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Ravilla J, Yarrrarapu SN, Gaddameedi SR, Kruger A, Du D. An Uncommon Finding in an Adult: A Case Report of Hypoplastic Left Heart Syndrome and Protein-Losing Enteropathy. Cureus 2024; 16:e62705. [PMID: 38903982 PMCID: PMC11188018 DOI: 10.7759/cureus.62705] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/19/2024] [Indexed: 06/22/2024] Open
Abstract
Protein-losing enteropathy (PLE) is a rare disorder with diverse causes, but the treatments are limited and understudied. It is often associated with significant mortality and morbidity. The survival of hypoplastic left heart syndrome (HLHS) in infants without any intervention is usually 4.5 days, and 30-day mortality is 95%. However, with surgical intervention, survival at 20 years is 80%. HLHS can lead to protein-leading enteropathy and is corrected by the three-step procedures (Norwood, Glenn, and Fontan) during infancy. We report a case of Fontan procedure postoperative HLHS associated with PLE and describe its clinical course and outcome. The main intention of reporting this case is to provide awareness among physicians while dealing with refractory cases of hypoproteinemia and appropriate management based on the literature.
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Affiliation(s)
| | | | | | - Andrew Kruger
- Gastroenterology and Hepatology, Monmouth Medical Center, Long Branch, USA
| | - Doantrang Du
- Internal Medicine, Monmouth Medical Center, Long Branch, USA
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2
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Bauer C, Scala M, Rome JJ, Tulzer G, Dori Y. Lymphatic Imaging and Intervention in Congenital Heart Disease. JOURNAL OF THE SOCIETY FOR CARDIOVASCULAR ANGIOGRAPHY & INTERVENTIONS 2024; 3:101174. [PMID: 39131972 PMCID: PMC11308220 DOI: 10.1016/j.jscai.2023.101174] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 01/02/2023] [Revised: 09/01/2023] [Accepted: 09/05/2023] [Indexed: 08/13/2024]
Abstract
The lymphatic system plays a central role in some of the most devastating complications associated with congenital heart defects. Diseases like protein-losing enteropathy, plastic bronchitis, postoperative chylothorax, and chylous ascites are now proven to be lymphatic in origin. Novel imaging modalities, most notably, noncontrast magnetic resonance lymphangiography and dynamic contrast-enhanced magnetic resonance lymphangiography, can now depict lymphatic anatomy and function in all major lymphatic compartments and are essential for modern therapy planning. Based on the new pathophysiologic understanding of lymphatic flow disorders, innovative minimally invasive procedures have been invented during the last few years with promising results. Abnormal lymphatic flow can now be redirected with catheter-based interventions like thoracic duct embolization, selective lymphatic duct embolization, and liver lymphatic embolization. Lymphatic drainage can be improved through surgical or interventional techniques such as thoracic duct decompression or lympho-venous anastomosis.
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Affiliation(s)
- Christoph Bauer
- Department of Paediatric Cardiology, Kepler University Hospital GmbH, Linz, Austria
- Johannes Kepler University Linz, Linz, Austria
| | - Mario Scala
- Johannes Kepler University Linz, Linz, Austria
- Central Radiology Institute, Kepler University Hospital GmbH, Linz, Austria
| | - Jonathan J. Rome
- Department of Cardiology, Jill and Mark Fishman Center for Lymphatic Disorders, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Gerald Tulzer
- Department of Paediatric Cardiology, Kepler University Hospital GmbH, Linz, Austria
- Johannes Kepler University Linz, Linz, Austria
| | - Yoav Dori
- Department of Cardiology, Jill and Mark Fishman Center for Lymphatic Disorders, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
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Mendel B, Kohar K, Amirah S, Vidya AP, Utama KE, Prakoso R, Siagian SN. The outcomes of fetal aortic valvuloplasty in critical aortic stenosis: A systematic review and meta-analysis. Int J Cardiol 2023; 382:106-111. [PMID: 36996909 DOI: 10.1016/j.ijcard.2023.03.050] [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: 12/06/2022] [Revised: 03/08/2023] [Accepted: 03/21/2023] [Indexed: 04/01/2023]
Abstract
BACKGROUND Critical aortic stenosis that appears in mid-gestation tends to develop to growth retardation of left ventricle, known as hypoplastic left heart syndrome (HLHS). Despite better clinical management of HLHS, the morbidity and mortality rates of univentricular circulation patients remain high. In this paper, we sought to perform a systematic review and meta-analysis to know the outcomes of fetal aortic valvuloplasty in critical aortic stenosis patients. METHODS This systematic review and meta-analysis was conducted according to the Preferred Reporting Items for Systematic Review and Meta-Analyses (PRISMA) statement. A systematic search on fetal aortic valvuloplasty procedure for critical aortic stenosis was performed through PubMed, Scopus, EBSCOhost, ProQuest, and Google Scholar. The primary endpoint of each group was overall mortality. We used R software (version 4.1.3) to estimate the overall proportion of each outcome using random-effects model of proportional meta-analysis. RESULTS A total of 389 fetal subjects from 10 cohort studies were included in this systematic review and meta-analysis. Fetal aortic valvuloplasty (FAV) was successfully performed in 84% of patients. It revealed a successful conversion to biventricular circulation rate of 33% with a mortality rate of 20%. Bradycardia and pleural effusion requiring treatment were two most common fetal complications, whereas maternal complication reported was only placental abruption in one patient. CONCLUSIONS FAV has a high technical success rate with the ability to achieve biventricular circulation and a low rate of procedure-related mortality if carried out by experienced operators.
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Affiliation(s)
- Brian Mendel
- Division of Pediatric Cardiology and Congenital Heart Disease, Department of Cardiology and Vascular Medicine, National Cardiovascular Center Harapan Kita, Universitas Indonesia, Jakarta, Indonesia; Department of Cardiology and Vascular Medicine, Sultan Sulaiman Government Hospital, Serdang Bedagai, North Sumatera, Indonesia.
| | - Kelvin Kohar
- Faculty of Medicine, Universitas Indonesia, Jakarta, Indonesia
| | - Shakira Amirah
- Faculty of Medicine, Universitas Indonesia, Jakarta, Indonesia
| | | | | | - Radityo Prakoso
- Division of Pediatric Cardiology and Congenital Heart Disease, Department of Cardiology and Vascular Medicine, National Cardiovascular Center Harapan Kita, Universitas Indonesia, Jakarta, Indonesia
| | - Sisca Natalia Siagian
- Division of Pediatric Cardiology and Congenital Heart Disease, Department of Cardiology and Vascular Medicine, National Cardiovascular Center Harapan Kita, Universitas Indonesia, Jakarta, Indonesia
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Savla JJ, Kelly B, Krogh E, Smith CL, Krishnamurthy G, Glatz AC, DeWitt AG, Pinto EM, Ravishankar C, Gillespie MJ, O’Byrne ML, Escobar FA, Rome JJ, Hjortdal V, Dori Y. Occlusion Pressure of the Thoracic Duct in Fontan Patients With Lymphatic Failure: Does Dilatation Challenge Contractility? World J Pediatr Congenit Heart Surg 2022; 13:737-744. [DOI: 10.1177/21501351221119394] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background The Fontan circulation challenges the lymphatic system. Increasing production of lymphatic fluid and impeding lymphatic return, increased venous pressure may cause lymphatic dilatation and decrease lymphatic contractility. In-vitro studies have reported a lymphatic diameter-tension curve, with increasing passive stretch affecting the intrinsic contractile properties of each thoracic duct segment. We aimed to describe thoracic duct occlusion pressure and asses if thoracic duct dilation impairs contractility in individuals with a Fontan circulation and lymphatic failure. Methods Central venous pressure and thoracic duct measurements were retrospectively collected from 31 individuals with a Fontan circulation. Thoracic duct occlusion pressure was assessed during a period of external manual compression and used as an indicator of lymphatic vessel contractility. Measurements of pressure were correlated with measurements of the thoracic duct diameter in images obtained by dynamic contrast-enhanced MR lymphangiography. Results The average central venous pressure and average pressure of the thoracic duct were 17 mm Hg. During manual occlusion, the thoracic duct pressure significantly increased to 32 mm Hg. The average thoracic duct diameter was 3.3 mm. Thoracic duct diameter correlated closely with the central venous pressure. The rise in pressure following manual occlusion showed an inverse correlation with the diameter of the thoracic duct. Conclusion Higher central venous pressures are associated with increasing diameters of the thoracic duct. When challenged by manual occlusion, dilated thoracic ducts display a decreased ability to increase pressure. Dilatation and a resulting decreased contractility may partly explain the challenged lymphatic system in individuals with a Fontan circulation.
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Affiliation(s)
- Jill J. Savla
- Division of Cardiology, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Benjamin Kelly
- Department of Cardiothoracic Surgery, Aarhus University Hospital, Aarhus, Denmark
- Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
| | - Emil Krogh
- Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
| | - Christopher L. Smith
- Division of Cardiology, Children's Hospital of Philadelphia, Philadelphia, PA, USA
- The Jill and Mark Fishman Center for Lymphatic Disorders, Children's Hospital of Philadelphia, PA, USA
| | - Ganesh Krishnamurthy
- The Jill and Mark Fishman Center for Lymphatic Disorders, Children's Hospital of Philadelphia, PA, USA
- Department of Radiology, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Andrew C. Glatz
- Division of Cardiology, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Aaron G. DeWitt
- The Jill and Mark Fishman Center for Lymphatic Disorders, Children's Hospital of Philadelphia, PA, USA
- Division of Critical Care, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Erin M. Pinto
- Division of Cardiology, Children's Hospital of Philadelphia, Philadelphia, PA, USA
- The Jill and Mark Fishman Center for Lymphatic Disorders, Children's Hospital of Philadelphia, PA, USA
| | - Chitra Ravishankar
- Division of Cardiology, Children's Hospital of Philadelphia, Philadelphia, PA, USA
- The Jill and Mark Fishman Center for Lymphatic Disorders, Children's Hospital of Philadelphia, PA, USA
| | - Matthew J. Gillespie
- Division of Cardiology, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Michael L. O’Byrne
- Division of Cardiology, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Fernando A. Escobar
- The Jill and Mark Fishman Center for Lymphatic Disorders, Children's Hospital of Philadelphia, PA, USA
- Department of Radiology, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Jonathan J. Rome
- Division of Cardiology, Children's Hospital of Philadelphia, Philadelphia, PA, USA
- The Jill and Mark Fishman Center for Lymphatic Disorders, Children's Hospital of Philadelphia, PA, USA
| | - Vibeke Hjortdal
- Department of Cardiothoracic Surgery, Rigshospitalet, Aarhus, Denmark
| | - Yoav Dori
- Division of Cardiology, Children's Hospital of Philadelphia, Philadelphia, PA, USA
- The Jill and Mark Fishman Center for Lymphatic Disorders, Children's Hospital of Philadelphia, PA, USA
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5
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Sagray E, Johnson JN, Schumacher KR, West S, Lowery RE, Simpson K. Protein-losing enteropathy recurrence after pediatric heart transplantation: Multicenter case series. Pediatr Transplant 2022; 26:e14295. [PMID: 35451219 DOI: 10.1111/petr.14295] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/13/2022] [Revised: 04/03/2022] [Accepted: 04/09/2022] [Indexed: 11/28/2022]
Abstract
BACKGROUND Protein-losing enteropathy (PLE) is a devastating complication of the Fontan circulation. Although orthotopic heart transplantation (HTx) typically results in resolution of PLE symptoms, isolated cases of PLE relapse have been described after HTx. METHODS Patients with Fontan-related PLE who had undergone HTx at participating centers and experienced relapse of PLE during follow-up were retrospectively identified. Available data related to pre- and post-HTx characteristics and PLE events were collected. RESULTS Eight patients from four different centers were identified. Median time from Fontan procedure to the development of PLE was 8 years, and median age at HTx was 17 years (range 7.7-21). In all patients, PLE resolved at a median time of 1 month after HTx (0.3-5). PLE recurrences occurred at a median time of 7.5 months after HTx (2-132). Each occurrence was associated with one or more significant clinical events; most commonly cellular- or antibody-mediated rejection; and less commonly graft dysfunction, infection, thrombosis, and posttransplant lymphoproliferative disease. PLE recurrences resolved after the successful treatment of the concomitant event, after a median time of 2 months in seven cases, while persisted and recurred in one patient in association with atypical mycobacterium infection and subsequent PTLD onset and relapses. Six patients were alive during follow-up at a median time of 4 years (1.3-22.5) after HTx. CONCLUSIONS This is the largest series of PLE recurrence after HTx. All cases were associated with one or more concomitant and significant clinical events. PLE typically resolved after resolution of the inciting clinical event.
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Affiliation(s)
- Ezequiel Sagray
- Division of Pediatric Cardiology, Department of Pediatric and Adolescent Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Jonathan N Johnson
- Division of Pediatric Cardiology, Department of Pediatric and Adolescent Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Kurt R Schumacher
- Division of Pediatric Cardiology, Department of Pediatrics, University of Michigan, Ann Arbor, Michigan, USA
| | - Shawn West
- Pediatric Cardiology, Children's Hospital of Pittsburgh, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Ray E Lowery
- Division of Pediatric Cardiology, Department of Pediatrics, University of Michigan, Ann Arbor, Michigan, USA
| | - Kathleen Simpson
- Division of Cardiology, Department of Pediatrics, Children's Hospital of Colorado, University of Colorado Denver, Aurora, Colorado, USA
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Villard N, Meuwly JY, Righini M, Alberti N, Habre C. Renal peripelvic lymphangiectasia after bilateral renal vein thrombosis. BMJ Case Rep 2022; 15:e245666. [PMID: 35858735 PMCID: PMC9305717 DOI: 10.1136/bcr-2021-245666] [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] [Accepted: 06/10/2022] [Indexed: 11/04/2022] Open
Abstract
Renal peripelvic lymphangiectasia (RPL) is one of the rare conditions that mimic renal cysts. Its physiopathology remains unknown, but an association with renal vein thrombosis has been reported. We share the case of a male patient in his 20s suffering from antiphosphlipid syndrome. The patient was hospitalised for thrombosis of the inferior vena cava (IVC) extending from the iliac veins to the level of renal veins. Consecutive CT and clinical follow-up over the course of 14 years showed the development of numerous retroperitoneal venous collaterals and the apparition of several bilateral peripelvic cystic lesions after extensive thrombosis of the IVC and both renal veins. The renal function remained normal throughout the follow-up. We suggest that the development of RPL is secondary to bilateral renal vein thrombosis. The presumed mechanism would be an increased hydrostatic pressure in the kidney capillaries leading to a more important interstitial fluid drainage by the lymphatic system. To our knowledge, this is the first well-documented case of renal vein thrombosis followed by RPL, contrasting with the previous hypothesis that compression by the lymphangiectasia could cause the thrombosis.
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Affiliation(s)
- Nicolas Villard
- Service de radiodiagnostic et radiologie interventionnelle, Département de radiologie médicale, Lausanne University Hospital (CHUV), Lausanne, Switzerland
| | - Jean-Yves Meuwly
- Service de radiodiagnostic et radiologie interventionnelle, Département de radiologie médicale, Lausanne University Hospital (CHUV), Lausanne, Switzerland
| | - Marc Righini
- Service d'angiologie et d'hémostase, Départment de médecine, University Hospitals (HUG), Geneva, Switzerland
| | - Nicolas Alberti
- Groupe d'expertise en imagerie abdominale, TMF, Bordeaux, France
| | - Céline Habre
- Service de radiologie, Département diagnostique, Geneva University Hospitals (HUG), Geneva, Switzerland
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Saef J, Montgomery R, Cedars A, Tang WHW, Rossano JW, Maeda K, Kim YY, Vaikunth SS. Durable Mechanical Circulatory Support in Adult Congenital Heart Disease: Reviewing Clinical Considerations and Experience. J Clin Med 2022; 11:jcm11113200. [PMID: 35683587 PMCID: PMC9181100 DOI: 10.3390/jcm11113200] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2022] [Revised: 05/25/2022] [Accepted: 06/01/2022] [Indexed: 12/10/2022] Open
Abstract
Adults with congenital heart disease (ACHD) patients are one of the fastest growing populations in cardiology, and heart failure (HF) is the most common cause of morbidity and mortality amongst them. The need for advanced HF therapies in ACHD patients stands to grow substantially. The anatomic considerations for placing durable mechanical circulatory support (MCS) devices in ACHD patients often require specialized approaches. Despite this, increasing evidence suggests that durable MCS can be implanted safely with favorable outcomes in ACHD patients. Expansion of MCS use in ACHD patients is imperative to improve their clinical outcomes. Knowledge of ACHD-specific anatomic and physiologic considerations is crucial to HF programs’ success as they work to provide care to this growing population.
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Affiliation(s)
- Joshua Saef
- Division of Cardiovascular Medicine, Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA 19104, USA; (J.S.); (Y.Y.K.)
- Division of Cardiology, Children’s Hospital of Philadelphia, 3401 Civic Center Boulevard, Philadelphia, PA 19104, USA;
| | - Robert Montgomery
- Robert and Suzanne Tomsich Department of Cardiovascular Medicine, Sydell and Arnold Miller Family Heart, Vascular and Thoracic Institute, Cleveland Clinic Foundation, Cleveland, OH 44195, USA; (R.M.); (W.H.W.T.)
| | - Ari Cedars
- Division of Cardiology, Johns Hopkins Medicine, Baltimore, MD 21287, USA;
| | - Wai H. Wilson Tang
- Robert and Suzanne Tomsich Department of Cardiovascular Medicine, Sydell and Arnold Miller Family Heart, Vascular and Thoracic Institute, Cleveland Clinic Foundation, Cleveland, OH 44195, USA; (R.M.); (W.H.W.T.)
| | - Joseph W. Rossano
- Division of Cardiology, Children’s Hospital of Philadelphia, 3401 Civic Center Boulevard, Philadelphia, PA 19104, USA;
| | - Katsuhide Maeda
- Division of Cardiothoracic Surgery, Children’s Hospital of Philadelphia, 3401 Civic Center Boulevard, Philadelphia, PA 19104, USA;
| | - Yuli Y. Kim
- Division of Cardiovascular Medicine, Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA 19104, USA; (J.S.); (Y.Y.K.)
- Division of Cardiology, Children’s Hospital of Philadelphia, 3401 Civic Center Boulevard, Philadelphia, PA 19104, USA;
| | - Sumeet S. Vaikunth
- Division of Cardiovascular Medicine, Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA 19104, USA; (J.S.); (Y.Y.K.)
- Division of Cardiology, Children’s Hospital of Philadelphia, 3401 Civic Center Boulevard, Philadelphia, PA 19104, USA;
- Correspondence: ; Tel.: +215-615-3388
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Otani IM, Lehman HK, Jongco AM, Tsao LR, Azar AE, Tarrant TK, Engel E, Walter JE, Truong TQ, Khan DA, Ballow M, Cunningham-Rundles C, Lu H, Kwan M, Barmettler S. Practical guidance for the diagnosis and management of secondary hypogammaglobulinemia: A Work Group Report of the AAAAI Primary Immunodeficiency and Altered Immune Response Committees. J Allergy Clin Immunol 2022; 149:1525-1560. [PMID: 35176351 DOI: 10.1016/j.jaci.2022.01.025] [Citation(s) in RCA: 54] [Impact Index Per Article: 27.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2021] [Revised: 12/31/2021] [Accepted: 01/21/2022] [Indexed: 11/17/2022]
Abstract
Secondary hypogammaglobulinemia (SHG) is characterized by reduced immunoglobulin levels due to acquired causes of decreased antibody production or increased antibody loss. Clarification regarding whether the hypogammaglobulinemia is secondary or primary is important because this has implications for evaluation and management. Prior receipt of immunosuppressive medications and/or presence of conditions associated with SHG development, including protein loss syndromes, are histories that raise suspicion for SHG. In patients with these histories, a thorough investigation of potential etiologies of SHG reviewed in this report is needed to devise an effective treatment plan focused on removal of iatrogenic causes (eg, discontinuation of an offending drug) or treatment of the underlying condition (eg, management of nephrotic syndrome). When iatrogenic causes cannot be removed or underlying conditions cannot be reversed, therapeutic options are not clearly delineated but include heightened monitoring for clinical infections, supportive antimicrobials, and in some cases, immunoglobulin replacement therapy. This report serves to summarize the existing literature regarding immunosuppressive medications and populations (autoimmune, neurologic, hematologic/oncologic, pulmonary, posttransplant, protein-losing) associated with SHG and highlights key areas for future investigation.
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Affiliation(s)
- Iris M Otani
- Division of Pulmonary, Critical Care, Allergy and Sleep Medicine, UCSF Medical Center, San Francisco, Calif.
| | - Heather K Lehman
- Division of Allergy, Immunology, and Rheumatology, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo, NY
| | - Artemio M Jongco
- Division of Allergy and Immunology, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Great Neck, NY
| | - Lulu R Tsao
- Division of Pulmonary, Critical Care, Allergy and Sleep Medicine, UCSF Medical Center, San Francisco, Calif
| | - Antoine E Azar
- Division of Allergy and Clinical Immunology, Johns Hopkins University School of Medicine, Baltimore
| | - Teresa K Tarrant
- Division of Rheumatology and Immunology, Duke University, Durham, NC
| | - Elissa Engel
- Division of Hematology and Oncology, Cincinnati Children's Hospital, Cincinnati, Ohio
| | - Jolan E Walter
- Division of Allergy and Immunology, Johns Hopkins All Children's Hospital, St Petersburg, Fla; Division of Allergy and Immunology, Morsani College of Medicine, University of South Florida, Tampa; Division of Allergy and Immunology, Massachusetts General Hospital for Children, Boston
| | - Tho Q Truong
- Divisions of Rheumatology, Allergy and Clinical Immunology, National Jewish Health, Denver
| | - David A Khan
- Division of Allergy and Immunology, University of Texas Southwestern Medical Center, Dallas
| | - Mark Ballow
- Division of Allergy and Immunology, Morsani College of Medicine, Johns Hopkins All Children's Hospital, St Petersburg
| | | | - Huifang Lu
- Department of General Internal Medicine, Section of Rheumatology and Clinical Immunology, The University of Texas MD Anderson Cancer Center, Houston
| | - Mildred Kwan
- Division of Rheumatology, Allergy, and Immunology, Department of Medicine, University of North Carolina School of Medicine, Chapel Hill
| | - Sara Barmettler
- Allergy and Immunology, Massachusetts General Hospital, Boston.
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Protein-losing enteropathy in Fontan circulation: Pathophysiology, outcome and treatment options of a complex condition. INTERNATIONAL JOURNAL OF CARDIOLOGY CONGENITAL HEART DISEASE 2022. [DOI: 10.1016/j.ijcchd.2022.100322] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023] Open
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10
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Brownell JN, Biko DM, Mamula P, Krishnamurthy G, Escobar F, Srinivasan A, Laje P, Piccoli DA, Pinto E, Smith CL, Dori Y. Dynamic Contrast Magnetic Resonance Lymphangiography Localizes Lymphatic Leak to the Duodenum in Protein-Losing Enteropathy. J Pediatr Gastroenterol Nutr 2022; 74:38-45. [PMID: 34406998 PMCID: PMC8714618 DOI: 10.1097/mpg.0000000000003287] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
OBJECTIVES Protein-losing enteropathy (PLE) is a disorder of intestinal lymphatic flow resulting in leakage of protein-rich lymph into the gut lumen. Our primary aim was to report the imaging findings of dynamic contrast magnetic resonance lymphangiography (DCMRL) in patients with PLE. Our secondary objective was to use these imaging findings to characterize lymphatic phenotypes. METHODS Single-center retrospective cohort study of patients with PLE unrelated to single-ventricle circulation who underwent DCMRL. We report imaging findings of intranodal (IN), intrahepatic (IH), and intramesenteric (IM) access points for DCMRL. RESULTS Nineteen patients 0.3-58 years of age (median 1.2 years) underwent 29 DCMRL studies. Primary intestinal lymphangiectasia (PIL) was the most common referring diagnosis (42%). Other etiologies included constrictive pericarditis, thoracic insufficiency syndrome, and genetic disorders. IN-DCMRL demonstrated a normal central lymphatic system in all patients with an intact thoracic duct and localized duodenal leak in one patient (1/19, 5%). IH-DCMRL detected a duodenal leak in 12 of 17 (71%), and IM-DCMRL detected duodenal leak in 5 of 6 (83%). Independent of etiology, lymphatic leak was only visualized in the duodenum. CONCLUSIONS In patients with PLE, imaging via DCMRL reveals that leak is localized to the duodenum regardless of etiology. Comprehensive imaging evaluation with three access points can provide detailed information about the site of duodenal leak.
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Affiliation(s)
- Jefferson N. Brownell
- Division of Gastroenterology, Hepatology and Nutrition, Department of Pediatrics, Children’s Hospital of Philadelphia and University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
| | - David M. Biko
- Department of Radiology, Children’s Hospital of Philadelphia and University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
| | - Petar Mamula
- Division of Gastroenterology, Hepatology and Nutrition, Department of Pediatrics, Children’s Hospital of Philadelphia and University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
| | - Ganesh Krishnamurthy
- Department of Radiology, Children’s Hospital of Philadelphia and University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
| | - Fernando Escobar
- Department of Radiology, Children’s Hospital of Philadelphia and University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
| | - Abhay Srinivasan
- Department of Radiology, Children’s Hospital of Philadelphia and University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
| | - Pablo Laje
- Department of Surgery, Children’s Hospital of Philadelphia and University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
| | - David A. Piccoli
- Division of Gastroenterology, Hepatology and Nutrition, Department of Pediatrics, Children’s Hospital of Philadelphia and University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
| | - Erin Pinto
- Division of Cardiology, Department of Pediatrics, Children’s Hospital of Philadelphia and University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
| | - Christopher L. Smith
- Division of Cardiology, Department of Pediatrics, Children’s Hospital of Philadelphia and University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
| | - Yoav Dori
- Division of Cardiology, Department of Pediatrics, Children’s Hospital of Philadelphia and University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
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11
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Hedlund E, Lundell B. Fontan circulation has improved life expectancy for infants born with complex heart disease over the last 50 years but has also resulted in significant morbidity. Acta Paediatr 2022; 111:11-16. [PMID: 34235784 DOI: 10.1111/apa.16023] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/22/2021] [Revised: 06/22/2021] [Accepted: 07/06/2021] [Indexed: 12/17/2022]
Abstract
The prognosis for infants born with complex heart disease improved dramatically with the introduction of the Fontan circulation 50 years ago. With today's carefully designed and staged operations to a Fontan circulation, life expectancy has increased and most children will survive into adult life. The Fontan circulation entails an unphysiological circulation with high risk for multiple organ system dysfunction. Neurodevelopmental disabilities with adverse psychosocial effects are prevalent. The Fontan circulation may eventually fail and necessitate heart transplantation. CONCLUSION: Fifty years development of the Fontan circulation to today's staged surgical procedures has improved survival but also revealed the burden of a high morbidity for a growing number of patients.
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Affiliation(s)
- Eva Hedlund
- Department of Women's and Children's Health Karolinska Institutet Stockholm Sweden
| | - Bo Lundell
- Department of Women's and Children's Health Karolinska Institutet Stockholm Sweden
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12
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Alsaied T, Lubert AM, Goldberg DJ, Schumacher K, Rathod R, Katz DA, Opotowsky AR, Jenkins M, Smith C, Rychik J, Amdani S, Lanford L, Cetta F, Kreutzer C, Feingold B, Goldstein BH. Protein losing enteropathy after the Fontan operation. INTERNATIONAL JOURNAL OF CARDIOLOGY CONGENITAL HEART DISEASE 2022. [DOI: 10.1016/j.ijcchd.2022.100338] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
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13
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Driesen BW, Voskuil M, Grotenhuis HB. Current Treatment Options for the Failing Fontan Circulation. Curr Cardiol Rev 2022; 18:e060122200067. [PMID: 34994331 PMCID: PMC9893132 DOI: 10.2174/1573403x18666220106114518] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/21/2020] [Revised: 10/22/2021] [Accepted: 11/16/2021] [Indexed: 11/22/2022] Open
Abstract
The Fontan operation was introduced in 1968. For congenital malformations, where biventricular repair is unsuitable, the Fontan procedure has provided a long-term palliation strategy with improved outcomes compared to the initially developed procedures. Despite these improvements, several complications merely due to a failing Fontan circulation, including myocardial dysfunction, arrhythmias, increased pulmonary vascular resistance, protein-losing enteropathy, hepatic dysfunction, plastic bronchitis, and thrombo-embolism, may occur, thereby limiting the life-expectancy in this patient cohort. This review provides an overview of the most common complications of Fontan circulation and the currently available treatment options.
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Affiliation(s)
- Bart W. Driesen
- Department of Pediatric Cardiology, Wilhelmina Children’s Hospital, University Medical Center, Utrecht, Utrecht, The Netherlands
- Department of Cardiology, University Medical Center Utrecht, Utrecht, The Netherlands
- Department of Cardiology, Laurentius Ziekenhuis, Roermond, The Netherlands
| | - Michiel Voskuil
- Department of Cardiology, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Heynric B. Grotenhuis
- Department of Pediatric Cardiology, Wilhelmina Children’s Hospital, University Medical Center, Utrecht, Utrecht, The Netherlands
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14
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Yoon JK, Kim GB, Song MK, Lee SY, Kim SH, Jang SI, Kim WH, Lee CH, Ahn KJ, Bae EJ. Long-term Outcome of Fontan-Associated Protein-Losing Enteropathy: Treatment Modality and Predictive Factor of Mortality. Korean Circ J 2022; 52:606-620. [PMID: 35491478 PMCID: PMC9353248 DOI: 10.4070/kcj.2021.0309] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2021] [Revised: 02/18/2022] [Accepted: 02/23/2022] [Indexed: 11/15/2022] Open
Abstract
We conducted the first retrospective study on Fontan-associated protein-losing enteropathy (PLE) in Korea. Fontan-associated PLE is still challenging to treat, although the survival rate has improved. There is no best treatment for PLE, and relapse occurs frequently. However, selected patients show promising results after various treatments. It would be helpful to identify the risk factors of mortality in patients with Fontan-associated PLE. High-risk patients should undergo comprehensive evaluations and receive more aggressive therapies for PLE. This study emphasizes the necessity for developing aggressive and individually targeted treatment strategies by sharing our long-term experience on Fontan-associated PLE in the current era. Background and Objectives Protein-losing enteropathy (PLE) is a devastating complication after the Fontan operation. This study aimed to investigate the clinical characteristics, treatment response, and outcomes of Fontan-associated PLE. Methods We reviewed the medical records of 38 patients with Fontan-associated PLE from 1992 to 2018 in 2 institutions in Korea. Results PLE occurred in 4.6% of the total 832 patients after the Fontan operation. After a mean period of 7.7 years after Fontan operation, PLE was diagnosed at a mean age of 11.6 years. The mean follow-up period was 8.9 years. The survival rates were 81.6% at 5 years and 76.5% at 10 years. In the multivariate analysis, New York Heart Association Functional classification III or IV (p=0.002), low aortic oxygen saturation (<90%) (p=0.003), and ventricular dysfunction (p=0.032) at the time of PLE diagnosis were found as predictors of mortality. PLE was resolved in 10 of the 38 patients after treatment. Among medical managements, an initial heparin response was associated with survival (p=0.043). Heparin treatment resulted in resolution in 4 patients. We found no evidence on pulmonary vasodilator therapy alone. PLE was also resolved after surgical Fontan fenestration (2/6), aortopulmonary collateral ligation (1/1), and transplantation (1/1). Conclusions The survival rate of patients with Fontan-associated PLE has improved with the advancement of conservative care. Although there is no definitive method, some treatments led to the resolution of PLE in one-fourth of the patients. Further investigations are needed to develop the best prevention and therapeutic strategies for PLE.
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Affiliation(s)
- Ja-Kyoung Yoon
- Department of Pediatrics, Sejong General Hospital, Bucheon, Korea
| | - Gi Beom Kim
- Department of Pediatrics, Seoul National University Children’s Hospital, Seoul National University College of Medicine, Seoul, Korea
| | - Mi Kyoung Song
- Department of Pediatrics, Seoul National University Children’s Hospital, Seoul National University College of Medicine, Seoul, Korea
| | - Sang Yun Lee
- Department of Pediatrics, Seoul National University Children’s Hospital, Seoul National University College of Medicine, Seoul, Korea
| | - Seong Ho Kim
- Department of Pediatrics, Sejong General Hospital, Bucheon, Korea
| | - So Ick Jang
- Department of Pediatrics, Sejong General Hospital, Bucheon, Korea
| | - Woong Han Kim
- Department of Thoracic and Cardiovascular Surgery, Seoul National University Children’s Hospital, Seoul, Korea
| | - Chang-Ha Lee
- Department of Thoracic and Cardiovascular Surgery, Sejong General Hospital, Bucheon, Korea
| | - Kyung Jin Ahn
- Department of Pediatrics, Gachon University Gil Medical Center, Incheon, Korea
| | - Eun Jung Bae
- Department of Pediatrics, Seoul National University Children’s Hospital, Seoul National University College of Medicine, Seoul, Korea
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15
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Constantine A, Dimopoulos K, Jenkins P, Tulloh RMR, Condliffe R, Jansen K, Chung NAY, Oliver J, Parry H, Fitzsimmons S, Walker N, Wort SJ, Papaioannou V, von Klemperer K, Clift P. Use of Pulmonary Arterial Hypertension Therapies in Patients with a Fontan Circulation: Current Practice Across the United Kingdom. J Am Heart Assoc 2021; 11:e023035. [PMID: 34927465 PMCID: PMC9075198 DOI: 10.1161/jaha.121.023035] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Background The Fontan circulation is a successful operative strategy for abolishing cyanosis and chronic volume overload in patients with congenital heart disease with single ventricle physiology. “Fontan failure” is a major cause of poor quality of life and mortality in these patients. We assessed the number and clinical characteristics of adult patients with Fontan physiology receiving pulmonary arterial hypertension (PAH) therapies across specialist centers in the United Kingdom. Methods and Results We identified all adult patients with a Fontan‐type circulation under active follow‐up in 10 specialist congenital heart disease centers in England and Scotland between 2009 and 2019. Patients taking PAH therapies were matched to untreated patients. A survey of experts was also performed. Of 1538 patients with Fontan followed in specialist centers, only 76 (4.9%) received PAH therapies during follow‐up. The vast majority (90.8%) were treated with a phosphodiesterase‐5 inhibitor. In 33% of patients, PAH therapies were started after surgery or during hospital admission. In the matched cohort, treated patients were more likely to be significantly limited, have ascites, have a history of protein‐losing enteropathy, or receive loop diuretics (P<0.0001 for all), also reflecting survey responses indicating that failing Fontan is an important treatment target. After a median of 12 months (11–15 months), functional class was more likely to improve in the treated group (P=0.01), with no other changes in clinical parameters or safety issues. Conclusions PAH therapies are used in adult patients with Fontan circulation followed in specialist centers, targeting individuals with advanced disease or complications. Follow‐up suggests stabilization of the clinical status after 12 months of therapy.
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Affiliation(s)
- Andrew Constantine
- Adult Congenital Heart Centre and Centre for Pulmonary Hypertension, Royal Brompton HospitalRoyal Brompton and Harefield HospitalsGuy's and St Thomas' NHS Foundation Trust London United Kingdom.,National Heart and Lung InstituteImperial College London London United Kingdom
| | - Konstantinos Dimopoulos
- Adult Congenital Heart Centre and Centre for Pulmonary Hypertension, Royal Brompton HospitalRoyal Brompton and Harefield HospitalsGuy's and St Thomas' NHS Foundation Trust London United Kingdom.,National Heart and Lung InstituteImperial College London London United Kingdom
| | - Petra Jenkins
- North West ACHD ServiceLiverpool Heart and Chest HospitalLiverpool Heart and Chest Hospital NHS Foundation Trust Liverpool United Kingdom
| | - Robert M R Tulloh
- Bristol Heart InstituteUniversity Hospital Bristol and Weston NHS Foundation Trust Bristol United Kingdom
| | - Robin Condliffe
- Pulmonary Vascular Disease Unit Royal Hallamshire HospitalSheffield Teaching Hospitals NHS Foundation Trust Sheffield United Kingdom
| | - Katrijn Jansen
- Adult Congenital and Paediatric Heart Unit Freeman HospitalNewcastle Upon Tyne Hospitals NHS Foundation Trust Newcastle Upon Tyne United Kingdom
| | - Natali A Y Chung
- Adult Congenital Heart Disease Service, St Thomas' HospitalGuy's and St Thomas' NHS Foundation Trust London United Kingdom
| | - James Oliver
- Yorkshire Heart Centre, Leeds General InfirmaryLeeds Teaching Hospitals NHS Trust Leeds United Kingdom
| | - Helen Parry
- Yorkshire Heart Centre, Leeds General InfirmaryLeeds Teaching Hospitals NHS Trust Leeds United Kingdom
| | - Samantha Fitzsimmons
- Congenital Cardiac Centre, Southampton General HospitalUniversity Hospital Southampton NHS Foundation Trust Southampton United Kingdom
| | - Niki Walker
- Scottish Adult Congenital Cardiology Service Golden Jubilee National Hospital Glasgow United Kingdom
| | - Stephen John Wort
- Adult Congenital Heart Centre and Centre for Pulmonary Hypertension, Royal Brompton HospitalRoyal Brompton and Harefield HospitalsGuy's and St Thomas' NHS Foundation Trust London United Kingdom.,National Heart and Lung InstituteImperial College London London United Kingdom
| | - Vasilios Papaioannou
- North West ACHD ServiceLiverpool Heart and Chest HospitalLiverpool Heart and Chest Hospital NHS Foundation Trust Liverpool United Kingdom
| | - Kate von Klemperer
- Grown-Up Congenital Heart Disease Service Barts Heart CentreSt Bartholomew's HospitalBarts Health NHS Trust London United Kingdom
| | - Paul Clift
- Department of Cardiology Queen Elizabeth Hospital Birmingham United Kingdom
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16
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Djukic M, Djordjevic SA, Pavlovic AS, Stefanovic I, Topalovic M, Dähnert I. Protein-losing enteropathy managed with percutaneous enlargement of a restrictive atrial septal defect. Rev Port Cardiol 2021; 40:895.e1-895.e4. [PMID: 34857165 DOI: 10.1016/j.repce.2021.11.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2018] [Accepted: 09/30/2018] [Indexed: 11/25/2022] Open
Abstract
Protein-losing enteropathy is one of the most feared complications of the Fontan circulation. The diagnosis of protein-losing enteropathy in this setting should prompt a thorough investigation for the presence of a treatable hemodynamic impairment. In this report, we describe a complete reversal of protein-losing enteropathy following percutaneous enlargement of a restrictive atrial septal defect in a patient with a fenestrated lateral tunnel Fontan and severe mitral stenosis.
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Affiliation(s)
- Milan Djukic
- Department of Cardiology, University Children's Hospital, Belgrade, Serbia
| | | | - Andrija S Pavlovic
- Department of Cardiology, University Children's Hospital, Belgrade, Serbia
| | - Igor Stefanovic
- Department of Cardiology, University Children's Hospital, Belgrade, Serbia
| | - Mirko Topalovic
- Department of Cardiology, University Children's Hospital, Belgrade, Serbia
| | - Ingo Dähnert
- Department of Pediatric Cardiology, Heart Center Leipzig, Leipzig, Germany
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17
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Protein-losing enteropathy managed with percutaneous enlargement of a restrictive atrial septal defect. Rev Port Cardiol 2021. [DOI: 10.1016/j.repc.2021.09.001] [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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18
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Krishnan GS, Gnanasekharan P, Sharma D, Chandrashekhar A, Rao KGS, Balakrishnan KR. Heart transplantation for patients with single ventricle physiology. Indian J Thorac Cardiovasc Surg 2021; 37:647-661. [PMID: 34642557 PMCID: PMC8495435 DOI: 10.1007/s12055-021-01241-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2021] [Revised: 07/12/2021] [Accepted: 07/13/2021] [Indexed: 11/29/2022] Open
Abstract
Background There is a growing population of palliated and unpalliated single ventricle physiology patients for whom heart transplantation is the only treatment option available. There is a paucity of reports of heart transplantation in this challenging and growing subset of patients from our part of the world. The purpose of the article is to briefly review our experience in the subgroup and compare it with the available literature. Methods This was a single-institution retrospective observational study of 16 patients with single ventricle physiology who were transplanted between 2016 and 2019 and their outcomes. The study groups were divided into those with ventricular dysfunction (group 1), who fare substantially better than those with normal ventricular function (group 2) whose short-term outcomes were poorer. Worsening cyanosis, poor candidature for completion Fontan procedure due to severe atrioventricular valve regurgitation or pulmonary artery anatomy, protein-losing enteropathy, plastic bronchitis, and worsening systemic venous congestion are indications in those with normal ventricular function. Results Patients with ventricular dysfunction as the main indication had excellent early survival with no early mortality compared to 40% mortality in patients with normal ventricular function. Patients who survived to leave the hospital had however similar long-term outcomes. Two patients with protein-losing enteropathy resolved completely by one month. Normal ventricular function, pulmonary artery stenting, early Fontan failure (6 months), ascites, and need for desensitization were risk factors for early mortality. After the early acute phase of increased risk, the mortality risk plateaued off. Conclusion Transplantation in patients with single ventricle and ventricular dysfunction can be offered with a good early and late outcome. There is a need to have multi-institutional and multi-disciplinary collaboration along with work in basic sciences to better understand the effects of failed Fontan physiology with normal ventricular function.
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Affiliation(s)
- Ganapathy Subramaniam Krishnan
- Institute of Heart and Lung Transplant and Mechanical Circulatory Support, MGM Healthcare, No. 72, Nelson Manickam Road, Aminjikarai, Chennai, 600029 Tamil -Nadu India
| | - Pradeep Gnanasekharan
- Institute of Heart and Lung Transplant and Mechanical Circulatory Support, MGM Healthcare, No. 72, Nelson Manickam Road, Aminjikarai, Chennai, 600029 Tamil -Nadu India
| | - Dhruva Sharma
- Department of Cardiothoracic and Vascular Surgery, SMS Medical College & Attached Hospitals, J L N Marg, Jaipur, 302001 Rajasthan India
| | - Anitha Chandrashekhar
- Institute of Heart and Lung Transplant and Mechanical Circulatory Support, MGM Healthcare, No. 72, Nelson Manickam Road, Aminjikarai, Chennai, 600029 Tamil -Nadu India
| | - Kemundel Genny Suresh Rao
- Cardiac Anaesthesia & Critical Care, MGM Healthcare, No. 72, Nelson Manickam Road, Aminjikarai, Chennai, 600029 Tamil-Nadu India
| | - Komarakshi Rajagopalan Balakrishnan
- Institute of Heart and Lung Transplant and Mechanical Circulatory Support, MGM Healthcare, No. 72, Nelson Manickam Road, Aminjikarai, Chennai, 600029 Tamil -Nadu India
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19
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Alsaied T, Rathod RH, Aboulhosn JA, Budts W, Anderson JB, Baumgartner H, Brown DW, Cordina R, D'udekem Y, Ginde S, Goldberg DJ, Goldstein BH, Lubert AM, Oechslin E, Opotowsky AR, Rychik J, Schumacher KR, Valente AM, Wright G, Veldtman GR. Reaching consensus for unified medical language in Fontan care. ESC Heart Fail 2021; 8:3894-3905. [PMID: 34190428 PMCID: PMC8497335 DOI: 10.1002/ehf2.13294] [Citation(s) in RCA: 36] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2020] [Revised: 02/03/2021] [Accepted: 02/19/2021] [Indexed: 02/04/2023] Open
Abstract
Aims The Fontan operation has resulted in improved survival in patients with single‐ventricle congenital heart disease. As a result, there is a growing population of teenagers and adults with a Fontan circulation. Many co‐morbidities have been increasingly recognized in this population due to the unique features of the Fontan circulation. Standardization of how Fontan co‐morbid conditions are defined will help facilitate understanding, consistency and interpretability of research and clinical experience. Unifying common language usage in Fontan is a critical precursor step for data comparison of research findings and clinical outcomes and ultimately accelerating improvements in management for this growing group of patients. This manuscript aimed to create unified definitions for morbidities seen after the Fontan palliation. Methods In association of many congenital heart disease organizations, this work used Delphi methodology to reach a broad consensus among recognized experts regarding commonly used terms in Fontan care and research. Each definition underwent at least three rounds of revisions to reach a final definition through surveys sent to experts in the field of single‐ventricle care. Results The process of reaching a consensus on multiple morbidities associated with the Fontan procedure is summarized in this manuscript. The different versions that preceded reaching the consensus are also presented in the Supporting Information. Table 1 represents the final definitions according to the consensus. Conclusions We propose the use of these definitions for clinical care, future research studies, registry development and clinical trials.
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Affiliation(s)
- Tarek Alsaied
- Heart Institute, Department of Pediatrics, Pittsburgh Children's Hospital Medical Center, Pittsburgh, PA, USA.,Heart Institute, Department of Pediatrics, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - Rahul H Rathod
- Department of Cardiology, Boston Children's Hospital, Boston, MA, USA
| | - Jamil A Aboulhosn
- Ahmanson/UCLA Adult Congenital Heart Disease Center, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA
| | - Werner Budts
- Division of Congenital and Structural Cardiology, University Hospitals Leuven, Leuven, Belgium
| | - Jeffrey B Anderson
- Heart Institute, Department of Pediatrics, Pittsburgh Children's Hospital Medical Center, Pittsburgh, PA, USA
| | - Helmut Baumgartner
- Department of Cardiology: Adult Congenital and Valvular Heart Disease, University Hospital Muenster, Muenster, Germany
| | - David W Brown
- Department of Cardiology, Boston Children's Hospital, Boston, MA, USA
| | - Rachael Cordina
- Adult Congenital Heart Disease Service and Pulmonary Hypertension Service, Royal Prince Alfred Hospital, Sydney, Australia
| | - Yves D'udekem
- Department of Cardiac Surgery and Children's National Heart Institute, Children's National Hospital, Washington, DC, USA
| | - Salil Ginde
- Division of Pediatric Cardiology, Department of Pediatrics, Medical College of Wisconsin, Milwaukee, WI, USA
| | - David J Goldberg
- Division of Cardiology, Department of Pediatrics, The Children's Hospital of Philadelphia, Perelman School of Medicine, University of Pennsylvania School of Medicine, Philadelphia, PA, USA
| | - Bryan H Goldstein
- Heart Institute, UPMC Children's Hospital of Pittsburgh, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Adam M Lubert
- Heart Institute, Department of Pediatrics, Pittsburgh Children's Hospital Medical Center, Pittsburgh, PA, USA
| | - Erwin Oechslin
- Congenital Cardiac Centre for Adults, Peter Munk Cardiac Centre, University Health Network, Toronto, Canada
| | - Alexander R Opotowsky
- Heart Institute, Department of Pediatrics, Pittsburgh Children's Hospital Medical Center, Pittsburgh, PA, USA
| | - Jack Rychik
- Division of Cardiology, Department of Pediatrics, The Children's Hospital of Philadelphia, Perelman School of Medicine, University of Pennsylvania School of Medicine, Philadelphia, PA, USA
| | - Kurt R Schumacher
- Congenital Heart Center, C.S. Mott Children's Hospital, University of Michigan, Ann Arbor, MI, USA
| | | | - Gail Wright
- Division of Cardiology, Department of Pediatrics, Stanford University School of Medicine, Santa Clara, CA, USA
| | - Gruschen R Veldtman
- Adult Congenital Heart Disease Service, Heart Centre, King Faisal Specialist Hospital and Research Centre, Riyadh, Saudi Arabia
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20
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Abdominal Imaging of Children and Young Adults With Fontan Circulation: Pathophysiology and Surveillance. AJR Am J Roentgenol 2021; 217:207-217. [PMID: 33909464 DOI: 10.2214/ajr.20.23404] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
OBJECTIVE. The Fontan procedure has significantly improved the survival in children with a functional single ventricle, but it is associated with chronically elevated systemic venous pressure that leads to multisystemic complications. Imaging plays an important role in assessing these complications and guiding management. The pathophysiology, imaging modalities, and current surveillance recommendations are discussed and illustrated. CONCLUSION. Significant improvement in survival of patients with Fontan circulation is associated with ongoing cardiac and extracardiac comorbidities and multisystemic complications. The liver and intestines are particularly vulnerable to damage. In addition, this patient population has been shown to be at increased risk of certain malignancies such as hepatocellular carcinoma and neuroendocrine tumors. Familiarity with imaging findings of Fontan-associated liver disease and other abdominal complications of the Fontan circulation is essential for radiologists because we are likely to encounter these patients in our general practice.
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21
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Mourato MF, Mourato FA, Mattos SDS, Neves JR. Echocardiographic and Ultrasonographic Parameters Associated with Protein-losing Enteropathy in Patients with Fontan Physiology: a Systematic Review with Meta-analysis. INTERNATIONAL JOURNAL OF CARDIOVASCULAR SCIENCES 2021. [DOI: 10.36660/ijcs.20200047] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
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22
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Gooty VD, Veeram Reddy SR, Greer JS, Blair Z, Zahr RA, Arar Y, Castellanos DA, Pimplawar S, Greil GF, Dillenbeck J, Hussain T. Lymphatic pathway evaluation in congenital heart disease using 3D whole-heart balanced steady state free precession and T2-weighted cardiovascular magnetic resonance. J Cardiovasc Magn Reson 2021; 23:16. [PMID: 33641664 PMCID: PMC7919323 DOI: 10.1186/s12968-021-00707-6] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2020] [Accepted: 01/06/2021] [Indexed: 11/17/2022] Open
Abstract
BACKGROUND Due to passive blood flow in palliated single ventricle, central venous pressure increases chronically, ultimately impeding lymphatic drainage. Early visualization and treatment of these malformations is essential to reduce morbidity and mortality. Cardiovascular magnetic resonance (CMR) T2-weighted lymphangiography (T2w) is used for lymphatic assessment, but its low signal-to-noise ratio may result in incomplete visualization of thoracic duct pathway. 3D-balanced steady state free precession (3D-bSSFP) is commonly used to assess congenital cardiac disease anatomy. Here, we aimed to improve diagnostic imaging of thoracic duct pathway using 3D-bSSFP. METHODS Patients underwent CMR during single ventricle or central lymphatic system assessment using T2w and 3D-bSSFP. T2w parameters included 3D-turbo spin echo (TSE), TE/TR = 600/2500 ms, resolution = 1 × 1 × 1.8 mm, respiratory triggering with bellows. 3D-bSSFP parameters included electrocardiogram triggering and diaphragm navigator, 1.6 mm isotropic resolution, TE/TR = 1.8/3.6 ms. Thoracic duct was identified independently in T2w and 3D-bSSFP images, tracked completely from cisterna chyli to its drainage site, and classified based on severity of lymphatic abnormalities. RESULTS Forty-eight patients underwent CMR, 46 of whom were included in the study. Forty-five had congenital heart disease with single ventricle physiology. Median age at CMR was 4.3 year (range 0.9-35.1 year, IQR 2.4 year), and median weight was 14.4 kg (range, 7.9-112.9 kg, IQR 5.2 kg). Single ventricle with right dominant ventricle was noted in 31 patients. Thirty-eight patients (84%) were status post bidirectional Glenn and 7 (16%) were status post Fontan anastomosis. Thoracic duct visualization was achieved in 45 patients by T2w and 3D-bSSFP. Complete tracking to drainage site was attained in 11 patients (24%) by T2w vs 25 (54%) by 3D-bSSFP and in 28 (61%) by both. Classification of lymphatics was performed in 31 patients. CONCLUSION Thoracic duct pathway can be visualized by 3D-bSSFP combined with T2w lymphangiography. Cardiac triggering and respiratory navigation likely help retain lymphatic signal in the retrocardiac area by 3D-bSSFP. Visualizing lymphatic system leaks is challenging on 3D-bSSFP images alone, but 3D-bSSFP offers good visualization of duct anatomy and landmark structures to help plan interventions. Together, these sequences can define abnormal lymphatic pathway following single ventricle palliative surgery, thus guiding lymphatic interventional procedures.
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Affiliation(s)
- Vasu D Gooty
- Department of Pediatrics, Division of Pediatric Cardiology, University of Tennessee Health Science Center, Le Bonheur Children's Hospital, 49N Dunlap Street, 3rd Floor, Memphis, TN, 38015, USA.
- Department of Pediatrics, Division of Pediatric Cardiology, University of Texas Southwestern Medical Center, Dallas Children's Medical Center, Dallas, TX, USA.
| | - Surendranath R Veeram Reddy
- Department of Pediatrics, Division of Pediatric Cardiology, University of Texas Southwestern Medical Center, Dallas Children's Medical Center, Dallas, TX, USA
| | - Joshua S Greer
- Department of Pediatrics, Division of Pediatric Cardiology, University of Texas Southwestern Medical Center, Dallas Children's Medical Center, Dallas, TX, USA
| | - Zachary Blair
- University of Texas Southwestern Medical School, Dallas, TX, USA
| | - Riad Abou Zahr
- Department of Pediatrics, Division of Pediatric Cardiology, University of Texas Southwestern Medical Center, Dallas Children's Medical Center, Dallas, TX, USA
| | - Yousef Arar
- Department of Pediatrics, Division of Pediatric Cardiology, University of Texas Southwestern Medical Center, Dallas Children's Medical Center, Dallas, TX, USA
| | - Daniel A Castellanos
- Department of Pediatrics, Division of Pediatric Cardiology, University of Texas Southwestern Medical Center, Dallas Children's Medical Center, Dallas, TX, USA
| | - Sheena Pimplawar
- Department of Pediatric Radiology, University of Texas Southwestern Medical Center, Dallas Children's Medical Center, Dallas, TX, USA
| | - Gerald F Greil
- Department of Pediatrics, Division of Pediatric Cardiology, University of Texas Southwestern Medical Center, Dallas Children's Medical Center, Dallas, TX, USA
| | - Jeanne Dillenbeck
- Department of Pediatric Radiology, University of Texas Southwestern Medical Center, Dallas Children's Medical Center, Dallas, TX, USA
| | - Tarique Hussain
- Department of Pediatrics, Division of Pediatric Cardiology, University of Texas Southwestern Medical Center, Dallas Children's Medical Center, Dallas, TX, USA
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23
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Moosmann J, Toka O, Lukassen S, Ekici AB, Mackensen A, Völkl S, Dittrich S. Lymphocyte Immune Response and T Cell Differentiation in Fontan Patients with protein-losing enteropathy. Thorac Cardiovasc Surg 2021; 69:e10-e20. [PMID: 33607694 PMCID: PMC7909601 DOI: 10.1055/s-0041-1723781] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
Background
Protein-losing enteropathy (PLE) is a severe complication of the Fontan circulation. There is increasing discussion about whether lymphatic dysregulation is involved as pathomechanism of PLE. This investigation focuses on the interplay between alteration of lymphatic cells and immunologic pathway alterations.
Methods
Micro-ribonucleic acid (miRNA) expression profiling was performed in 49 patients (
n
= 10 Fontan patients with PLE,
n
= 30 Fontan patients without PLE, and
n
= 9 patients with dextro-transposition of the great arteries (dTGA). miRNA pathway analysis was performed to identify significantly enriched pathways. To determine lymphocyte populations and subtypes multiparameter flow cytometry was used.
Results
miRNAs pathway analysis of Fontan patients with PLE revealed 20 significantly changed networks of which four of the ten largest were associated with immunologic processes. This finding is supported by significant T cell deficiency with decreased CD4+ count (
p
= 0.0002), altered CD4 +/CD8+ ratio, and significantly modified CD4+ (
p
< 0.0001) and CD8+ (
p
= 0.0002) T cell differentiation toward effector and terminal differentiated T cells in Fontan patients with PLE. Analyses of CD4+ T cell subsets demonstrated significantly increased frequencies of CD4+ CD25+ CD127– regulatory T cells (Treg) in Fontan patients with PLE (
p
= 0.0011).
Conclusion
PLE in Fontan patients is associated with severe lymphopenia, T cell deficiency, significant alterations of T cell differentiation, and increased Treg frequency reflecting an immune status of chronic inflammation and shortened protection against pathogens and autoimmunity. These cellular alterations seemed to be dysregulated by several miRNA controlled immunological pathways.
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Affiliation(s)
- Julia Moosmann
- Department of Pediatric Cardiology, Friedrich-Alexander Universität Erlangen-Nürnberg (FAU), Erlangen, Germany
| | - Okan Toka
- Pediatric and Adolescent Clinic, Fürth, Germany
| | - Sören Lukassen
- Institute of Human Genetics, Friedrich-Alexander Universität Erlangen-Nürnberg (FAU), Erlangen, Germany
| | - Arif B Ekici
- Institute of Human Genetics, Friedrich-Alexander Universität Erlangen-Nürnberg (FAU), Erlangen, Germany
| | - Andreas Mackensen
- Department of Internal Medicine 5, Haematology and Oncology, Universität Erlangen-Nürnberg (FAU), Erlangen, Germany
| | - Simon Völkl
- Department of Internal Medicine 5, Haematology and Oncology, Universität Erlangen-Nürnberg (FAU), Erlangen, Germany
| | - Sven Dittrich
- Department of Pediatric Cardiology, Friedrich-Alexander Universität Erlangen-Nürnberg (FAU), Erlangen, Germany
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Martínez-Quintana E, Sánchez-Matos MM, Estupiñán-León H, Rojas-Brito AB, González-Martín JM, Rodríguez-González F, Tugores A. Malnutrition is independently associated with an increased risk of major cardiovascular events in adult patients with congenital heart disease. Nutr Metab Cardiovasc Dis 2021; 31:481-488. [PMID: 33223403 DOI: 10.1016/j.numecd.2020.09.026] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/27/2020] [Revised: 09/19/2020] [Accepted: 09/21/2020] [Indexed: 12/28/2022]
Abstract
BACKGROUND AND AIMS Malnutrition is found frequently during chronic diseases, and its prevalence and relation to disease outcome in adult patients with congenital heart disease (CHD) remains unknown. METHODS AND RESULTS A cohort of 393 consecutive stable congenital heart disease (CHD) patients was followed up in a single dedicated clinical unit. Demographic, clinical and laboratory parameters, along with a nutritional risk index (NRI), were studied, as well as major acute cardiovascular events (MACE), defined as arterial thrombotic events, heart failure requiring hospitalization or cardiovascular and non-cardiovascular mortality. The median age of the patients was 23 years (17-35) and 225 (57%) were males. Median plasma albumin concentration was 4.5 (4.2-4.7) g/dL, the body mass index was 23 (21-27) kg/m2, the NRI was 112 (106-118), and 33 (8%) patients showed malnutrition (NIR<100). A worse NYHA functional class (II and III), total cholesterol and serum glucose levels were significant risk factors associated with malnutrition (NRI<100) in CHD patients. During a median follow-up of 8 (5-10) years, 39 (10%) CHD patients suffered a MACE. Multivariable Cox regression analysis showed that older patients (years) [HR 1.06 (1.04-1.09), p < 0.001], CHD patients with great anatomical complexity [HR 4.24 (2.17-8.27), p < 0.001] and those with a lower NRI [HR 0.95 (0.93-0.98), p = 0.001] had a significant worse MACE-free survival, being the NRI a better predictor of MACE than albumin concentration. CONCLUSIONS A low NRI is independently associated with a significant increased risk of MACE in CHD patients.
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Affiliation(s)
- Efrén Martínez-Quintana
- Cardiology Service, Complejo Hospitalario Universitario Insular-Materno Infantil, Las Palmas de Gran Canaria, Spain; Department of Medical and Surgical Sciences, Faculty of Health Sciences, Universidad de Las Palmas de Gran Canaria, Las Palmas de Gran Canaria, Spain.
| | - Michelle María Sánchez-Matos
- Department of Medical and Surgical Sciences, Faculty of Health Sciences, Universidad de Las Palmas de Gran Canaria, Las Palmas de Gran Canaria, Spain
| | - Hiurma Estupiñán-León
- Department of Medical and Surgical Sciences, Faculty of Health Sciences, Universidad de Las Palmas de Gran Canaria, Las Palmas de Gran Canaria, Spain
| | - Ana Beatriz Rojas-Brito
- Department of Medical and Surgical Sciences, Faculty of Health Sciences, Universidad de Las Palmas de Gran Canaria, Las Palmas de Gran Canaria, Spain
| | - Jesús María González-Martín
- Research Unit, Complejo Hospitalario Universitario Insular- Materno Infantil, Las Palmas de Gran Canaria, Spain
| | | | - Antonio Tugores
- Research Unit, Complejo Hospitalario Universitario Insular- Materno Infantil, Las Palmas de Gran Canaria, Spain
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25
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The interplay between gastrointestinal and cardiovascular diseases: a narrative review focusing on the clinical perspective. Eur J Gastroenterol Hepatol 2021; 32:132-139. [PMID: 32516176 DOI: 10.1097/meg.0000000000001779] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
Both cardiovascular and gastrointestinal disorders represent considerable health burden on community clinics and hospitals with overwhelming economic cost. An overlap in the occurrence of these disorders is encountered in daily practice. Both affect each other in bidirectional manner through several mechanisms including altered hemodynamics, systemic inflammation, bacterial overgrowth and interactions and adverse effects of medications. In addition, to the known overlap in the symptoms occurrence of upper gastrointestinal tract diseases and cardiovascular diseases (CVDs). Awareness of this interplay and its clinical manifestations optimizes patient management, and could prevent catastrophic consequences and even save lives. In this review, we highlighted the clinical aspects of this bidirectional association between gastrointestinal and CVDs aiming to shed light on this topic and improve patients' care.
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26
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Higher Incidence of Protein-Losing Enteropathy in Patients with Single Systemic Right Ventricle. Pediatr Cardiol 2021; 42:178-181. [PMID: 32975605 PMCID: PMC7867645 DOI: 10.1007/s00246-020-02468-y] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/21/2020] [Accepted: 09/16/2020] [Indexed: 10/23/2022]
Abstract
Patients with single ventricle congenital heart disease are at risk of unpredictable protein-losing enteropathy (PLE) after surgical palliation. Based on prior reports of physiologic differences for patients with single morphologic right versus left ventricles, we hypothesized that those with right ventricular morphology would have a higher incidence of PLE. We performed a retrospective review of > 15 million pediatric hospitalizations from the Healthcare Cost and Utilization Project KID 2000-2012 databases for admissions 5-21 years old with ICD-9 codes for hypoplastic left heart syndrome (HLHS) and tricuspid atresia (TA) with and without PLE. Incidence of PLE was compared between those with HLHS and TA. In addition, outcomes and costs were compared between admissions with and without PLE and between HLHS and TA. Of 1623 HLHS admissions, 289 (17.8%) had PLE, and of 926 TA admissions, 58 (5.9%) had PLE (p < 0.001). Admissions with PLE were older compared to those without PLE (12 vs 10 years, p < 0.001) and PLE onset occurred at a younger age for HLHS than TA (11 vs 14 years, p < 0.001). There were no differences in hospital outcomes or costs. Review of this large administrative database suggests a higher incidence of PLE in patients with HLHS and a younger age of onset compared to those with TA. These data suggest that a single systemic right ventricle may be an independent risk factor for developing PLE.
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Dittrich S, Weise A, Cesnjevar R, Rompel O, Rüffer A, Schöber M, Moosmann J, Glöckler M. Association of Lymphatic Abnormalities with Early Complications after Fontan Operation. Thorac Cardiovasc Surg 2020; 69:e1-e9. [PMID: 33383591 PMCID: PMC7909602 DOI: 10.1055/s-0040-1722178] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
Background
Increased central venous pressure is inherent in Fontan circulation but not strongly related to Fontan complication. Abnormalities of the lymphatic circulation may play a crucial role in early Fontan complications.
Methods
This was a retrospective, single-center study of patients undergoing Fontan operation from 2008 to 2015. The primary outcome was significant early Fontan complication defined as secondary in-hospital treatment due to peripheral edema, ascites, pleural effusions, protein-losing enteropathy, or plastic bronchitis. All patients received T2-weighted magnetic resonance images to assess abdominal and thoracic lymphatic perfusion pattern 6 months after Fontan completion with respect to localization, distribution, and extension of lymphatic perfusion pattern (type 1–4) and with application of an area score (0–12 points).
Results
Nine out of 42 patients developed early Fontan complication. Patients with complication had longer chest tube drainage (mean 28 [interquartile range [IQR]: 13–60] vs. 13 [IQR: 2–22] days,
p
= 0.01) and more often obstructions in the Fontan circuit 6 months after surgery (56 vs. 15%,
p
= 0.02). Twelve patients showed little or no abnormalities of lymphatic perfusion (lymphatic perfusion pattern type 1). Most frequently magnetic resonance imaging showed lymphatic congestion in the supraclavicular region (24/42 patients). Paramesenteric lymphatic congestion was observed in eight patients. Patients with early Fontan complications presented with higher lymphatic area score (6 [min–max: 2–10] vs. 2 [min–max: 0–8]),
p
= 0.001) and greater distribution and extension of thoracic lymphatic congestion (type 3–4:
n
= 5/9 vs.
n
= 1/33,
p
= 0.001).
Conclusion
Early Fontan complication is related to hemodynamic factors such as circuit obstruction and to the occurrence and extent of lymphatic congestion.
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Affiliation(s)
- Sven Dittrich
- Department of Pediatric Cardiology, Friedrich-Alexander-Universitat Erlangen-Nürnberg, Erlangen, Germany
| | - Anja Weise
- Department of Pediatric Cardiology, Friedrich-Alexander-Universitat Erlangen-Nürnberg, Erlangen, Germany
| | - Robert Cesnjevar
- Department of Pediatric Cardiac Surgery, University Hospital Erlangen, Erlangen, Bavaria, Germany
| | - Oliver Rompel
- Radiology Institute, Friedrich-Alexander-Universitat Erlangen-Nürnberg, Erlangen, Germany
| | - André Rüffer
- Department of Pediatric Cardiac Surgery, Friedrich-Alexander-Universitat Erlangen-Nürnberg, Erlangen, Germany
| | - Martin Schöber
- Department of Pediatric Cardiology, Friedrich-Alexander-Universitat Erlangen-Nürnberg, Erlangen, Germany
| | - Julia Moosmann
- Department of Pediatric Cardiology, Friedrich-Alexander-Universitat Erlangen-Nürnberg, Erlangen, Germany
| | - Martin Glöckler
- Department of Pediatric Cardiology, Friedrich-Alexander-Universitat Erlangen-Nürnberg, Erlangen, Germany
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Cardiovascular and abdominal flow alterations in adults with morphologic evidence of liver disease post Fontan palliation. Int J Cardiol 2020; 317:63-69. [PMID: 32470536 DOI: 10.1016/j.ijcard.2020.05.064] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/23/2019] [Revised: 03/11/2020] [Accepted: 05/18/2020] [Indexed: 01/16/2023]
Abstract
BACKGROUND Although morphologic abnormalities in the liver are commonly encountered post Fontan palliation, the relationships between hepatic morphology, vascular flows, and clinical status remain incompletely understood. We therefore aimed to explore flow characteristics in hepatic and intestinal vessels and to examine cardiovascular associations with liver disease. METHODS This was a retrospective study of adults post Fontan palliation undergoing clinically indicated cardiovascular magnetic resonance imaging (MRI). Patients were included if MRI flow quantification was available for cardiac, hepatic and intestinal vessels; patients were excluded if phase-contrast flow imaging was insufficient for analysis. RESULTS Thirty patients were studied (median age at MRI 28.5 years [range 19-47]). Eighteen subjects (60%) were classified as having morphologic liver disease according to validated criteria based on available MRI imaging. Abdominal and cardiovascular flows were quantified. Patients with morphologic liver disease had a 41% reduction in superior mesenteric artery (211 ± 124 versus 358 ± 181 mL/min/m2, p = .004), a 36% reduction in hepatic vein (496 ± 247 versus 778 ± 220 mL/min/m2, p = .01), a 31% reduction in portal vein (399 ± 133 versus 580 ± 159 mL/min/m2, p = .004), and an 18% reduction in Fontan pathway flows (1358 ± 429 versus 1651 ± 270 mL/min/m2, p = .04) compared with the remaining population. Adverse cardiovascular events were not associated with morphologic liver disease. CONCLUSION Morphologic liver disease appears to be associated with flow alterations within the heart, liver and intestine post Fontan palliation. These novel observations suggest that a potential relationship exists between morphologic disease and vascular flows thereby providing further insights into the pathophysiology of liver disease in this high-risk population.
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29
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Thromboembolic complications in adult congenital heart disease: the knowns and the unknowns. Clin Res Cardiol 2020; 110:1380-1391. [PMID: 33037501 DOI: 10.1007/s00392-020-01746-2] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/30/2020] [Accepted: 09/08/2020] [Indexed: 10/23/2022]
Abstract
Despite impressive improvement in long-term survival, adults with congenital heart disease (CHD) remain exposed to a significant cardiovascular morbidity over lifetime. Thromboembolic events (TE) are a major issue. Specific anatomic groups have been shown a particular high risk of TE, including cyanotic heart disease and Fontan circulation. Many intercurrent clinical factors add a substantial risk such as intracardiac medical devices, atrial arrhythmia, endocarditis, or pregnancy. Nevertheless, what is unknown exceeds what is known, especially regarding the management of this heterogenous patient population. Anticoagulation decision should always be individualized weighing balanced with the alternative risk of hemorrhagic complications. In this review, we aim to synthetize existing literature on TE in adults with CHD, discuss management issues, highlight gaps in knowledge, and intend to suggest high priority research.
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30
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Iwamoto Y, Matsumura S, Ishido H, Senzaki H, Masutani S. Steroid-Refractory Protein-Losing Enteropathy with Gastrointestinal Bleeding in a Patient with Fontan Circulation. Int Heart J 2020; 61:851-855. [PMID: 32728004 DOI: 10.1536/ihj.20-038] [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: 11/18/2022]
Abstract
Protein-losing enteropathy (PLE) is one of the major complications after a Fontan operation. Some PLE patients suffer from concurrent gastrointestinal bleeding. An effective treatment regimen for such patients has not been established yet. Further, it remains unknown whether PLE and gastrointestinal bleeding coexist independently, or protein losing is associated with gastrointestinal bleeding. We report a 7-year-old steroid-refractory post-Fontan PLE case suggesting the latter pathogenesis together with a literature review.
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Affiliation(s)
- Yoichi Iwamoto
- Department of Pediatrics, Saitama Medical Center, Saitama Medical University
| | - Shun Matsumura
- Department of Pediatrics, Saitama Medical Center, Saitama Medical University
| | - Hirotaka Ishido
- Department of Pediatrics, Saitama Medical Center, Saitama Medical University
| | - Hideaki Senzaki
- Department of Pediatrics, The International University of Health and Welfare Narita Hospital
| | - Satoshi Masutani
- Department of Pediatrics, Saitama Medical Center, Saitama Medical University
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31
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Ibe DO, Rapp JB, Whitehead KK, Otero HJ, Smith CL, Fogel MA, Biko DM. Pearls and Pitfalls in Pediatric Fontan Operation Imaging. Semin Ultrasound CT MR 2020; 41:442-450. [PMID: 32980091 DOI: 10.1053/j.sult.2020.05.009] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
Abstract
The Fontan operation or the total cavopulmonary connection is a palliative surgery for single ventricle congenital heart disease where the systemic venous return circumvents a pumping chamber and flows directly into the pulmonary circuit. With surgical and medical advances, there has been improvement in life expectancy of these patients, however, it has also resulted in unique complications from the physiology that requires diligent surveillance. A critical component relies on optimal imaging for diagnosis and treatment of these complications. This article describes the normal anatomy of the Fontan circulation, current imaging modalities and techniques, and frequently encountered complications seen when imaging the patients who have undergone Fontan palliation.
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Affiliation(s)
- Donald O Ibe
- Department of Radiology, Silhouette Diagnostic Consultants, Abuja, Nigeria
| | - Jordan B Rapp
- Department of Radiology, Children's Hospital of Philadelphia, Philadelphia, PA; Perelman School of Medicine at The University of Pennsylvania, Philadelphia, PA
| | - Kevin K Whitehead
- Perelman School of Medicine at The University of Pennsylvania, Philadelphia, PA; Division of Cardiology, Children's Hospital of Philadelphia, Philadelphia, PA
| | - Hansel J Otero
- Department of Radiology, Children's Hospital of Philadelphia, Philadelphia, PA; Division of Cardiology, Children's Hospital of Philadelphia, Philadelphia, PA
| | - Christopher L Smith
- Perelman School of Medicine at The University of Pennsylvania, Philadelphia, PA; Division of Cardiology, Children's Hospital of Philadelphia, Philadelphia, PA
| | - Mark A Fogel
- Perelman School of Medicine at The University of Pennsylvania, Philadelphia, PA; Division of Cardiology, Children's Hospital of Philadelphia, Philadelphia, PA
| | - David M Biko
- Department of Radiology, Children's Hospital of Philadelphia, Philadelphia, PA; Division of Cardiology, Children's Hospital of Philadelphia, Philadelphia, PA.
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Abstract
OBJECTIVE Protein-losing enteropathy is an infrequent but severe condition occurring after Fontan procedure. The multifactorial pathogenesis remains unclear and no single proposed treatment strategy has proven universally successful. Therefore, we sought to describe different treatment strategies and their effect on clinical outcome and mortality. MATERIAL AND METHODS We performed a retrospective observational study. From the total cohort of 439 Fontan patients treated in our institution during the study period 1986-2019, 30 patients (6.8%) with protein-losing enteropathy were identified. Perioperative, clinical, echocardiographic, laboratory, and invasive haemodynamic findings and treatment details were analysed. RESULTS Median follow-up after disease onset was 13.1 years [interquartile range 10.6]. Twenty-five patients received surgical or interventional treatment for haemodynamic restrictions. Medical treatment, predominantly pulmonary vasodilator and/or systemic anti-inflammatory therapy with budesonide, was initiated in 28 patients. In 15 patients, a stable remission could be achieved by medical or surgical procedures (n = 3 each), by combined multimodal therapy (n = 8), or ultimately by cardiac transplantation (n = 1). Phrenic palsy, bradyarrhythmia, Fontan pathway stenosis, and absence of a fenestration were significantly associated with development of protein-losing enteropathy (p = 0.001-0.48). Ten patients (33.3%) died during follow-up; 5-year survival estimate was 96.1%. In unadjusted analysis, medical therapy with budesonide and pulmonary vasodilator therapy in combination was associated with improved survival. CONCLUSIONS Protein-losing enteropathy is a serious condition limiting survival after the Fontan procedure. Comprehensive assessment and individual treatment strategies are mandatory to achieve best possible outcome. Nevertheless, relapse is frequent and long-term mortality substantial. Cardiac transplantation should be considered early as treatment option.
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33
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Broda CR, Castellanos DA, Pham TDN, Dreyer WJ, Opina AD, Ermis PR, Lam WW. Improvement in Protein-Losing Enteropathy in a Patient With Fontan Circulation After Cardiac Rehabilitation and Prescriptive Exercise. World J Pediatr Congenit Heart Surg 2020; 11:364-365. [PMID: 32294000 DOI: 10.1177/2150135119896557] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Fontan-associated protein-losing enteropathy is difficult to treat and associated with poor prognosis. Cardiac rehabilitation and exercise are thought to have beneficial effects for patients with Fontan circulation. We report the case of a young adult patient palliated to Fontan circulation, with a decade-long history of symptoms related to protein-losing enteropathy. At age 23 years, he appreciated an improvement in symptoms and laboratory values after cardiac rehabilitation and prescriptive exercise.
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Affiliation(s)
- Christopher R Broda
- Department of Pediatrics, Section of Pediatric and Adult Congenital Cardiology, Baylor College of Medicine/Texas Children's Hospital, Houston, TX, USA
| | - Daniel A Castellanos
- Department of Pediatrics, Section of Pediatric and Adult Congenital Cardiology, Baylor College of Medicine/Texas Children's Hospital, Houston, TX, USA
| | - Tam Dan N Pham
- Department of Pediatrics, Section of Pediatric and Adult Congenital Cardiology, Baylor College of Medicine/Texas Children's Hospital, Houston, TX, USA
| | - W Jeff Dreyer
- Department of Pediatrics, Section of Pediatric and Adult Congenital Cardiology, Baylor College of Medicine/Texas Children's Hospital, Houston, TX, USA
| | - Angeline D Opina
- Department of Pediatrics, Section of Pediatric and Adult Congenital Cardiology, Baylor College of Medicine/Texas Children's Hospital, Houston, TX, USA
| | - Peter R Ermis
- Department of Pediatrics, Section of Pediatric and Adult Congenital Cardiology, Baylor College of Medicine/Texas Children's Hospital, Houston, TX, USA
| | - Wilson W Lam
- Department of Pediatrics, Section of Pediatric and Adult Congenital Cardiology, Baylor College of Medicine/Texas Children's Hospital, Houston, TX, USA
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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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35
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Kumar TKS. The failing Fontan. Indian J Thorac Cardiovasc Surg 2020; 37:82-90. [PMID: 33603286 DOI: 10.1007/s12055-020-00931-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2019] [Revised: 01/13/2020] [Accepted: 01/28/2020] [Indexed: 11/30/2022] Open
Abstract
Nearly 50 years back, Francis Fontan pioneered an operation for tricuspid atresia that bears his name today. The operation has since undergone numerous modifications and continues to be widely applied to an array of single ventricles. Despite restoring normal oxygen levels in the body, the operation creates a neoportal system where adequate cardiac output can be generated only at the expense of increased systemic venous congestion. This results in slow but relentless damage to the end organ systems especially the liver. Continuous surveillance of the patient to monitor this circulation, that will ultimately fail, is of paramount importance. Timely medical and cardiac catheterization and surgical intervention can extend the life span of Fontan patients. Ultimately a change of the hemodynamic circuit in the form of heart transplantation or ventricular assist device will be required to salvage the failing Fontan circuit.
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Affiliation(s)
- T K Susheel Kumar
- Department of Cardiothoracic Surgery, New York University, 530 First Avenue, New York, NY 10016 USA
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36
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Evidence of Systemic Absorption of Enteral Budesonide in Patients with Fontan-Associated Protein-Losing Enteropathy. Pediatr Cardiol 2020; 41:241-250. [PMID: 31707491 DOI: 10.1007/s00246-019-02248-3] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/28/2019] [Accepted: 10/31/2019] [Indexed: 12/25/2022]
Abstract
To evaluate for evidence of systemic glucocorticoid absorption in cases of Fontan-associated protein-losing enteropathy (PLE) treated with enteral budesonide, we reviewed the charts of 27 patients with Fontan-associated PLE followed at Children's Hospital Colorado from 2005 to 2018. Cases were excluded for lack of budesonide thserapy or a treatment duration of less than 6 months. Charts were examined by two endocrinologists for review of prior biochemical endocrine evaluations, alterations in linear growth, and physical exam findings consistent with steroid excess. Twelve patients met inclusion criteria. Eight had prior documented cortisol screening. Three patients were tested while on treatment with a median fasting AM cortisol of 0.9 mcg/dL; two of these had a concomitantly measured ACTH, both below the detectable limit. Five patients were tested while weaning or having discontinued budesonide, with a median fasting AM cortisol of 9.1 mcg/dL. Eleven patients had decreases in height velocity associated with starting budesonide. Six patients had documentation of cushingoid features by an endocrinologist. In this cohort of children treated with budesonide for PLE following Fontan, clinical signs of systemic glucocorticoid absorption were frequent. Cortisol secretion was suppressed while on therapy, with adrenal recovery noted once budesonide was discontinued. Growth failure and cushingoid features were common findings. While these findings should be confirmed in larger cohorts, we recommend that the evaluation for systemic absorption of exogenous steroids be considered in patients treated with long-term enteral budesonide given the potential risk for adrenal crisis in times of physiologic stressors.
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Atrioventricular Valve Failure in Fontan Palliation. J Am Coll Cardiol 2020; 73:810-822. [PMID: 30784675 DOI: 10.1016/j.jacc.2018.12.025] [Citation(s) in RCA: 77] [Impact Index Per Article: 19.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/05/2018] [Revised: 11/29/2018] [Accepted: 12/10/2018] [Indexed: 11/20/2022]
Abstract
BACKGROUND Atrioventricular valve failure (moderate or greater regurgitation, or valve operation) is a risk factor for adverse outcomes in patients undergoing Fontan palliation. OBJECTIVES This study determined the incidence of atrioventricular valve failure and its clinical impact on patients undergoing Fontan palliation. METHODS A retrospective cohort longitudinal study was conducted using patient data extracted from an existing bi-national, population-based registry. RESULTS A total of 1,468 patients who underwent Fontan palliation were identified; complete follow-up data were available for 1,199 patients. Six hundred eighty-six patients had 2 atrioventricular valves, 286 had a single mitral valve, 130 had a common atrioventricular valve, and 97 had a single tricuspid valve. A total of 132 repairs were performed in 110 patients, and 15 replacements were performed in 13 patients. The cumulative incidence of atrioventricular valve failure at 25 years of age for patients with a common atrioventricular, single tricuspid, single mitral, and 2 atrioventricular valves was 56% (95% confidence interval [CI]: 46% to 67%), 46% (95% CI: 31% to 61%), 8% (95% CI: 4% to 12%), and 26% (95% CI: 21% to 30%), respectively. In patients without valve failure, freedom from Fontan failure at 10 and 20 years post-Fontan palliation was 91% (95% CI: 89% to 93%) and 77% (95% CI: 73% to 81%), respectively, compared with 77% (95% CI: 69% to 85%) and 54% (95% CI: 42% to 68%), respectively, in patients with valve failure (hazard ratio: 2.43; 95% CI: 1.74 to 3.39; p < 0.001). CONCLUSIONS Atrioventricular valve failure occurs frequently in patients undergoing Fontan palliation. Patients with valve failure are twice as likely to have their Fontan circulation fail than those without valve failure.
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38
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Rathgeber SL, Guttman OR, Lee AF, Voss C, Hemphill NM, Schreiber RA, Harris KC. Fontan-Associated Liver Disease: Spectrum of Disease in Children and Adolescents. J Am Heart Assoc 2020; 9:e012529. [PMID: 31902322 PMCID: PMC6988152 DOI: 10.1161/jaha.119.012529] [Citation(s) in RCA: 30] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/11/2019] [Accepted: 09/23/2019] [Indexed: 12/14/2022]
Abstract
Background Information is evolving on liver disease in pediatric patients with Fontan physiology. The purpose of this investigation is to evaluate the spectrum of liver disease in a pediatric population of patients with Fontan physiology and evaluate transient elastography (TE) as a noninvasive marker of liver disease. Methods and Results We prospectively enrolled all children with Fontan physiology. All patients underwent comprehensive liver evaluation including liver enzymes (alanine aminotransferase, aspartate aminotransferase, gamma-glutamyl transferase, alkaline phosphatase), aspartate transaminase to platelet ratio index, albumin, bilirubin, international normalized ratio, complete blood cell count, abdominal ultrasound, and TE. Transjugular liver biopsies and hemodynamic measurements were performed in a subset of patients. A total of 76 children (median, 11.7; interquartile range, 8.4-14.8 [56% male]) were evaluated, with 17 having a transjugular liver biopsy (median 14.8 years; interquartile range, 14.3-17.4). All biopsies showed pathological changes. The severity of liver pathology did not correlate with TE. There was a positive correlation between TE and time since Fontan (R=0.42, P<0.01), aspartate transaminase to platelet ratio index (R=0.29, P=0.02), aspartate transaminase (R=-0.42, P<0.01), and platelets (R=-0.42, P<0.01). Splenomegaly on abdominal ultrasound was correlated with TE (z=-2.2, P=0.03), low platelet count (z=1.9, P=0.05), low aspartate transaminase (z=1.9, P=0.02), and low alkaline phosphatase (z=2.4, P=0.02). Conclusions Liver disease was ubiquitous in our cohort of pediatric patients with Fontan Physiology. Given the correlation between TE and time from Fontan, TE shows potential as a prospective marker of liver pathology. However, individual measurements with TE do not correlate with the severity of pathology. Given the prevalence of liver disease in this population, protective measures of liver health as well as routine liver health surveillance should be implemented with consideration for hepatology consultation and biopsy in the event of abnormal liver biochemical markers or imaging.
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Affiliation(s)
- Steven L. Rathgeber
- Division of CardiologyDepartment of PediatricsBritish Columbia Children's Hospital and University of British ColumbiaVancouverBritish ColumbiaCanada
| | - Orlee R. Guttman
- Division of GastroenterologyDepartment of PediatricsBritish Columbia Children's Hospital and University of British ColumbiaVancouverBritish ColumbiaCanada
| | - Anna F. Lee
- Department of Pathology and Laboratory MedicineBritish Columbia Children's Hospital and University of British ColumbiaVancouverBritish ColumbiaCanada
| | - Christine Voss
- Division of CardiologyDepartment of PediatricsBritish Columbia Children's Hospital and University of British ColumbiaVancouverBritish ColumbiaCanada
| | - Nicole M. Hemphill
- Division of CardiologyDepartment of PediatricsBritish Columbia Children's Hospital and University of British ColumbiaVancouverBritish ColumbiaCanada
| | - Richard A. Schreiber
- Division of GastroenterologyDepartment of PediatricsBritish Columbia Children's Hospital and University of British ColumbiaVancouverBritish ColumbiaCanada
| | - Kevin C. Harris
- Division of CardiologyDepartment of PediatricsBritish Columbia Children's Hospital and University of British ColumbiaVancouverBritish ColumbiaCanada
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Rychik J, Dodds KM, Goldberg D, Glatz AC, Fogel M, Rossano J, Chen J, Pinto E, Ravishankar C, Rand E, Rome JJ, Dori Y. Protein Losing Enteropathy After Fontan Operation: Glimpses of Clarity Through the Lifting Fog. World J Pediatr Congenit Heart Surg 2019; 11:92-96. [DOI: 10.1177/2150135119890555] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
Fontan-associated protein losing enteropathy is a challenge to treat and is a major contributor to morbidity and mortality in patients with palliated single ventricle. Numerous strategies for management have been proposed, with confusion as to how best to stratify and implement care among the many treatments available. Medical management can be helpful in some, while novel lymphatic interventions hold potential for remission with good results. We review our institutional approach to protein losing enteropathy after Fontan operation and provide a suggested algorithm and pathway for effective care.
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Affiliation(s)
- Jack Rychik
- Cardiac Center at The Children’s Hospital of Philadelphia, Philadelphia, PA, USA
| | - Kathryn M. Dodds
- Cardiac Center at The Children’s Hospital of Philadelphia, Philadelphia, PA, USA
| | - David Goldberg
- Cardiac Center at The Children’s Hospital of Philadelphia, Philadelphia, PA, USA
| | - Andrew C. Glatz
- Cardiac Center at The Children’s Hospital of Philadelphia, Philadelphia, PA, USA
| | - Mark Fogel
- Cardiac Center at The Children’s Hospital of Philadelphia, Philadelphia, PA, USA
| | - Joseph Rossano
- Cardiac Center at The Children’s Hospital of Philadelphia, Philadelphia, PA, USA
| | - Jonathan Chen
- Cardiac Center at The Children’s Hospital of Philadelphia, Philadelphia, PA, USA
| | - Erin Pinto
- Cardiac Center at The Children’s Hospital of Philadelphia, Philadelphia, PA, USA
| | - Chitra Ravishankar
- Cardiac Center at The Children’s Hospital of Philadelphia, Philadelphia, PA, USA
| | - Elizabeth Rand
- Cardiac Center at The Children’s Hospital of Philadelphia, Philadelphia, PA, USA
| | - Jonathan J. Rome
- Cardiac Center at The Children’s Hospital of Philadelphia, Philadelphia, PA, USA
| | - Yoav Dori
- Cardiac Center at The Children’s Hospital of Philadelphia, Philadelphia, PA, USA
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40
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Kewcharoen J, Mekraksakit P, Limpruttidham N, Kanitsoraphan C, Charoenpoonsiri N, Poonsombudlert K, Pattison RJ, Rattanawong P. Budesonide for Protein Losing Enteropathy in Patients with Fontan Circulation: A Systematic Review and Meta-Analysis. World J Pediatr Congenit Heart Surg 2019; 11:85-91. [DOI: 10.1177/2150135119872196] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Abstract
Background: Recent studies have shown that oral budesonide can be used to improve albumin level in patients with protein-losing enteropathy (PLE) following Fontan procedure. However, there has never been a systematic review and meta-analysis to confirm this finding. We performed a systematic review and meta-analysis to explore the therapeutic effect of budesonide in patients with PLE post-Fontan procedure. Methods: We searched the databases of MEDLINE and EMBASE from inception to January 2019. Included studies were published studies that evaluate albumin level before and after budesonide therapy in patients with PLE following Fontan procedure. Data from each study were combined using the random-effects model. Results: Five studies with 36 post-Fontan operation patients with PLE were included. In random-effects model, there was a statistically significant difference in albumin level between before and after budesonide treatment (weighted mean difference = 1.28, 95% confidence interval: 0.76-1.79). No publication bias was observed on a funnel plot and Egger test with a P value of .676. Conclusions: The results of this systematic review and meta-analysis show that budesonide can be used to increase albumin level in patients with PLE following Fontan operation. Further studies may focus on the impact of outcome of budesonide in this population.
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Affiliation(s)
- Jakrin Kewcharoen
- University of Hawaii Internal Medicine Residency Program, Honolulu, HI, USA
| | | | - Nath Limpruttidham
- University of Hawaii Internal Medicine Residency Program, Honolulu, HI, USA
| | | | | | | | - Robert J. Pattison
- University of Hawaii Internal Medicine Residency Program, Honolulu, HI, USA
| | - Pattara Rattanawong
- University of Hawaii Internal Medicine Residency Program, Honolulu, HI, USA
- Faculty of Medicine, Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
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41
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Ozen A. CHAPLE syndrome uncovers the primary role of complement in a familial form of Waldmann's disease. Immunol Rev 2019; 287:20-32. [PMID: 30565236 DOI: 10.1111/imr.12715] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2018] [Accepted: 08/31/2018] [Indexed: 12/17/2022]
Abstract
Primary intestinal lymphangiectasia (PIL) or Waldmann's disease was described in 1961 as an important cause of protein-losing enteropathy (PLE). PIL can be the sole finding in rare individuals or occur as part of a multisystemic genetic syndrome. Although genetic etiologies of many lymphatic dysplasia syndromes associated with PIL have been identified, the pathogenesis of isolated PIL (with no associated syndromic features) remains unknown. Familial cases and occurrence at birth suggest genetic etiologies in certain cases. Recently, CD55 deficiency with hyperactivation of complement, angiopathic thrombosis, and PLE (the CHAPLE syndrome) has been identified as a monogenic form of PIL. Surprisingly, loss of CD55, a key regulator of complement system leads to a predominantly gut condition. Similarly to other complement disorders, namely paroxysmal nocturnal and hemoglobinuria (PNH) and atypical hemolytic uremic syndrome (aHUS), CHAPLE disease involves pathogenic cross-activation of the coagulation system, predisposing individuals to severe thrombosis. The observation that complement system is overly active in CHAPLE disease introduced a novel concept into the management of PLE; anti-complement therapy. While CD55 deficiency constitutes a treatable subgroup in the larger pool of patients with isolated PIL, the etiology remains to be identified in the remaining patients with intact CD55.
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Affiliation(s)
- Ahmet Ozen
- Division of Allergy and Immunology, Marmara University School of Medicine, Istanbul, Turkey.,The Istanbul Jeffrey Modell Diagnostic Center for Primary Immunodeficiency Diseases, Istanbul, Turkey
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42
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Haxel C, Glickstein J, Parravicini E. Neonatal Palliative Care for Complicated Cardiac Anomalies: A 10-Year Experience of an Interdisciplinary Program at a Large Tertiary Cardiac Center. J Pediatr 2019; 214:79-88. [PMID: 31655705 DOI: 10.1016/j.jpeds.2019.07.044] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/26/2019] [Revised: 06/18/2019] [Accepted: 07/18/2019] [Indexed: 12/30/2022]
Abstract
OBJECTIVES To report the outcomes of a Neonatal Palliative Care (NPC) Program at a large tertiary cardiac center caring for a subset of fetuses and neonates with life-limiting cardiac diagnoses or cardiac diagnoses with medical comorbidities leading to adverse prognoses. STUDY DESIGN The Neonatal Comfort Care Program at New York-Presbyterian Morgan Stanley Children's Hospital/Columbia University Medical Center is an interdisciplinary team that offers the option of NPC to neonates prenatally diagnosed with life-limiting conditions, including single ventricle (SV) congenital heart disease (CHD) or less severe forms of CHD complicated by multiorgan dysfunction or genetic syndromes. RESULTS From 2008 to 2017, the Neonatal Comfort Care Program cared for 75 fetuses or neonates including 29 with isolated SV CHD, 36 with CHD and multiorgan dysfunction and/or severe genetic abnormalities, and 10 neonates with a prenatal diagnosis of isolated CHD and postnatal diagnoses of severe conditions who were initially in intensive care before transitioning to NPC because of a poor prognosis. CONCLUSIONS At New York-Presbyterian Morgan Stanley Children's Hospital/Columbia University Medical Center, a large tertiary cardiac center, 13.5% of parents of fetuses or neonates with isolated SV CHD opted for NPC. Twenty-six of 29 newborns with SV CHD treated with NPC died. Of the remaining, 2 neonates with mixing lesions are alive at 3 and 5 years of age, and 1 neonate was initially treated with NPC and then pursued surgical palliation. These results suggest that NPC is a reasonable choice for neonates with SV CHD.
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Affiliation(s)
- Caitlin Haxel
- Division of Pediatric Cardiology, Department of Pediatrics, Children's Hospital Colorado, University of Colorado Denver School of Medicine, Aurora, CO; Division of Pediatric Cardiology, Department of Pediatrics, NewYork-Presbyterian Morgan Stanley Children's Hospital, Columbia University Medical Center, New York, NY.
| | - Julie Glickstein
- Division of Pediatric Cardiology, Department of Pediatrics, NewYork-Presbyterian Morgan Stanley Children's Hospital, Columbia University Medical Center, New York, NY
| | - Elvira Parravicini
- Division of Pediatric Cardiology, Department of Pediatrics, NewYork-Presbyterian Morgan Stanley Children's Hospital, Columbia University Medical Center, New York, NY
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Maleux G, Storme E, Cools B, Heying R, Boshoff D, Louw JJ, Frerich S, Malekzadeh‐Milanii S, Hubrechts J, Brown SC, Gewillig M. Percutaneous embolization of lymphatic fistulae as treatment for protein‐losing enteropathy and plastic bronchitis in patients with failing Fontan circulation. Catheter Cardiovasc Interv 2019; 94:996-1002. [DOI: 10.1002/ccd.28501] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/01/2019] [Revised: 09/04/2019] [Accepted: 09/07/2019] [Indexed: 12/14/2022]
Affiliation(s)
- Geert Maleux
- Interventional RadiologyUniversity Hospitals Leuven Leuven Belgium
| | - Emma Storme
- Department of Paediatric and Congenital CardiologyUniversity Hospitals Leuven Leuven Belgium
| | - Bjorn Cools
- Department of Paediatric and Congenital CardiologyUniversity Hospitals Leuven Leuven Belgium
| | - Ruth Heying
- Department of Paediatric and Congenital CardiologyUniversity Hospitals Leuven Leuven Belgium
| | - Derize Boshoff
- Department of Paediatric and Congenital CardiologyUniversity Hospitals Leuven Leuven Belgium
| | - Jacoba J. Louw
- Paediatric CardiologyUniversity Hospital Maastricht Maastricht the Netherlands
| | - Stefan Frerich
- Paediatric CardiologyUniversity Hospital Maastricht Maastricht the Netherlands
| | | | - Jelena Hubrechts
- Department of Paediatric and Congenital CardiologyUniversity Hospitals Leuven Leuven Belgium
| | - Stephen C. Brown
- Department of Paediatric and Congenital CardiologyUniversity Hospitals Leuven Leuven Belgium
- Paediatric CardiologyUniversity of the Free State Bloemfontein South Africa
| | - Marc Gewillig
- Department of Paediatric and Congenital CardiologyUniversity Hospitals Leuven Leuven Belgium
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44
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Peyton C. Protein-Losing Enteropathy and Plastic Bronchitis After the Fontan Operation. Crit Care Nurse 2019; 38:e5-e12. [PMID: 30504504 DOI: 10.4037/ccn2018784] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022]
Abstract
Protein-losing enteropathy and plastic bronchitis remain challenging to treat despite recent treatment advances. Protein-losing enteropathy and plastic bronchitis have been diagnosed in patients with cardiomyopathy, constrictive pericarditis, and congestive heart failure. This article focuses on patients with protein-losing enteropathy or plastic bronchitis following the Fontan procedure. Patients with single-ventricle physiology who have undergone the Fontan procedure are at risk for these conditions. Fontan physiology predisposes patients to chronically low cardiac output, increased central venous pressure, and congestive heart failure. These altered hemodynamics lead to increased mesenteric vascular resistance, resulting in venous hypertension and congestion in protein-losing enteropathy. Plastic bronchitis is a complex disease in which chronic high lymphatic pressures from Fontan physiology cause acellular bronchial casts to develop. These entities may also occur in patients with normal Fontan hemodynamics. This article also covers medical and surgical interventions for protein-losing enteropathy and plastic bronchitis. (Critical Care Nurse 2018;38[6]:e5-e12).
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Affiliation(s)
- Christine Peyton
- Christine Peyton is a clinical nurse specialist at the Heart Institute at Children's Hospital Colorado, Aurora, Colorado.
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45
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Mohanakumar S, Telinius N, Kelly B, Lauridsen H, Boedtkjer D, Pedersen M, de Leval M, Hjortdal V. Morphology and Function of the Lymphatic Vasculature in Patients With a Fontan Circulation. Circ Cardiovasc Imaging 2019; 12:e008074. [DOI: 10.1161/circimaging.118.008074] [Citation(s) in RCA: 38] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Affiliation(s)
- Sheyanth Mohanakumar
- Department of Cardiothoracic and Vascular Surgery, Aarhus University Hospital, Denmark (S.M., N.T., B.K., V.H.)
- Department of Clinical Medicine (S.M., N.T., B.K., D.B., M.P., V.H.), Aarhus University, Denmark
| | - Niklas Telinius
- Department of Cardiothoracic and Vascular Surgery, Aarhus University Hospital, Denmark (S.M., N.T., B.K., V.H.)
- Department of Clinical Medicine (S.M., N.T., B.K., D.B., M.P., V.H.), Aarhus University, Denmark
| | - Benjamin Kelly
- Department of Cardiothoracic and Vascular Surgery, Aarhus University Hospital, Denmark (S.M., N.T., B.K., V.H.)
- Department of Clinical Medicine (S.M., N.T., B.K., D.B., M.P., V.H.), Aarhus University, Denmark
| | - Henrik Lauridsen
- Comparative Medicine Lab, Department of Clinical Medicine (H.L., M.P.), Aarhus University, Denmark
| | - Donna Boedtkjer
- Department of Clinical Medicine (S.M., N.T., B.K., D.B., M.P., V.H.), Aarhus University, Denmark
- Department of Biomedicine (D.B.), Aarhus University, Denmark
| | - Michael Pedersen
- Department of Clinical Medicine (S.M., N.T., B.K., D.B., M.P., V.H.), Aarhus University, Denmark
- Comparative Medicine Lab, Department of Clinical Medicine (H.L., M.P.), Aarhus University, Denmark
| | - Marc de Leval
- The Harley Street Clinic Children’s Hospital, London, United Kingdom (M.d.L.)
| | - Vibeke Hjortdal
- Department of Cardiothoracic and Vascular Surgery, Aarhus University Hospital, Denmark (S.M., N.T., B.K., V.H.)
- Department of Clinical Medicine (S.M., N.T., B.K., D.B., M.P., V.H.), Aarhus University, Denmark
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46
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Conway J, Tunuguntla H. Impact of disease process on post-transplant outcomes: Protein-losing enteropathy in Fontan patients. J Heart Lung Transplant 2018; 38:3-4. [PMID: 30558740 DOI: 10.1016/j.healun.2018.11.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2018] [Revised: 11/05/2018] [Accepted: 11/09/2018] [Indexed: 11/18/2022] Open
Affiliation(s)
- Jennifer Conway
- Stollery Children's Hospital, University of Alberta, Edmonton, Alberta, Canada.
| | - Hari Tunuguntla
- Department of Pediatrics, Baylor College of Medicine, Houston, Texas, USA
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47
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Schumacher KR, Yu S, Butts R, Castleberry C, Chen S, Edens E, Godown J, Johnson J, Kemna M, Lin K, Lowery R, Simpson K, West S, Wilmot I, Gossett JG. Fontan-associated protein-losing enteropathy and post‒heart transplant outcomes: A multicenter study. J Heart Lung Transplant 2018; 38:17-25. [PMID: 30391195 DOI: 10.1016/j.healun.2018.09.024] [Citation(s) in RCA: 41] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2018] [Revised: 08/08/2018] [Accepted: 09/25/2018] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND The influence of Fontan-associated protein-losing enteropathy's (PLE) severity, duration, and treatment on heart transplant (HTx) outcomes is unknown. We hypothesized that long-standing PLE and PLE requiring more intensive therapy are associated with increased post-HTx mortality. METHODS This 12-center, retrospective cohort study of post-Fontan patients with PLE referred for HTx from 2003 to 2015 involved collection of demographic, medical, surgical, and catheterization data, as well as PLE-specific data, including duration of disease, intensity/details of treatment, hospitalizations, and complications. Factors associated with waitlist and post-HTx outcomes and PLE resolution were sought. RESULTS Eighty patients (median of 5 per center) were referred for HTx evaluation. Of 68 patients listed for HTx, 8 were removed due to deterioration, 4 died waiting, and 4 remain listed. In 52 patients undergoing HTx, post-HTx 1-month survival was 92% and 1-year survival was 83%. PLE-specific factors, including duration of PLE pre-HTx, pre-HTx hospitalizations, need for/frequency of albumin replacement, PLE therapies, and growth parameters had no association with post-HTx mortality. Immunosuppressant regimen was associated with mortality; standard mycophenolate mofetil immunotherapy was used in 95% of survivors compared with only 44% of non-survivors (p = 0.03). Rejection (53%) and infection (42%) post-HTx were common, but not associated with PLE-specific factors. PLE resolved completely in all but 1 HTx survivor at a median of 1 month (interquartile range 1 to 3 months); resolution was not affected by PLE-specific factors. CONCLUSIONS PLE severity, duration, and treatment do not influence post-HTx outcome, but immunosuppressive regimen may have an impact on survival. PLE resolves in nearly all survivors.
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Affiliation(s)
- Kurt R Schumacher
- University of Michigan Congenital Heart Center, Ann Arbor, Michigan, USA.
| | - Sunkyung Yu
- University of Michigan Congenital Heart Center, Ann Arbor, Michigan, USA
| | - Ryan Butts
- University of Texas-Southwestern Children's Medical Center Dallas, Dallas, Texas, USA
| | - Chesney Castleberry
- Washington University, St. Louis Children's Hospital, St. Louis, Missouri, USA
| | - Sharon Chen
- Stanford University, Lucile Packard Children's Hospital, Palo Alto, California, USA
| | - Erik Edens
- University of Iowa, Iowa City, Iowa, USA
| | - Justin Godown
- Vanderbilt University, Monroe Carell Chidren's Hospital, Nashville, Tennessee, USA
| | | | - Mariska Kemna
- Seattle Children's Hospital, Seattle, Washington, USA
| | - Kimberly Lin
- Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Ray Lowery
- University of Michigan Congenital Heart Center, Ann Arbor, Michigan, USA
| | - Kathleen Simpson
- Washington University, St. Louis Children's Hospital, St. Louis, Missouri, USA
| | - Shawn West
- Children's Hospital of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Ivan Wilmot
- Cincinnati Children's Medical Center, Cincinnati, Ohio, USA
| | - Jeffrey G Gossett
- University of California‒San Francisco Benioff Children's Hospital, San Francisco, California, USA
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48
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Kay WA, Moe T, Suter B, Tennancour A, Chan A, Krasuski RA, Zaidi AN. Long Term Consequences of the Fontan Procedure and How to Manage Them. Prog Cardiovasc Dis 2018; 61:365-376. [PMID: 30236751 DOI: 10.1016/j.pcad.2018.09.005] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/11/2018] [Accepted: 09/11/2018] [Indexed: 12/12/2022]
Abstract
In 1971, Fontan and Baudet described a surgical technique for successful palliation of patients with tricuspid atresia. Subsequently, this technique has been applied to treat most forms of functional single ventricles and has become the current standard of care for long-term palliation of all patients with single ventricle congenital heart disease. Since 1971, the Fontan procedure has undergone several variations. These patients require lifelong management including a thorough knowledge of their anatomic substrate, hemodynamic status, management of rhythm and ventricular function along with multi organ evaluation. As these patients enter middle age, there is increasing awareness regarding the long-term complications and mortality. This review highlights the long-term outcomes of the Fontan procedure and management of late sequelae.
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Affiliation(s)
- W Aaron Kay
- Indiana University School of Medicine, Krannert Institute of Cardiology, IN.
| | - Tabitha Moe
- University of Arizona School of Medicine, Phoenix, AZ.
| | - Blair Suter
- Indiana University School of Medicine, Departments of Medicine and Pediatrics, IN.
| | - Andrea Tennancour
- Indiana University School of Medicine, Krannert Institute of Cardiology, IN.
| | - Alice Chan
- Children's Hospital at Montefiore, Montefiore Medical Center, Albert Einstein College of Medicine, NY.
| | | | - Ali N Zaidi
- Children's Hospital at Montefiore, Montefiore Medical Center, Albert Einstein College of Medicine, NY.
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49
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Soquet J, Mufti HN, Jones B, Konstantinov IE, Brink J, Brizard CP, d'Udekem Y. Patients With Systemic Right Ventricle Are at Higher Risk of Chylothorax After Cavopulmonary Connections. Ann Thorac Surg 2018; 106:1414-1420. [PMID: 30171852 DOI: 10.1016/j.athoracsur.2018.06.077] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/29/2018] [Revised: 06/24/2018] [Accepted: 06/27/2018] [Indexed: 10/28/2022]
Abstract
BACKGROUND Chylothorax is a rare but severe complication after pediatric cardiac surgical procedures and is related to significant morbidity and mortality. It is suspected to be more frequent after single-ventricle staged palliation procedures, but focused studies on chylothorax in patients with univentricular heart physiology are scarce. METHODS From January 2008 to December 2016, a total of 289 patients underwent 376 cavopulmonary connection (CPC) procedures over 9 years (superior cavopulmonary connection [SCPC], 199; Fontan completion, 177). Patients were classified according to whether they had a chylothorax (group 1) or not (group 2). Chylothorax was confirmed on a pleural fluid test. RESULTS The rate of chylothorax after a CPC procedure was 19.7% (74 of 376): 15.6% after SCPC and 24.3% after Fontan completion. Mean follow-up was 4.3 ± 0.1 years. Systemic right ventricle was more frequent in group 1 than in group 2 (64.9% vs 46%, respectively; p = 0.003). Chylothorax was associated with a higher rate of early reoperation (p = 0.001) and late failure of the CPC (p < 0.001). Late mortality was also more frequent in group 1 than in group 2 (17.6% vs 4.3%; p < 0.001). By multivariate analysis, having a systemic right ventricle was the only identified predictor for the development of chylothorax (odds ratio, 2.49; 95% confidence interval, 1.4 to 4.7; p = 0.004). CONCLUSIONS The incidence of chylothorax in patients undergoing the univentricular pathway procedure is higher than previously suggested. Having a systemic right ventricle is a significant risk factor for developing a chylothorax after a CPC.
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Affiliation(s)
- Jerome Soquet
- Department of Cardiac Surgery, The Royal Children's Hospital Melbourne, Parkville, Australia
| | - Hani N Mufti
- Department of Cardiac Surgery, The Royal Children's Hospital Melbourne, Parkville, Australia
| | - Bryn Jones
- Department of Cardiology, The Royal Children's Hospital Melbourne, Parkville, Australia; Department of Pediatrics, University of Melbourne, Parkville, Australia; Murdoch Childrens Research Institute, Parkville, Australia
| | - Igor E Konstantinov
- Department of Cardiac Surgery, The Royal Children's Hospital Melbourne, Parkville, Australia; Department of Pediatrics, University of Melbourne, Parkville, Australia; Murdoch Childrens Research Institute, Parkville, Australia
| | - Johann Brink
- Department of Cardiac Surgery, The Royal Children's Hospital Melbourne, Parkville, Australia
| | - Christian P Brizard
- Department of Cardiac Surgery, The Royal Children's Hospital Melbourne, Parkville, Australia; Department of Pediatrics, University of Melbourne, Parkville, Australia; Murdoch Childrens Research Institute, Parkville, Australia
| | - Yves d'Udekem
- Department of Cardiac Surgery, The Royal Children's Hospital Melbourne, Parkville, Australia; Department of Pediatrics, University of Melbourne, Parkville, Australia; Murdoch Childrens Research Institute, Parkville, Australia.
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50
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Di Salvo G, Miller O, Babu Narayan S, Li W, Budts W, Valsangiacomo Buechel ER, Frigiola A, van den Bosch AE, Bonello B, Mertens L, Hussain T, Parish V, Habib G, Edvardsen T, Geva T, Baumgartner H, Gatzoulis MA, Delgado V, Haugaa KH, Lancellotti P, Flachskampf F, Cardim N, Gerber B, Masci PG, Donal E, Gimelli A, Muraru D, Cosyns B. Imaging the adult with congenital heart disease: a multimodality imaging approach—position paper from the EACVI. Eur Heart J Cardiovasc Imaging 2018; 19:1077-1098. [DOI: 10.1093/ehjci/jey102] [Citation(s) in RCA: 42] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/24/2018] [Accepted: 06/28/2018] [Indexed: 12/18/2022] Open
Affiliation(s)
- Giovanni Di Salvo
- Department of Adult Congenital Heart Disease, National Heart and Lung Institute, Imperial College London, Royal Brompton Hospital, Sydney Street, London, UK
| | - Owen Miller
- Department of Congenital Heart Disease, Evelina London Children's Hospital, Guy's and St. Thomas' NHS Foundation Trust, Westminster Bridge Road, London, UK
| | - Sonya Babu Narayan
- Department of Adult Congenital Heart Disease, National Heart and Lung Institute, Imperial College London, Royal Brompton Hospital, Sydney Street, London, UK
| | - Wei Li
- Department of Adult Congenital Heart Disease, National Heart and Lung Institute, Imperial College London, Royal Brompton Hospital, Sydney Street, London, UK
| | - Werner Budts
- Department Cardiovascular Sciences (KU Leuven), Congenital and Structural Cardiology (CSC UZ Leuven), Leuven, Belgium
| | | | - Alessandra Frigiola
- Adult Congenital Heart Disease, Guy's and St Thomas' Hospital, Westminster Bridge Road, London, UK
| | | | - Beatrice Bonello
- Department of Paediatric Cardiology, Great Ormond Street Hospital, London, UK
| | - Luc Mertens
- Division of Cardiology, Labatt Family Heart Centre, Hospital for Sick Children and University of Toronto, SickKids, 555 University Avenue Toronto, Ontario, Canada
| | - Tarique Hussain
- Division of Imaging Sciences and Biomedical Engineering, King's College London, London, UK
- Departments of Paediatrics, University of Texas, Southwestern Medical Center, Dallas, TX, USA
| | | | - Gilbert Habib
- APHM, La Timone Hospital, Cardiology Department, Boulevard Jean Moulin, Marseille, France
| | - Thor Edvardsen
- Department of Cardiology, Sognsvannsveien 20, Oslo, Norvegia
| | - Tal Geva
- Department of Cardiology, 300 Longwood Avenue, Farley, Boston, Massachusetts, USA
| | | | - Michael A Gatzoulis
- Department of Adult Congenital Heart Disease, National Heart and Lung Institute, Imperial College London, Royal Brompton Hospital, Sydney Street, London, UK
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