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Peled Y, Ducharme A, Kittleson M, Bansal N, Stehlik J, Amdani S, Saeed D, Cheng R, Clarke B, Dobbels F, Farr M, Lindenfeld J, Nikolaidis L, Patel J, Acharya D, Albert D, Aslam S, Bertolotti A, Chan M, Chih S, Colvin M, Crespo-Leiro M, D'Alessandro D, Daly K, Diez-Lopez C, Dipchand A, Ensminger S, Everitt M, Fardman A, Farrero M, Feldman D, Gjelaj C, Goodwin M, Harrison K, Hsich E, Joyce E, Kato T, Kim D, Luong ML, Lyster H, Masetti M, Matos LN, Nilsson J, Noly PE, Rao V, Rolid K, Schlendorf K, Schweiger M, Spinner J, Townsend M, Tremblay-Gravel M, Urschel S, Vachiery JL, Velleca A, Waldman G, Walsh J. International Society for Heart and Lung Transplantation Guidelines for the Evaluation and Care of Cardiac Transplant Candidates-2024. J Heart Lung Transplant 2024; 43:1529-1628.e54. [PMID: 39115488 DOI: 10.1016/j.healun.2024.05.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2024] [Accepted: 05/14/2024] [Indexed: 08/18/2024] Open
Abstract
The "International Society for Heart and Lung Transplantation Guidelines for the Evaluation and Care of Cardiac Transplant Candidates-2024" updates and replaces the "Listing Criteria for Heart Transplantation: International Society for Heart and Lung Transplantation Guidelines for the Care of Cardiac Transplant Candidates-2006" and the "2016 International Society for Heart Lung Transplantation Listing Criteria for Heart Transplantation: A 10-year Update." The document aims to provide tools to help integrate the numerous variables involved in evaluating patients for transplantation, emphasizing updating the collaborative treatment while waiting for a transplant. There have been significant practice-changing developments in the care of heart transplant recipients since the publication of the International Society for Heart and Lung Transplantation (ISHLT) guidelines in 2006 and the 10-year update in 2016. The changes pertain to 3 aspects of heart transplantation: (1) patient selection criteria, (2) care of selected patient populations, and (3) durable mechanical support. To address these issues, 3 task forces were assembled. Each task force was cochaired by a pediatric heart transplant physician with the specific mandate to highlight issues unique to the pediatric heart transplant population and ensure their adequate representation. This guideline was harmonized with other ISHLT guidelines published through November 2023. The 2024 ISHLT guidelines for the evaluation and care of cardiac transplant candidates provide recommendations based on contemporary scientific evidence and patient management flow diagrams. The American College of Cardiology and American Heart Association modular knowledge chunk format has been implemented, allowing guideline information to be grouped into discrete packages (or modules) of information on a disease-specific topic or management issue. Aiming to improve the quality of care for heart transplant candidates, the recommendations present an evidence-based approach.
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Affiliation(s)
- Yael Peled
- Leviev Heart & Vascular Center, Sheba Medical Center, Tel Hashomer, Ramat Gan, Israel; Faculty of Medical & Health Sciences, Tel Aviv University, Tel Aviv, Israel.
| | - Anique Ducharme
- Deparment of Medicine, Montreal Heart Institute, Université de Montréal, Montreal, Quebec, Canada.
| | - Michelle Kittleson
- Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, California, USA
| | - Neha Bansal
- Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Josef Stehlik
- Division of Cardiovascular Medicine, Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City, Utah, USA
| | - Shahnawaz Amdani
- Department of Pediatric Cardiology, Cleveland Clinic Children's, Cleveland, Ohio, USA
| | - Diyar Saeed
- Heart Center Niederrhein, Helios Hospital Krefeld, Krefeld, Germany
| | - Richard Cheng
- Division of Cardiology, University of Washington, Seattle, WA, USA
| | - Brian Clarke
- Division of Cardiology, University of British Columbia, St Paul's Hospital, Vancouver, British Columbia, Canada
| | - Fabienne Dobbels
- Academic Centre for Nursing and Midwifery, Department of Public Health and Primary Care, KU Leuven, Leuven, Belgium
| | - Maryjane Farr
- Division of Cardiology, Department of Internal Medicine, UT Southwestern Medical Center, Dallas, TX; Parkland Health System, Dallas, TX, USA
| | - JoAnn Lindenfeld
- Division of Cardiovascular Medicine, Vanderbilt University, Nashville, TN, USA
| | | | - Jignesh Patel
- Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, California, USA
| | - Deepak Acharya
- Division of Cardiovascular Diseases, University of Arizona Sarver Heart Center, Tucson, Arizona, USA
| | - Dimpna Albert
- Department of Paediatric Cardiology, Paediatric Heart Failure and Cardiac Transplant, Heart Center, King Faisal Specialist Hospital and Research Center, Riyadh, Saudi Arabia
| | - Saima Aslam
- Division of Infectious Diseases and Global Public Health, Department of Medicine, University of California San Diego, La Jolla, California, USA
| | - Alejandro Bertolotti
- Heart and Lung Transplant Service, Favaloro Foundation University Hospital, Buenos Aires, Argentina
| | - Michael Chan
- University of Alberta Hospital, Edmonton, Alberta, Canada
| | - Sharon Chih
- Heart Failure and Transplantation, Division of Cardiology, University of Ottawa Heart Institute, Ottawa, Ontario, Canada
| | - Monica Colvin
- Department of Cardiology, University of Michigan, Ann Arbor, MI; Scientific Registry of Transplant Recipients, Hennepin Healthcare Research Institute, Minneapolis, MN, USA
| | - Maria Crespo-Leiro
- Cardiology Department Complexo Hospitalario Universitario A Coruna (CHUAC), CIBERCV, INIBIC, UDC, La Coruna, Spain
| | - David D'Alessandro
- Massachusetts General Hospital, Boston; Harvard School of Medicine, Boston, MA, USA
| | - Kevin Daly
- Boston Children's Hospital & Harvard Medical School, Boston, MA, USA
| | - Carles Diez-Lopez
- Advanced Heart Failure and Heart Transplant Unit, Department of Cardiology, Hospital Universitari de Bellvitge, L'Hospitalet de Llobregat, Barcelona, Spain
| | - Anne Dipchand
- Division of Cardiology, Department of Paediatrics, Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
| | | | - Melanie Everitt
- Department of Pediatrics, University of Colorado School of Medicine, Aurora, CO, USA
| | - Alexander Fardman
- Leviev Heart & Vascular Center, Sheba Medical Center, Tel Hashomer, Ramat Gan, Israel; Faculty of Medical & Health Sciences, Tel Aviv University, Tel Aviv, Israel
| | - Marta Farrero
- Department of Cardiology, Hospital Clínic, Barcelona, Spain
| | - David Feldman
- Newark Beth Israel Hospital & Rutgers University, Newark, NJ, USA
| | - Christiana Gjelaj
- Department of Cardiovascular and Thoracic Surgery, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY, USA
| | - Matthew Goodwin
- Division of Cardiothoracic Surgery, University of Utah, Salt Lake City, UT, USA
| | - Kimberly Harrison
- Department of Pharmaceutical Services, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Eileen Hsich
- Cleveland Clinic Foundation, Division of Cardiovascular Medicine, Cleveland, OH, USA
| | - Emer Joyce
- Department of Cardiology, Mater University Hospital, Dublin, Ireland; School of Medicine, University College Dublin, Dublin, Ireland
| | - Tomoko Kato
- Department of Cardiology, International University of Health and Welfare School of Medicine, Narita, Chiba, Japan
| | - Daniel Kim
- University of Alberta & Mazankowski Alberta Heart Institute, Edmonton, Alberta, Canada
| | - Me-Linh Luong
- Division of Infectious Disease, Department of Medicine, University of Montreal Hospital Center, Montreal, Quebec, Canada
| | - Haifa Lyster
- Department of Heart and Lung Transplantation, The Royal Brompton and Harefield NHS Foundation Trust, Harefield Hospital, Harefield, Middlesex, UK
| | - Marco Masetti
- Heart Failure and Transplant Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | | | - Johan Nilsson
- Department of Cardiothoracic and Vascular Surgery, Skane University Hospital, Lund, Sweden
| | | | - Vivek Rao
- Division of Cardiac Surgery, University of Toronto, Toronto, Ontario, Canada
| | - Katrine Rolid
- Department of Cardiology, Oslo University Hospital, Rikshospitalet, Oslo, Norway
| | - Kelly Schlendorf
- Division of Cardiology, Vanderbilt University Medical Center, Nashville, TN, USA
| | | | - Joseph Spinner
- Section of Pediatric Cardiology, Texas Children's Hospital, Baylor College of Medicine, Houston, TX, USA
| | - Madeleine Townsend
- Division of Pediatric Cardiology, Stollery Children's Hospital, Edmonton, Alberta, Canada
| | - Maxime Tremblay-Gravel
- Deparment of Medicine, Montreal Heart Institute, Université?de Montréal, Montreal, Quebec, Canada
| | - Simon Urschel
- Stollery Children's Hospital, University of Alberta, Edmonton, Alberta, Canada
| | - Jean-Luc Vachiery
- Department of Cardiology, Cliniques Universitaires de Bruxelles, Hôpital Académique Erasme, Bruxelles, Belgium
| | - Angela Velleca
- Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, California, USA
| | - Georgina Waldman
- Department of Pharmacy, Massachusetts General Hospital, Boston, MA, USA
| | - James Walsh
- Allied Health Research Collaborative, The Prince Charles Hospital, Brisbane; Heart Lung Institute, The Prince Charles Hospital, Brisbane, Australia
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2
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Das T, Rampersad P, Ghobrial J. Caring for the Critically Ill Adult Congenital Heart Disease Patient. Curr Cardiol Rep 2024; 26:283-291. [PMID: 38592571 PMCID: PMC11136725 DOI: 10.1007/s11886-024-02034-5] [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: 02/21/2024] [Indexed: 04/10/2024]
Abstract
PURPOSE OF REVIEW This review aims to discuss the unique challenges that adult congenital heart disease (ACHD) patients present in the intensive care unit. RECENT FINDINGS Recent studies suggest that ACHD patients make up an increasing number of ICU admissions, and that their care greatly improves in centers with specialized ACHD care. Common reasons for admission include arrhythmia, hemorrhage, heart failure, and pulmonary disease. It is critical that the modern intensivist understand not only the congenital anatomy and subsequent repairs an ACHD patient has undergone, but also how that anatomy can predispose the patient to critical illness. Additionally, intensivists should rely on a multidisciplinary team, which includes an ACHD specialist, in the care of these patients.
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Affiliation(s)
- Thomas Das
- Heart, Vascular and Thoracic Institute, Cleveland Clinic, 9500 Euclid Avenue, Cleveland, OH, 44195, USA
| | - Penelope Rampersad
- Heart, Vascular and Thoracic Institute, Cleveland Clinic, 9500 Euclid Avenue, Cleveland, OH, 44195, USA
| | - Joanna Ghobrial
- Heart, Vascular and Thoracic Institute, Cleveland Clinic, 9500 Euclid Avenue, Cleveland, OH, 44195, USA.
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3
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Marshall V WH, McConnell P. Surgical Considerations in Adult Congenital Heart Disease Heart Failure. Heart Fail Clin 2024; 20:199-208. [PMID: 38462324 DOI: 10.1016/j.hfc.2023.12.007] [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] [Indexed: 03/12/2024]
Abstract
Surgical intervention is often used in the management of heart failure in patients with adult congenital heart disease. This review addresses anatomic variations and complications due to prior surgical interventions, including sternal reentry, collateral vessels, and the neo-aortic root after the Damus-Kaye-Stansel procedure. Surgical considerations for systemic atrioventricular valvular surgery, Fontan revision, and advanced heart failure therapies including ventricular assist devices, heart transplant, and combined heart-liver transplant are discussed, with a focus on unique patient populations including those with systemic right ventricles and those with Fontan circulation.
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Affiliation(s)
- William H Marshall V
- Department of Internal Medicine, Division of Cardiovascular Medicine, Davis Heart and Lung Research Institute, Wexner Medical Center at The Ohio State University, 473 West 12th Avenue Suite 200, Columbus, OH 43210, USA; The Heart Center, Nationwide Children's Hospital, Columbus, OH, USA.
| | - Patrick McConnell
- Department of Cardiothoracic Surgery, Nationwide Children's Hospital, The Heart Center, 700 Children's Drive, 4th Floor Tower, Columbus, OH 43105, USA; Department of Surgery, Division of Cardiac Surgery, The Ohio State University, Columbus, OH, USA
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4
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Duarte VE, Rajpal S. The Role of Multimodality Imaging in the Evaluation of Heart Failure and Surgical Transplant Planning of Patients with Adult Congenital Heart Disease. Heart Fail Clin 2024; 20:189-198. [PMID: 38462323 DOI: 10.1016/j.hfc.2024.01.002] [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] [Indexed: 03/12/2024]
Abstract
Cardiac imaging is pivotal in evaluating ventricular function, residual lesions, and long-term complications in patients with adult congenital heart disease (ACHD). Longitudinal imaging in ACHD is key for the timely identification of patients requiring evaluation for advanced therapies. The guidelines recommend routine imaging surveillance. In all patients undergoing evaluation with cardiac imaging, it is critical that studies are performed at centers with expertise and that the imaging protocols are tailored to the specific condition. The authors briefly highlight the utility and diagnostic yield of different modalities, review pertinent considerations for special populations, and focus on imaging for transplant planning.
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Affiliation(s)
- Valeria E Duarte
- Department of Cardiology, Houston Methodist DeBakey Heart and Vascular Center, 6550 Fannin St, Smith Tower suite 1801, Houston, TX 77030, USA.
| | - Saurabh Rajpal
- Department of Cardiology, Division of Cardiovascular Medicine, The Ohio State University, 473 W 12th Avenue, Davis Heart and Lung Research Institute, Columbus, OH 43210, USA
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5
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Iyengar A, Weingarten N, Herbst DA, Helmers MR, Kelly JJ, Meldrum D, Dominic J, Guevara-Plunkett S, Atluri P. Waitlist Trends in Heart-Liver Transplantation With Updated US Heart Allocation System. Ann Thorac Surg 2023; 116:1270-1275. [PMID: 35987345 DOI: 10.1016/j.athoracsur.2022.08.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/30/2022] [Revised: 07/10/2022] [Accepted: 08/01/2022] [Indexed: 11/28/2022]
Abstract
BACKGROUND In October 2018, the United States implemented a change in the donor heart allocation policy from a three-tiered to a six-tiered status system. The purpose of the current study was to examine changes in waitlist patterns among patients listed for concomitant heart-liver transplantation with implementation of the new allocation system. METHODS Patients listed for heart-liver transplantation between January 1, 2012, and June 30, 2021, were identified from the United Network for Organ Sharing database. Patients were grouped by era according to initial list date before or after October 18, 2018. Competing risks regression for mortality, transplantation, removal from waitlist due to illness was performed according to the method of Fine and Gray. Waitlist data were censored at 3 years from initial listing. RESULTS Overall, 523 patients were identified, of whom 310 were listed before (era 1, 59%) and 213 after (era 2, 41%) allocation change. Patients in era 1 were older, had more restrictive cardiomyopathy, and more preoperative inotrope use (all P < .05). However, patients in era 2 has longer ischemic times (3.5 ± 1.1 vs 3.1 ± 1.1 hours, P < .01) and more intraaortic balloon pump use (8.9% vs 3.9%, P = .016). Era 2 was associated with lower subdistribution hazard for death (hazard ratio 0.37; 95% CI, 0.13-1.02; P = .054) and increased transplantation (hazard ratio 1.35; 95% CI, 1.06-1.72; P = .015). CONCLUSIONS The implementation of the US donor heart allocation policy was associated with more preoperative intraaortic balloon pump use for patients listed for heart-liver transplantation. Despite that, the modern era was associated with lower waitlist mortality and more frequent transplantation, without increased risk of delisting due to illness.
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Affiliation(s)
- Amit Iyengar
- Division of Cardiovascular Surgery, Department of Surgery, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Noah Weingarten
- Division of Cardiovascular Surgery, Department of Surgery, University of Pennsylvania, Philadelphia, Pennsylvania
| | - David A Herbst
- Division of Cardiovascular Surgery, Department of Surgery, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Mark R Helmers
- Division of Cardiovascular Surgery, Department of Surgery, University of Pennsylvania, Philadelphia, Pennsylvania
| | - John J Kelly
- Division of Cardiovascular Surgery, Department of Surgery, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Danika Meldrum
- Division of Cardiovascular Surgery, Department of Surgery, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Jessica Dominic
- Division of Cardiovascular Surgery, Department of Surgery, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Sara Guevara-Plunkett
- Division of Cardiovascular Surgery, Department of Surgery, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Pavan Atluri
- Division of Cardiovascular Surgery, Department of Surgery, University of Pennsylvania, Philadelphia, Pennsylvania.
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6
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Matsukuma K, Yeh MM. Practical Guide, Challenges, and Pitfalls in Liver Fibrosis Staging. Surg Pathol Clin 2023; 16:457-472. [PMID: 37536882 DOI: 10.1016/j.path.2023.04.002] [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: 08/05/2023]
Abstract
Liver fibrosis staging has many challenges, including the large number of proposed staging systems, the heterogeneity of the histopathologic changes of many primary liver diseases, and the potential for slight differences in histologic interpretation to significantly affect clinical management. This review focuses first on fibrosis regression. Following this, each of the major categories of liver disease is discussed in regard to (1) appropriate fibrosis staging systems, (2) emerging concepts, (3) current clinical indications for liver biopsy, (4) clinical decisions determined by fibrosis stage, and (5) histologic challenges and pitfalls related to staging.
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Affiliation(s)
- Karen Matsukuma
- University of California Davis, Pathology and Laboratory Medicine, 4400 V Street, Sacramento, CA 95817, USA.
| | - Matthew M Yeh
- University of Washington Medical Center - Montlake, Box 356100, 1959 NE Pacific Street, Seattle, WA 98195, USA
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7
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Kittleson MM, Sharma K, Brennan DC, Cheng XS, Chow SL, Colvin M, DeVore AD, Dunlay SM, Fraser M, Garonzik-Wang J, Khazanie P, Korenblat KM, Pham DT. Dual-Organ Transplantation: Indications, Evaluation, and Outcomes for Heart-Kidney and Heart-Liver Transplantation: A Scientific Statement From the American Heart Association. Circulation 2023; 148:622-636. [PMID: 37439224 DOI: 10.1161/cir.0000000000001155] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 07/14/2023]
Abstract
Although heart transplantation is the preferred therapy for appropriate patients with advanced heart failure, the presence of concomitant renal or hepatic dysfunction can pose a barrier to isolated heart transplantation. Because donor organ supply limits the availability of organ transplantation, appropriate allocation of this scarce resource is essential; thus, clear guidance for simultaneous heart-kidney transplantation and simultaneous heart-liver transplantation is urgently required. The purposes of this scientific statement are (1) to describe the impact of pretransplantation renal and hepatic dysfunction on posttransplantation outcomes; (2) to discuss the assessment of pretransplantation renal and hepatic dysfunction; (3) to provide an approach to patient selection for simultaneous heart-kidney transplantation and simultaneous heart-liver transplantation and posttransplantation management; and (4) to explore the ethics of multiorgan transplantation.
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8
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Lewis MJ, Reardon LC, Aboulhosn J, Haeffele C, Chen S, Kim Y, Fuller S, Forbess L, Alshawabkeh L, Urey MA, Book WM, Rodriguez F, Menachem JN, Clark DE, Valente AM, Carazo M, Egbe A, Connolly HM, Krieger EV, Angiulo J, Cedars A, Ko J, Jacobsen RM, Earing MG, Cramer JW, Ermis P, Broda C, Nugaeva N, Ross H, Awerbach JD, Krasuski RA, Rosenbaum M. Morbidity and Mortality in Adult Fontan Patients After Heart or Combined Heart-Liver Transplantation. J Am Coll Cardiol 2023; 81:2161-2171. [PMID: 37257951 DOI: 10.1016/j.jacc.2023.03.422] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/03/2023] [Revised: 03/07/2023] [Accepted: 03/27/2023] [Indexed: 06/02/2023]
Abstract
BACKGROUND An increasing number of adult Fontan patients require heart transplantation (HT) or combined heart-liver transplant (CHLT); however, data regarding outcomes and optimal referral time remain limited. OBJECTIVES The purpose of this study was to define survivorship post-HT/CHLT and predictors of post-transplant mortality, including timing of referral, in the adult Fontan population. METHODS A retrospective cohort study of adult Fontan patients who underwent HT or CHLT across 15 centers in the United States and Canada was performed. Inclusion criteria included the following: 1) Fontan; 2) HT/CHLT referral; and 3) age ≥16 years at the time of referral. Date of "failing" Fontan was defined as the earliest of the following: worsening fluid retention, new ascites, refractory arrhythmia, "failing Fontan" diagnosis by treating cardiologist, or admission for heart failure. RESULTS A total of 131 patients underwent transplant, including 40 CHLT, from 1995 to 2021 with a median post-transplant follow-up time of 1.6 years (Q1 0.35 years, Q3 4.3 years). Survival was 79% at 1 year and 66% at 5 years. Survival differed by decade of transplantation and was 87% at 1 year and 76% at 5 years after 2010. Time from Fontan failure to evaluation (HR/year: 1.23 [95% CI: 1.11-1.36]; P < 0.001) and markers of failure, including NYHA functional class IV (HR: 2.29 [95% CI: 1.10-5.28]; P = 0.050), lower extremity varicosities (HR: 3.92 [95% CI: 1.68-9.14]; P = 0.002), and venovenous collaterals (HR: 2.70 [95% CI: 1.17-6.20]; P = 0.019), were associated with decreased post-transplant survival at 1 year in a bivariate model that included transplant decade. CONCLUSIONS In our multicenter cohort, post-transplant survival improved over time. Late referral after Fontan failure and markers of failing Fontan physiology, including worse functional status, lower extremity varicosities, and venovenous collaterals, were associated with post-transplant mortality.
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Affiliation(s)
- Matthew J Lewis
- Division of Cardiology, Department of Medicine, Columbia University Medical Center, New York, New York, USA.
| | - Leigh C Reardon
- Department of Medicine, Division of Cardiology, Ahmason/UCLA Adult Congenital Heart Disease Center, University of California Los Angeles, Los Angeles, California, USA
| | - Jamil Aboulhosn
- Department of Medicine, Division of Cardiology, Ahmason/UCLA Adult Congenital Heart Disease Center, University of California Los Angeles, Los Angeles, California, USA
| | - Christiane Haeffele
- Division of Pediatric Cardiology, Department of Pediatrics, Stanford University, Palo Alto, California, USA
| | - Sharon Chen
- Division of Pediatric Cardiology, Department of Pediatrics, Stanford University, Palo Alto, California, USA
| | - Yuli Kim
- Division of Cardiology, Department of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Stephanie Fuller
- Division of Cardiothoracic Surgery, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Lisa Forbess
- Division of Pediatric Cardiology, Department of Pediatrics, Northwestern University, Ann and Robert Lurie Children's Hospital, Chicago, Illinois, USA
| | - Laith Alshawabkeh
- Division of Cardiology, Department of Medicine, University of California, San Diego, California, USA
| | - Marcus A Urey
- Division of Cardiology, Department of Medicine, University of California, San Diego, California, USA
| | - Wendy M Book
- Division of Cardiology, Department of Medicine, Emory University, Atlanta, Georgia, USA
| | - Fred Rodriguez
- Division of Cardiology, Department of Medicine, Emory University, Atlanta, Georgia, USA
| | - Jonathan N Menachem
- Division of Cardiology, Department of Medicine, Vanderbilt University, Nashville, Tennessee, USA
| | - Daniel E Clark
- Division of Cardiology, Department of Medicine, Vanderbilt University, Nashville, Tennessee, USA
| | - Anne Marie Valente
- Department of Cardiology, Boston Children's Hospital, Division of Cardiology, Department of Medicine, Brigham and Women's Hospital, Harvard University, Boston, Massachusetts, USA
| | - Matthew Carazo
- Department of Cardiology, Boston Children's Hospital, Division of Cardiology, Department of Medicine, Brigham and Women's Hospital, Harvard University, Boston, Massachusetts, USA
| | - Alexander Egbe
- Division of Cardiology, Department of Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Heidi M Connolly
- Division of Cardiology, Department of Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Eric V Krieger
- Division of Cardiology, Department of Medicine University of Washington and Seattle Children's Hospital, Seattle, Washington, USA
| | - Jilian Angiulo
- Division of Cardiology, Department of Medicine University of Washington and Seattle Children's Hospital, Seattle, Washington, USA
| | - Ari Cedars
- Division of Cardiology, Department of Medicine, UT Southwestern, Dallas, Texas, USA
| | - Jong Ko
- Division of Cardiology, Department of Medicine, UT Southwestern, Dallas, Texas, USA
| | - Roni M Jacobsen
- Division of Cardiology, Department of Medicine, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | - Michael G Earing
- Division of Cardiology, Department of Medicine, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | - Jonathan W Cramer
- Department of Pediatrics and Internal Medicine, Division of Cardiology, University of Nebraska Medical Center, Omaha, Nebraska, USA
| | - Peter Ermis
- Division of Pediatric Cardiology and Adult Congenital Heart Disease, Department of Pediatrics, Texas Children's Hospital/Baylor College of Medicine, Houston, Texas, USA
| | - Christopher Broda
- Division of Pediatric Cardiology and Adult Congenital Heart Disease, Department of Pediatrics, Texas Children's Hospital/Baylor College of Medicine, Houston, Texas, USA
| | - Natalia Nugaeva
- Division of Cardiology, Department of Medicine, University Health Network, Toronto, Ontario, Canada
| | - Heather Ross
- Division of Cardiology, Department of Medicine, University Health Network, Toronto, Ontario, Canada
| | - Jordan D Awerbach
- Division of Cardiology, Phoenix Children's, Phoenix, AZ, Divisions of Child Health and Internal Medicine, University of Arizona College of Medicine-Phoenix, Phoenix, Arizona, USA
| | - Richard A Krasuski
- Division of Cardiology, Department of Medicine, Duke University, Raleigh Durham, North Carolina, USA
| | - Marlon Rosenbaum
- Division of Cardiology, Department of Medicine, Columbia University Medical Center, New York, New York, USA
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9
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Griffiths ER, Lambert LM, Ou Z, Shaaban A, Rezvani M, Carlo WF, Schumacher KR, DiPaola F, O'Connor MJ, Nandi D, Zangwill S, McCulloch MA, Friedland-Little JM, West SC, Lee TM, Alejos JC, Chen S, Molina KM. Fontan-associated liver disease after heart transplant. Pediatr Transplant 2023; 27:e14435. [PMID: 36380561 DOI: 10.1111/petr.14435] [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: 02/09/2022] [Revised: 09/14/2022] [Accepted: 09/26/2022] [Indexed: 11/18/2022]
Abstract
BACKGROUND Fontan associated liver disease (FALD) potentially impacts Fontan patients undergoing heart transplant. This multi-center study sought to identify pre-transplant risk factors and characterize any post-transplant liver recovery in those patients undergoing heart-alone transplant. METHODS Review of Fontan patients at 12 pediatric institutions who underwent heart transplant between 2001-2019. Radiologists reviewed pre and post-transplant liver imaging for fibrosis. Laboratory, pathology and endoscopy studies were reviewed. RESULTS 156 patients underwent transplant due to decreased ventricular function (49%), protein losing enteropathy (31%) or plastic bronchitis (10%); median age at transplant was 13.6 years (interquartile range IQR 7.8, 17.2) with a median of 9.3 years (IQR 3.2, 13.4) between the Fontan operation and transplant. Few patients had pre-transplant endoscopy (18%), and liver biopsy (19%). There were 31 deaths (20%). The median time from transplant to death was 0.5 years (95% Confidence Interval CI 0.0, 3.6). The five-year survival was 73% (95% CI 64%, 83%). Deaths were related to cardiac causes in 68% (21/31) and infection in 6 (19%). A pre-transplant elevation in bilirubin was a predictor of death. Higher platelet levels were protective. Immediate post-transplant elevations in creatinine, AST, ALT, and INR were predictive of death. Advanced liver fibrosis identified on ultrasound, computed tomography, or magnetic resonance imaging was not predictive of death. Liver imaging suggested some improvement in liver congestion post-transplant. CONCLUSIONS Elevated bilirubin, but not fibrosis on liver imaging, was associated with post-heart transplant mortality in Fontan patients in this multicenter retrospective study. Additionally, heart transplant may alter the progression of FALD.
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Affiliation(s)
- Eric R Griffiths
- Pediatric Cardiothoracic Surgery, University of Utah, Primary Children's Hospital, Salt Lake City, Utah, USA
| | - Linda M Lambert
- Pediatric Cardiothoracic Surgery, University of Utah, Primary Children's Hospital, Salt Lake City, Utah, USA
| | - Zhining Ou
- Division of Epidemiology, Department of Internal Medicine, University of Utah, Salt Lake City, Utah, USA
| | - Akraam Shaaban
- Department of Radiology, University of Utah, Salt Lake City, Utah, USA
| | - Maryam Rezvani
- Department of Radiology, University of Utah, Salt Lake City, Utah, USA
| | - Waldemar F Carlo
- Department of Pediatrics, University of Alabama Birmingham, Birmingham, Alabama, USA
| | - Kurt R Schumacher
- Pediatric Cardiology, C.S. Mott Children's Hospital, University of Michigan, Ann Arbor, Michigan, USA
| | - Frank DiPaola
- Department of Pediatrics, Division of Hepatology, University of Virginia Children's Hospital, Charlottesville, Virginia, USA
| | - Matthew J O'Connor
- Pediatric Cardiology, Children's Hospital of Philadelphia, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Deipanjan Nandi
- Pediatric Cardiology, Nationwide Children's Hospital, The Ohio State University, Columbus, Ohio, USA
| | - Steven Zangwill
- Pediatric Cardiology, Phoenix Children's Hospital, Phoenix, Arizona, USA
| | - Michael A McCulloch
- Pediatric Cardiology, University of Virginia Children's Hospital, Charlottesville, Virginia, USA
| | - Joshua M Friedland-Little
- Pediatric Cardiology, Seattle Children's Hospital, University of Washington, Seattle, Washington, USA
| | - Shawn C West
- Pediatric Cardiology, Children's Hospital of Pittsburg, University of Pittsburg Medical Center, Pittsburgh, Pennsylvania, USA
| | - Teresa M Lee
- Pediatric Cardiology, Columbia University Medical Center, New York, New York, USA
| | - Juan C Alejos
- Pediatric Cardiology, UCLA Mattel Children's Hospital, Los Angeles, California, USA
| | - Sharon Chen
- Pediatric Cardiology, Stanford University, Stanford, California, USA
| | - Kimberly M Molina
- Division of Pediatric Cardiology, University of Utah, Primary Children's Hospital, Salt Lake City, Utah, USA
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10
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Velleca A, Shullo MA, Dhital K, Azeka E, Colvin M, DePasquale E, Farrero M, García-Guereta L, Jamero G, Khush K, Lavee J, Pouch S, Patel J, Michaud CJ, Shullo M, Schubert S, Angelini A, Carlos L, Mirabet S, Patel J, Pham M, Urschel S, Kim KH, Miyamoto S, Chih S, Daly K, Grossi P, Jennings D, Kim IC, Lim HS, Miller T, Potena L, Velleca A, Eisen H, Bellumkonda L, Danziger-Isakov L, Dobbels F, Harkess M, Kim D, Lyster H, Peled Y, Reinhardt Z. The International Society for Heart and Lung Transplantation (ISHLT) Guidelines for the Care of Heart Transplant Recipients. J Heart Lung Transplant 2022; 42:e1-e141. [PMID: 37080658 DOI: 10.1016/j.healun.2022.10.015] [Citation(s) in RCA: 117] [Impact Index Per Article: 58.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
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11
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Velleca A, Shullo MA, Dhital K, Azeka E, Colvin M, DePasquale E, Farrero M, García-Guereta L, Jamero G, Khush K, Lavee J, Pouch S, Patel J, Michaud CJ, Shullo M, Schubert S, Angelini A, Carlos L, Mirabet S, Patel J, Pham M, Urschel S, Kim KH, Miyamoto S, Chih S, Daly K, Grossi P, Jennings D, Kim IC, Lim HS, Miller T, Potena L, Velleca A, Eisen H, Bellumkonda L, Danziger-Isakov L, Dobbels F, Harkess M, Kim D, Lyster H, Peled Y, Reinhardt Z. The International Society for Heart and Lung Transplantation (ISHLT) Guidelines for the Care of Heart Transplant Recipients. J Heart Lung Transplant 2022. [DOI: 10.1016/j.healun.2022.09.023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
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12
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Cieplucha A, Budts W, Gewillig M, Van De Bruaene A. Fontan-associated Liver Disease in Adults: What a Cardiologist Needs to Know. A Comprehensive Review for Clinical Practitioners. US CARDIOLOGY REVIEW 2022. [DOI: 10.15420/usc.2022.02] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
Nowadays most patients with a univentricular heart after Fontan repair survive until adulthood. One of the hallmarks of Fontan circulation is
permanently elevated central venous pressure, which leads to congestive hepatopathy. Subsequently, liver fibrosis, cirrhosis, or hepatocellular carcinoma may occur, all of them constituting an entity called Fontan-associated liver disease (FALD). Given that these complications convey poor
prognosis, the need for life-long hepatic surveillance is not in doubt. Many serum biomarkers and sophisticated imaging techniques have been proposed to avoid invasive liver biopsy in this cohort, but none proved to be a relevant surrogate of liver fibrosis seen in histopathological specimens. The surveillance models proposed to date require an extensive diagnostic work-up, which can be problematic, particularly in resource-depleted countries. Moreover, the question of combined heart–liver transplant is gaining more attention in the Fontan cohort. The aim of this study is to provide practical information on the pathophysiology of FALD and to propose a simplified framework for the routine assessment of liver status in Fontan patients that would be helpful in the decision-making process.
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Affiliation(s)
- Aleksandra Cieplucha
- First Department of Cardiology, Poznan University of Medical Sciences, Poznan, Poland
| | - Werner Budts
- Department of Cardiovascular Sciences, KU Leuven, Belgium
| | - Marc Gewillig
- Division of Pediatric Cardiology, University Hospitals Leuven, Belgium
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13
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Emamaullee J, Martin S, Goldbeck C, Rocque B, Barbetta A, Kohli R, Starnes V. Evaluation of Fontan-associated Liver Disease and Ethnic Disparities in Long-term Survivors of the Fontan Procedure: A Population-based Study. Ann Surg 2022; 276:482-490. [PMID: 35766375 PMCID: PMC9388565 DOI: 10.1097/sla.0000000000005581] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVES Fontan-associated liver disease (FALD) has emerged as a nearly universal chronic comorbidity in patients with univentricular congenital heart disease who undergo the Fontan procedure. There is a paucity of data reporting long-term outcomes and the impact of FALD in this population. METHODS Patients who underwent the Fontan procedure between 1992 and 2018 were identified using California registry data. Presumed FALD was assessed by a composite of liver disease codes. Primary outcomes were mortality and transplant. Multivariable regression and survival analyses were performed. RESULTS Among 1436 patients post-Fontan, 75.9% studied were adults, with a median follow-up of 12.6 (8.4, 17.3) years. The population was 46.3% Hispanic. Overall survival at 20 years was >80%, but Hispanic patients had higher mortality risk compared with White patients [hazard ratio: 1.49 (1.09-2.03), P =0.012]. Only 225 patients (15.7%) had presumed FALD, although >54% of patients had liver disease by age 25. FALD was associated with later deaths [median: 9.6 (6.4-13.2) years post-Fontan] compared with patients who died without liver disease [4.1 (1.4-10.4) years, P =0.02]. Patients with FALD who underwent combined heart liver transplant had 100% survival at 5 years, compared with only 70.7% of patients who underwent heart transplant alone. CONCLUSIONS In this population-based analysis of long-term outcomes post-Fontan, Hispanic ethnicity was associated with increased all-cause mortality. Further, the prevalence of FALD is underrecognized, but our data confirms that its incidence increases with age. FALD is associated with late mortality but excellent posttransplant survival. This emphasizes the need for FALD-specific liver surveillance strategies in patients post-Fontan.
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Affiliation(s)
- Juliet Emamaullee
- Keck School of Medicine, University of Southern California, Los Angeles, CA
- Department of Surgery, University of Southern California, Los Angeles, CA
| | - Sean Martin
- Keck School of Medicine, University of Southern California, Los Angeles, CA
- Department of Surgery, University of Southern California, Los Angeles, CA
| | - Cameron Goldbeck
- Keck School of Medicine, University of Southern California, Los Angeles, CA
- Department of Surgery, University of Southern California, Los Angeles, CA
| | - Brittany Rocque
- Keck School of Medicine, University of Southern California, Los Angeles, CA
- Department of Surgery, University of Southern California, Los Angeles, CA
| | - Arianna Barbetta
- Keck School of Medicine, University of Southern California, Los Angeles, CA
- Department of Surgery, University of Southern California, Los Angeles, CA
| | - Rohit Kohli
- Keck School of Medicine, University of Southern California, Los Angeles, CA
- Department of Pediatrics, University of Southern California, Los Angeles, CA
- Division of Gastroenterology, Children’s Hospital Los Angeles, Los Angeles, CA
| | - Vaughn Starnes
- Keck School of Medicine, University of Southern California, Los Angeles, CA
- Department of Surgery, University of Southern California, Los Angeles, CA
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14
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Rezkalla J, Kamath M, Reardon L. Observations and Single-Center Outcomes in Orthotopic Heart Transplant for Patients With Adult Congenital Heart Disease: A Call for Equity and Parity. Transplant Proc 2022; 54:1887-1893. [PMID: 35933235 DOI: 10.1016/j.transproceed.2022.04.031] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2021] [Revised: 03/08/2022] [Accepted: 04/13/2022] [Indexed: 11/15/2022]
Abstract
BACKGROUND For persons with adult congenital heart disease (ACHD), optimum patient selection and eligibility for orthotopic heart transplant (OHT) is not well defined. There is difficulty quantifying risk in patients with ACHD, leading to variability in OHT listing time and status. They are often disadvantaged due to a lack of mechanical support options, a shortage of congenital surgeons, and encounters with risk adverse health care programs. We examined patient characteristics and outcomes of a contemporary cohort of patients with ACHD undergoing OHT at a single high-volume Adult Congenital Heart Association accredited transplant center. METHODS Retrospective analysis of 49 consecutive patients with ACHD who underwent OHT from November 2010 through March 2020 was performed. Survival analysis was performed using Kaplan-Meier analysis. RESULTS Survival at 1 month, 1 year, 3 years, and 10 years was 94%, 92%, 92%, and 83%, respectively. CONCLUSIONS This study highlights the diversity and complexity of the population with ACHD proceeding to OHT as well as the multispecialty care needed to overcome disadvantages and optimize survival. Continued national discussions and policy adjustments will be necessary to bring parity and equity to this unique population.
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Affiliation(s)
- Joshua Rezkalla
- Department of Medicine-Pediatrics, David Geffen School of Medicine, University of California Los Angeles, Los Angeles, California.
| | - Megan Kamath
- Ahmanson/UCLA Cardiomyopathy Center, Los Angeles, California
| | - Leigh Reardon
- Ahmanson/UCLA Adult Congenital Heart Disease Center, Los Angeles, California
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15
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Serai S, Tsitsiou Y, Wilkins B, Ghosh A, Cahill A, Biko D, Rychik J, Rand E, Goldberg D. MR elastography-based staging of liver fibrosis in Fontan procedure associated liver disease is confounded by effects of venous congestion. Clin Radiol 2022; 77:e776-e782. [DOI: 10.1016/j.crad.2022.06.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2022] [Revised: 05/31/2022] [Accepted: 06/24/2022] [Indexed: 11/03/2022]
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16
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Scalzo N, Canastar M, Lebovics E. Part 2: Disease of the Heart and Liver: A Relationship That Cuts Both Ways. Cardiol Rev 2022; 30:161-166. [PMID: 33337653 DOI: 10.1097/crd.0000000000000380] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Diseases known to affect both the heart and liver include a variety of infectious, autoimmune, and metabolic disorders, as well as toxins: most commonly alcohol. As damage to both the heart and liver progresses, transplantation is a reasonable therapeutic option. Heart failure patients with underlying congestive hepatopathy receiving cardiac transplant have demonstrated improved liver enzyme levels posttransplant. Patients with severe end-stage liver disease requiring a liver transplant must undergo careful preoperative evaluation as surgical stress exposes the myocardium to high levels of catecholamines. Clinicians must consider both cardiac and hepatic complications when evaluating heart failure, cirrhosis, and nonalcoholic fatty liver disease. In Part 2 of this review, we discuss new noninvasive techniques for assessing liver fibrosis in the preoperative stage. Both serum and radiologic studies, such as transient elastography, have begun to take the place of liver biopsy due to their decreased morbidity. Last, we explore the current research examining the benefit of combined heart-liver transplant, although more longitudinal outcome studies are needed.
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Affiliation(s)
- Nicholas Scalzo
- From the Department of Medicine, Section of Gastroenterology & Hepatobiliary Diseases, New York Medical College and Westchester Medical Center, Valhalla, NY
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17
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Marelli A, Beauchesne L, Colman J, Ducas R, Grewal J, Keir M, Khairy P, Oechslin E, Therrien J, Vonder Muhll IF, Wald RM, Silversides C, Barron DJ, Benson L, Bernier PL, Horlick E, Ibrahim R, Martucci G, Nair K, Poirier NC, Ross HJ, Baumgartner H, Daniels CJ, Gurvitz M, Roos-Hesselink JW, Kovacs AH, McLeod CJ, Mulder BJ, Warnes CA, Webb GD. Canadian Cardiovascular Society 2022 Guidelines for Cardiovascular Interventions in Adults With Congenital Heart Disease. Can J Cardiol 2022; 38:862-896. [PMID: 35460862 DOI: 10.1016/j.cjca.2022.03.021] [Citation(s) in RCA: 32] [Impact Index Per Article: 16.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2021] [Revised: 03/15/2022] [Accepted: 03/30/2022] [Indexed: 12/12/2022] Open
Abstract
Interventions in adults with congenital heart disease (ACHD) focus on surgical and percutaneous interventions in light of rapidly evolving ACHD clinical practice. To bring rigour to our process and amplify the cumulative nature of evidence ACHD care we used the ADAPTE process; we systematically adjudicated, updated, and adapted existing guidelines by Canadian, American, and European cardiac societies from 2010 to 2020. We applied this to interventions related to right and left ventricular outflow obstruction, tetralogy of Fallot, coarctation, aortopathy associated with bicuspid aortic valve, atrioventricular canal defects, Ebstein anomaly, complete and congenitally corrected transposition, and patients with the Fontan operation. In addition to tables indexed to evidence, clinical flow diagrams are included for each lesion to facilitate a practical approach to clinical decision-making. Excluded are recommendations for pacemakers, defibrillators, and arrhythmia-directed interventions covered in separate designated documents. Similarly, where overlap occurs with other guidelines for valvular interventions, reference is made to parallel publications. There is a paucity of high-level quality of evidence in the form of randomized clinical trials to support guidelines in ACHD. We accounted for this in the wording of the strength of recommendations put forth by our national and international experts. As data grow on long-term follow-up, we expect that the evidence driving clinical practice will become increasingly granular. These recommendations are meant to be used to guide dialogue between clinicians, interventional cardiologists, surgeons, and patients making complex decisions relative to ACHD interventions.
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Affiliation(s)
- Ariane Marelli
- McGill University Health Centre, Montréal, Québec, Canada.
| | - Luc Beauchesne
- University of Ottawa Heart Institute, Ottawa, Ontario, Canada
| | - Jack Colman
- Toronto Adult Congenital Heart Disease Program, Division of Cardiology, Peter Munk Cardiac Centre, University Health Network, University of Toronto, Toronto, Ontario, Canada
| | - Robin Ducas
- St. Boniface General Hospital, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Jasmine Grewal
- St. Paul's Hospital, University of British Columbia, Vancouver, British Columbia, Canada
| | | | - Paul Khairy
- Montreal Heart Institute, Université de Montréal, Montréal, Québec, Canada
| | - Erwin Oechslin
- Toronto Adult Congenital Heart Disease Program, Division of Cardiology, Peter Munk Cardiac Centre, University Health Network, University of Toronto, Toronto, Ontario, Canada
| | - Judith Therrien
- Jewish General Hospital, MAUDE Unit, McGill University, Montréal, Québec, Canada
| | | | - Rachel M Wald
- Toronto Adult Congenital Heart Disease Program, Division of Cardiology, Peter Munk Cardiac Centre, University Health Network, University of Toronto, Toronto, Ontario, Canada
| | - Candice Silversides
- Toronto Adult Congenital Heart Disease Program, Division of Cardiology, Peter Munk Cardiac Centre, University Health Network, University of Toronto, Toronto, Ontario, Canada
| | | | - Lee Benson
- The Hospital for Sick Children, University Health Network, Toronto, Ontario, Canada
| | - Pierre-Luc Bernier
- McGill University Health Centre, Montreal Heart Institute, Montréal, Québec, Canada
| | - Eric Horlick
- Toronto Adult Congenital Heart Disease Program, Division of Cardiology, Peter Munk Cardiac Centre, University Health Network, University of Toronto, Toronto, Ontario, Canada
| | - Réda Ibrahim
- Montreal Heart Institute, Université de Montréal, Montréal, Québec, Canada
| | | | - Krishnakumar Nair
- Toronto Adult Congenital Heart Disease Program, Division of Cardiology, Peter Munk Cardiac Centre, University Health Network, University of Toronto, Toronto, Ontario, Canada
| | - Nancy C Poirier
- Université de Montréal, CHU-ME Ste-Justine, Institut de Cardiologie de Montréal, Montréal, Québec, Canada
| | - Heather J Ross
- Toronto Adult Congenital Heart Disease Program, Division of Cardiology, Peter Munk Cardiac Centre, University Health Network, University of Toronto, Toronto, Ontario, Canada
| | - Helmut Baumgartner
- Department of Cardiology III: Adult Congenital and Valvular Heart Disease, University Hospital Muenster, Muenster, Germany
| | - Curt J Daniels
- The Ohio State University Medical Center, Columbus, Ohio, USA
| | - Michelle Gurvitz
- Boston Adult Congenital Heart Program, Boston Children's Hospital, Boston, Massachusetts, USA
| | | | - Adrienne H Kovacs
- Department of Medicine, Oregon Health & Science University, Portland, Oregon, USA
| | | | | | | | - Gary D Webb
- Cincinnati Children's Hospital Heart Institute, Cincinnati, Ohio, USA
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18
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Neethling E, Heggie JE. Considerations in Critical Care and Anesthetic Management of Adult Patients Living with Fontan Circulation. Can J Cardiol 2022; 38:1100-1110. [PMID: 35490923 DOI: 10.1016/j.cjca.2022.04.017] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2021] [Revised: 04/21/2022] [Accepted: 04/21/2022] [Indexed: 11/02/2022] Open
Abstract
The Fontan procedure is a staged palliation for various complex congenital cardiac lesions, including tricuspid atresia (TA), pulmonary atresia (PA), hypoplastic left heart syndrome (HLHS), and double inlet left ventricle (DILV), all of which involve a functional single-ventricle physiology. The complexity of the patients' original anatomy combined with the anatomical and physiological consequences of the Fontan circulation creates challenges. Teens and adults living with Fontan palliation will need perioperative support for non-cardiac surgery, peripartum management for labor and delivery, interventions related to their structural heart disease, electrophysiology procedures, pacemakers, cardioversions, cardiac surgery, transplant, and advanced mechanical support. This review focuses on the anesthetic and ICU management of these patients during their perioperative journey, with an emphasis on the continuity of pre-intervention planning, referral pathways, and post-intervention intensive care unit (ICU) management. Requests for recipes and doses of medications are frequent; however, as in normal anesthesia and ICU practice, the method of anesthesia and dosing are dependent on the presenting medical/surgical conditions and the underlying anatomy and physiological reserve. A patient with Fontan palliation in their early 20s attending school full-time with a cavopulmonary connection is likely to have more reserve than a patient in their late 40s with an atrio- pulmonary (AP) Fontan at home waiting for a heart transplant. Each case will require an anesthetic and critical care plan tailored to their situation. The critical care environment is a natural extension of the anesthetic management of a patient, with complex considerations for a patient with Fontan palliation.
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Affiliation(s)
| | - Jane E Heggie
- Toronto General Hospital, University Health Network, Toronto.
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19
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Bravo-Jaimes K, Axsom K, Menachem J, Danford D, Kutty S, Cedars A. Impact of the new UNOS donor heart allocation system on waitlist outcomes and early posttransplant mortality among adults with congenital heart disease. Am J Transplant 2022; 22:1123-1132. [PMID: 34859574 DOI: 10.1111/ajt.16900] [Citation(s) in RCA: 16] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2021] [Revised: 11/21/2021] [Accepted: 11/21/2021] [Indexed: 01/25/2023]
Abstract
Adults with congenital heart disease (ACHD) experience worse waitlist outcomes and higher early posttransplant mortality compared to non-ACHD patients. On October 18, 2018; the UNOS donor heart allocation system was redesigned giving unique listing status to ACHD patients. The impact of this change on outcomes in transplant-listed patients is unstudied. Using the Scientific Registry of Transplant Recipients (SRTR) we compared ACHD patients listed for the first-time for heart transplantation from two eras of equal duration. We analyzed waitlist outcomes, posttransplant mortality and length of stay among ACHD patients in both eras and between ACHD and non-ACHD patients in the new era. Of 12 723 listed patients, 535 had ACHD (293 in the new era) and 12 188 did not (6258 in the new era). A total of 163 (56%) ACHD patients in the new era versus 150 (62%) in the prior era were transplanted; 11 (3.8%) versus 15 (6.2%) died on the waitlist; 32 (11%) versus 35 (14%) were delisted and 15 (9.2%) versus 19 (12.7%) died within 30 days of transplant, respectively. The new UNOS donor heart allocation system improved waitlist time and decreased the proportion not transplanted during the first 300 days after listing among ACHD patients without altering early posttransplant outcomes or significantly changing the gap in outcomes compared to non-ACHD patients.
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Affiliation(s)
- Katia Bravo-Jaimes
- Ahmanson/UCLA Adult Congenital Heart Disease Center, Division of Cardiology, University of California Los Angeles, Los Angeles, California, USA
| | - Kelly Axsom
- Columbia University Irving Medical Center, New York, New York, USA
| | | | | | - Shelby Kutty
- Johns Hopkins University, Baltimore, Maryland, USA
| | - Ari Cedars
- Johns Hopkins University, Baltimore, Maryland, USA
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20
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Heart transplant indications, considerations and outcomes in Fontan patients: Age-related nuances, transplant listing and disease-specific indications. THE CANADIAN JOURNAL OF CARDIOLOGY 2022; 38:1072-1085. [PMID: 35240250 DOI: 10.1016/j.cjca.2022.02.019] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Subscribe] [Scholar Register] [Received: 12/20/2021] [Revised: 02/09/2022] [Accepted: 02/21/2022] [Indexed: 11/23/2022]
Abstract
In the current era, 5-10% of Fontan patients die or need a transplant in childhood, and approximately 50% will experience the same fate by age 40 years. Heart transplant (HTx) can be successful for selected children and adults with Fontan circulatory failure (FCF) of any mechanism, with a 1-year post-transplant survival approaching 90% in children and 80% in the largest single-centre adult Fontan HTx experience. Protein losing enteropathy and plastic bronchitis can be expected to resolve post-transplant and limited data suggests patients with FALD who survive HTx can expect improvement in liver health. Early Fontan failure, within 12 months of Fontan completion, is not easily rescued by HTx and late referrals / failure to refer adult patients remains problematic. Very little is known about the numbers of patients not referred, turned down following assessment for HTx, or dying on the waiting list which are needed to understand the complete picture of HTx in the Fontan population and to identify where best to focus quality improvement efforts. Recent revisions to listing prioritization in Canada with considerations specific to the Fontan population aim to mitigate the fact that the status listing criteria are not tailored to the congenital heart population. Transplanting high-risk children prior to Fontan completion, developing ACHD transplant centres of expertise which can also offer combined heart-liver transplant when appropriate, and improving single ventricle mechanical support options and criteria for both adults and children may help mitigate the early post-listing mortality.
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21
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Nederend M, Egorova AD, Vliegen HW, Roest AAW, Ruijter BN, Korteweg T, Ninaber MK, Zeppenfeld K, Hazekamp MG, Kiès P, Jongbloed MRM. Case report of the broad spectrum of late complications in an adult patient with univentricular physiology palliated by the Fontan circulation. Eur Heart J Case Rep 2022; 6:ytac067. [PMID: 35224438 PMCID: PMC8867817 DOI: 10.1093/ehjcr/ytac067] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2021] [Revised: 12/14/2021] [Accepted: 01/24/2022] [Indexed: 11/18/2022]
Abstract
Background At the most severe end of the spectrum of congenital heart disease are patients with an univentricular physiology. They comprise a heterogeneous group of congenital heart malformations that have the common characteristic that the cardiac morphology is not equipped for sustaining a biventricular circulation. Case summary Here, we present a case of an adult patient after Fontan palliation, illustrative of the complex clinical course and the broad spectrum of complications that can be encountered during follow-up, highlighting the need for a multidisciplinary approach in the clinical care for these patients. Discussion During the surgical Fontan procedure, the inferior vena cava is connected to the pulmonary circulation, after prior connection of the superior vena cava to the pulmonary arterial circulation. The resulting cavopulmonary connection, thus lacking a subpulmonic ventricle, provides non-pulsatile passive flow of oxygen-poor blood from the systemic venous circulation into the lungs, and the functional monoventricle pumps the oxygen-rich pulmonary venous return blood into the aorta. With an operative mortality of <5% and current 30-year survival rates up to 85%, the adult population of patients with a Fontan circulation is growing. This increase in survival is, however, inevitably accompanied by long-term complications affecting multiple organ systems, resulting in decline in cardiovascular performance. Conclusion For optimal treatment, the evaluation in a multidisciplinary team is mandatory, using the specific expertise of the team members to timely detect and address late complications and to support quality of life.
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Affiliation(s)
- Marieke Nederend
- CAHAL, Center for Congenital Heart Disease Amsterdam Leiden, Leiden University Medical Center, Leiden, the Netherlands
- Department of Cardiology, Leiden University Medical Center, Albinusdreef 2, 2333 ZA Leiden, the Netherlands
| | - Anastasia D Egorova
- CAHAL, Center for Congenital Heart Disease Amsterdam Leiden, Leiden University Medical Center, Leiden, the Netherlands
- Department of Cardiology, Leiden University Medical Center, Albinusdreef 2, 2333 ZA Leiden, the Netherlands
| | - Hubert W Vliegen
- CAHAL, Center for Congenital Heart Disease Amsterdam Leiden, Leiden University Medical Center, Leiden, the Netherlands
- Department of Cardiology, Leiden University Medical Center, Albinusdreef 2, 2333 ZA Leiden, the Netherlands
| | - Arno A W Roest
- CAHAL, Center for Congenital Heart Disease Amsterdam Leiden, Leiden University Medical Center, Leiden, the Netherlands
- Division of Paediatric Cardiology, Department of Paediatrics, Leiden University Medical Center, Albinusdreef 2, 2333 ZA Leiden, the Netherlands
| | - Bastian N Ruijter
- Department of Gastroenterology, Leiden University Medical Center, Leiden, Albinusdreef 2, 2333 ZA Leiden, the Netherlands
| | - Tijmen Korteweg
- Department of Radiology, Leiden University Medical Center, Albinusdreef 2, 2333 ZA Leiden, the Netherlands
| | - Maarten K Ninaber
- Department of Pulmonology, Leiden University Medical Center, Albinusdreef 2, 2333 ZA Leiden, the Netherlands
| | - Katja Zeppenfeld
- Department of Cardiology, Leiden University Medical Center, Albinusdreef 2, 2333 ZA Leiden, the Netherlands
| | - Mark G Hazekamp
- CAHAL, Center for Congenital Heart Disease Amsterdam Leiden, Leiden University Medical Center, Leiden, the Netherlands
- Department of Cardiothoracic Surgery, Leiden University Medical Center, Albinusdreef 2, 2333 ZA Leiden, the Netherlands
| | - Philippine Kiès
- CAHAL, Center for Congenital Heart Disease Amsterdam Leiden, Leiden University Medical Center, Leiden, the Netherlands
- Department of Cardiology, Leiden University Medical Center, Albinusdreef 2, 2333 ZA Leiden, the Netherlands
| | - Monique R M Jongbloed
- CAHAL, Center for Congenital Heart Disease Amsterdam Leiden, Leiden University Medical Center, Leiden, the Netherlands
- Department of Cardiology, Leiden University Medical Center, Albinusdreef 2, 2333 ZA Leiden, the Netherlands
- Department of Anatomy & Embryology, Leiden University Medical Center, Albinusdreef 2, 2333 ZA Leiden, the Netherlands
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Sadat-Hossieny S, Karamlou T, Marino BS, Gossett JG, Schumacher K, Patel A, Worley S, Alsaied T, Amdani S. Contemporary Provider Management Practices and Attitudes Toward Referral for Advanced Heart Failure Therapies in Fontan Patients Across North America. J Card Fail 2021; 28:576-587. [PMID: 34991953 DOI: 10.1016/j.cardfail.2021.10.016] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2021] [Revised: 10/27/2021] [Accepted: 10/27/2021] [Indexed: 11/17/2022]
Abstract
BACKGROUND To date, no reports have described clinicians' management practices for patients with Fontan circulatory failure or their understanding of risk factors for mortality and transplant outcomes in these patients. METHODS AND RESULTS A cross-sectional survey of caregivers across North America was conducted from February to September 2020. Responses were compared by primary specialty (heart failure/transplant vs non-heart failure/transplant), years of experience (early, mid, and late career), and Fontan center volume (low, medium, and high). Of 400 responses, the majority were from general cardiologists (111, 28%) followed by heart failure/transplant specialists (93, 23%). Although most agreed that patients with Fontan physiology will have signs/symptoms of heart failure (369 [93%]) and eventuate in heart transplant (286 [72%]), many disagreed (180 [45%]) that routine evaluation by a transplant cardiologist is needed without symptoms. Transplant providers were more likely than non-transplant providers to suggest referral for manifestations of Fontan circulatory failure such as protein-losing enteropathy, plastic bronchitis, liver fibrosis/cirrhosis, and worsening valve regurgitation. Non-transplant providers were more likely to suggest that protein-losing enteropathy, plastic bronchitis, and Fontan-associated liver disease lead to inferior outcomes after transplantation. Early career and transplant providers more favorably viewed ventricular assist device use for Fontan patients failing traditional heart failure therapy (P < .05 for all). CONCLUSIONS There is significant variation in the management of Fontan patients, including heterogeneous timing of referral of such patients to the heart failure/transplant team, which may have implications for future outcomes.
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Affiliation(s)
- Sara Sadat-Hossieny
- Department of Pediatric Cardiology, Cleveland Clinic Children's, Cleveland, Ohio
| | - Tara Karamlou
- Heart, Vascular, and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio
| | - Bradley S Marino
- Department of Pediatric Cardiology, Cleveland Clinic Children's, Cleveland, Ohio
| | - Jeffrey G Gossett
- Cohen Children's Medical Center, Northwell Health, New Hyde Park, New York
| | - Kurt Schumacher
- Congenital Heart Center, C.S. Mott Children's Hospital, University of Michigan, Ann Arbor, Michigan
| | - Angira Patel
- Division of Cardiology, Ann & Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Sarah Worley
- Department of Quantitative Health Sciences, Cleveland Clinic, Cleveland, Ohio
| | - Tarek Alsaied
- University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Shahnawaz Amdani
- Department of Pediatric Cardiology, Cleveland Clinic Children's, Cleveland, Ohio.
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Márquez-González H, Hernández-Vásquez JG, Del Valle-Lom M, Yáñez-Gutiérrez L, Klünder-Klünder M, Almeida-Gutiérrez E, Koretzky SG. Failures of the Fontan System in Univentricular Hearts and Mortality Risk in Heart Transplantation: A Systematic Review and Meta-Analysis. Life (Basel) 2021; 11:1363. [PMID: 34947894 PMCID: PMC8709145 DOI: 10.3390/life11121363] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2021] [Revised: 11/12/2021] [Accepted: 11/13/2021] [Indexed: 02/07/2023] Open
Abstract
The Fontan procedure (FP) is the standard surgical treatment for Univentricular heart diseases. Over time, the Fontan system fails, leading to pathologies such as protein-losing enteropathy (PLE), plastic bronchitis (PB), and heart failure (HF). FP should be considered as a transitional step to the final treatment: heart transplantation (HT). This systematic review and meta-analysis aims to establish the risk of death following HT according to the presence of FP complications. There was a total of 691 transplanted patients in the 18 articles, immediate survival 88% (n = 448), survival from 1 to 5 years of 78% (n = 427) and survival from 5.1 to 10 years of 69% (n = 208), >10 years 61% (n = 109). The relative risk (RR) was 1.12 for PLE (95% confidence interval [CI] = 0.89-1.40, p = 0.34), 1.03 for HF (0.7-1.51, p = 0.88), 0.70 for Arrhythmias (0.39-1.24, p = 0.22), 0.46 for PB (0.08-2.72, p = 0.39), and 5.81 for CKD (1.70-19.88, p = 0.005). In patients with two or more failures, the RR was 1.94 (0.99-3.81, p = 0.05). After FP, the risk of death after HT is associated with CKD and with the presence of two or more failures.
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Affiliation(s)
- Horacio Márquez-González
- Department of Clinical Research, Federico Gómez Children’s Hospital, Mexico City 06720, Mexico; (H.M.-G.); (J.G.H.-V.); (M.D.V.-L.); (M.K.-K.)
- Centro Médico Nacional Siglo XXI, IMSS, Department Congenital Heart Diseases, Mexico City 06720, Mexico; (L.Y.-G.); (E.A.-G.)
| | - Jose Gustavo Hernández-Vásquez
- Department of Clinical Research, Federico Gómez Children’s Hospital, Mexico City 06720, Mexico; (H.M.-G.); (J.G.H.-V.); (M.D.V.-L.); (M.K.-K.)
| | - Montserrat Del Valle-Lom
- Department of Clinical Research, Federico Gómez Children’s Hospital, Mexico City 06720, Mexico; (H.M.-G.); (J.G.H.-V.); (M.D.V.-L.); (M.K.-K.)
| | - Lucelli Yáñez-Gutiérrez
- Centro Médico Nacional Siglo XXI, IMSS, Department Congenital Heart Diseases, Mexico City 06720, Mexico; (L.Y.-G.); (E.A.-G.)
| | - Miguel Klünder-Klünder
- Department of Clinical Research, Federico Gómez Children’s Hospital, Mexico City 06720, Mexico; (H.M.-G.); (J.G.H.-V.); (M.D.V.-L.); (M.K.-K.)
| | - Eduardo Almeida-Gutiérrez
- Centro Médico Nacional Siglo XXI, IMSS, Department Congenital Heart Diseases, Mexico City 06720, Mexico; (L.Y.-G.); (E.A.-G.)
| | - Solange Gabriela Koretzky
- Department of Clinical Research, Nacional de Cardiología “Ignacio Chávez”, Mexico City 14080, Mexico
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24
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Kramer P, Ovroutski S. Fontan conversion for Fontan failure: lessons from a vanishing craft. Eur J Cardiothorac Surg 2021; 61:346-347. [PMID: 34871350 DOI: 10.1093/ejcts/ezab524] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/01/2021] [Accepted: 11/09/2021] [Indexed: 11/12/2022] Open
Affiliation(s)
- Peter Kramer
- Department for Pediatric Cardiology and Congenital Heart Disease, German Heart Center Berlin, Berlin, Germany
| | - Stanislav Ovroutski
- Department for Pediatric Cardiology and Congenital Heart Disease, German Heart Center Berlin, Berlin, Germany
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25
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Occlusion of aortopulmonary and venovenous collaterals prior to heart or combined heart-liver transplantation in Fontan patients: A single-center experience. INTERNATIONAL JOURNAL OF CARDIOLOGY CONGENITAL HEART DISEASE 2021. [DOI: 10.1016/j.ijcchd.2021.100260] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
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26
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Ybarra AM, Khanna G, Turmelle YP, Stoll J, Castleberry CD, Scheel J, Ballweg JA, Ameduri R, Kimberling M, Makil E, Birnbaum BF, Exil V, Canter CE, Simpson KE. Heterogeneous outcomes of liver disease after heart transplantation for a failed Fontan procedure. Pediatr Transplant 2021; 25:e14094. [PMID: 34296503 DOI: 10.1111/petr.14094] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/12/2021] [Revised: 05/29/2021] [Accepted: 07/02/2021] [Indexed: 01/03/2023]
Abstract
BACKGROUND Fontan-associated liver disease (FALD) uniformly affects patients with long-term Fontan physiology. The effect of isolated heart transplant (HT) on the course of FALD post-HT is not well understood. METHODS We evaluated serial liver imaging pre- and post-HT to assess liver changes over time in a single-center retrospective analysis of Fontan HT recipients who had pre- and ≥1-year post-HT liver imaging. Available patient demographic and clinical data were reviewed, including available liver biopsy results. RESULTS Serial liver imaging was available in 19 patients with a median age at HT of 12 years (range 3-23), the median age from Fontan to HT of 5.7 years (range 0.8-16), and the median time from imaging to follow up of 27 months (range 12-136 months). Pre-HT liver imaging was classified as follows: normal (n=1), congested (n=9), fibrotic (n=7), and cirrhotic (n=2). The majority of transplanted patients (15/19) had improvement in their post-HT liver imaging, including 13 patients with initially abnormal imaging pre-HT having normal liver imaging at follow-up. One patient had persistent cirrhosis at 26-month follow-up, one patient had unchanged fibrosis at 18-month follow-up, and one patient progressed from fibrosis pre-HT to cirrhosis post-HT at 136 months. No patients had overt isolated liver failure during pre- or post-HT follow-up. Liver biopsy did not consistently correlate with imaging findings. CONCLUSIONS Post-HT liver imaging evaluation in Fontan patients reveals heterogeneous liver outcomes. These results not only provide evidence for the improvement of FALD post-HT but also show the need for serial liver imaging follow-up post-HT.
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Affiliation(s)
- Aecha M Ybarra
- Department of Pediatrics, Washington University School of Medicine, St. Louis, MO, USA
| | - Geetika Khanna
- Department of Radiology, Washington University School of Medicine, St. Louis, MO, USA
| | - Yumirle P Turmelle
- Department of Radiology, Washington University School of Medicine, St. Louis, MO, USA
| | - Janis Stoll
- Department of Pediatrics, Washington University School of Medicine, St. Louis, MO, USA
| | - Chesney D Castleberry
- Department of Pediatrics, Washington University School of Medicine, St. Louis, MO, USA
| | - Janet Scheel
- Department of Pediatrics, Washington University School of Medicine, St. Louis, MO, USA
| | - Jean A Ballweg
- Department of Pediatrics, University of Nebraska, Omaha, NE, USA
| | - Rebecca Ameduri
- Department of Pediatrics, University of Minnesota Masonic Children's Hospital, Minneapolis, MN, USA
| | | | - Elizabeth Makil
- Department of Pediatrics, University of Oklahoma Health Sciences Center, Oklahoma City, OK, USA
| | - Brian F Birnbaum
- Department of Pediatrics, University of Missouri-Kansas City, Kansas City, MO, USA
| | - Vernat Exil
- Department of Pediatrics, University of Iowa Hospitals and Clinics, Iowa City, IA, USA
| | - Charles E Canter
- Department of Pediatrics, Washington University School of Medicine, St. Louis, MO, USA
| | - Kathleen E Simpson
- Department of Pediatrics, Washington University School of Medicine, St. Louis, MO, USA
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27
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Greenberg JW, Morales DL. Commentary: High achievement occurs under the framework of high expectations. JTCVS OPEN 2021; 8:576-577. [PMID: 36004054 PMCID: PMC9390153 DOI: 10.1016/j.xjon.2021.08.023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/13/2021] [Revised: 08/13/2021] [Accepted: 08/16/2021] [Indexed: 12/05/2022]
Affiliation(s)
- Jason W. Greenberg
- Department of Cardiovascular Surgery, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - David L.S. Morales
- Department of Cardiovascular Surgery, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
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28
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Menteer J, Goldbeck C, Herrington C, Yanni G, Emamaullee JA. Immunologic and Survival Benefits of Combined Heart-liver Transplantation in Children. Transplantation 2021; 105:e107-e108. [PMID: 34416752 PMCID: PMC8932196 DOI: 10.1097/tp.0000000000003810] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Affiliation(s)
- Jondavid Menteer
- Heart Institute, Children’s Hospital Los Angeles, Los Angeles, CA
- Keck School of Medicine, University of Southern California, Los Angeles, CA
| | - Cameron Goldbeck
- Keck School of Medicine, University of Southern California, Los Angeles, CA
- Division of Hepatobiliary and Abdominal Organ Transplant Surgery, University of Southern California, Los Angeles, CA
| | - Cynthia Herrington
- Heart Institute, Children’s Hospital Los Angeles, Los Angeles, CA
- Keck School of Medicine, University of Southern California, Los Angeles, CA
| | - George Yanni
- Keck School of Medicine, University of Southern California, Los Angeles, CA
- Division of Gastroenterology and Hepatology, Department of Pediatrics, Children’s Hospital Los Angeles, Los Angeles, CA
| | - Juliet A. Emamaullee
- Keck School of Medicine, University of Southern California, Los Angeles, CA
- Division of Hepatobiliary and Abdominal Organ Transplant Surgery, University of Southern California, Los Angeles, CA
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29
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Clark DE, Byrne RD, Mazurek JA, Opotowsky AR, Schlendorf KH, Xu M, Zalawadiya S, Menachem JN. Sizing heart transplant donors in adults with congenital heart disease. J Thorac Cardiovasc Surg 2021; 162:422-428.e1. [DOI: 10.1016/j.jtcvs.2020.01.099] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/10/2019] [Revised: 01/15/2020] [Accepted: 01/20/2020] [Indexed: 02/08/2023]
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30
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Big Data in Transplantation Practice-the Devil Is in the Detail-Fontan-associated Liver Disease. Transplantation 2021; 105:18-22. [PMID: 32639398 DOI: 10.1097/tp.0000000000003308] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
BACKGROUND As a result of the Fontan procedure, the prognosis of congenital single-ventricle heart disease has improved, with many affected children surviving into adulthood. However, the unanticipated consequences of chronic exposure to Fontan hemodynamics have revealed a new set of secondary noncardiac complications. Fontan-associated liver disease (FALD) is characterized by progressive hepatic fibrosis in nearly all patients post-Fontan, with the potential to develop cirrhosis, hepatocellular carcinoma, and the need for liver transplantation. A lack of data regarding FALD-related prognosis makes consideration of indications for and timing of heart alone versus combined heart-liver transplantation challenging. METHODS A multidisciplinary group within the American Society for Transplantation analyzed several administrative datasets to study the epidemiology of FALD. RESULTS This approach presented several obstacles, and efforts to characterize FALD were limited by a lack of Fontan- and FALD-specific diagnostic codes and an inability to follow individual patients through multiple health systems. Several ongoing Fontan registries were also reviewed but these do not adequately capture FALD-related variables. Such barriers highlight the need for large-scale data collection in patients post-Fontan to better understand and care for this complex population. CONCLUSIONS This study emphasizes the challenges of studying emerging transplant-related diagnoses in existing datasets and the need for mechanisms to adapt registries to appropriately identify patients with rare or emerging conditions.
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31
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Dolgner SJ, Nguyen VP, Krieger EV, Stempien-Otero A, Dardas TF. Long-term adult congenital heart disease survival after heart transplantation: A restricted mean survival time analysis. J Heart Lung Transplant 2021; 40:698-706. [PMID: 33965332 DOI: 10.1016/j.healun.2021.02.019] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2020] [Revised: 02/10/2021] [Accepted: 02/26/2021] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND Adult Congenital Heart Disease (ACHD) heart transplant recipients may have lower post-transplant survival resulting from higher peri-operative mortality than non-ACHD patients. However, the late risk of mortality appears lower in ACHD recipients. This study seeks to establish whether long-term heart transplant survival is reduced among ACHD recipients relative to non-ACHD recipients. METHODS Adult patients who received a heart transplant between January, 2000 and December, 2019 in the United Network for Organ Sharing database were stratified by the presence of ACHD. Propensity-matched cohorts (1:4) were created to adjust for differences between groups. Graft survival at time points from 1 to 18 years was compared between groups using restricted mean survival time (RMST) analysis. RESULTS The matched cohort included 1,139 ACHD and 4,293 non-ACHD patients. Median age was 35 years and 61% were male. Average survival time at 1 year was 0.85 years for ACHD patients and 0.93 years for non-ACHD patients (average difference: -0.08 years, 95% Confidence Interval [CI] -0.10 to -0.06, p < 0.001), reflecting higher immediate post-transplant mortality. Average survival time at 18 years was not clinically or statistically different: 11.14 years for ACHD patients and 11.40 years for non-ACHD patients (average difference: -0.26 years, 95% CI: -0.85 to + 0.32 years, p = 0.38). CONCLUSIONS Despite increased medium-term mortality among ACHD patients after heart transplant, differences in long-term survival are minimal. Allocation of hearts to ACHD patients results in acceptable utility of donor hearts.
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Affiliation(s)
- Stephen J Dolgner
- Department of Medicine, Division of Cardiology, University of Washington School of Medicine, Seattle Washington.
| | - Vidang P Nguyen
- Providence St. Vincent's Medical Center, Heart Institute, Seattle Washington
| | - Eric V Krieger
- Department of Medicine, Division of Cardiology, University of Washington School of Medicine, Seattle Washington
| | - April Stempien-Otero
- Department of Medicine, Division of Cardiology, University of Washington School of Medicine, Seattle Washington
| | - Todd F Dardas
- Department of Medicine, Division of Cardiology, University of Washington School of Medicine, Seattle Washington
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32
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Orthotopic Heart and Combined Heart Liver Transplantation: the Ultimate Treatment Option for Failing Fontan Physiology. CURRENT TRANSPLANTATION REPORTS 2021; 8:9-20. [PMID: 33564612 PMCID: PMC7861581 DOI: 10.1007/s40472-021-00315-4] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/07/2021] [Indexed: 02/07/2023]
Abstract
Purpose of the Review This is a comprehensive update on failing Fontan physiology and the role of heart and combined heart and liver transplantation in the current era. Recent Findings Single ventricle physiology encompasses a series of rare congenital cardiac abnormalities that are characterized by absence of or hypoplasia of one ventricle. This effectively results in a single ventricular pumping chamber. These abnormalities are rarely compatible with long-term survival if left without surgical palliation in the first few years of life. Surgical treatment of single ventricle physiology has evolved over the past 60 years and is characterized by numerous creative innovations. These include the development of arteriopulmonary shunts, the evolution of partial cavopulmonary connections, and the eventual development of the "Fontan" operation. Regardless of the type of Fontan modification, the long-term consequences of the Fontan operation are predominantly related to chronic central venous hypertension and the multi-organ consequences thereof. Atrial arrhythmias can further compromise this circulation.Patients with single ventricle physiology represent a special sub-segment of congenital cardiac transplants and are arguably the most challenging patients considered for transplantation. Summary This review describes in detail the challenges and opportunities of heart and liver transplantation in Fontan patients, as viewed and managed by the experienced team at the Ahmanson/UCLA Adult Congenital Heart Center.
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33
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Perquy D, Pirenne J, Van De Bruaene A, Rex S, van Malenstein H. Liver-only Transplantation in a Patient With Complex Congenital Heart Disease: Case Report and Review of the Literature. Transplant Direct 2021; 7:e649. [PMID: 33437864 PMCID: PMC7793398 DOI: 10.1097/txd.0000000000001096] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2020] [Revised: 09/30/2020] [Accepted: 10/14/2020] [Indexed: 11/26/2022] Open
Abstract
BACKGROUND Patients with liver failure due to or in addition to congenital heart disease (CHD) represent a growing population in need of organ transplantation. Traditionally, these patients received a combined heart and liver transplantation carrying a high risk of perioperative morbidity and mortality. METHODS We discuss a patient with complex cyanotic CHD and biliary atresia undergoing liver-only transplantation. Furthermore, a literature study was performed on combined congenital heart and liver disease in the setting of transplantation. RESULTS We describe a unique case of a patient with severe CHD undergoing orthotopic liver transplantation for biliary atresia. In the literature, congenital malformations affecting different organs seems not that infrequent. Liver-only transplantation has been described in mild CHD, although data in adult patients are scarce. In severe CHD, the liver usually suffers from congestion. The severity of liver disease and reversibility should be estimated to decide on combined heart-liver transplantation. CONCLUSIONS Our case and a review of the literature demonstrate that a patient-tailored approach with liver-only transplantation may be an appropriate alternative to combined heart and liver transplantation in selected cases.
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Affiliation(s)
- David Perquy
- Department of Abdominal Transplant Surgery, University Hospitals Leuven, Leuven, Belgium
| | - Jacques Pirenne
- Department of Abdominal Transplant Surgery, University Hospitals Leuven, Leuven, Belgium
| | - Alexander Van De Bruaene
- Department of Cardiovascular Disease, University Hospitals Leuven, Leuven, Belgium
- Department of Cardiovascular Sciences, KU Leuven, Leuven, Belgium
| | - Steffen Rex
- Department of Cardiovascular Sciences, KU Leuven, Leuven, Belgium
- Department of Anesthesiology, University Hospitals Leuven, Leuven, Belgium
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34
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Vaikunth SS, Higgins JP, Concepcion W, Haeffele C, Wright GE, Chen S, Lui GK, Daugherty T. Does liver biopsy accurately measure fibrosis in Fontan-associated liver disease? A comparison of liver biopsy pre-combined heart and liver transplant and liver explant post-transplant. Clin Transplant 2020; 34:e14120. [PMID: 33053213 DOI: 10.1111/ctr.14120] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2020] [Revised: 09/13/2020] [Accepted: 09/30/2020] [Indexed: 01/12/2023]
Abstract
The accuracy of liver biopsy to stage fibrosis due to Fontan-associated liver disease (FALD) remains unclear. We compared the results of biopsy pre-combined heart and liver transplantation (CHLT) to the results of whole liver explant. Liver biopsy and explants from 15 Fontan patients (ages 16-49, median 28 years) were retrospectively reviewed. Staging was as follows: stage 0: no fibrosis, stage 1: pericellular fibrosis, stage 2: bridging fibrosis, and stage 3: regenerative nodules. There is no stage 4. Clinical characteristics including Model of End-stage Liver Disease eXcluding INR and Varices, Ascites, Splenomegaly, and Thrombocytopenia (VAST) scores were collected, and descriptive statistics and Mann-Whitney U tests were used to analyze the data. All patients had biopsies with at least bridging fibrosis, and all had nodularity on explant; transjugular biopsy never overestimated fibrosis. Explant showed higher-grade fibrosis (stage 3) than pre-CHLT biopsy (stage 2) in 6 of 15 patients and equal grade of fibrosis (stage 3) in 9 of 15 patients. Though clinical characteristics varied significantly, VAST score was ≥2 in all but two patients. Transjugular liver biopsy does not overestimate and can underestimate fibrosis in Fontan patients undergoing CHLT, likely due to the patchy nature of fibrosis in FALD.
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Affiliation(s)
- Sumeet S Vaikunth
- Division of Cardiovascular Medicine, Department of Medicine, Stanford University School of Medicine, Palo Alto, CA, USA
| | - John P Higgins
- Department of Pathology, Stanford University School of Medicine, Palo Alto, CA, USA
| | - Waldo Concepcion
- Division of Abdominal Transplantation, Department of Surgery, Stanford University School of Medicine, Palo Alto, CA, USA
| | - Christiane Haeffele
- Division of Cardiovascular Medicine, Department of Medicine, Stanford University School of Medicine, Palo Alto, CA, USA.,Division of Pediatric Cardiology, Department of Pediatrics, Stanford University School of Medicine, Palo Alto, CA, USA
| | - Gail E Wright
- Division of Pediatric Cardiology, Department of Pediatrics, Stanford University School of Medicine, Palo Alto, CA, USA
| | - Sharon Chen
- Division of Pediatric Cardiology, Department of Pediatrics, Stanford University School of Medicine, Palo Alto, CA, USA
| | - George K Lui
- Division of Cardiovascular Medicine, Department of Medicine, Stanford University School of Medicine, Palo Alto, CA, USA.,Division of Pediatric Cardiology, Department of Pediatrics, Stanford University School of Medicine, Palo Alto, CA, USA
| | - Tami Daugherty
- Division of Gastroenterology and Hepatology, Department of Medicine, Stanford University School of Medicine, Palo Alto, CA, USA
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35
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Bui CCM, Tanner C, Nguyen-Buckley C, Scovotti J, Wray C, Xia VW. Combined Cardiothoracic Surgery and Liver Transplantation Versus Isolated Liver Transplantation. J Cardiothorac Vasc Anesth 2020; 35:2363-2369. [PMID: 32951998 DOI: 10.1053/j.jvca.2020.08.051] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/11/2020] [Revised: 08/20/2020] [Accepted: 08/21/2020] [Indexed: 11/11/2022]
Abstract
OBJECTIVE Combined cardiothoracic surgery and liver transplantation (cCSLT) recently increasingly has been used. Despite that, liver transplant immediately after cardiothoracic surgery has not been well-characterized. The authors aimed to compare perioperative management and postoperative outcomes between patients undergoing cCSLT and isolated liver transplantation (iLT). DESIGN A retrospective study. SETTING University tertiary medical center. PARTICIPANTS Twenty-five cCSLT patients and 1091 iLT patients at a single institution from 2010 to 2017. INTERVENTIONS Twenty-five cCSLT patients were compared with 100 randomly selected and 100 propensity-matched iLT patients. MEASUREMENTS AND MAIN RESULTS All cCSLT patients underwent comprehensive preoperative evaluation by a multidisciplinary team. Of 25 cardiothoracic surgeries, heart transplant (n = 9) was most common, followed by coronary artery bypass grafting (n = 5) and lung transplant (n = 3). Intraoperative management of cCSLT was provided by 2 separate teams, one for cardiothoracic surgery and one for liver transplantation. Patients undergoing cCSLT often required cardiopulmonary bypass, an intra-aortic balloon pump, extracorporeal membrane oxygenation, or cardiac pharmacologic therapies and, additionally, needed more interventions including antifibrinolytic administration, venovenous bypass, massive blood transfusion, and platelet transfusions compared with iLT patients. Ninety-day survival rates were similar in the cCSLT (100%) and iLT groups (random iLT 87% and matched iLT 93%, log-rank test p = 0.089). CONCLUSIONS Despite having end-stage liver disease and advanced cardiothoracic disorders and experiencing a complex intraoperative course, cCSLT patients had comparable 90-day survival to iLT patients. Comprehensive planning before transplant, optimal patient/donor selection, the multiple-team model, and meticulous intraoperative management are critical to the success of cCSLT.
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Affiliation(s)
- Christine C Myo Bui
- Department of Anesthesiology and Perioperative Medicine, David Geffen School of Medicine at UCLA, Los Angeles, CA
| | - Colby Tanner
- Department of Anesthesiology and Perioperative Medicine, David Geffen School of Medicine at UCLA, Los Angeles, CA
| | - Christine Nguyen-Buckley
- Department of Anesthesiology and Perioperative Medicine, David Geffen School of Medicine at UCLA, Los Angeles, CA
| | - Jennifer Scovotti
- Department of Anesthesiology and Perioperative Medicine, David Geffen School of Medicine at UCLA, Los Angeles, CA
| | - Christopher Wray
- Department of Anesthesiology and Perioperative Medicine, David Geffen School of Medicine at UCLA, Los Angeles, CA
| | - Victor W Xia
- Department of Anesthesiology and Perioperative Medicine, David Geffen School of Medicine at UCLA, Los Angeles, CA.
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Khan S, Aziz H, Emamaullee J. Research priorities in Fontan-associated liver disease. Curr Opin Organ Transplant 2020; 25:489-495. [PMID: 32833705 DOI: 10.1097/mot.0000000000000803] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
PURPOSE OF REVIEW Fontan-associated liver disease (FALD) is an emerging condition in patients who have undergone surgical correction of univentricular congenital heart disease. There is little known about the epidemiology of FALD, including risk factors for end-organ failure or hepatocellular carcinoma nor a consensus on surveillance guidelines. Furthermore, there is a need to understand the role of heart versus combined heart-liver transplantation in this population. Research is limited by systemic barriers hindering the ability to track longitudinal FALD outcomes. RECENT FINDINGS Nearly all patients post-Fontan develop histological features of FALD as a function of time post-Fontan, regardless of Fontan hemodynamics. In cases of end-organ disease, single-center studies have shown promising outcomes of combined heart-liver transplant in this population, with decreased rates of acute rejection. However, despite the burden of disease, it is not currently possible to identify the population of patients with FALD using existing clinical databases and registries due to a lack of diagnostic codes. SUMMARY Strategies proposed to address barriers to understanding FALD include developing appropriate diagnostic and transplant-related codes for existing registries. Efforts should also be targeted at initiating prospective studies to understand recognized comorbidities related to Fontan physiology, guided by a team of multidisciplinary subspecialists.
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Affiliation(s)
| | - Hassan Aziz
- Keck School of Medicine.,Department of Surgery, University of Southern California, Los Angeles, California, USA
| | - Juliet Emamaullee
- Keck School of Medicine.,Department of Surgery, University of Southern California, Los Angeles, California, USA
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Anesthetic considerations for combined heart--liver transplantation in patients with Fontan-associated liver disease. Curr Opin Organ Transplant 2020; 25:501-505. [PMID: 32773506 DOI: 10.1097/mot.0000000000000800] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE OF REVIEW The success of the Fontan procedure has led to increased survival of patients born with certain congenital heart disease to the point that new sequlae, as a result of Fontan circulation, are being discovered. Included among these is Fontan-associated liver disease (FALD). The purpose of this review is to present available literature on the perioperative management of the combined heart--liver transplantation (CHLT) in patients with FALD. RECENT FINDINGS The perioperative management of a combined heart-liver transplant in a patient with Fontan circulation is complex. The patient is at risk for hemodynamic disturbances, significant blood loss, coagulopathies, and metabolic derangements. The maintenance of an appropriate transpulmonary pressure gradient is paramount to success. Postoperative management should be accomplished by a multidisciplinary care team. Limited series have demonstrated good outcomes in patients who have undergone CHLT. SUMMARY The perioperative management of CHLT in patients with FALD is complex and available literature is limited. Future studies are needed to further assess proper perioperative management of patients with FALD who undergo CHLT.
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Emamaullee J, Zaidi AN, Schiano T, Kahn J, Valentino PL, Hofer RE, Taner T, Wald JW, Olthoff K, Bucuvalas J, Fischer R. Fontan-Associated Liver Disease: Screening, Management, and Transplant Considerations. Circulation 2020; 142:591-604. [PMID: 32776846 PMCID: PMC7422927 DOI: 10.1161/circulationaha.120.045597] [Citation(s) in RCA: 112] [Impact Index Per Article: 28.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Surgical innovation and multidisciplinary management have allowed children born with univentricular physiology congenital heart disease to survive into adulthood. An estimated global population of 70 000 patients have undergone the Fontan procedure and are alive today, most of whom are <25 years of age. Several unexpected consequences of the Fontan circulation include Fontan-associated liver disease. Surveillance biopsies have demonstrated that virtually 100% of these patients develop clinically silent fibrosis by adolescence. As they mature, there are increasing reports of combined heart-liver transplantation resulting from advanced liver disease, including bridging fibrosis, cirrhosis, and hepatocellular carcinoma, in this population. In the absence of a transplantation option, these young patients face a poor quality of life and overall survival. Acknowledging that there are no consensus guidelines for diagnosing and monitoring Fontan-associated liver disease or when to consider heart transplantation versus combined heart-liver transplantation in these patients, a multidisciplinary working group reviewed the literature surrounding Fontan-associated liver disease, with a specific focus on considerations for transplantation.
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Affiliation(s)
- Juliet Emamaullee
- Liver Transplant Center, Children’s Hospital-Los Angeles, Los Angeles, CA
- Department of Surgery, Keck School of Medicine, University of Southern California, Los Angeles, CA
| | - Ali N. Zaidi
- Mount Sinai Cardiovascular Institute & The Children’s Heart Center, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Thomas Schiano
- Division of Hepatology, Recanati/Miller Transplantation Institute, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Jeff Kahn
- Division of Gastrointestinal and Liver Diseases, Keck School of Medicine of USC, Los Angeles, CA
| | - Pamela L. Valentino
- Section of Gastroenterology and Hepatology, Department of Pediatrics, Yale University School of Medicine, New Haven, CT
| | - Ryan E. Hofer
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, MN
| | - Timucin Taner
- Departments of Surgery and Immunology, Mayo Clinic, Rochester, MN
| | - Joyce W. Wald
- Division of Cardiology, Department of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Kim Olthoff
- Department of Surgery, University of Pennsylvania, Philadelphia, PA
| | - John Bucuvalas
- Division of Pediatric Hepatology, Recanati/Miller Transplantation Institute, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Ryan Fischer
- Department of Gastroenterology, Liver Care Center, Children’s Mercy Kansas City, Kansas City, MO
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Geoffrion T, Fuller S. Surgery for Adult Congenital Heart Disease. Cardiol Clin 2020; 38:435-443. [PMID: 32622495 DOI: 10.1016/j.ccl.2020.04.013] [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] [Indexed: 10/24/2022]
Abstract
Technical and medical improvements for congenital cardiac disease in children have contributed to an increasing population of patients who survive into adulthood. These patients may be prone to progression of their native palliated disease or suffer from sequelae of their childhood repair that requires repeat surgical intervention. Surgery for adult congenital cardiac disease poses unique challenges and risks.
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Affiliation(s)
- Tracy Geoffrion
- The Division of Cardiothoracic Surgery, Children's Hospital of Philadelphia, 3401 Civic Center Boulevard, Philadelphia, PA 19104, USA.
| | - Stephanie Fuller
- The Division of Cardiothoracic Surgery, Children's Hospital of Philadelphia, 3401 Civic Center Boulevard, Philadelphia, PA 19104, USA; Division of Cardiothoracic Surgery, Children's Hospital of Philadelphia, The Perelman School of Medicine, University of Pennsylvania, 3401 Civic Center Boulevard, Philadelphia, PA 19104, USA
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Monaco J, Khanna A, Khazanie P. Transplant and mechanical circulatory support in patients with adult congenital heart disease. Heart Fail Rev 2020; 25:671-683. [PMID: 32472522 PMCID: PMC7811764 DOI: 10.1007/s10741-020-09976-2] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
Advances in surgery and pediatric care over the past decades have achieved improved survival for children born with congenital heart disease (CHD) and have produced a large, growing population of patients with adult congenital heart disease (ACHD). Heart failure has emerged as the leading cause of death and a major cause of morbidity among the ACHD population, while as little evidence supports the efficacy of guideline-directed medical therapies in this population. It is increasingly important that clinicians caring for these patients understand how to utilize mechanical circulatory support (MCS) in ACHD. In this review, we summarize the data on transplantation and MCS in the ACHD-heart failure population and provide a framework for how ACHD patients may benefit from advanced heart failure therapies like transplantation and MCS.
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Affiliation(s)
- James Monaco
- Colorado University Hospital, University of Colorado Anschutz Medical Center, Aurora, CO, USA.
| | - Amber Khanna
- Colorado University Hospital, University of Colorado Anschutz Medical Center, Aurora, CO, USA
| | - Prateeti Khazanie
- Colorado University Hospital, University of Colorado Anschutz Medical Center, Aurora, CO, USA
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Congenital heart disease in adults (when kids grow up) pediatric geriatric anesthesia. Curr Opin Anaesthesiol 2020; 33:335-342. [PMID: 32371630 DOI: 10.1097/aco.0000000000000849] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE OF REVIEW The current review focuses on the new development of adult congenital heart disease (ACHD) patients in the areas of imaging, percutaneous interventions, ventricular assist devices and transplantation. RECENT FINDINGS Since the last ACHD publication in the journal, several advances have been made in the evaluation and treatment of these patients. As CHD patients' longevity increases pregnancy, comorbities and acquired heart disease become a concern. Recent data show that the incidence of complications in low-risk CHD is not higher that the regular population. In addition, breakthrough research in percutaneous valve implantation has been published showing good outcomes but needing intensive care recovery in a significant number of patients. In the ACHD heart failure population, assist device and transplant fields mounting evidence shows that these therapies should not be the last resort since low-risk ACHD patient may have similar outcomes to those with acquired heart disease. Finally risk stratification is important in ACHD to define better ways to recover from surgery and anesthesia. SUMMARY The field of anesthesia for ACHD is growing with new indications for diagnostic, interventional and surgical procedures. Tailoring cardiac and noncardiac care to the different risk profile in ACHD patients will be defined in the next few years. VIDEO ABSTRACT Motta summary clip: http://links.lww.com/COAN/A65.
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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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Advanced Heart Failure in Adults With Congenital Heart Disease. JACC-HEART FAILURE 2020; 8:87-99. [DOI: 10.1016/j.jchf.2019.08.012] [Citation(s) in RCA: 27] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/22/2019] [Revised: 07/08/2019] [Accepted: 08/07/2019] [Indexed: 12/11/2022]
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Advanced Heart Failure Therapies for Adults With Congenital Heart Disease. J Am Coll Cardiol 2019; 74:2295-2312. [DOI: 10.1016/j.jacc.2019.09.004] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/12/2019] [Revised: 08/20/2019] [Accepted: 09/03/2019] [Indexed: 12/15/2022]
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Byrne RD, Weingarten AJ, Clark DE, Huang S, Perri RE, Scanga AE, Menachem JN, Markham LW, Frischhertz BP. More than the heart: Hepatic, renal, and cardiac dysfunction in adult Fontan patients. CONGENIT HEART DIS 2019; 14:765-771. [PMID: 31282062 DOI: 10.1111/chd.12820] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/29/2019] [Revised: 06/11/2019] [Accepted: 06/19/2019] [Indexed: 12/12/2022]
Abstract
SETTING Fontan-associated liver disease universally affects adults with single ventricle heart disease. Chronic kidney disease is also highly prevalent in adult Fontan patients. In this study, we evaluate the relationship of Fontan hemodynamics invasively and noninvasively with extra-cardiac dysfunction as measured by MELD and MELD-XI. OBJECTIVE We hypothesize that invasive and noninvasive measures of Fontan circuit congestion and ventricular dysfunction are associated with increased MELD and MELD-XI scores. DESIGN Single-center data from adults with Fontan palliation who had ongoing care, including cardiac catheterization, were retrospectively collected. Hemodynamic data from cardiac catheterization and echocardiographic assessment of ventricular and atrioventricular valve function were tested for association with serum creatinine, MELD, and MELD-XI. Linear regression was used to perform multivariable analysis in the echocardiogram cohort. RESULTS Fifty-seven patients had congruent lab and catheterization data for analysis. Sixty-three and sixty-nine patients had congruent lab and echocardiogram data for MELD and MELD-XI, respectively. Of the hemodynamic variables analyzed, only decreased systemic oxygen saturation had significant correlation with elevated MELD and MELD-XI (P = .045). Patients with moderately or severely reduced ejection fraction by echocardiogram had significantly higher MELD and MELD-XI scores compared to those with normal or mildly depressed systolic ventricular function (P = .008 and P < .001 for MELD and MELD-XI, respectively). Significant differences in creatinine were also found among the ventricular dysfunction groups (P = .02). CONCLUSIONS In adults following Fontan palliation, systolic ventricular dysfunction and decreased oxygen saturation were associated with hepatic and renal dysfunction as assessed by elevated serum creatinine, MELD, and MELD-XI scores.
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Affiliation(s)
- Ryan D Byrne
- Departments of Internal Medicine and Pediatrics, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Angela J Weingarten
- Vanderbilt Heart and Vascular Institute, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Daniel E Clark
- Vanderbilt Heart and Vascular Institute, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Shi Huang
- Department of Biostatistics, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Roman E Perri
- Department of Internal Medicine, Division of Gastroenterology, Hepatology and Nutrition, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Andrew E Scanga
- Department of Internal Medicine, Division of Gastroenterology, Hepatology and Nutrition, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Jonathan N Menachem
- Vanderbilt Heart and Vascular Institute, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Larry W Markham
- Departments of Pediatrics and Internal Medicine, Division of Cardiology, Indiana University School of Medicine, Riley Hospital for Children, Indianapolis, Indiana
| | - Benjamin P Frischhertz
- Vanderbilt Heart and Vascular Institute, Vanderbilt University Medical Center, Nashville, Tennessee
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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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Hörer J. Current spectrum, challenges and new developments in the surgical care of adults with congenital heart disease. Cardiovasc Diagn Ther 2018; 8:754-764. [PMID: 30740322 DOI: 10.21037/cdt.2018.10.06] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Today, more than two thirds of patients with congenital heart disease (CHD) are adults. Cardiac surgery plays an essential role in restoring and maintaining cardiac function, aside from evolving medical treatment and catheter-based interventions. The aim of the present publication was to describe the spectrum of operations performed on adults with CHD (ACHD) by reviewing current literature. Currently, surgery for ACHD is predominantly valve surgery, since valvular pathologies are often either a part of the basic heart defect or develop as sequelae of corrective or palliative surgery. Surgical techniques for valve repair, established in patients with acquired heart disease (non-ACHD), can often be transferred to ACHD. New valve substitutes may help to reduce the number of redo operations. Most of valve operations yield good results in terms of survival and quality of life, with the precondition that the ventricular function is preserved. Heart failure due to end-stage CHD is the most frequent cause of mortality in ACHD. However, surgical treatment by means of mechanical circulatory support (MCS) is still uncommon and the mortality exceeds the one following other operations in ACHD. Currently, different devices are used and new technical developments are in progress. However, there still is no ideal assist device available. Therefore, heart transplantation remains the only valid option for end-stage CHD. Despite higher early mortality following heart transplantation in ACHD compared to non-ACHD, the long-term survival compares favorably to non-ACHD. There is room for improvement by refining the indications, the time of listing, and the perioperative care of ACHD transplant patients. Sudden death is the second most frequent cause of mortality in ACHD. Ventricular tachycardia is the most frequent cause of sudden death followed by coronary artery anomaly. Due to the increasing awareness of physicians and the improved imaging techniques, coronary artery anomalies are coming more into the focus of cardiac surgeons. However, the reported experience is limited and it is currently difficult to provide a standardized and generally applicable recommendation for the indication and the adequate surgical technique. With the increasing age and complexity of ACHD, treatment of rhythm disturbances by surgical ablation, pacemaker or implantable cardioverter defibrillator (ICD) implantation and resynchronisation gains importance. A risk score specifically designed for surgery in ACHD is among the newest developments in predicting the outcome of surgical treatment of ACHD. This evidence-based score, derived from and validated with data from the Society of Thoracic Surgeons Congenital Heart Surgery Database, enables comparison of risk-adjusted performance of the whole spectrum of procedures performed in ACHD and helps in understanding the differences in surgical outcomes. The score is thus a powerful tool for quality control and quality improvement. In conclusion, new developments in surgery for ACHD are currently made with regard to valve surgery, which comprises more than half of all operations in ACHD and in treatment of end-stage CHD, which still yields high mortality and morbidity.
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Affiliation(s)
- Jürgen Hörer
- Department of Pediatric Cardiology and Congenital Heart Disease, Hôpital Marie Lannelongue, Université Paris-Sud, Le Plessis Robinson, France
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