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Constantine A, Ferrero P, Gribaudo E, Mitropoulou P, Krishnathasan K, Costola G, Lwin MT, Fitzsimmons S, Brida M, Montanaro C, Kempny A, Heng EL, Chessa M, Dimopoulos K, Rafiq I. Morbidity and mortality in adults with a Fontan circulation beyond the fourth decade of life. Eur J Prev Cardiol 2024:zwae031. [PMID: 38306409 DOI: 10.1093/eurjpc/zwae031] [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: 11/05/2023] [Revised: 01/02/2024] [Accepted: 01/15/2024] [Indexed: 02/04/2024]
Abstract
AIMS To evaluate the late outcomes of adults (above 35 years) with a Fontan-type circulation, for whom current data on morbidity and mortality are lacking. METHODS AND RESULTS Data were collected retrospectively on consecutive patients with Fontan circulation above the age of 35 years followed in three European specialist centres. Overall, 115 Fontan patients were included [median age 35 (range 35-48) years, 47.8% female]. The most common underlying congenital heart disease diagnosis was tricuspid atresia (n = 58, 50.4%), and the age at first Fontan completion was 9.1 (interquartile range 5.0-15.8) years. Almost two-thirds (61.7%) of patients had undergone an atriopulmonary Fontan, and 23.5% had received a total cavopulmonary connection. One-third required repeat surgery or intervention. Most patients (55.9%) were in New York Heart Association functional class II or class I (30.6%), 76 (66.1%) patients had experienced at least one arrhythmia, and eight (7.0%) protein-losing enteropathy. At a median follow-up of 5.0 (2.4-10.3) years, 15 (13.0%) patients were referred for transplantation assessment and 19 (16.5%) patients died, mainly from heart failure (84.2%). Univariable predictors of death or transplantation included lower serum albumin level [hazard ratio (HR) 1.09 per g/L decrease, 95% confidence interval (CI): 1.04-1.15, P = 0.0009], prior heart failure admission (HR 4.28, 95% CI:1.75-10.44, P = 0.001), prior atrial tachycardia or flutter (HR 3.02, 95% CI: 1.23-7.38, P = 0.02), and baseline pulmonary vasodilator therapy (HR 8.59, 95% CI:1.05-70.13, P = 0.04). Lower serum albumin and prior atrial tachycardia or flutter remained significant on bivariable analysis. CONCLUSION Our study highlights the significant morbidity and mortality in older adults with a Fontan-type circulation, emphasizing the need for lifelong specialist surveillance with frequent risk stratification, close monitoring, and early consideration for transplantation assessment.
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Affiliation(s)
- Andrew Constantine
- Adult Congenital Heart Centre and Centre for Pulmonary Hypertension, Royal Brompton Hospital, Royal Brompton & Harefield Hospitals, Guy's and St Thomas' NHS Foundation Trust, Sydney Street, SW3 6NP London, UK
- National Heart and Lung Institute, Imperial College London, Guy Scadding Building, Dovehouse Street, SW3 6LY London, UK
| | - Paolo Ferrero
- ACHD Unit, IRCCS-Policlinico San Donato, San Donato Milanese, Milan, Italy
| | - Elena Gribaudo
- Adult Congenital Heart Centre and Centre for Pulmonary Hypertension, Royal Brompton Hospital, Royal Brompton & Harefield Hospitals, Guy's and St Thomas' NHS Foundation Trust, Sydney Street, SW3 6NP London, UK
| | - Panagiota Mitropoulou
- Congenital Cardiac Centre, Southampton General Hospital, University Hospital Southampton NHS Foundation Trust, Southampton, UK
| | - Kaushiga Krishnathasan
- Adult Congenital Heart Centre and Centre for Pulmonary Hypertension, Royal Brompton Hospital, Royal Brompton & Harefield Hospitals, Guy's and St Thomas' NHS Foundation Trust, Sydney Street, SW3 6NP London, UK
- National Heart and Lung Institute, Imperial College London, Guy Scadding Building, Dovehouse Street, SW3 6LY London, UK
| | - Giulia Costola
- Adult Congenital Heart Centre and Centre for Pulmonary Hypertension, Royal Brompton Hospital, Royal Brompton & Harefield Hospitals, Guy's and St Thomas' NHS Foundation Trust, Sydney Street, SW3 6NP London, UK
| | - Myo T Lwin
- Congenital Cardiac Centre, Southampton General Hospital, University Hospital Southampton NHS Foundation Trust, Southampton, UK
| | - Samantha Fitzsimmons
- Congenital Cardiac Centre, Southampton General Hospital, University Hospital Southampton NHS Foundation Trust, Southampton, UK
| | - Margarita Brida
- Adult Congenital Heart Centre and Centre for Pulmonary Hypertension, Royal Brompton Hospital, Royal Brompton & Harefield Hospitals, Guy's and St Thomas' NHS Foundation Trust, Sydney Street, SW3 6NP London, UK
- National Heart and Lung Institute, Imperial College London, Guy Scadding Building, Dovehouse Street, SW3 6LY London, UK
- Department of Medical Rehabilitation, Medical Faculty University of Rijeka, Rijeka, Croatia
| | - Claudia Montanaro
- Adult Congenital Heart Centre and Centre for Pulmonary Hypertension, Royal Brompton Hospital, Royal Brompton & Harefield Hospitals, Guy's and St Thomas' NHS Foundation Trust, Sydney Street, SW3 6NP London, UK
- National Heart and Lung Institute, Imperial College London, Guy Scadding Building, Dovehouse Street, SW3 6LY London, UK
| | - Aleksander Kempny
- Adult Congenital Heart Centre and Centre for Pulmonary Hypertension, Royal Brompton Hospital, Royal Brompton & Harefield Hospitals, Guy's and St Thomas' NHS Foundation Trust, Sydney Street, SW3 6NP London, UK
- National Heart and Lung Institute, Imperial College London, Guy Scadding Building, Dovehouse Street, SW3 6LY London, UK
| | - Ee Ling Heng
- Adult Congenital Heart Centre and Centre for Pulmonary Hypertension, Royal Brompton Hospital, Royal Brompton & Harefield Hospitals, Guy's and St Thomas' NHS Foundation Trust, Sydney Street, SW3 6NP London, UK
- National Heart and Lung Institute, Imperial College London, Guy Scadding Building, Dovehouse Street, SW3 6LY London, UK
| | - Massimo Chessa
- ACHD Unit, IRCCS-Policlinico San Donato, San Donato Milanese, Milan, Italy
- UniSR - Vita Salute Sal Raffaele University, Milan, Italy
| | - Konstantinos Dimopoulos
- Adult Congenital Heart Centre and Centre for Pulmonary Hypertension, Royal Brompton Hospital, Royal Brompton & Harefield Hospitals, Guy's and St Thomas' NHS Foundation Trust, Sydney Street, SW3 6NP London, UK
- National Heart and Lung Institute, Imperial College London, Guy Scadding Building, Dovehouse Street, SW3 6LY London, UK
| | - Isma Rafiq
- Adult Congenital Heart Centre and Centre for Pulmonary Hypertension, Royal Brompton Hospital, Royal Brompton & Harefield Hospitals, Guy's and St Thomas' NHS Foundation Trust, Sydney Street, SW3 6NP London, UK
- National Heart and Lung Institute, Imperial College London, Guy Scadding Building, Dovehouse Street, SW3 6LY London, UK
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