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Téllez L, Payancé A, Tjwa E, Del Cerro MJ, Idorn L, Ovroutski S, De Bruyne R, Verkade HJ, De Rita F, de Lange C, Angelini A, Paradis V, Rautou PE, García-Pagán JC. EASL-ERN position paper on liver involvement in patients with Fontan-type circulation. J Hepatol 2023; 79:1270-1301. [PMID: 37863545 DOI: 10.1016/j.jhep.2023.07.013] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/06/2023] [Accepted: 07/06/2023] [Indexed: 10/22/2023]
Abstract
Fontan-type surgery is the final step in the sequential palliative surgical treatment of infants born with a univentricular heart. The resulting long-term haemodynamic changes promote liver damage, leading to Fontan-associated liver disease (FALD), in virtually all patients with Fontan circulation. Owing to the lack of a uniform definition of FALD and the competitive risk of other complications developed by Fontan patients, the impact of FALD on the prognosis of these patients is currently debatable. However, based on the increasing number of adult Fontan patients and recent research interest, the European Association for The Study of the Liver and the European Reference Network on Rare Liver Diseases thought a position paper timely. The aims of the current paper are: (1) to provide a clear definition and description of FALD, including clinical, analytical, radiological, haemodynamic, and histological features; (2) to facilitate guidance for staging the liver disease; and (3) to provide evidence- and experience-based recommendations for the management of different clinical scenarios.
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Affiliation(s)
- Luis Téllez
- Gastroenterology and Hepatology Department, Hospital Universitario Ramón y Cajal, Madrid, Spain; Instituto Ramón y Cajal de Investigación Sanitaria (IRYCIS), CIBEREHD (Centro de Investigación Biomédica en Red Enfermedades Hepáticas y Digestivas), University of Alcalá, Madrid, Spain
| | - Audrey Payancé
- DHU Unity, Pôle des Maladies de l'Appareil Digestif, Service d'Hépatologie, Hôpital Beaujon, AP-HP, Clichy, France; Université Denis Diderot-Paris 7, Sorbonne Paris Cité, Paris, France
| | - Eric Tjwa
- Department of Gastroenterology and Hepatology, Radboud University Medical Center, Nijmegen, The Netherlands
| | - María Jesús Del Cerro
- Pediatric Cardiology Department, Hospital Universitario Ramón y Cajal, Madrid, Spain; Instituto Ramón y Cajal de Investigación Sanitaria (IRYCIS), University of Alcalá, Madrid, Spain
| | - Lars Idorn
- Department of Pediatrics, Section of Pediatric Cardiology, Rigshospitalet, Copenhagen, Denmark
| | - Stanislav Ovroutski
- Department of Congenital Heart Disease/Pediatric Cardiology, Deutsches Herzzentrum Berlin, Berlin, Germany
| | - Ruth De Bruyne
- Department of Pediatric Gastroenterology, Hepatology and Nutrition, Ghent University Hospital, Belgium
| | - Henkjan J Verkade
- Department of Pediatrics, Beatrix Children's Hospital/University Medical Center Groningen, The Netherlands
| | - Fabrizio De Rita
- Adult Congenital and Paediatric Heart Unit, Freeman Hospital, Newcastle Upon Tyne Hospitals NHS Foundation Trust, Newcastle Upon Tyne, UK
| | - Charlotte de Lange
- Department of Pediatric Radiology, Queen Silvia Childrens' Hospital, Sahlgrenska University Hospital, Behandlingsvagen 7, 41650 Göteborg, Sweden
| | - Annalisa Angelini
- Pathology of Cardiac Transplantation and Regenerative Medicine Unit, Department of Cardiac, Thoracic and Vascular Sciences and Public Health, University of Padua, Padua, Italy
| | - Valérie Paradis
- Centre de recherche sur l'inflammation, INSERM1149, Université Paris Cité, Paris, France; Pathology Department, Beaujon Hospital, APHP.Nord, Clichy, France
| | - Pierre Emmanuel Rautou
- AP-HP, Service d'Hépatologie, Hôpital Beaujon, DMU DIGEST, Centre de Référence des Maladies Vasculaires du Foie, FILFOIE, Clichy, France; Université Paris-Cité, Inserm, Centre de recherche sur l'inflammation, UMR 1149, Paris, France
| | - Juan Carlos García-Pagán
- Barcelona Hepatic Hemodynamic Laboratory, Liver Unit, Hospital Clínic, Institut de Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Departament de Medicina i Ciències de la Salut, University of Barcelona, Barcelona, Spain; CIBEREHD (Centro de Investigación Biomédica en Red Enfermedades Hepáticas y Digestivas), Health Care Provider of the European Reference Network on Rare Liver Disorders (ERN-Liver), Spain.
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Raimondi F, Martins D, Coenen R, Panaioli E, Khraiche D, Boddaert N, Bonnet D, Atkins M, El-Said H, Alshawabkeh L, Hsiao A. Prevalence of Venovenous Shunting and High-Output State Quantified with 4D Flow MRI in Patients with Fontan Circulation. Radiol Cardiothorac Imaging 2021; 3:e210161. [PMID: 34934948 PMCID: PMC8686005 DOI: 10.1148/ryct.210161] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2021] [Revised: 11/04/2021] [Accepted: 11/12/2021] [Indexed: 11/11/2022]
Abstract
PURPOSE To assess the ability of four-dimensional (4D) flow MRI to quantify flow volume of the Fontan circuit, including the frequency and hemodynamic contribution of systemic-to-pulmonary venovenous collateral vessels. MATERIALS AND METHODS In this retrospective study, patients with Fontan circulation were included from three institutions (2017-2021). Flow measurements were performed at several locations along the circuit by two readers, and collateral shunt volumes were quantified. The frequency of venovenous collaterals and structural defects were tabulated from concurrent MR angiography, contemporaneous CT, or catheter angiography and related to Fontan clinical status. Statistical analysis included Pearson and Spearman correlation and Bland-Altman analysis. RESULTS Seventy-five patients (mean age, 20 years; range, 5-58 years; 46 female and 29 male patients) were included. Interobserver agreement was high for aortic output, pulmonary arteries, pulmonary veins, superior vena cava (Glenn shunt), and inferior vena cava (Fontan conduit) (range, ρ = 0.913-0.975). Calculated shunt volume also showed strong agreement, on the basis of the difference between aortic and pulmonary flow (ρ = 0.935). A total of 37 of 75 (49%) of the patients exhibited shunts exceeding 1.00 L/min, 81% (30 of 37) of whom had pulmonary venous or atrial flow volume step-ups and corresponding venovenous collaterals. A total of 12% of patients (nine of 75) exhibited a high-output state (>4 L/min/m2), most of whom had venovenous shunts exceeding 30% of cardiac output. CONCLUSION Fontan flow and venovenous shunting can be reliably quantified at 4D flow MRI; high-output states were found in a higher proportion of patients than expected, among whom venovenous collaterals were common and constituted a substantial proportion of cardiac output.Keywords: Pediatrics, MR Angiography, Cardiac, Technology Assessment, Hemodynamics/Flow Dynamics, Congenital Supplemental material is available for this article. © RSNA, 2021.
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Affiliation(s)
- Francesca Raimondi
- From the Unité Médico-Chirurgicale de Cardiologie
Congénitale et Pédiatrique, Centre de Référence des
Maladies Cardiaques Congénitales Complexes-M3C, Hôpital
Universitaire Necker-Enfants Malades, Université de Paris, Paris, France
(F.R., D.K., D.B.); Pediatric Radiology Unit, Hôpital Universitaire
Necker-Enfants Malades, Université de Paris, Paris, France (F.R., E.P.,
N.B.); Decision and Bayesian Computation, Computation Biology Department, CNRS,
URS 3756, Neuroscience Department, CNRS UMR 3571, Institut Pasteur, Paris,
France (F.R.); School of Biomedical Engineering & Imaging Sciences,
King’s College London, Lambeth Wing, St Thomas’ Hospital, London,
England (F.R.); Department of Pediatric Cardiology, Hospital de Santa Cruz,
Centro Hospitalar Lisboa Ocidental, Lisbon, Portugal (D.M.); Radiology and
Cardiology Unit, Erasmus MC, Rotterdam, the Netherlands (R.C.); Fairfax
Radiological Consultants, Fairfax, Va (M.A.); and Departments of Pediatric
Cardiology (H.E.S.), Cardiovascular Medicine (L.A.), and Radiology (A.H.),
University of California, San Diego, 9300 Campus Point Dr, Room 7756, La Jolla,
CA 92037-7756
| | - Duarte Martins
- From the Unité Médico-Chirurgicale de Cardiologie
Congénitale et Pédiatrique, Centre de Référence des
Maladies Cardiaques Congénitales Complexes-M3C, Hôpital
Universitaire Necker-Enfants Malades, Université de Paris, Paris, France
(F.R., D.K., D.B.); Pediatric Radiology Unit, Hôpital Universitaire
Necker-Enfants Malades, Université de Paris, Paris, France (F.R., E.P.,
N.B.); Decision and Bayesian Computation, Computation Biology Department, CNRS,
URS 3756, Neuroscience Department, CNRS UMR 3571, Institut Pasteur, Paris,
France (F.R.); School of Biomedical Engineering & Imaging Sciences,
King’s College London, Lambeth Wing, St Thomas’ Hospital, London,
England (F.R.); Department of Pediatric Cardiology, Hospital de Santa Cruz,
Centro Hospitalar Lisboa Ocidental, Lisbon, Portugal (D.M.); Radiology and
Cardiology Unit, Erasmus MC, Rotterdam, the Netherlands (R.C.); Fairfax
Radiological Consultants, Fairfax, Va (M.A.); and Departments of Pediatric
Cardiology (H.E.S.), Cardiovascular Medicine (L.A.), and Radiology (A.H.),
University of California, San Diego, 9300 Campus Point Dr, Room 7756, La Jolla,
CA 92037-7756
| | - Raluca Coenen
- From the Unité Médico-Chirurgicale de Cardiologie
Congénitale et Pédiatrique, Centre de Référence des
Maladies Cardiaques Congénitales Complexes-M3C, Hôpital
Universitaire Necker-Enfants Malades, Université de Paris, Paris, France
(F.R., D.K., D.B.); Pediatric Radiology Unit, Hôpital Universitaire
Necker-Enfants Malades, Université de Paris, Paris, France (F.R., E.P.,
N.B.); Decision and Bayesian Computation, Computation Biology Department, CNRS,
URS 3756, Neuroscience Department, CNRS UMR 3571, Institut Pasteur, Paris,
France (F.R.); School of Biomedical Engineering & Imaging Sciences,
King’s College London, Lambeth Wing, St Thomas’ Hospital, London,
England (F.R.); Department of Pediatric Cardiology, Hospital de Santa Cruz,
Centro Hospitalar Lisboa Ocidental, Lisbon, Portugal (D.M.); Radiology and
Cardiology Unit, Erasmus MC, Rotterdam, the Netherlands (R.C.); Fairfax
Radiological Consultants, Fairfax, Va (M.A.); and Departments of Pediatric
Cardiology (H.E.S.), Cardiovascular Medicine (L.A.), and Radiology (A.H.),
University of California, San Diego, 9300 Campus Point Dr, Room 7756, La Jolla,
CA 92037-7756
| | - Elena Panaioli
- From the Unité Médico-Chirurgicale de Cardiologie
Congénitale et Pédiatrique, Centre de Référence des
Maladies Cardiaques Congénitales Complexes-M3C, Hôpital
Universitaire Necker-Enfants Malades, Université de Paris, Paris, France
(F.R., D.K., D.B.); Pediatric Radiology Unit, Hôpital Universitaire
Necker-Enfants Malades, Université de Paris, Paris, France (F.R., E.P.,
N.B.); Decision and Bayesian Computation, Computation Biology Department, CNRS,
URS 3756, Neuroscience Department, CNRS UMR 3571, Institut Pasteur, Paris,
France (F.R.); School of Biomedical Engineering & Imaging Sciences,
King’s College London, Lambeth Wing, St Thomas’ Hospital, London,
England (F.R.); Department of Pediatric Cardiology, Hospital de Santa Cruz,
Centro Hospitalar Lisboa Ocidental, Lisbon, Portugal (D.M.); Radiology and
Cardiology Unit, Erasmus MC, Rotterdam, the Netherlands (R.C.); Fairfax
Radiological Consultants, Fairfax, Va (M.A.); and Departments of Pediatric
Cardiology (H.E.S.), Cardiovascular Medicine (L.A.), and Radiology (A.H.),
University of California, San Diego, 9300 Campus Point Dr, Room 7756, La Jolla,
CA 92037-7756
| | - Diala Khraiche
- From the Unité Médico-Chirurgicale de Cardiologie
Congénitale et Pédiatrique, Centre de Référence des
Maladies Cardiaques Congénitales Complexes-M3C, Hôpital
Universitaire Necker-Enfants Malades, Université de Paris, Paris, France
(F.R., D.K., D.B.); Pediatric Radiology Unit, Hôpital Universitaire
Necker-Enfants Malades, Université de Paris, Paris, France (F.R., E.P.,
N.B.); Decision and Bayesian Computation, Computation Biology Department, CNRS,
URS 3756, Neuroscience Department, CNRS UMR 3571, Institut Pasteur, Paris,
France (F.R.); School of Biomedical Engineering & Imaging Sciences,
King’s College London, Lambeth Wing, St Thomas’ Hospital, London,
England (F.R.); Department of Pediatric Cardiology, Hospital de Santa Cruz,
Centro Hospitalar Lisboa Ocidental, Lisbon, Portugal (D.M.); Radiology and
Cardiology Unit, Erasmus MC, Rotterdam, the Netherlands (R.C.); Fairfax
Radiological Consultants, Fairfax, Va (M.A.); and Departments of Pediatric
Cardiology (H.E.S.), Cardiovascular Medicine (L.A.), and Radiology (A.H.),
University of California, San Diego, 9300 Campus Point Dr, Room 7756, La Jolla,
CA 92037-7756
| | - Nathalie Boddaert
- From the Unité Médico-Chirurgicale de Cardiologie
Congénitale et Pédiatrique, Centre de Référence des
Maladies Cardiaques Congénitales Complexes-M3C, Hôpital
Universitaire Necker-Enfants Malades, Université de Paris, Paris, France
(F.R., D.K., D.B.); Pediatric Radiology Unit, Hôpital Universitaire
Necker-Enfants Malades, Université de Paris, Paris, France (F.R., E.P.,
N.B.); Decision and Bayesian Computation, Computation Biology Department, CNRS,
URS 3756, Neuroscience Department, CNRS UMR 3571, Institut Pasteur, Paris,
France (F.R.); School of Biomedical Engineering & Imaging Sciences,
King’s College London, Lambeth Wing, St Thomas’ Hospital, London,
England (F.R.); Department of Pediatric Cardiology, Hospital de Santa Cruz,
Centro Hospitalar Lisboa Ocidental, Lisbon, Portugal (D.M.); Radiology and
Cardiology Unit, Erasmus MC, Rotterdam, the Netherlands (R.C.); Fairfax
Radiological Consultants, Fairfax, Va (M.A.); and Departments of Pediatric
Cardiology (H.E.S.), Cardiovascular Medicine (L.A.), and Radiology (A.H.),
University of California, San Diego, 9300 Campus Point Dr, Room 7756, La Jolla,
CA 92037-7756
| | - Damien Bonnet
- From the Unité Médico-Chirurgicale de Cardiologie
Congénitale et Pédiatrique, Centre de Référence des
Maladies Cardiaques Congénitales Complexes-M3C, Hôpital
Universitaire Necker-Enfants Malades, Université de Paris, Paris, France
(F.R., D.K., D.B.); Pediatric Radiology Unit, Hôpital Universitaire
Necker-Enfants Malades, Université de Paris, Paris, France (F.R., E.P.,
N.B.); Decision and Bayesian Computation, Computation Biology Department, CNRS,
URS 3756, Neuroscience Department, CNRS UMR 3571, Institut Pasteur, Paris,
France (F.R.); School of Biomedical Engineering & Imaging Sciences,
King’s College London, Lambeth Wing, St Thomas’ Hospital, London,
England (F.R.); Department of Pediatric Cardiology, Hospital de Santa Cruz,
Centro Hospitalar Lisboa Ocidental, Lisbon, Portugal (D.M.); Radiology and
Cardiology Unit, Erasmus MC, Rotterdam, the Netherlands (R.C.); Fairfax
Radiological Consultants, Fairfax, Va (M.A.); and Departments of Pediatric
Cardiology (H.E.S.), Cardiovascular Medicine (L.A.), and Radiology (A.H.),
University of California, San Diego, 9300 Campus Point Dr, Room 7756, La Jolla,
CA 92037-7756
| | - Melany Atkins
- From the Unité Médico-Chirurgicale de Cardiologie
Congénitale et Pédiatrique, Centre de Référence des
Maladies Cardiaques Congénitales Complexes-M3C, Hôpital
Universitaire Necker-Enfants Malades, Université de Paris, Paris, France
(F.R., D.K., D.B.); Pediatric Radiology Unit, Hôpital Universitaire
Necker-Enfants Malades, Université de Paris, Paris, France (F.R., E.P.,
N.B.); Decision and Bayesian Computation, Computation Biology Department, CNRS,
URS 3756, Neuroscience Department, CNRS UMR 3571, Institut Pasteur, Paris,
France (F.R.); School of Biomedical Engineering & Imaging Sciences,
King’s College London, Lambeth Wing, St Thomas’ Hospital, London,
England (F.R.); Department of Pediatric Cardiology, Hospital de Santa Cruz,
Centro Hospitalar Lisboa Ocidental, Lisbon, Portugal (D.M.); Radiology and
Cardiology Unit, Erasmus MC, Rotterdam, the Netherlands (R.C.); Fairfax
Radiological Consultants, Fairfax, Va (M.A.); and Departments of Pediatric
Cardiology (H.E.S.), Cardiovascular Medicine (L.A.), and Radiology (A.H.),
University of California, San Diego, 9300 Campus Point Dr, Room 7756, La Jolla,
CA 92037-7756
| | - Howaida El-Said
- From the Unité Médico-Chirurgicale de Cardiologie
Congénitale et Pédiatrique, Centre de Référence des
Maladies Cardiaques Congénitales Complexes-M3C, Hôpital
Universitaire Necker-Enfants Malades, Université de Paris, Paris, France
(F.R., D.K., D.B.); Pediatric Radiology Unit, Hôpital Universitaire
Necker-Enfants Malades, Université de Paris, Paris, France (F.R., E.P.,
N.B.); Decision and Bayesian Computation, Computation Biology Department, CNRS,
URS 3756, Neuroscience Department, CNRS UMR 3571, Institut Pasteur, Paris,
France (F.R.); School of Biomedical Engineering & Imaging Sciences,
King’s College London, Lambeth Wing, St Thomas’ Hospital, London,
England (F.R.); Department of Pediatric Cardiology, Hospital de Santa Cruz,
Centro Hospitalar Lisboa Ocidental, Lisbon, Portugal (D.M.); Radiology and
Cardiology Unit, Erasmus MC, Rotterdam, the Netherlands (R.C.); Fairfax
Radiological Consultants, Fairfax, Va (M.A.); and Departments of Pediatric
Cardiology (H.E.S.), Cardiovascular Medicine (L.A.), and Radiology (A.H.),
University of California, San Diego, 9300 Campus Point Dr, Room 7756, La Jolla,
CA 92037-7756
| | - Laith Alshawabkeh
- From the Unité Médico-Chirurgicale de Cardiologie
Congénitale et Pédiatrique, Centre de Référence des
Maladies Cardiaques Congénitales Complexes-M3C, Hôpital
Universitaire Necker-Enfants Malades, Université de Paris, Paris, France
(F.R., D.K., D.B.); Pediatric Radiology Unit, Hôpital Universitaire
Necker-Enfants Malades, Université de Paris, Paris, France (F.R., E.P.,
N.B.); Decision and Bayesian Computation, Computation Biology Department, CNRS,
URS 3756, Neuroscience Department, CNRS UMR 3571, Institut Pasteur, Paris,
France (F.R.); School of Biomedical Engineering & Imaging Sciences,
King’s College London, Lambeth Wing, St Thomas’ Hospital, London,
England (F.R.); Department of Pediatric Cardiology, Hospital de Santa Cruz,
Centro Hospitalar Lisboa Ocidental, Lisbon, Portugal (D.M.); Radiology and
Cardiology Unit, Erasmus MC, Rotterdam, the Netherlands (R.C.); Fairfax
Radiological Consultants, Fairfax, Va (M.A.); and Departments of Pediatric
Cardiology (H.E.S.), Cardiovascular Medicine (L.A.), and Radiology (A.H.),
University of California, San Diego, 9300 Campus Point Dr, Room 7756, La Jolla,
CA 92037-7756
| | - Albert Hsiao
- From the Unité Médico-Chirurgicale de Cardiologie
Congénitale et Pédiatrique, Centre de Référence des
Maladies Cardiaques Congénitales Complexes-M3C, Hôpital
Universitaire Necker-Enfants Malades, Université de Paris, Paris, France
(F.R., D.K., D.B.); Pediatric Radiology Unit, Hôpital Universitaire
Necker-Enfants Malades, Université de Paris, Paris, France (F.R., E.P.,
N.B.); Decision and Bayesian Computation, Computation Biology Department, CNRS,
URS 3756, Neuroscience Department, CNRS UMR 3571, Institut Pasteur, Paris,
France (F.R.); School of Biomedical Engineering & Imaging Sciences,
King’s College London, Lambeth Wing, St Thomas’ Hospital, London,
England (F.R.); Department of Pediatric Cardiology, Hospital de Santa Cruz,
Centro Hospitalar Lisboa Ocidental, Lisbon, Portugal (D.M.); Radiology and
Cardiology Unit, Erasmus MC, Rotterdam, the Netherlands (R.C.); Fairfax
Radiological Consultants, Fairfax, Va (M.A.); and Departments of Pediatric
Cardiology (H.E.S.), Cardiovascular Medicine (L.A.), and Radiology (A.H.),
University of California, San Diego, 9300 Campus Point Dr, Room 7756, La Jolla,
CA 92037-7756
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