]
Abstract
Fontan associated liver disease is associated with morbidity and mortality in palliated single-ventricle congenital heart disease patients. Magnetic resonance elastography (MRE) provides a quantitative assessment of liver stiffness in Fontan patients. We hypothesized that MRE liver stiffness correlates with liver enzymes, hemodynamics, portal hypertension, and Fontan failure (FF). All adult Fontan patients who had MRE between 2011 and 2018 were included. Radiologic portal hypertension was defined as splenomegaly, ascites, and/or varices. FF was defined as death, transplantation, or heart failure symptoms requiring escalation of diuretics. Seventy patients with a median age of 24.7 years and a median follow-up from MRE of 3.9 years were included. The median liver stiffness was 4.3 kPa (interquartile range [IQR]: 3.8 to 5.0 kPa). There was a weak, positive correlation between liver stiffness and Fontan pathway pressure (r = 0.34, p = 0.03). There was a moderate negative correlation of liver stiffness with ventricular ejection fraction (r = -0.52, p = 0.03). Liver stiffness was weakly positively correlated with liver transaminases and gamma glutamyl transferase. Patients with portal hypertension had higher liver stiffness compared to patients without (5.2 ± 1.3 vs 4.2 ± 0.8 kPa, p = 0.03). At MRE or during follow-up, 13 patients (19%) met definition of FF and had significantly higher liver stiffness compared to patients without FF (5.1 [IQR: 4.3 to 6.3] vs 4.2 [IQR: 3.7 to 4.7] kPa, p = 0.01). Liver stiffness above 4.5 kPa differentiated FF with a sensitivity of 77% and specificity of 77%. In conclusion, elevated MRE-derived liver stiffness is associated with worse hemodynamics, liver enzymes and clinical outcomes in Fontan patients. This measure may serve as a global imaging biomarker of Fontan health.
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Affiliation(s)
- Tarek Alsaied
- Cincinnati Children's Hospital Heart Institute, Department of Pediatrics, University of Cincinnati College of Medicine Cincinnati, Ohio.
| | - Mathias Possner
- Cincinnati Children's Hospital Heart Institute, Department of Pediatrics, University of Cincinnati College of Medicine Cincinnati, Ohio
| | - Adam M Lubert
- Cincinnati Children's Hospital Heart Institute, Department of Pediatrics, University of Cincinnati College of Medicine Cincinnati, Ohio
| | - Andrew T Trout
- Cincinnati Children's Hospital Medical Center, Department of Radiology, University of Cincinnati College of Medicine Cincinnati, Ohio
| | - Cassandra Szugye
- Cincinnati Children's Hospital Heart Institute, Department of Pediatrics, University of Cincinnati College of Medicine Cincinnati, Ohio
| | - Joseph J Palermo
- Cincinnati Children's Hospital Medical Center, Division of Gastroenterology, Department of Pediatrics, University of Cincinnati College of Medicine Cincinnati, Ohio
| | - Angela Lorts
- Cincinnati Children's Hospital Heart Institute, Department of Pediatrics, University of Cincinnati College of Medicine Cincinnati, Ohio
| | - Bryan H Goldstein
- Cincinnati Children's Hospital Heart Institute, Department of Pediatrics, University of Cincinnati College of Medicine Cincinnati, Ohio
| | - Gruschen R Veldtman
- Cincinnati Children's Hospital Heart Institute, Department of Pediatrics, University of Cincinnati College of Medicine Cincinnati, Ohio; Adult Congenital Heart Disease, Heart Centre, King Faisal Specialist Hospital and Research Centre, Riyadh, Saudi Arabia
| | - Nadeem Anwar
- University of Cincinnati Medical Center, Division of Gastroenterology, Department of Medicine, University of Cincinnati College of Medicine Cincinnati, Ohio
| | - Johnathan R Dillman
- Cincinnati Children's Hospital Medical Center, Department of Radiology, University of Cincinnati College of Medicine Cincinnati, Ohio
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20
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Komatsu H, Inui A, Kishiki K, Kawai H, Yoshio S, Osawa Y, Kanto T, Fujisawa T. Liver disease secondary to congenital heart disease in children. Expert Rev Gastroenterol Hepatol 2019; 13:651-666. [PMID: 31131680 DOI: 10.1080/17474124.2019.1621746] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Introduction: Hepatic fibrosis and hepatocellular carcinoma (HCC) can develop in children with congenital heart disease. Although hepatic fibrosis and HCC are prone to develop after the Fontan operation, they can also develop in patients suffering from congenital heart disease who have not undergone Fontan operation. Area covered: The history of cardiac hepatopathy including Fontan-associated liver disease is described. Patient characteristics, liver histology, imaging examinations and blood tests are reviewed to elucidate the mechanism of cardiac hepatopathy. In addition, a flowchart for the follow-up management of cardiac hepatopathy in children with congenital heart disease is proposed. Expert opinion: Congestion and low cardiac output are the main causes of cardiac hepatopathy. Advanced hepatic fibrosis is presumed to be associated with HCC. HCC can develop in both adolescents and young adults. Regardless of whether the Fontan operation is performed, children with a functional single ventricle and chronic heart failure should be regularly examined for cardiac hepatopathy. There is no single reliable laboratory parameter to accurately detect cardiac hepatopathy; hepatic fibrosis indices and elastography have shown inconsistent results for detection of this disease. Further studies using liver specimen-confirmed patients and standardization of evaluation protocols are required to clarify the pathogenesis of cardiac hepatopathy.
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Affiliation(s)
- Haruki Komatsu
- a Department of Pediatrics , Toho University, Sakura Medical Center , Chiba , Japan
| | - Ayano Inui
- b Department of Pediatric Hepatology and Gastroenterology , Eastern Yokohama Hospital , Kanagawa , Japan
| | - Kanako Kishiki
- c Department of Pediatric Cardiology , Sakakibara Heart Institute , Tokyo , Japan
| | - Hironari Kawai
- d Research Center for Hepatitis and Immunology, National Center for Global Health and Medicine , Chiba , Japan
| | - Sachiyo Yoshio
- d Research Center for Hepatitis and Immunology, National Center for Global Health and Medicine , Chiba , Japan
| | - Yosuke Osawa
- d Research Center for Hepatitis and Immunology, National Center for Global Health and Medicine , Chiba , Japan
| | - Tatsuya Kanto
- d Research Center for Hepatitis and Immunology, National Center for Global Health and Medicine , Chiba , Japan
| | - Tomoo Fujisawa
- b Department of Pediatric Hepatology and Gastroenterology , Eastern Yokohama Hospital , Kanagawa , Japan
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21
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Fontan-Associated Liver Disease: Evidence for Early Surveillance of Liver Health in Pediatric Fontan Patients. Can J Cardiol 2019; 35:217-220. [DOI: 10.1016/j.cjca.2018.11.019] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2018] [Revised: 11/26/2018] [Accepted: 11/26/2018] [Indexed: 11/17/2022] Open
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22
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Ing RJ, Twite MD. Noteworthy Literature published in 2017 for Congenital Cardiac Anesthesiologists. Semin Cardiothorac Vasc Anesth 2018; 22:35-48. [DOI: 10.1177/1089253217753398] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
This review focuses on the literature published during the 13 months from December 2016 to December 2017 that is of interest to anesthesiologists taking care of children and adults with congenital heart disease. Five themes are addressed during this time period and 100 peer-reviewed articles are discussed.
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Affiliation(s)
- Richard J. Ing
- Children’s Hospital Colorado, Anschutz Medical Campus, Aurora, CO, USA
- University of Colorado, Aurora, CO, USA
| | - Mark D. Twite
- Children’s Hospital Colorado, Anschutz Medical Campus, Aurora, CO, USA
- University of Colorado, Aurora, CO, USA
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