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Brás PG, Mano TB, Rito T, Castelo A, Ferreira V, Agapito A, Ferreira RC, Pinto F, de Sousa L. Non-VKA Oral Anticoagulants in Adult Congenital Heart Disease: a Single-Center Study. Cardiovasc Drugs Ther 2023; 37:1077-1086. [PMID: 35713747 DOI: 10.1007/s10557-022-07357-5] [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] [Accepted: 06/09/2022] [Indexed: 11/03/2022]
Abstract
PURPOSE Non-VKA oral anticoagulants (NOACs) prescription is increasing in adults with congenital heart disease (ACHD). However, data on efficacy and safety in ACHD is unclear, particularly in severe CHD. The study aimed to review the safety and efficacy of NOACs in ACHD. METHODS Retrospective evaluation of ACHD patients started on NOACs from 2014 to 2020, with the primary endpoints of bleeding or thromboembolic events (TE). CHA2DS2-VASc and HAS-BLED scores were calculated, mortality was assessed, and risk factors for bleeding were identified. RESULTS A total of 93 patients were included, the mean age was 52 ± 15 years, 58% were female, 55.9% had moderate CHD, and 23.7% had severe CHD (3.2% Fontan). Most (66%) had a CHA2DS2-VASc score ≥ 2 and 82% HAS-BLED ≤ 2. In a median follow-up of 41 (IQR 21) months (400.4 patient-years), there were TE in two patients. The annual risk for TE was 0.49%/patient/year. The cardiovascular mortality was 2% and all-cause mortality 5%; there were no fatal TE or bleeding events. Minor (n = 6, 6.5%) and major (n = 3, 3.2%) bleeding events were observed, a median of 12 (IQR 15) months after starting NOAC therapy. The annual risk for bleeding was 2.2%/patient/year. Renal disease (HR 14.6 [95% CI 1.23-73.6], p = 0.033) and the HAS-BLED score were predictors of major (adjusted HR 6.97 [95% CI 1.69-28.78], p = 0.007) and minor (adjusted HR 3.80 [95% CI 1.48-9.78], p = 0.006) bleeding complications. CONCLUSION In this real-life cohort of selected ACHD, the use of NOACs was safe and effective, with a low incidence of bleeding events.
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Affiliation(s)
- Pedro Garcia Brás
- Department of Cardiology, Santa Marta Hospital, Centro Hospitalar Universitário de Lisboa Central, Rua de Santa Marta, n.50, 1169-024, Lisbon, Portugal.
| | - Tânia Branco Mano
- Department of Cardiology, Santa Marta Hospital, Centro Hospitalar Universitário de Lisboa Central, Rua de Santa Marta, n.50, 1169-024, Lisbon, Portugal
| | - Tiago Rito
- Department of Pediatric Cardiology, Santa Marta Hospital, Centro Hospitalar Universitário de Lisboa Central, Lisbon, Portugal
| | - Alexandra Castelo
- Department of Cardiology, Santa Marta Hospital, Centro Hospitalar Universitário de Lisboa Central, Rua de Santa Marta, n.50, 1169-024, Lisbon, Portugal
| | - Vera Ferreira
- Department of Cardiology, Santa Marta Hospital, Centro Hospitalar Universitário de Lisboa Central, Rua de Santa Marta, n.50, 1169-024, Lisbon, Portugal
| | - Ana Agapito
- Department of Cardiology, Santa Marta Hospital, Centro Hospitalar Universitário de Lisboa Central, Rua de Santa Marta, n.50, 1169-024, Lisbon, Portugal
| | - Rui Cruz Ferreira
- Department of Cardiology, Santa Marta Hospital, Centro Hospitalar Universitário de Lisboa Central, Rua de Santa Marta, n.50, 1169-024, Lisbon, Portugal
| | - Fatima Pinto
- Department of Pediatric Cardiology, Santa Marta Hospital, Centro Hospitalar Universitário de Lisboa Central, Lisbon, Portugal
| | - Lídia de Sousa
- Department of Cardiology, Santa Marta Hospital, Centro Hospitalar Universitário de Lisboa Central, Rua de Santa Marta, n.50, 1169-024, Lisbon, Portugal
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2
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Kazerouninia A, Georgekutty J, Kendsersky P, Byrne RD, Seto B, Chu PY, Wang Y, Rodriguez FH, Smith C, Saraf A, Lloyd MS, Frischhertz BP, Parekh DR, Ermis PR, Franklin WJ, Lam WW. A Multisite Retrospective Review of Direct Oral Anticoagulants Compared to Warfarin in Adult Fontan Patients. Cardiovasc Drugs Ther 2023; 37:519-527. [PMID: 35022950 PMCID: PMC11040449 DOI: 10.1007/s10557-021-07298-5] [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] [Accepted: 11/29/2021] [Indexed: 11/25/2022]
Abstract
PURPOSE Direct oral anticoagulants (DOACs) are not recommended in adult Fontan patients (Level of Evidence C). We hypothesized that DOACs are comparable to warfarin and do not increase thrombotic and embolic complications (TEs) or clinically significant bleeds. METHODS We reviewed the medical records of adult Fontan patients on DOACs or warfarin at three major medical centers. We identified 130 patients: 48 on DOACs and 107 on warfarin. In total, they were treated for 810 months on DOACs and 5637 months on warfarin. RESULTS The incidence of TEs in patients on DOACs compared to those on warfarin was not increased in a statistically significant way (hazard ratio [HR] 1.7 and p value 0.431). Similarly, the incidence of nonmajor and major bleeds in patients on DOACs compared to those on warfarin was also not increased in a statistically significant way (HR for nonmajor bleeds in DOAC patients was 2.8 with a p value of 0.167 and the HR for major bleeds was 2.0 with a p value 0.267). In multivariate analysis, congestive heart failure (CHF) was a risk factor for TEs across both groups (odds ratio [OR] = 4.8, 95% confidence interval [CI] = 1.3-17.6) and bleed history was a risk factor for clinically significant bleeds (OR = 6.8, 95% CI = 2.7-17.2). CONCLUSION In this small, retrospective multicenter study, the use of DOACs did not increase the risk of TEs or clinically significant bleeds compared to warfarin in a statistically significant way.
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Affiliation(s)
- Amir Kazerouninia
- Departments of Internal Medicine and Pediatrics, Baylor College of Medicine, Houston, TX, USA.
| | - Justin Georgekutty
- Division of Pediatric Cardiology, Cohen Children's Medical Center/Northwell Health, New Hyde Park, NY, USA
| | - Payton Kendsersky
- Department of Medicine, Duke University School of Medicine, Durham, NC, USA
| | - Ryan D Byrne
- Departments of Internal Medicine and Pediatrics, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Brendan Seto
- University of Hawaii, John A. Burns School of Medicine, Honolulu, HI, USA
| | - Patricia Y Chu
- Departments of Internal Medicine and Pediatrics, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Yunfei Wang
- Division of Pediatric Cardiology, Texas Children's Hospital/Baylor College of Medicine, Houston, TX, USA
| | - Fred H Rodriguez
- Departments of Pediatrics and Internal Medicine, Division of Cardiology, Emory University, Atlanta, GA, USA
- Sibley Heart Center Cardiology, Atlanta, GA, USA
| | - Clayton Smith
- Departments of Pediatrics and Internal Medicine, Division of Cardiology, Emory University, Atlanta, GA, USA
- Sibley Heart Center Cardiology, Atlanta, GA, USA
| | - Anita Saraf
- Departments of Pediatrics and Internal Medicine, Division of Cardiology, Emory University, Atlanta, GA, USA
- Sibley Heart Center Cardiology, Atlanta, GA, USA
| | - Michael S Lloyd
- Department of Internal Medicine, Division of Cardiology, Emory University, Atlanta, GA, USA
| | - Benjamin P Frischhertz
- Vanderbilt Heart and Vascular Institute, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Dhaval R Parekh
- Division of Adult Congenital Cardiology, Texas Children's Hospital/Baylor College of Medicine, Houston, TX, USA
| | - Peter R Ermis
- Division of Adult Congenital Cardiology, Texas Children's Hospital/Baylor College of Medicine, Houston, TX, USA
| | - Wayne J Franklin
- Division of Adult Congenital Cardiology, Texas Children's Hospital/Baylor College of Medicine, Houston, TX, USA
| | - Wilson W Lam
- Division of Adult Congenital Cardiology, Texas Children's Hospital/Baylor College of Medicine, Houston, TX, USA
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3
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Skubera M, Gołąb A, Sternalski T, Trojnarska O, Plicner D, Smaś-Suska M, Mazurek-Kula A, Bartczak-Rutkowska A, Pająk J, Podolec P, Tomkiewicz-Pająk L. Thromboembolic Complications in Adult Patients Following Fontan Procedure-A Multicenter Study. J Clin Med 2023; 12:jcm12103465. [PMID: 37240571 DOI: 10.3390/jcm12103465] [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: 02/20/2023] [Revised: 04/20/2023] [Accepted: 05/12/2023] [Indexed: 05/28/2023] Open
Abstract
BACKGROUND Morbidity and mortality following Fontan (FO) surgery are primarily thromboembolic in nature. However, follow-up data regarding thromboembolic complications (TECs) in adult patients after FO procedure are inconsistent. In this multicenter study, we investigated the incidence of TECs in FO patients. METHODS We studied 91 patients who underwent FO procedure. Clinical data, laboratory, and imaging investigations were collected prospectively during the scheduled medical appointments in 3 Adult Congenital Heart Disease Departments in Poland. TECs were recorded during a median follow-up of 31 months. RESULTS Four patients (4.4%) were lost to follow-up. The mean age of patients was 25.3 (±6.0) years at enrollment, and the mean time between FO operation and investigation was 22.1 (±5.1) years. A total of 21 out of 91 patients (23.1%) had a history of 24 TECs since an FO procedure, mainly pulmonary embolism (PE; n = 12, 13.2%), including 4 (33.3%) silent PE. The mean time since FO operation to the first TEC was 17.8 (±5.1) years. During follow-up, we documented 9 TECs in 7 (8.0%) patients, mainly PE (n = 5, 5.5%). Most patients with TEC had a left type of systemic ventricle (57.1%). Three patients (42.9%) were treated with aspirin, 3 (3.4%) with Vitamin K antagonists or novel oral anticoagulants, and 1 patient had no antithrombotic treatment at the time of TEC occurrence. Supraventricular tachyarrhythmias were present in 3 patients (42.9%). CONCLUSIONS This prospective study shows that TECs are common in FO patients, and a significant number of these events occur during adolescence and young adulthood. We also indicated how much TECs are underestimated in the growing adult FO population. The complexity of the problem requires more studies, especially to standardize the prevention of TECs in the whole FO population.
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Affiliation(s)
- Maciej Skubera
- Department of Cardiac and Vascular Diseases, John Paul II Hospital, 31-202 Krakow, Poland
| | - Aleksandra Gołąb
- Faculty of Medicine and Dentistry, Pomeranian Medical University in Szczecin, 70-204 Szczecin, Poland
- Center for Research and Innovative Technology, John Paul II Hospital, 31-202 Krakow, Poland
| | - Tomasz Sternalski
- Faculty of Medicine, Collegium Medicum Jagiellonian University, 31-008 Krakow, Poland
| | - Olga Trojnarska
- 1st Department of Cardiology, Poznan University of Medical Sciences, 61-701 Poznan, Poland
| | - Dariusz Plicner
- Department of Cardiovascular Surgery and Transplantation, John Paul II Hospital, 31-202 Krakow, Poland
- Unit of Experimental Cardiology and Cardiac Surgery, Faculty of Medicine and Health Sciences, Andrzej Frycz Modrzewski Krakow University, 30-705 Krakow, Poland
| | - Monika Smaś-Suska
- Department of Liver Diseases, John Paul II Hospital, 31-202 Krakow, Poland
| | - Anna Mazurek-Kula
- Department of Cardiology, Polish Mother's Memorial Hospital, Research Institute, 93-338 Lodz, Poland
| | | | - Jacek Pająk
- Institute of Medical Sciences, Department of Surgery, Medical College of Rzeszow University, 35-025 Rzeszow, Poland
| | - Piotr Podolec
- Department of Cardiac and Vascular Diseases, John Paul II Hospital, 31-202 Krakow, Poland
- Institute of Cardiology, Jagiellonian University Medical College, 31-008 Krakow, Poland
| | - Lidia Tomkiewicz-Pająk
- Department of Cardiac and Vascular Diseases, John Paul II Hospital, 31-202 Krakow, Poland
- Department of Liver Diseases, John Paul II Hospital, 31-202 Krakow, Poland
- Institute of Cardiology, Jagiellonian University Medical College, 31-008 Krakow, Poland
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4
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Samarai D, Isma N, Lindstedt S, Hlebowicz J. Novel oral anticoagulant use in adults with congenital heart disease: a single-center experience report. Egypt Heart J 2023; 75:3. [PMID: 36624331 PMCID: PMC9829939 DOI: 10.1186/s43044-022-00326-1] [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: 07/07/2022] [Accepted: 12/28/2022] [Indexed: 01/11/2023] Open
Abstract
BACKGROUND Adults with congenital heart disease (ACHD) are a group with an increased risk of thromboembolic complications and arrhythmias. Vitamin K antagonists are the most commonly used thromboprophylaxis therapy in this population. Studies on the efficacy and safety of novel oral anticoagulants (NOAC) are scare in ACHD. A retrospective study on ACHD patients on NOAC treatment registered in the National Quality Registry for Congenital Heart Disease, SWEDCON, and National Quality Registry for Atrial fibrillation and Anticoagulation, AuriculA, from Southern Sweden. RESULTS Thirty patients who had been taking NOAC treatment for a minimum of 3 months were included. Their median age was 55 years (SD 17 years) and 57% were male. Median follow-up was 17 months (IQR: 10-41). Eliquis was the most used NOAC (47%). Median CHA2DS2-VASc score was 2 (IQR: 0-3) and HAS-BLED was 1 (IQR: 0-2). Complex ACHD was prevalent in 27% of the patients. No thromboembolic events were recorded; however, one major bleeding, unspecified, was reported during the total cumulative patient follow-up time of 64 years. CONCLUSIONS The results of our study, although limited in size, suggest that NOAC appear safe and effective in ACHD patients. Further and larger studies on NOAC in ACHD patients are warranted.
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Affiliation(s)
- Daniel Samarai
- grid.4514.40000 0001 0930 2361Clinical Sciences, Lund University, Lund, Sweden
| | - Nazim Isma
- grid.4514.40000 0001 0930 2361Clinical Sciences, Lund University, Lund, Sweden ,grid.411843.b0000 0004 0623 9987Department of Cardiology, Skåne University Hospital, Lund University, Entrégatan 7, 221 85 Lund, Sweden
| | - Sandra Lindstedt
- grid.4514.40000 0001 0930 2361Clinical Sciences, Lund University, Lund, Sweden ,grid.411843.b0000 0004 0623 9987Department of Cardiothoracic Surgery, Lund University, Lund University Hospital, Lund, Sweden
| | - Joanna Hlebowicz
- grid.4514.40000 0001 0930 2361Clinical Sciences, Lund University, Lund, Sweden ,grid.411843.b0000 0004 0623 9987Department of Cardiology, Skåne University Hospital, Lund University, Entrégatan 7, 221 85 Lund, Sweden
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5
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Basmaji S, Samuel M, Shohoudi A, Hamilton RM, Aboulhosn J, Broberg CS, Chaix MA, Cohen S, Cook S, Dore A, Fernandes SM, Fortier A, Fournier A, Guertin MC, Kay J, Mondésert B, Mongeon FP, Opotowsky AR, Proietti A, Ting J, Zaidi A, Khairy P. Time in Therapeutic Range With Vitamin K Antagonists in Congenital Heart Disease: A Multicentre Study. Can J Cardiol 2022; 38:1751-1758. [PMID: 35964887 DOI: 10.1016/j.cjca.2022.08.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2022] [Revised: 08/01/2022] [Accepted: 08/03/2022] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Vitamin K antagonists (VKAs) are frequently prescribed to patients with congenital heart disease (CHD) for atrial arrhythmias or Fontan palliation, but there is a paucity of data regarding time spent in the therapeutic range (TTR). We sought to determine the TTR in patients with CHD and atrial arrhythmias or Fontan palliation prescribed VKAs and explore associations with thromboembolic and bleeding events. METHODS A multicentre North American cohort study was conducted on patients with CHD who received VKAs for sustained atrial arrhythmia or Fontan palliation. TTR was calculated using the Rosendaal linear interpolation method. Generalized estimating equations were used to explore factors associated with time outside the therapeutic range. RESULTS A total of 567 patients, aged 33 ± 17 years, 56% female, received VKAs for 11.5 ± 8.4 years for atrial arrhythmias (63.0%) or Fontan palliation (58.0%). CHD was simple, moderate, and complex in 10.8%, 20.3%, and 69.0%, respectively. Site investigators perceived good control over international normalized ratio (INR) levels in most patients (75.3%), with no or minor compliance or adherence issues (85.6%). The mean TTR was 41.9% (95% confidence interval [CI], 39.0%-44.8%). Forty-seven (8.3%) and 34 (6.0%) patients had thromboembolic and bleeding events, respectively. Thromboembolic events were associated with a higher proportion of time below the therapeutic range (31.3% vs 19.1%, P = 0.003) and bleeding complications with a higher proportion of time above the therapeutic range (32.5% vs 19.5%, P = 0.006). CONCLUSIONS Patients with CHD who receive VKAs spend < 42% of their time with INR levels in the therapeutic range, with repercussions regarding thromboembolic and bleeding complications.
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Affiliation(s)
- Samir Basmaji
- Montreal Heart Institute, Université de Montréal, Montréal, Québec, Canada
| | - Michelle Samuel
- Montreal Heart Institute, Université de Montréal, Montréal, Québec, Canada
| | - Azadeh Shohoudi
- Montreal Heart Institute, Université de Montréal, Montréal, Québec, Canada
| | - Robert M Hamilton
- The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
| | | | | | - Marie-A Chaix
- Montreal Heart Institute, Université de Montréal, Montréal, Québec, Canada
| | - Scott Cohen
- The Wisconsin Adult Congenital Heart (WAtCH) Program, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | - Stephen Cook
- Children's Hospital of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Annie Dore
- Montreal Heart Institute, Université de Montréal, Montréal, Québec, Canada
| | | | - Annik Fortier
- Montreal Heart Institute, Université de Montréal, Montréal, Québec, Canada
| | - Anne Fournier
- Hôpital Sainte-Justine, Université de Montréal, Montréal, Québec, Canada
| | | | - Joseph Kay
- University of Colorado Denver, Aurora, Colorado, USA
| | - Blandine Mondésert
- Montreal Heart Institute, Université de Montréal, Montréal, Québec, Canada
| | | | - Alexander R Opotowsky
- Boston Adult Congenital Heart Service, Boston Children's Hospital and Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Anna Proietti
- Montreal Heart Institute, Université de Montréal, Montréal, Québec, Canada
| | - Jennifer Ting
- Milton S. Hershey Medical Center, Pennsylvania State University, Hershey, Pennsylvania, USA
| | - Ali Zaidi
- Nationwide Children's Hospital, Ohio State University, Columbus, Ohio, USA
| | - Paul Khairy
- Montreal Heart Institute, Université de Montréal, Montréal, Québec, Canada.
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6
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Ban JE. Non-vitamin K antagonist oral anticoagulants in adults with congenital heart disease. INTERNATIONAL JOURNAL OF ARRHYTHMIA 2022. [DOI: 10.1186/s42444-022-00071-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
AbstractDespite an improved survival rate, cardiovascular accidents including thromboembolic events are a common cause of death in adults with congenital heart disease (CHD). Therefore, many adult patients with CHD require long-term oral anticoagulants depending on disease complexity, atrial tachyarrhythmia, residual intracardiac shunt, ventricular dysfunction, and the presence of a prosthetic valve. Although prevention of stroke and pulmonary embolism has traditionally been managed with vitamin K antagonists (VKA), recent guidelines suggest the use of non-vitamin K antagonist oral anticoagulants (NOACs) in patients with adult CHD presenting with atrial fibrillation (AF), stroke, or pulmonary embolism. NOACs are an efficient alternative to VKA with reduced bleeding propensity, relatively low dietary and drug interactions, and the potential to eliminate the need for international normalized ratio monitoring in patients with nonvalvular AF. Recently, several multicenter studies reported the indication for thromboprophylaxis and the potential role of NOACs in adult CHD patients. In this review, we aim to assess the efficacy and safety of NOACs in adult CHD patients and to pursue adequate anticoagulation strategies in this special population.
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7
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Schreinlechner M, Geiger R, Mair J. Ultrasound-assisted catheter-directed thrombolysis for successful rescue treatment of acute pulmonary embolism in decompensated Fontan palliation. J Cardiol Cases 2022; 25:326-329. [PMID: 35685255 PMCID: PMC9168972 DOI: 10.1016/j.jccase.2021.12.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2021] [Revised: 11/24/2021] [Accepted: 12/03/2021] [Indexed: 11/20/2022] Open
Abstract
A 22-year-old woman with complete Fontan palliation for tricuspid valve hypoplasia and chronic anemia presented to a local hospital for swelling of her left arm. Initially, the patient was hemodynamically stable without dyspnea or chest pain. Admission hemoglobin was 53 g/L and D-dimer 0.51 mg/L. Sonography showed signs of venous congestion of the left arm, but no definitive signs of venous thrombosis. Subsequently she developed dyspnea with a decrease in transcutaneous oxygen saturation to 85%. Computed tomography angiography revealed bilateral pulmonary embolism with occlusion of the right pulmonary artery. The patient was transferred to a tertiary care center. Gastroscopy detected only small stomach ulcers, and because of ongoing hemodynamic instability, the decision was to initiate rescue ultrasound-assisted catheter-directed local thrombolysis. This treatment was effective with rapid hemodynamic stabilization without bleeding complications and without residual emboli in a long-term follow-up cardiac catheterization. .
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Affiliation(s)
- Michael Schreinlechner
- Department of Internal Medicine III – Cardiology and Angiology, Medical University Innsbruck, Innsbruck, Austria
| | - Ralf Geiger
- Department of Child and Adolescent Health, Pediatrics III – Cardiology and Pulmology, Medical University Innsbruck, Innsbruck, Austria
| | - Johannes Mair
- Department of Internal Medicine III – Cardiology and Angiology, Medical University Innsbruck, Innsbruck, Austria
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8
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The Fontan circulation: from ideal to failing hemodynamics and drug therapies for optimization. Can J Cardiol 2022; 38:1059-1071. [DOI: 10.1016/j.cjca.2022.04.014] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2021] [Revised: 04/13/2022] [Accepted: 04/14/2022] [Indexed: 12/19/2022] Open
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9
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Van Den Helm S, Sparks CN, Ignjatovic V, Monagle P, Attard C. Increased Risk for Thromboembolism After Fontan Surgery: Considerations for Thromboprophylaxis. Front Pediatr 2022; 10:803408. [PMID: 35419321 PMCID: PMC8996130 DOI: 10.3389/fped.2022.803408] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/27/2021] [Accepted: 02/28/2022] [Indexed: 11/13/2022] Open
Abstract
The Fontan circulation introduces an increased risk of thromboembolism which is associated with substantial mortality and morbidity. Adverse outcomes of thromboembolic complications post-Fontan surgery vary in both nature and severity, ranging from local tissue infarction and pulmonary embolism to Fontan failure and ischemic stroke. Furthermore, recent studies have identified that subclinical stroke is common yet underdiagnosed in Fontan patients. Fontan patients are commonly treated with antiplatelet agents and/or anticoagulants as primary thromboprophylaxis. Optimal thromboprophylaxis management in the Fontan population is still unclear, and clinical consensus remains elusive despite the growing literature on the subject. This perspective will describe the nature of thromboembolism post-Fontan surgery and provide evidence for the use of both current and emerging thromboprophylaxis options for children and adults living with Fontan circulation.
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Affiliation(s)
- Suelyn Van Den Helm
- Haematology Research, Murdoch Children's Research Institute, Melbourne, VIC, Australia.,Department of Paediatrics, The University of Melbourne, Melbourne, VIC, Australia
| | - Christopher Noel Sparks
- Haematology Research, Murdoch Children's Research Institute, Melbourne, VIC, Australia.,Department of Anatomy and Physiology, The University of Melbourne, Melbourne, VIC, Australia
| | - Vera Ignjatovic
- Haematology Research, Murdoch Children's Research Institute, Melbourne, VIC, Australia.,Department of Paediatrics, The University of Melbourne, Melbourne, VIC, Australia
| | - Paul Monagle
- Haematology Research, Murdoch Children's Research Institute, Melbourne, VIC, Australia.,Department of Paediatrics, The University of Melbourne, Melbourne, VIC, Australia.,Kids Cancer Centre, Sydney Children's Hospital, Randwick, NSW, Australia.,Department of Haematology, Royal Children's Hospital, Melbourne, VIC, Australia
| | - Chantal Attard
- Haematology Research, Murdoch Children's Research Institute, Melbourne, VIC, Australia.,Department of Anatomy and Physiology, The University of Melbourne, Melbourne, VIC, Australia
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10
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Westhoff-Bleck M, Klages C, Zwadlo C, Sonnenschein K, Sieweke JT, Bauersachs J, Bertram H, Grosse U. Thromboembolic characteristics and role of anticoagulation in long-standing Fontan circulation. INTERNATIONAL JOURNAL OF CARDIOLOGY CONGENITAL HEART DISEASE 2022. [DOI: 10.1016/j.ijcchd.2022.100328] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
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11
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Sinning C, Zengin E, Blankenberg S, Rickers C, von Kodolitsch Y, Diller G, Kirchhof P. Anticoagulation management in adult patients with congenital heart disease: a narrative review. Cardiovasc Diagn Ther 2021; 11:1324-1333. [PMID: 35070801 PMCID: PMC8748474 DOI: 10.21037/cdt-20-631] [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] [Received: 07/10/2020] [Accepted: 09/29/2020] [Indexed: 12/01/2023]
Abstract
With improvements in treatment of congenital heart disease more paediatric patients are surviving with palliative or corrective interventions during childhood, thus becoming adults with congenital heart disease (ACHD). Overall, the ACHD population is at a higher risk of arrhythmias and stroke. The abnormal structure and function of their corrected hearts suggests that in addition to established stroke risk factors, such as prior stroke or older age, additional stroke risk factors need to be considered to determine the risk and establish the indication for oral anticoagulation (OAC) in ACHD patients. In structurally normal hearts non-vitamin-K oral anticoagulants (NOACs) offer at least equal stroke prevention with a better safety profile compared to vitamin K antagonists (VKA) in patients with atrial fibrillation (AF) or pulmonary embolism. Current guidelines recommend NOACs in ACHD patients with simple lesions and indication for OAC, while there is less certainty about their safety in ACHD patients with moderate or complex congenital heart disease such as patients with transposition of the great arteries (TGA) after atrial switch operation (Senning or Mustard operation), Fontan circulation or congenital corrected transposition of the great arteries (ccTGA). This review summarises the available evidence characterising stroke risk in patients with ACHD and the use of anticoagulants and interventional therapies to reduce that risk.
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Affiliation(s)
- Christoph Sinning
- Department of Cardiology, University Heart & Vascular Center Hamburg, Hamburg, Germany
- German Center for Cardiovascular Science (DZHK) Hamburg/Lübeck/Kiel, Hamburg, Germany
- Adult Congenital Heart Disease Section, University Heart Center Hamburg, Hamburg, Germany
| | - Elvin Zengin
- Department of Cardiology, University Heart & Vascular Center Hamburg, Hamburg, Germany
- Adult Congenital Heart Disease Section, University Heart Center Hamburg, Hamburg, Germany
| | - Stefan Blankenberg
- Department of Cardiology, University Heart & Vascular Center Hamburg, Hamburg, Germany
- German Center for Cardiovascular Science (DZHK) Hamburg/Lübeck/Kiel, Hamburg, Germany
| | - Carsten Rickers
- Adult Congenital Heart Disease Section, University Heart Center Hamburg, Hamburg, Germany
| | - Yskert von Kodolitsch
- Department of Cardiology, University Heart & Vascular Center Hamburg, Hamburg, Germany
| | - Gerhard Diller
- Department of Cardiology III, University Hospital Münster, Münster, Germany
| | - Paulus Kirchhof
- Department of Cardiology, University Heart & Vascular Center Hamburg, Hamburg, Germany
- German Center for Cardiovascular Science (DZHK) Hamburg/Lübeck/Kiel, Hamburg, Germany
- Institute of Cardiovascular Sciences and SWBH and UHB NHS Trusts, Birmingham, UK
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12
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Kleindorfer DO, Towfighi A, Chaturvedi S, Cockroft KM, Gutierrez J, Lombardi-Hill D, Kamel H, Kernan WN, Kittner SJ, Leira EC, Lennon O, Meschia JF, Nguyen TN, Pollak PM, Santangeli P, Sharrief AZ, Smith SC, Turan TN, Williams LS. 2021 Guideline for the Prevention of Stroke in Patients With Stroke and Transient Ischemic Attack: A Guideline From the American Heart Association/American Stroke Association. Stroke 2021; 52:e364-e467. [PMID: 34024117 DOI: 10.1161/str.0000000000000375] [Citation(s) in RCA: 1175] [Impact Index Per Article: 391.7] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
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13
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Park J, Hong BY, Kim JS, Park JG, Jung J, Lim SH. Could DOAC Be a Better Choice Than Warfarin in Low Compliance Patients with Fontan Procedure? ACTA ACUST UNITED AC 2021; 57:medicina57050465. [PMID: 34068569 PMCID: PMC8151865 DOI: 10.3390/medicina57050465] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2021] [Revised: 05/04/2021] [Accepted: 05/05/2021] [Indexed: 11/16/2022]
Abstract
Background and Objectives: After the Fontan procedure, thromboembolic events need to be prevented. We present a young patient with a history of Fontan procedure and poor adherence to warfarin who developed systemic thromboembolism. He was changed to maintenance dabigatran, which is one of the available direct oral anticoagulants (DOACs). Case presentation: A 20-year-old man was diagnosed with cerebral infarct, pulmonary thromboembolism (PTE), and renal infarcts. He was prescribed warfarin to prevent thromboembolic events after the Fontan procedure. Based on his poor adherence to warfarin, we decided to change the anticoagulant therapy from warfarin to dabigatran 150 mg bid. One month later, his pulmonary thromboembolism regressed. Conclusion: Our case report showed a young adult with low compliance to warfarin who developed cerebral, pulmonary, and renal thromboembolic events. Thus, in our opinion, the change from warfarin to a DOAC was necessary for further prevention and treatment of PTE. A change from warfarin to a DOAC should be considered in patients with poor compliance who are at high risk of thromboembolic events, for example, after the Fontan procedure.
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Affiliation(s)
| | | | | | | | | | - Seong-Hoon Lim
- Correspondence: ; Tel.: +82-(31)-249-7650; Fax: +82-(31)-251-4481
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14
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Wasmer K, Eckardt L, Baumgartner H, Köbe J. Therapy of supraventricular and ventricular arrhythmias in adults with congenital heart disease-narrative review. Cardiovasc Diagn Ther 2021; 11:550-562. [PMID: 33968633 DOI: 10.21037/cdt-20-634] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Arrhythmias are among the most common late complications in adults with congenital heart disease (ACHD) and a frequent reason for hospital admission. Both, supraventricular and ventricular arrhythmias, not only cause debilitating symptoms, but may be life-threatening by increasing risk of stroke, causing or worsening heart failure and being associated with sudden death. Substrate and risk for arrhythmia differs widely between congenital defects with specific arrhythmias being much more common in some patients than others. Atrial macroreentrant arrhythmias are particularly frequent in patients with atrial septal defects and repair that involves atrial incisions including patients with transposition of the great arteries (TGA) and atrial switch. Accessory pathways and related arrhythmias are often associated with Ebstein's anomaly and congenitally corrected TGA. Monomorphic ventricular arrhythmias occur in patients with ventricular incisions, namely patients with Tetralogy of Fallot. Changes in surgical repair techniques influence arrhythmia prevalence and substrate as well as anatomical access for catheter ablation procedures. In addition, epidemiologic changes associated with improved long-term survival will further increase the prevalence of atrial fibrillation in ACHD. This article summarizes current understanding of prevalence of specific arrhythmias, underlying mechanisms, medical and interventional treatment options and their outcome in ACHD.
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Affiliation(s)
- Kristina Wasmer
- Department of Cardiology II - Electrophysiology, University Hospital Muenster, Cardiology, Muenster, Germany
| | - Lars Eckardt
- Department of Cardiology II - Electrophysiology, University Hospital Muenster, Cardiology, Muenster, Germany
| | - Helmut Baumgartner
- Department of Cardiology III, Division of Adult Congenital and Valvular Heart Disease, University Hospital Muenster, Cardiology, Muenster, Germany
| | - Julia Köbe
- Department of Cardiology II - Electrophysiology, University Hospital Muenster, Cardiology, Muenster, Germany
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15
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Jamal J, Jamal S. Novel oral anticoagulant use in adults with Fontan circulation- current evidence and future challenges. INTERNATIONAL JOURNAL OF CARDIOLOGY CONGENITAL HEART DISEASE 2021. [DOI: 10.1016/j.ijcchd.2021.100078] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
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16
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Kawamatsu N, Ishizu T, Machino-Ohtsuka T, Masuda K, Horigome H, Takechi F, Tateno S, Fukuda T, Kijima Y, Shiina Y, Komiyama N, Niwa K, Hiramatsu Y, Ieda M. Direct oral anticoagulant use and outcomes in adult patients with Fontan circulation: A multicenter retrospective cohort study. Int J Cardiol 2020; 327:74-79. [PMID: 33220361 DOI: 10.1016/j.ijcard.2020.11.024] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/03/2020] [Revised: 11/07/2020] [Accepted: 11/12/2020] [Indexed: 12/25/2022]
Abstract
BACKGROUND Many adult patients with Fontan circulation are treated with antithrombotic agents, including direct oral anticoagulants (DOACs). However, few studies have investigated the efficacy, feasibility, and safety of DOACs in adult patients with Fontan circulation. METHODS AND RESULTS In this retrospective cohort study, clinical records of 139 adult patients with Fontan circulation (70 females, 50.4%) from April 2015 to March 2018 were reviewed and classified into five groups according to the therapeutic agents used: DOAC (n = 36), vitamin K antagonist (VKA; n = 41), antiplatelet drug (n = 43), combination of an antiplatelet and anticoagulant (n = 14), and no-antithrombotic prophylaxis (n = 5). In a 1114-patient-year follow-up, 28 major events occurred, including 10 thrombotic and 18 bleeding events; 11 of 18 (61%) female patients had severe menorrhagia. The incidence (% patient-years) of major events was 0.6, 1.42, 3.74, and 5.13 in the DOAC, antiplatelet, VKA, combination, and no-antithrombotic groups, respectively. The Cox proportional hazards analysis revealed that the DOAC group had a lower rate of primary endpoints than the VKA group in males. CONCLUSIONS DOAC may be a safe antithrombotic agent for use in adult patients with Fontan circulation, particularly in males. However, these findings should be confirmed in multi-institutional prospective studies.
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Affiliation(s)
- Naoto Kawamatsu
- Department of Cardiology, Faculty of Medicine, University of Tsukuba, Tsukuba, Japan
| | - Tomoko Ishizu
- Department of Cardiology, Faculty of Medicine, University of Tsukuba, Tsukuba, Japan.
| | | | - Keita Masuda
- Department of Cardiology, Faculty of Medicine, University of Tsukuba, Tsukuba, Japan
| | - Hitoshi Horigome
- Department of Child Health, University of Tsukuba, Tsukuba, Japan
| | - Fumie Takechi
- Department of Adult Congenital Heart Disease, Chiba Cerebral and Cardiovascular Center, Chiba, Japan
| | - Shigeru Tateno
- Department of Adult Congenital Heart Disease, Chiba Cerebral and Cardiovascular Center, Chiba, Japan
| | - Terunobu Fukuda
- Department of Cardiovascular Medicine, St. Luke's International Hospital, Tokyo, Japan
| | - Yasufumi Kijima
- Department of Cardiovascular Medicine, St. Luke's International Hospital, Tokyo, Japan
| | - Yumi Shiina
- Department of Cardiovascular Medicine, St. Luke's International Hospital, Tokyo, Japan
| | - Nobuyuki Komiyama
- Department of Cardiovascular Medicine, St. Luke's International Hospital, Tokyo, Japan
| | - Koichiro Niwa
- Department of Cardiovascular Medicine, St. Luke's International Hospital, Tokyo, Japan
| | - Yuji Hiramatsu
- Division of Cardiovascular Surgery, University of Tsukuba, Tsukuba, Japan
| | - Masaki Ieda
- Department of Cardiology, Faculty of Medicine, University of Tsukuba, Tsukuba, Japan
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17
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Freisinger E, Gerß J, Makowski L, Marschall U, Reinecke H, Baumgartner H, Koeppe J, Diller GP. Current use and safety of novel oral anticoagulants in adults with congenital heart disease: results of a nationwide analysis including more than 44 000 patients. Eur Heart J 2020; 41:4168-4177. [DOI: 10.1093/eurheartj/ehaa844] [Citation(s) in RCA: 33] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/22/2020] [Revised: 08/19/2020] [Accepted: 09/25/2020] [Indexed: 12/22/2022] Open
Abstract
Abstract
Aims
To evaluate the use of novel oral anticoagulants (NOACs) compared with vitamin K antagonists (VKAs) in adult congenital heart disease (ACHD) and assess outcome in a nationwide analysis.
Methods and results
Using data from one of Germany’s largest Health Insurers, all ACHD patients treated with VKAs or NOACs were identified and changes in prescription patterns were assessed. Furthermore, the association between anticoagulation regimen and complications including mortality was studied. Between 2005 and 2018, the use of oral anticoagulants in ACHD increased from 6.3% to 12.4%. Since NOACs became available their utilization increased constantly, accounting for 45% of prescribed anticoagulants in ACHD in 2018. Adult congenital heart disease patients on NOACs had higher thromboembolic (3.8% vs. 2.8%), MACE (7.8% vs. 6.0%), bleeding rates (11.7% vs. 9.0%), and all-cause mortality (4.0% vs. 2.8%; all P < 0.05) after 1 year of therapy compared with VKAs. After comprehensive adjustment for patient characteristics, NOACs were still associated with increased risk of MACE (hazard rate—HR 1.22; 95% CI 1.09–1.36) and increased all-cause mortality (HR 1.43; 95% CI 1.24–1.65; both P < 0.001), but also bleeding (HR 1.16; 95% CI 1.04–1.29; P = 0.007) during long-term follow-up.
Conclusion
Despite the lack of prospective studies in ACHD, NOACs are increasingly replacing VKAs and now account for almost half of all oral anticoagulant prescriptions. Particularly, NOACs were associated with excess long-term risk of MACE, and mortality in this nationwide analysis, emphasizing the need for prospective studies before solid recommendations for their use in ACHD can be provided.
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Affiliation(s)
- Eva Freisinger
- Department of Cardiology I—Coronary and Peripheral Vascular Disease, Heart Failure, University Hospital Muenster, Albert Schweitzer Campus 1, A1, 48149 Muenster, Germany
| | - Joachim Gerß
- Institute of Biostatistics and Clinical Research, University of Muenster, Schmeddingstrasse 56, 48149 Muenster, Germany
| | - Lena Makowski
- Department of Cardiology I—Coronary and Peripheral Vascular Disease, Heart Failure, University Hospital Muenster, Albert Schweitzer Campus 1, A1, 48149 Muenster, Germany
| | - Ursula Marschall
- Department of Medicine and Health Services Research, BARMER Health Insurance, Lichtscheider Strasse 89, 42285 Wuppertal, Germany
| | - Holger Reinecke
- Department of Cardiology I—Coronary and Peripheral Vascular Disease, Heart Failure, University Hospital Muenster, Albert Schweitzer Campus 1, A1, 48149 Muenster, Germany
| | - Helmut Baumgartner
- Department of Cardiology III—Adult Congenital and Valvular Heart Disease, University Hospital Muenster, Albert Schweitzer Campus 1, A1, 48149 Muenster, Germany
| | - Jeanette Koeppe
- Institute of Biostatistics and Clinical Research, University of Muenster, Schmeddingstrasse 56, 48149 Muenster, Germany
| | - Gerhard-Paul Diller
- Department of Cardiology III—Adult Congenital and Valvular Heart Disease, University Hospital Muenster, Albert Schweitzer Campus 1, A1, 48149 Muenster, Germany
- Competence Network for Congenital Heart Defects, Augustenburger Pl. 1, 13353 Berlin, Germany
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18
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Andrade JG, Aguilar M, Atzema C, Bell A, Cairns JA, Cheung CC, Cox JL, Dorian P, Gladstone DJ, Healey JS, Khairy P, Leblanc K, McMurtry MS, Mitchell LB, Nair GM, Nattel S, Parkash R, Pilote L, Sandhu RK, Sarrazin JF, Sharma M, Skanes AC, Talajic M, Tsang TSM, Verma A, Verma S, Whitlock R, Wyse DG, Macle L. The 2020 Canadian Cardiovascular Society/Canadian Heart Rhythm Society Comprehensive Guidelines for the Management of Atrial Fibrillation. Can J Cardiol 2020; 36:1847-1948. [PMID: 33191198 DOI: 10.1016/j.cjca.2020.09.001] [Citation(s) in RCA: 319] [Impact Index Per Article: 79.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2020] [Revised: 09/05/2020] [Accepted: 09/05/2020] [Indexed: 12/20/2022] Open
Abstract
The Canadian Cardiovascular Society (CCS) atrial fibrillation (AF) guidelines program was developed to aid clinicians in the management of these complex patients, as well as to provide direction to policy makers and health care systems regarding related issues. The most recent comprehensive CCS AF guidelines update was published in 2010. Since then, periodic updates were published dealing with rapidly changing areas. However, since 2010 a large number of developments had accumulated in a wide range of areas, motivating the committee to complete a thorough guideline review. The 2020 iteration of the CCS AF guidelines represents a comprehensive renewal that integrates, updates, and replaces the past decade of guidelines, recommendations, and practical tips. It is intended to be used by practicing clinicians across all disciplines who care for patients with AF. The Grading of Recommendations, Assessment, Development and Evaluations (GRADE) system was used to evaluate recommendation strength and the quality of evidence. Areas of focus include: AF classification and definitions, epidemiology, pathophysiology, clinical evaluation, screening and opportunistic AF detection, detection and management of modifiable risk factors, integrated approach to AF management, stroke prevention, arrhythmia management, sex differences, and AF in special populations. Extensive use is made of tables and figures to synthesize important material and present key concepts. This document should be an important aid for knowledge translation and a tool to help improve clinical management of this important and challenging arrhythmia.
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Affiliation(s)
- Jason G Andrade
- University of British Columbia, Vancouver, British Columbia, Canada; Institut de Cardiologie de Montréal, Université de Montréal, Montréal, Québec, Canada.
| | - Martin Aguilar
- Institut de Cardiologie de Montréal, Université de Montréal, Montréal, Québec, Canada
| | | | - Alan Bell
- University of Toronto, Toronto, Ontario, Canada
| | - John A Cairns
- University of British Columbia, Vancouver, British Columbia, Canada
| | | | - Jafna L Cox
- Dalhousie University, Halifax, Nova Scotia, Canada
| | - Paul Dorian
- University of Toronto, Toronto, Ontario, Canada
| | | | | | - Paul Khairy
- Institut de Cardiologie de Montréal, Université de Montréal, Montréal, Québec, Canada
| | | | | | | | - Girish M Nair
- University of Ottawa Heart Institute, Ottawa, Ontario, Canada
| | - Stanley Nattel
- Institut de Cardiologie de Montréal, Université de Montréal, Montréal, Québec, Canada
| | | | | | | | - Jean-François Sarrazin
- Institut universitaire de cardiologie et de pneumologie de Québec, Université Laval, Québec, Québec, Canada
| | - Mukul Sharma
- McMaster University, Population Health Research Institute, Hamilton, Ontario, Canada
| | | | - Mario Talajic
- Montreal Heart Institute, University of Montreal, Montréal, Quebec, Canada
| | - Teresa S M Tsang
- University of British Columbia, Vancouver, British Columbia, Canada
| | - Atul Verma
- Southlake Regional Health Centre, University of Toronto, Toronto, Ontario, Canada
| | | | | | | | - Laurent Macle
- Institut de Cardiologie de Montréal, Université de Montréal, Montréal, Québec, Canada
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19
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Kartas A, Doundoulakis I, Ntiloudi D, Koutsakis A, Kosmidis D, Rampidis G, Apostolopoulou S, Frogoudaki A, Tzifa A, Avramidis D, Ntzoyvara O, Liori S, Mousiama T, Mouratoglou SA, Karvounis H, Giannakoulas G. Rationale and design of a prospective, observational, multicentre study on the safety and efficacy of apixaban for the prevention of thromboembolism in adults with congenital heart disease and atrial arrhythmias: the PROTECT-AR study. BMJ Open 2020; 10:e038012. [PMID: 32963069 PMCID: PMC7509965 DOI: 10.1136/bmjopen-2020-038012] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/10/2023] Open
Abstract
INTRODUCTION The risk for stroke in adults with congenital heart disease (ACHD) is increased, especially in the setting of commonly ensuing atrial arrhythmias (AA), namely atrial fibrillation, atrial flutter or intra-atrial re-entrant tachycardia. Data are limited regarding treatment with non-vitamin K oral anticoagulants in long-term studies involving patients with ACHD and AA. METHODS AND ANALYSIS PReventiOn of ThromboEmbolism in Adults with Congenital HearΤ disease and Atrial aRrhythmias is a prospective, multicenter, single-arm, non-interventional cohort study designed to investigate the safety and efficacy of apixaban for the prevention of thromboembolism in ACHD with AA in a 'real-world' setting. Eligible patients will be evaluated by the means of available registries and clinical counter. The study aims to accumulate approximately 500 patient-years of exposure to apixaban as part of routine care. Enrolment will take place at four ACHD centres in Greece. The first patient was enrolled in July 2019. The primary efficacy endpoint is a composite of stroke, systemic or pulmonary embolism and intracardiac thrombosis. The primary safety endpoint is major bleeding, according to the International Society on Thrombosis and Haemostasis bleeding criteria. ETHICS AND DISSEMINATION The study protocol has been approved by the institutional review board/independent ethics committee at each site prior to study commencement. All patients will provide written informed consent. Results will be disseminated at scientific meetings and published in peer-reviewed journals. TRIAL REGISTRATION NUMBER NCT03854149; Pre-results.
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Affiliation(s)
- Anastasios Kartas
- Cardiology, University General Hospital of Thessaloniki AHEPA, Thessaloniki, Greece
| | - Ioannis Doundoulakis
- Cardiology, University General Hospital of Thessaloniki AHEPA, Thessaloniki, Greece
| | - Despoina Ntiloudi
- Cardiology, University General Hospital of Thessaloniki AHEPA, Thessaloniki, Greece
| | - Athanasios Koutsakis
- Cardiology, University General Hospital of Thessaloniki AHEPA, Thessaloniki, Greece
| | - Diamantis Kosmidis
- Cardiology, University General Hospital of Thessaloniki AHEPA, Thessaloniki, Greece
| | - Georgios Rampidis
- Cardiology, University General Hospital of Thessaloniki AHEPA, Thessaloniki, Greece
| | | | | | - Afrodite Tzifa
- Paediatric Cardiology & Adult Congenital Heart Disease, Mitera, Hygeia Group, Athens, Attica, Greece
- Division of Biomedical Engineering and Imaging Sciences, King's College, London, England
| | - Dimosthenis Avramidis
- Paediatric Cardiology & Adult Congenital Heart Disease, Mitera, Hygeia Group, Athens, Attica, Greece
| | - Olga Ntzoyvara
- Cardiology, Onassis Cardiac Surgery Centre, Athens, Attica, Greece
| | - Sotiria Liori
- Cardiology, General University Hospital Attikon, Athens, Attica, Greece
| | - Tereza Mousiama
- Paediatric Cardiology & Adult Congenital Heart Disease, Mitera, Hygeia Group, Athens, Attica, Greece
| | | | - Haralambos Karvounis
- Cardiology, University General Hospital of Thessaloniki AHEPA, Thessaloniki, Greece
| | - George Giannakoulas
- Cardiology, University General Hospital of Thessaloniki AHEPA, Thessaloniki, Greece
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20
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Keenahan LA, Poondla RK, Franklin WJ, Ermis PR, Ketwaroo P, Opina A, Gandhi M. Pulmonary Embolism After Vaginal Delivery in a Fontan Patient. JACC Case Rep 2020; 2:1713-1715. [PMID: 34317041 PMCID: PMC8311981 DOI: 10.1016/j.jaccas.2020.04.051] [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: 03/04/2020] [Accepted: 04/15/2020] [Indexed: 06/13/2023]
Abstract
The Fontan procedure was created to address the mixing of pulmonary and systemic venous return in patients with a single functional ventricle. The patient in this case with a Fontan repair experienced multiple pulmonary emboli 10 days post-partum. We outline management and recommendations when treating these patients. (Level of Difficulty: Beginner.).
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Affiliation(s)
| | | | - Wayne J. Franklin
- Department of Cardiology, Phoenix Children’s Hospital, Phoenix, Arizona
| | - Peter R. Ermis
- Baylor College of Medicine, Houston, Texas
- Adult Congenital Heart Disease Program, Texas Children’s Hospital Houston, Texas
| | - Pamela Ketwaroo
- Baylor College of Medicine, Houston, Texas
- Department of Radiology, Texas Children’s Hospital, Houston, Texas
| | - Angeline Opina
- Baylor College of Medicine, Houston, Texas
- Adult Congenital Heart Disease Program, Texas Children’s Hospital Houston, Texas
| | - Manisha Gandhi
- Baylor College of Medicine, Houston, Texas
- Department of Obstetrics and Gynecology, Texas Children’s Pavilion for Women, Houston, Texas
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21
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Thrombosis and thromboprophylactic strategies in the adult with Fontan circulation. INTERNATIONAL JOURNAL OF CARDIOLOGY CONGENITAL HEART DISEASE 2020. [DOI: 10.1016/j.ijcchd.2020.100054] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022] Open
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22
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Stalikas N, Doundoulakis I, Karagiannidis E, Bouras E, Kartas A, Frogoudaki A, Karvounis H, Dimopoulos K, Giannakoulas G. Non-Vitamin K Oral Anticoagulants in Adults with Congenital Heart Disease: A Systematic Review. J Clin Med 2020; 9:E1794. [PMID: 32526897 PMCID: PMC7356004 DOI: 10.3390/jcm9061794] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2020] [Revised: 05/30/2020] [Accepted: 06/04/2020] [Indexed: 01/10/2023] Open
Abstract
Adults with congenital heart disease (ACHD) experience more thromboembolic complications than the general population. We systematically searched and critically appraised all studies on the safety and efficacy of non-vitamin-K oral anticoagulants (NOACs) in adult patients with various forms of congenital heart disease. PubMed and the Cochrane Central Register of Controlled Trials (CENTRAL) were used, with duplicate extraction of data and risk of bias assessment. The Newcastle-Ottawa quality assessment scale was used to assess study quality. Three studies fulfilled the inclusion criteria and were analyzed. The total number of participants was 766, with a total follow-up of 923 patient-years. The majority of patients (77%) received a NOAC for atrial arrhythmias, while the remainder were prescribed NOACs for secondary (19%) or primary (4%) thromboprophylaxis. The annual rate of thromboembolic and major bleeding events was low: 0.98% (95% CI: 0.51-1.86) and 1.74% (95% CI: 0.86-3.49) respectively. In Fontan patients, the annual rate of thromboembolic and major bleeding events was 3.13% (95% CI: 1.18-8.03) and 3.17% (95% CI: 0.15-41.39) respectively. NOACs appear safe and effective in ACHD without mechanical prostheses. Additional studies are, however, needed to confirm their efficacy in complex ACHD, especially those with a Fontan-type circulation.
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Affiliation(s)
- Nikolaos Stalikas
- First Department of Cardiology, AHEPA Hospital, Aristotle University of Thessaloniki, 54 636 Thessaloniki, Greece; (N.S.); (I.D.); (E.K.); (A.K.); (H.K.)
- Department of Internal Medicine, General Hospital of Edessa, 582 00 Proastio, Greece
| | - Ioannis Doundoulakis
- First Department of Cardiology, AHEPA Hospital, Aristotle University of Thessaloniki, 54 636 Thessaloniki, Greece; (N.S.); (I.D.); (E.K.); (A.K.); (H.K.)
- Department of Cardiology, 424 General Military Training Hospital, 54 124 Thessaloniki, Greece
| | - Efstratios Karagiannidis
- First Department of Cardiology, AHEPA Hospital, Aristotle University of Thessaloniki, 54 636 Thessaloniki, Greece; (N.S.); (I.D.); (E.K.); (A.K.); (H.K.)
| | - Emmanouil Bouras
- Department of Hygiene, Social-Preventive Medicine & Medical Statistics, Medical School, Aristotle University of Thessaloniki, 54 124 Thessaloniki, Greece;
| | - Anastasios Kartas
- First Department of Cardiology, AHEPA Hospital, Aristotle University of Thessaloniki, 54 636 Thessaloniki, Greece; (N.S.); (I.D.); (E.K.); (A.K.); (H.K.)
| | - Alexandra Frogoudaki
- Second Department of Cardiology, Attikon University Hospital, University of Athens, 124 62 Athens, Greece;
| | - Haralambos Karvounis
- First Department of Cardiology, AHEPA Hospital, Aristotle University of Thessaloniki, 54 636 Thessaloniki, Greece; (N.S.); (I.D.); (E.K.); (A.K.); (H.K.)
| | - Konstantinos Dimopoulos
- Adult Congenital Heart Centre and National Centre for Pulmonary Hypertension, Royal Brompton Hospital and Imperial College, London SW3 6NP, UK;
| | - George Giannakoulas
- First Department of Cardiology, AHEPA Hospital, Aristotle University of Thessaloniki, 54 636 Thessaloniki, Greece; (N.S.); (I.D.); (E.K.); (A.K.); (H.K.)
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23
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Broda CR, Downing TE, John AS. Diagnosis and management of the adult patient with a failing Fontan circulation. Heart Fail Rev 2020; 25:633-646. [DOI: 10.1007/s10741-020-09932-0] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
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Thromboembolic Events Are Independently Associated with Liver Stiffness in Patients with Fontan Circulation. J Clin Med 2020; 9:jcm9020418. [PMID: 32032996 PMCID: PMC7073638 DOI: 10.3390/jcm9020418] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2020] [Revised: 01/26/2020] [Accepted: 01/31/2020] [Indexed: 01/20/2023] Open
Abstract
Background: Thromboembolism (TE) and Fontan-associated liver disease (FALD) are common and lead to significant morbidity in Fontan circulations. Risk factors for TE and the potential link between TE and FALD are not well understood. The objective of this study was to evaluate the association between TE and the severity of FALD based on radiologic liver stiffness. Methods: Using a retrospective cohort study design, 85 Fontan patients (aged 27.7 ± 8.2 years) who had liver stiffness measurement were included. Multivariable logistic regression was used to determine independent associations with TE. Results: Sixteen patients (19%) had a history of TE after the Fontan procedure at a mean age of 21.4 ± 15.0 years. Patients with TE were significantly older at the time of the last evaluation (33.8 ± 11.7 vs. 26.3 ± 6.5 years, p = 0.03). Liver stiffness by MRI and ultrasound was higher in the TE group (5.1 ± 1.4 vs. 4.3 ± 1.2 kPa, p = 0.04 and 2.8 ± 0.4 vs. 2.4 ± 0.5 m/s, p = 0.04, respectively). On multivariable analysis, higher liver stiffness (odds ratio (OR): 2.12, p = 0.03) and older age (OR: 1.11, p = 0.03) were associated with TE. Conclusions: This study found an association between TE, age, and radiologic liver stiffness.
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Callegari A, Christmann M, Albisetti M, Kretschmar O, Quandt D. Single Ventricle Physiology Patients and Coagulation Abnormalities: Is There a Relationship With Hemodynamic Data and Postoperative Course? A Pilot Study. Clin Appl Thromb Hemost 2019; 25:1076029619888695. [PMID: 31822112 PMCID: PMC7019413 DOI: 10.1177/1076029619888695] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023] Open
Abstract
This study evaluates coagulation profiles of single ventricle (SV) patients in relationship to liver function, hemodynamic variables and outcome. Twenty-six children with SV anatomy were included. Advanced coagulation profiles, invasive preoperative hemodynamic parameters and clinical course were retrospectively analyzed. Median (interquartile range) age and weight at the time of blood sampling was 25.5 (31) months and 10.5 (6.9) kg. Sixteen patients (16/26; 62%) showed decreased antithrombin and/or protein C (PC) and/or free protein S (PS) function and/or free PS antigen. Two patients showed abnormal activated PC resistance ratio due to heterozygous factor V Leiden mutation and 1 heterozygous prothrombin G20210A mutation. Group comparison (abnormal coagulation profile [group 1; n = 16] versus normal coagulation profile [group 2; n = 10]) showed longer postoperative hospitalization time (p = .04), longer postoperative catecholamine support (p = .01), a higher incidence of thromboembolic events (p = .04), and chylothoraxes (p = .007) in group 1. In 5 (31%) of 16 group 1 patients, thromboembolic complications occurred: cerebral stroke (n = 1), intestinal ischemia (n = 2), thrombus formation in inferior caval vein (n = 1), and pulmonary vein (n = 1). Abnormalities in coagulation parameters are common in SV patients. Coagulation abnormalities constitute a preoperative risk factor and affect postoperative course.
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Affiliation(s)
- Alessia Callegari
- Pediatric Cardiology, Department of Surgery, Pediatric Heart Center, University Children's Hospital Zurich, Zurich, Switzerland.,Children's Research Centre, University Children's Hospital Zurich, Zurich, Switzerland
| | - Martin Christmann
- Pediatric Cardiology, Department of Surgery, Pediatric Heart Center, University Children's Hospital Zurich, Zurich, Switzerland.,Children's Research Centre, University Children's Hospital Zurich, Zurich, Switzerland
| | - Manuela Albisetti
- Children's Research Centre, University Children's Hospital Zurich, Zurich, Switzerland.,Division of Hematology, University Children's Hospital Zurich, Zurich, Switzerland
| | - Oliver Kretschmar
- Pediatric Cardiology, Department of Surgery, Pediatric Heart Center, University Children's Hospital Zurich, Zurich, Switzerland.,Children's Research Centre, University Children's Hospital Zurich, Zurich, Switzerland
| | - Daniel Quandt
- Pediatric Cardiology, Department of Surgery, Pediatric Heart Center, University Children's Hospital Zurich, Zurich, Switzerland.,Children's Research Centre, University Children's Hospital Zurich, Zurich, Switzerland
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Mongeon FP, Macle L, Beauchesne LM, Bouma BJ, Schwerzmann M, Mulder BJ, Khairy P. Non-Vitamin K Antagonist Oral Anticoagulants in Adult Congenital Heart Disease. Can J Cardiol 2019; 35:1686-1697. [DOI: 10.1016/j.cjca.2019.06.022] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2019] [Revised: 06/18/2019] [Accepted: 06/18/2019] [Indexed: 12/14/2022] Open
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Waldmann V, Laredo M, Abadir S, Mondésert B, Khairy P. Atrial fibrillation in adults with congenital heart disease. Int J Cardiol 2019; 287:148-154. [DOI: 10.1016/j.ijcard.2019.01.079] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/17/2018] [Revised: 12/12/2018] [Accepted: 01/22/2019] [Indexed: 12/13/2022]
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Yang H, Veldtman GR, Bouma BJ, Budts W, Niwa K, Meijboom F, Scognamiglio G, Egbe AC, Schwerzmann M, Broberg C, Morissens M, Buber J, Tsai S, Polyzois I, Post MC, Greutmann M, Van Dijk A, Mulder BJ, Aboulhosn J. Non-vitamin K antagonist oral anticoagulants in adults with a Fontan circulation: are they safe. Open Heart 2019; 6:e000985. [PMID: 31245011 PMCID: PMC6560660 DOI: 10.1136/openhrt-2018-000985] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/05/2018] [Revised: 04/24/2019] [Accepted: 05/06/2019] [Indexed: 12/30/2022] Open
Abstract
Background In Fontan patients with atrial arrhythmias (AA), non-vitamin K antagonist oral anticoagulants(NOACs) have a class III recommendation according to the Pediatric & Congenital Electrophysiology Society (PACES)/Heart Rhythm Society (HRS) guideline in 2014, due to lack of data on outcomes as opposed to evidence of harm. To address this gap in data, we investigated the safety and efficacy of NOACs in adults with a Fontan circulation in a worldwide study. Methods This is an international multicentre prospective cohort study, using data from the NOTE (non-vitamin K antagonist oral anticoagulants for thromboembolic prevention in patients with congenital heart disease) registry. The study population comprised consecutive adults with a Fontan circulation using NOACs. Follow-up took place at 6 months and yearly thereafter. The primary endpoints were thromboembolism and major bleeding. Secondary endpoint was minor bleeding. Results From April 2014 onward, 74 patients (mean age 32±10 years (range 18–68), 54% male) with a Fontan circulation using NOACs were included. During a median follow-up of 1.2 (IQR 0.8–2.0) years, three thromboembolic events (2.9 per 100 patient-years (95% CI 0.7 to 7.6)) and three major bleedings (2.9 per 100 patient-years (95% CI 0.7 to 7.6)) occurred in five atriopulmonary Fontan and one total cavopulmonary connection Fontan patients with AA. Fifteen patients experienced minor bleeding episodes (15.8 per 100 patient-years (95% CI 9.1 to 25.2)). In patients (n=37) using vitamin K antagonists (VKAs) prior to the initiation of NOAC, annual incidence of historical thromboembolic events and major bleeding were 2.4% (95% CI 0.4% to 7.4%) (n = 2) and 1.2% (95% CI 0.7% to 5.1%) (n = 1), respectively. Conclusions In this review of the largest Fontan cohort using NOACs with prospective follow-up, NOACs appear to be well tolerated and their efficacy and safety during short-term follow-up seem comparable to VKAs. Longer term data are required to confirm these promising short-term results.
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Affiliation(s)
- Hayang Yang
- Deparment of Cardiology, AMC, Amsterdam, The Netherlands
| | - Gruschen R Veldtman
- Adolescent and Adult Congenital Heart Disease Program, Cincinnati Children's Hospital Medical Centre, Cincinnati, Ohio, USA
| | - Berto J Bouma
- Cardiology, Academical Medical Center-University of Amsterdam, Amsterdam, The Netherlands
| | - Werner Budts
- Department of Cardiology, University Hospital Gasthuisberg, Leuven, Belgium
| | - Koichiro Niwa
- Deparment of Cardiology, St Luke's International Hospital, Tokyo, Japan
| | - Folkert Meijboom
- Cardiology, University Medical Centre Utrecht, Utrecht, Netherlands
| | | | - Alexander Chima Egbe
- Deparment of Medicine, Division of Cardiovascular Diseases, Mayo Clinic, Rochester, New York, USA
| | - Markus Schwerzmann
- Adult Congenital Heart Diseae Program, University Hospital Inselspital, Bern, Switzerland
| | - Craig Broberg
- Knight Cardiovascular Institute, Oregon Health & Sciences University, Portland, Oregon, USA
| | | | | | - Shane Tsai
- Department of Cardiology, University of Nebraska Medical Centre, Omaha, Nebraska, USA
| | - Ioannis Polyzois
- Adult Congenital Heart Centre and Centre for Pulmonary Hypertension, Royal Brompton Hospital, London, UK
| | - Martijn C Post
- Department of Cardiology, St Antonius Hospital, Nieuwegein, The Netherlands
| | | | - Arie Van Dijk
- Cardiology, Nijmegen University Medical Center, Nijmegen, The Netherlands
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Simmons MA, Elder RW. Modern Day Care of Patients With Single Ventricle Heart Disease: Late Complications of Fontan Palliation. CURRENT PEDIATRICS REPORTS 2019. [DOI: 10.1007/s40124-019-00192-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
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30
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Smith JMC, Andrade JG, Human D, Field TS. Adults With Complex Congenital Heart Disease: Cerebrovascular Considerations for the Neurologist. Front Neurol 2019; 10:329. [PMID: 31019488 PMCID: PMC6458261 DOI: 10.3389/fneur.2019.00329] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2018] [Accepted: 03/18/2019] [Indexed: 01/15/2023] Open
Abstract
As infant and childhood mortality has decreased in congenital heart disease, this population is increasingly reaching adulthood. Adults with congenital heart disease (ACHD) represent a group with increased risk of stroke, silent brain infarcts, and vascular cognitive impairment. Cyanotic and other complex cardiac lesions confer the greatest risk of these cerebrovascular insults. ACHD patients, in addition to having an increased risk of stroke from structural cardiac issues and associated physiological changes, may have an accelerated burden of conventional vascular risk factors, including hypertension and impaired glucose metabolism. Adult neurologists should be aware of the risks of clinically evident and subclinical cerebrovascular disease in this population. We review the existing evidence on primary and secondary stroke prevention in individuals with complex congenital heart disease, and identify knowledge gaps in need of further research, including treatment of acute stroke in this population. Multisystemic genetic syndromes are outside the scope of this review.
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Affiliation(s)
- Jonathan M C Smith
- M.D. Senior Pediatric Neurology Resident, University of British Columbia, Vancouver, BC, Canada
| | - Jason G Andrade
- FRCPC Clinical Associate Professor of Cardiology, University of British Columbia, Vancouver, BC, Canada
| | - Derek Human
- FRCPC, Clinical Professor of Pediatric Cardiology, BC Children's Hospital, University of British Columbia, Vancouver, BC, Canada
| | - Thalia S Field
- M.D. Senior Pediatric Neurology Resident, University of British Columbia, Vancouver, BC, Canada.,FRCPC Clinical Associate Professor of Cardiology, University of British Columbia, Vancouver, BC, Canada.,FRCPC, Clinical Professor of Pediatric Cardiology, BC Children's Hospital, University of British Columbia, Vancouver, BC, Canada
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Kay WA, Moe T, Suter B, Tennancour A, Chan A, Krasuski RA, Zaidi AN. Long Term Consequences of the Fontan Procedure and How to Manage Them. Prog Cardiovasc Dis 2018; 61:365-376. [PMID: 30236751 DOI: 10.1016/j.pcad.2018.09.005] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/11/2018] [Accepted: 09/11/2018] [Indexed: 12/12/2022]
Abstract
In 1971, Fontan and Baudet described a surgical technique for successful palliation of patients with tricuspid atresia. Subsequently, this technique has been applied to treat most forms of functional single ventricles and has become the current standard of care for long-term palliation of all patients with single ventricle congenital heart disease. Since 1971, the Fontan procedure has undergone several variations. These patients require lifelong management including a thorough knowledge of their anatomic substrate, hemodynamic status, management of rhythm and ventricular function along with multi organ evaluation. As these patients enter middle age, there is increasing awareness regarding the long-term complications and mortality. This review highlights the long-term outcomes of the Fontan procedure and management of late sequelae.
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Affiliation(s)
- W Aaron Kay
- Indiana University School of Medicine, Krannert Institute of Cardiology, IN.
| | - Tabitha Moe
- University of Arizona School of Medicine, Phoenix, AZ.
| | - Blair Suter
- Indiana University School of Medicine, Departments of Medicine and Pediatrics, IN.
| | - Andrea Tennancour
- Indiana University School of Medicine, Krannert Institute of Cardiology, IN.
| | - Alice Chan
- Children's Hospital at Montefiore, Montefiore Medical Center, Albert Einstein College of Medicine, NY.
| | | | - Ali N Zaidi
- Children's Hospital at Montefiore, Montefiore Medical Center, Albert Einstein College of Medicine, NY.
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