1
|
Gaebert P, Schaeffer T, Palm J, Di Padua C, Niedermaier C, Piber N, Hager A, Ewert P, Hörer J, Ono M. Incidence, pathophysiology, and treatment of failing Fontan after the total cavopulmonary connection. Cardiol Young 2024:1-8. [PMID: 39358848 DOI: 10.1017/s1047951124025782] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/04/2024]
Abstract
BACKGROUND Failing Fontan poses a significant clinical challenge. This study aims to improve patients' outcomes by comprehensively understanding the incidence, pathophysiology, risk factors, and treatment of failing Fontan after total cavopulmonary connection. METHODS We performed a retrospective analysis of patients who underwent total cavopulmonary connection at the German Heart Center Munich between 1994 and 2022. The onset of failing Fontan was defined as: protein-losing enteropathy, plastic bronchitis, NYHA class IV, NYHA class III for > one year, unscheduled hospital admissions for heart failure symptoms, and evaluation for heart transplantation. RESULTS Among 634 patients, 76 patients presented with failing Fontan, and the incidence was 1.48 per 100 patient-years. Manifestations included protein-losing enteropathy (n = 34), hospital readmission (n = 28), NYHA III (n = 18), plastic bronchitis (n = 16), evaluation for heart transplantation (n = 14), and NYHA IV (n = 4). Risk factors for the onset of failing Fontan were dominant right ventricle (p = 0.010) and higher pulmonary artery pressure before total cavopulmonary connection (p = 0.004). A total of 72 interventions were performed in 59 patients, including balloon dilatation/stent implantation in the total cavopulmonary connection pathway (n = 49) and embolization of collaterals (n = 24). Heart transplantation was performed in four patients. The survival after the onset of Fontan failure was 77% at 10 years. Patients with failing Fontan revealed significantly higher zlog-NT-proBNP levels after onset compared to those without (p = 0.021). CONCLUSIONS The incidence of Fontan failure was 1.5 per 100 patient years. Dominant right ventricle and higher pulmonary artery pressure before total cavopulmonary connection were significant risks for the onset of failing Fontan. Zlog-NT-proBNP is only a late marker of Fontan failure.
Collapse
Affiliation(s)
- Paula Gaebert
- Department of Congenital and Pediatric Heart Surgery, Technische Universität München, German Heart Center Munich, Munich, Germany
- Division of Congenital and Pediatric Heart Surgery, University Hospital of Munich, Ludwig-Maximilians-Universität, Munich, Germany
- Europäisches Kinderherzzentrum München, Munich, Germany
| | - Thibault Schaeffer
- Department of Congenital and Pediatric Heart Surgery, Technische Universität München, German Heart Center Munich, Munich, Germany
- Division of Congenital and Pediatric Heart Surgery, University Hospital of Munich, Ludwig-Maximilians-Universität, Munich, Germany
- Europäisches Kinderherzzentrum München, Munich, Germany
| | - Jonas Palm
- Department of Congenital Heart Disease and Pediatric Cardiology, German Heart Center Munich at the Technical University of Munich, Munich, Germany
| | - Chiara Di Padua
- Department of Congenital and Pediatric Heart Surgery, Technische Universität München, German Heart Center Munich, Munich, Germany
- Division of Congenital and Pediatric Heart Surgery, University Hospital of Munich, Ludwig-Maximilians-Universität, Munich, Germany
- Europäisches Kinderherzzentrum München, Munich, Germany
| | - Carolin Niedermaier
- Department of Congenital and Pediatric Heart Surgery, Technische Universität München, German Heart Center Munich, Munich, Germany
- Division of Congenital and Pediatric Heart Surgery, University Hospital of Munich, Ludwig-Maximilians-Universität, Munich, Germany
- Europäisches Kinderherzzentrum München, Munich, Germany
| | - Nicole Piber
- Department of Cardiovascular Surgery, German Heart Center Munich, Technische Universität München, Munich, Germany
| | - Alfred Hager
- Department of Congenital Heart Disease and Pediatric Cardiology, German Heart Center Munich at the Technical University of Munich, Munich, Germany
| | - Peter Ewert
- Department of Congenital Heart Disease and Pediatric Cardiology, German Heart Center Munich at the Technical University of Munich, Munich, Germany
| | - Jürgen Hörer
- Department of Congenital and Pediatric Heart Surgery, Technische Universität München, German Heart Center Munich, Munich, Germany
- Division of Congenital and Pediatric Heart Surgery, University Hospital of Munich, Ludwig-Maximilians-Universität, Munich, Germany
- Europäisches Kinderherzzentrum München, Munich, Germany
| | - Masamichi Ono
- Department of Congenital and Pediatric Heart Surgery, Technische Universität München, German Heart Center Munich, Munich, Germany
| |
Collapse
|
2
|
Groody KR, Nicolson SC, Jobes DR. Anesthetic challenges in patients with multicompartmental lymphatic failure after Fontan palliation undergoing transcatheter thoracic duct decompression. Paediatr Anaesth 2024; 34:597-601. [PMID: 38651655 DOI: 10.1111/pan.14891] [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: 02/17/2024] [Revised: 03/22/2024] [Accepted: 03/26/2024] [Indexed: 04/25/2024]
Abstract
Lymphatic flow abnormalities are central to the development of protein losing enteropathy, plastic bronchitis, ascites and pleural effusions in patients palliated to the Fontan circulation. These complications can occur in isolation or multicompartmental (two or more). The treatment of multicompartmental lymphatic failure aims at improving thoracic duct drainage. Re-routing the innominate vein to the pulmonary venous atrium decompresses the thoracic duct, as atrial pressure is lower than systemic venous pressure in Fontan circulation. Transcatheter thoracic duct decompression is a new minimally invasive procedure that involves placing covered stents from the innominate vein to the atrium. Patients undergoing this procedure require multiple general anesthetics, presenting challenges in managing the sequelae of disordered lymphatic flow superimposed on Fontan physiology. We reviewed the first 20 patients at the Center for Lymphatic Imaging and Intervention at a tertiary care children's hospital presenting for transcatheter thoracic duct decompression between March 2018 and February 2023. The patients ranged in age from 3 to 26 years. The majority had failed prior catheter-based lymphatic intervention, including selective embolization of abnormal lympho-intestinal and lympho-bronchial connections to treat lymphatic failure in a single compartment. Fourteen had failure in three lymphatic compartments. Patients were functionally impaired (ASA 3-5) with significant comorbidities. Concurrent with thoracic duct decompression, three patients required fenestration closure for the resultant decrease in oxygen saturation. Ten patients had improvement in symptoms, seven had no changes and three have limited follow up. Five (25%) of these patients were deceased as of January 2024 due to non-lymphatic complications from Fontan failure.
Collapse
Affiliation(s)
- Kirsten R Groody
- Department of Anesthesiology and Critical Care, Division of Cardiothoracic Anesthesiology, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
- Department of Anesthesiology, Division of Pediatric Anesthesiology, The University of Michigan, Ann Arbor, Michigan, USA
| | - Susan C Nicolson
- Department of Anesthesiology and Critical Care, Division of Cardiothoracic Anesthesiology, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - David R Jobes
- Department of Anesthesiology and Critical Care, Division of Cardiothoracic Anesthesiology, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| |
Collapse
|
3
|
Reddy SV, Sinha SP. Lymphatic Interventions in Congenital Heart Disease. Interv Cardiol Clin 2024; 13:343-354. [PMID: 38839168 DOI: 10.1016/j.iccl.2024.03.002] [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] [Indexed: 06/07/2024]
Abstract
Lymphatic disorders in congenital heart disease can be broadly classified into chest compartment, abdominal compartment, or multicompartment disorders. Heavily T2-weighted noninvasive lymphatic imaging (for anatomy) and invasive dynamic contrast magnetic resonance lymphangiography (for flow) have become the main diagnostic modalities of choice to identify the cause of lymphatic disorders. Selective lymphatic duct embolization (SLDE) has largely replaced total thoracic duct embolization as the main lymphatic therapeutic procedure. Recurrence of symptoms needing repeat interventions is more common in patients who underwent SLDE. Novel surgical and transcatheter thoracic duct decompression strategies are promising, but long-term follow-up is critical and eagerly awaited.
Collapse
Affiliation(s)
- Surendranath Veeram Reddy
- Childrens/UT Southwestern Medical Center, Heart Center, B 405, Childrens Medical Center, 1935 Medical District Drive, Dallas, TX 75235, USA
| | - Sanjay Prakash Sinha
- CHOC/CS Cardiology, UC Irvine School of Medicine, UCLA Mattel Children's Hospital.
| |
Collapse
|
4
|
Smith CL, Krishnamurthy G, Srinivasan A, Dori Y. Lymphatic interventions in congenital heart disease. Semin Pediatr Surg 2024; 33:151419. [PMID: 38830312 DOI: 10.1016/j.sempedsurg.2024.151419] [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] [Indexed: 06/05/2024]
Abstract
Congenital heart disease affects 1/100 live births and is one of the most common congenital abnormalities. The relationship between congenital heart disease and lymphatic abnormalities and/or dysfunction is well documented and can be grossly divided into syndromic and non-syndromic etiologies. In patients with genetic syndromes (as examples listed above), there are known primary abnormal lymphatic development leading to a large pleiotropic manifestation of lymphatic dysfunction. Non-syndromic patients, or those without clear genetic etiologies for their lymphatic dysfunction, are often thought to be secondary to physiologic abnormalities as sequelae of congenital heart disease and palliative surgeries. Patients with congenital heart disease and lymphatic dysfunction have a wide variety of clinical manifestations for which there were not many therapeutic interventions available. The development of new imaging techniques allows us to understand better the pathophysiology of these problems and to develop different percutaneous interventions aiming to restore normal lymphatic function.
Collapse
Affiliation(s)
- Christopher L Smith
- Division of Cardiology The Children's Hospital of Philadelphia and Department of Pediatrics Perelman School of Medicine at The University of Pennsylvania, Philadelphia PA.
| | - Ganesh Krishnamurthy
- Department of Radiology The Children's Hospital of Philadelphia and Perelman School of Medicine at The University of Pennsylvania, Philadelphia PA
| | - Abhay Srinivasan
- Department of Radiology The Children's Hospital of Philadelphia and Perelman School of Medicine at The University of Pennsylvania, Philadelphia PA
| | - Yoav Dori
- Division of Cardiology The Children's Hospital of Philadelphia and Department of Pediatrics Perelman School of Medicine at The University of Pennsylvania, Philadelphia PA
| |
Collapse
|
5
|
Kelly B, Mohanakumar S, Ford B, Smith CL, Pinto E, Biko DM, Hjortdal VE, Dori Y. Sequential MRI Evaluation of Lymphatic Abnormalities over the Course of Fontan Completion. Radiol Cardiothorac Imaging 2024; 6:e230315. [PMID: 38814187 PMCID: PMC11211943 DOI: 10.1148/ryct.230315] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2023] [Revised: 02/11/2024] [Accepted: 03/11/2024] [Indexed: 05/31/2024]
Abstract
Purpose To evaluate lymphatic abnormalities before and after Fontan completion using noncontrast lymphatic imaging and relate findings with postoperative outcomes. Materials and Methods This study is a retrospective review of noncontrast T2-weighted lymphatic imaging performed at The Children's Hospital of Philadelphia from June 2012 to February 2023 in patients with single ventricle physiology. All individuals with imaging at both pre-Fontan and Fontan stages were eligible. Lymphatic abnormalities were classified into four types based on severity and location of lymphatic vessels. Classifications were compared between images and related to clinical outcomes such as postoperative drainage and hospitalization, lymphatic complications, heart transplant, and death. Results Forty-three patients (median age, 10 years [IQR, 8-11]; 20 [47%] boys, 23 [53%] girls) were included in the study. Lymphatic abnormalities progressed in 19 individuals after Fontan completion (distribution of lymphatic classifications: type 1, 23; type 2, 11; type 3, 6; type 4, 3 vs type 1, 10; type 2, 18; type 3, 10; type 4, 5; P = .04). Compared with individuals showing no progression of lymphatic abnormalities, those progressing to a high-grade lymphatic classification had longer postoperative drainage (median time, 9 days [IQR, 6-14] vs 17 days [IQR, 10-23]; P = .04) and hospitalization (median time, 13 days [IQR, 9-25] vs 26 days [IQR, 18-30]; P = .03) after Fontan completion and were more likely to develop chylothorax (12% [three of 24] vs 75% [six of eight]; P < .01) and/or protein-losing enteropathy (0% [0 of 24] vs 38% [three of eight]; P < .01) during a median follow-up of 8 years (IQR, 5-9). Progression to any type was not associated with an increased risk of adverse events. Conclusion The study demonstrated that lymphatic structural abnormalities may progress in select individuals with single ventricle physiology after Fontan completion, and progression of abnormalities to a high-grade classification was associated with worse postoperative outcomes. Keywords: Congenital Heart Disease, Glenn, Fontan, Lymphatic Imaging, Cardiovascular MRI Supplemental material is available for this article. Published under a CC BY 4.0 license.
Collapse
Affiliation(s)
- Benjamin Kelly
- From the Departments of Cardiothoracic Surgery (B.K.) and Radiology
(S.M.), Aarhus University Hospital, Palle Juul-Jensens Boulevard 99, 8200 Aarhus
N, Denmark; Division of Cardiology (B.K., B.F., C.L.S., E.P., Y.D.) and
Department of Radiology (D.M.B.), Children's Hospital of Philadelphia,
Philadelphia, Pa; and Department of Cardiothoracic Surgery, Copenhagen
University Hospital–Rigshospitalet, Copenhagen, Denmark (V.E.H.)
| | - Sheyanth Mohanakumar
- From the Departments of Cardiothoracic Surgery (B.K.) and Radiology
(S.M.), Aarhus University Hospital, Palle Juul-Jensens Boulevard 99, 8200 Aarhus
N, Denmark; Division of Cardiology (B.K., B.F., C.L.S., E.P., Y.D.) and
Department of Radiology (D.M.B.), Children's Hospital of Philadelphia,
Philadelphia, Pa; and Department of Cardiothoracic Surgery, Copenhagen
University Hospital–Rigshospitalet, Copenhagen, Denmark (V.E.H.)
| | - Brooke Ford
- From the Departments of Cardiothoracic Surgery (B.K.) and Radiology
(S.M.), Aarhus University Hospital, Palle Juul-Jensens Boulevard 99, 8200 Aarhus
N, Denmark; Division of Cardiology (B.K., B.F., C.L.S., E.P., Y.D.) and
Department of Radiology (D.M.B.), Children's Hospital of Philadelphia,
Philadelphia, Pa; and Department of Cardiothoracic Surgery, Copenhagen
University Hospital–Rigshospitalet, Copenhagen, Denmark (V.E.H.)
| | - Christopher L. Smith
- From the Departments of Cardiothoracic Surgery (B.K.) and Radiology
(S.M.), Aarhus University Hospital, Palle Juul-Jensens Boulevard 99, 8200 Aarhus
N, Denmark; Division of Cardiology (B.K., B.F., C.L.S., E.P., Y.D.) and
Department of Radiology (D.M.B.), Children's Hospital of Philadelphia,
Philadelphia, Pa; and Department of Cardiothoracic Surgery, Copenhagen
University Hospital–Rigshospitalet, Copenhagen, Denmark (V.E.H.)
| | - Erin Pinto
- From the Departments of Cardiothoracic Surgery (B.K.) and Radiology
(S.M.), Aarhus University Hospital, Palle Juul-Jensens Boulevard 99, 8200 Aarhus
N, Denmark; Division of Cardiology (B.K., B.F., C.L.S., E.P., Y.D.) and
Department of Radiology (D.M.B.), Children's Hospital of Philadelphia,
Philadelphia, Pa; and Department of Cardiothoracic Surgery, Copenhagen
University Hospital–Rigshospitalet, Copenhagen, Denmark (V.E.H.)
| | - David M. Biko
- From the Departments of Cardiothoracic Surgery (B.K.) and Radiology
(S.M.), Aarhus University Hospital, Palle Juul-Jensens Boulevard 99, 8200 Aarhus
N, Denmark; Division of Cardiology (B.K., B.F., C.L.S., E.P., Y.D.) and
Department of Radiology (D.M.B.), Children's Hospital of Philadelphia,
Philadelphia, Pa; and Department of Cardiothoracic Surgery, Copenhagen
University Hospital–Rigshospitalet, Copenhagen, Denmark (V.E.H.)
| | - Vibeke E. Hjortdal
- From the Departments of Cardiothoracic Surgery (B.K.) and Radiology
(S.M.), Aarhus University Hospital, Palle Juul-Jensens Boulevard 99, 8200 Aarhus
N, Denmark; Division of Cardiology (B.K., B.F., C.L.S., E.P., Y.D.) and
Department of Radiology (D.M.B.), Children's Hospital of Philadelphia,
Philadelphia, Pa; and Department of Cardiothoracic Surgery, Copenhagen
University Hospital–Rigshospitalet, Copenhagen, Denmark (V.E.H.)
| | - Yoav Dori
- From the Departments of Cardiothoracic Surgery (B.K.) and Radiology
(S.M.), Aarhus University Hospital, Palle Juul-Jensens Boulevard 99, 8200 Aarhus
N, Denmark; Division of Cardiology (B.K., B.F., C.L.S., E.P., Y.D.) and
Department of Radiology (D.M.B.), Children's Hospital of Philadelphia,
Philadelphia, Pa; and Department of Cardiothoracic Surgery, Copenhagen
University Hospital–Rigshospitalet, Copenhagen, Denmark (V.E.H.)
| |
Collapse
|
6
|
Srinivasan A, Smith CL, Dori Y, Krishnamurthy G. Percutaneous procedures for central lymphatic conduction disorders. Semin Pediatr Surg 2024; 33:151418. [PMID: 38830313 DOI: 10.1016/j.sempedsurg.2024.151418] [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] [Indexed: 06/05/2024]
Abstract
Percutaneous endovascular techniques established in interventional cardiology and radiology are well-suited for managing lymphatic conduction disorders. In this article, we provide a synopsis of technical aspects of these procedures, including access of the thoracic duct, selective lymphatic embolization, and management of thoracic duct obstruction. In aggregate, these techniques have developed into an integral component of multidisciplinary management of these complex diseases.
Collapse
Affiliation(s)
- Abhay Srinivasan
- Department of Radiology, Children's Hospital of Philadelphia, USA; Perelman School of Medicine at the University of Pennsylvania, USA.
| | - Christopher L Smith
- Department of Cardiology, Children's Hospital of Philadelphia, USA; Perelman School of Medicine at the University of Pennsylvania, USA
| | - Yoav Dori
- Department of Cardiology, Children's Hospital of Philadelphia, USA; Perelman School of Medicine at the University of Pennsylvania, USA
| | - Ganesh Krishnamurthy
- Department of Radiology, Children's Hospital of Philadelphia, USA; Perelman School of Medicine at the University of Pennsylvania, USA
| |
Collapse
|
7
|
Smood B, Smith C, Dori Y, Mavroudis CD, Fuller S, Gaynor JW, Maeda K. Lymphatic failure and lymphatic interventions: Knowledge gaps and future directions for a new frontier in congenital heart disease. Semin Pediatr Surg 2024; 33:151426. [PMID: 38820801 PMCID: PMC11229519 DOI: 10.1016/j.sempedsurg.2024.151426] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/02/2024]
Abstract
Lymphatic failure is a broad term that describes the lymphatic circulation's inability to adequately transport fluid and solutes out of the interstitium and into the systemic venous circulation, which can result in dysfunction and dysregulation of immune responses, dietary fat absorption, and fluid balance maintenance. Several investigations have recently elucidated the nexus between lymphatic failure and congenital heart disease, and the associated morbidity and mortality is now well-recognized. However, the precise pathophysiology and pathogenesis of lymphatic failure remains poorly understood and relatively understudied, and there are no targeted therapeutics or interventions to reliably prevent its development and progression. Thus, there is growing enthusiasm towards the development and application of novel percutaneous and surgical lymphatic interventions. Moreover, there is consensus that further investigations are needed to delineate the underlying mechanisms of lymphatic failure, which could help identify novel therapeutic targets and develop innovative procedures to improve the overall quality of life and survival of these patients. With these considerations, this review aims to provide an overview of the lymphatic circulation and its vasculature as it relates to current understandings into the pathophysiology and pathogenesis of lymphatic failure in patients with congenital heart disease, while also summarizing strategies for evaluating and managing lymphatic complications, as well as specific areas of interest for future translational and clinical research efforts.
Collapse
Affiliation(s)
- Benjamin Smood
- Division of Cardiothoracic Surgery, Department of Surgery, Children's Hospital of Philadelphia, Philadelphia, PA, 19104, United States of America; Division of Cardiovascular Surgery, Department of Surgery, The University of Pennsylvania, Philadelphia, Pennsylvania, 19104, United States of America.
| | - Christopher Smith
- Jill and Mark Fishman Center for Lymphatic Disorders, Children's Hospital of Philadelphia, Philadelphia, PA, United States; Department of Cardiology, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, 19104 United States of America
| | - Yoav Dori
- Jill and Mark Fishman Center for Lymphatic Disorders, Children's Hospital of Philadelphia, Philadelphia, PA, United States; Department of Cardiology, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, 19104 United States of America
| | - Constantine D Mavroudis
- Division of Cardiothoracic Surgery, Department of Surgery, Children's Hospital of Philadelphia, Philadelphia, PA, 19104, United States of America; Division of Cardiovascular Surgery, Department of Surgery, The University of Pennsylvania, Philadelphia, Pennsylvania, 19104, United States of America
| | - Stephanie Fuller
- Division of Cardiothoracic Surgery, Department of Surgery, Children's Hospital of Philadelphia, Philadelphia, PA, 19104, United States of America; Division of Cardiovascular Surgery, Department of Surgery, The University of Pennsylvania, Philadelphia, Pennsylvania, 19104, United States of America
| | - J William Gaynor
- Division of Cardiothoracic Surgery, Department of Surgery, Children's Hospital of Philadelphia, Philadelphia, PA, 19104, United States of America; Division of Cardiovascular Surgery, Department of Surgery, The University of Pennsylvania, Philadelphia, Pennsylvania, 19104, United States of America
| | - Katsuhide Maeda
- Division of Cardiothoracic Surgery, Department of Surgery, Children's Hospital of Philadelphia, Philadelphia, PA, 19104, United States of America; Division of Cardiovascular Surgery, Department of Surgery, The University of Pennsylvania, Philadelphia, Pennsylvania, 19104, United States of America; Jill and Mark Fishman Center for Lymphatic Disorders, Children's Hospital of Philadelphia, Philadelphia, PA, United States
| |
Collapse
|
8
|
Weinzierl A, Grünherz L, Puippe GD, Gnannt R, von Reibnitz D, Giovanoli P, Vetter D, Möhrlen U, Wildgruber M, Müller A, Pieper CC, Gutschow CA, Lindenblatt N. Microsurgical central lymphatic reconstruction-the role of thoracic duct lymphovenous anastomoses at different anatomical levels. Front Surg 2024; 11:1415010. [PMID: 38826811 PMCID: PMC11140048 DOI: 10.3389/fsurg.2024.1415010] [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] [Received: 04/09/2024] [Accepted: 05/09/2024] [Indexed: 06/04/2024] Open
Abstract
Introduction In recent years advances have been made in the microsurgical treatment of congenital or acquired central lymphatic lesions. While acquired lesions can result from any surgery or trauma of the central lymphatic system, congenital lymphatic lesions can have a variety of manifestations, ranging from singular thoracic duct abnormalities to complex multifocal malformations. Both conditions may cause recurrent chylous effusions and downstream lymphatic congestion depending on the anatomical location of the thoracic duct lesion and are associated with an increased mortality due to the permanent loss of protein and fluid. Methods We present a case series of eleven patients undergoing central lymphatic reconstruction, consisting of one patient with a cervical iatrogenic thoracic duct lesion and eleven patients with different congenital thoracic duct lesions or thrombotic occlusions. Results Anastomosis of the thoracic duct and a nearby vein was performed on different anatomical levels depending on the underlying central lymphatic pathology. Cervical (n = 4), thoracic (n = 1) or abdominal access (n = 5) was used for central lymphatic reconstruction with promising results. In 9 patients a postoperative benefit with varying degrees of symptom regression was reported. Conclusion The presented case series illustrates the current rapid advances in the field of central microsurgical reconstruction of lymphatic lesions alongside the relevant literature.
Collapse
Affiliation(s)
- Andrea Weinzierl
- Department of Plastic Surgery and Hand Surgery, University Hospital Zurich (USZ), Zurich, Switzerland
| | - Lisanne Grünherz
- Department of Plastic Surgery and Hand Surgery, University Hospital Zurich (USZ), Zurich, Switzerland
| | - Gilbert Dominique Puippe
- Institute of Diagnostic and Interventional Radiology, University Hospital Zurich (USZ), Zurich, Switzerland
| | - Ralph Gnannt
- Institute of Diagnostic and Interventional Radiology, University Hospital Zurich (USZ), Zurich, Switzerland
| | - Donata von Reibnitz
- Department of Plastic Surgery and Hand Surgery, University Hospital Zurich (USZ), Zurich, Switzerland
| | - Pietro Giovanoli
- Department of Plastic Surgery and Hand Surgery, University Hospital Zurich (USZ), Zurich, Switzerland
- Faculty of Medicine, University of Zurich (UZH), Zürich, Switzerland
| | - Diana Vetter
- Department of Visceral and Transplant Surgery, University Hospital Zurich (USZ), Zurich, Switzerland
| | - Ueli Möhrlen
- Faculty of Medicine, University of Zurich (UZH), Zürich, Switzerland
- Department of Pediatric Surgery, University Children’s Hospital Zurich, Zurich, Switzerland
| | - Moritz Wildgruber
- Department of Radiology, LMU University Hospital, LMU Munich, Munich, Germany
| | - Andreas Müller
- Department of Neonatology and Pediatric Intensive Care, Children’s Hospital, University of Bonn, Bonn, Germany
| | | | | | - Nicole Lindenblatt
- Department of Plastic Surgery and Hand Surgery, University Hospital Zurich (USZ), Zurich, Switzerland
- Faculty of Medicine, University of Zurich (UZH), Zürich, Switzerland
| |
Collapse
|
9
|
Schaffner D, Perez MH, Duran R, Pretre R, Di Bernardo S. Case Report: Transcatheter interventional procedure to innominate vein turn-down procedure for failing fontan circulation. Front Pediatr 2024; 12:1341443. [PMID: 38379912 PMCID: PMC10876887 DOI: 10.3389/fped.2024.1341443] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/20/2023] [Accepted: 01/17/2024] [Indexed: 02/22/2024] Open
Abstract
Fontan physiology creates a chronic state of decreased cardiac output and systemic venous congestion, leading to liver cirrhosis/malignancy, protein-losing enteropathy, chylothorax, or plastic bronchitis. Creating a fenestration improves cardiac output and relieves some venous congestion. The anatomic connection of the thoracic duct to the subclavian-jugular vein junction exposes the lymphatic system to systemic venous hypertension and could induce plastic bronchitis. To address this complication, two techniques have been developed. A surgical method that decompresses the thoracic duct by diverting the innominate vein to the atrium, and a percutaneous endovascular procedure that uses a covered stent to create an extravascular connection between the innominate vein and the left atrium. We report a novel variant transcatheter intervention of the innominate vein turn-down procedure without creating an extravascular connection in a 39-month-old patient with failing Fontan circulation complicated by plastic bronchitis and a 2-year post-intervention follow-up.
Collapse
Affiliation(s)
- Damien Schaffner
- Pediatric Cardiology Unit, Women Mother and Child Department, Lausanne University Hospital, Lausanne, Switzerland
| | - Maria-Helena Perez
- Pediatric Intensive Care Unit, Women Mother and Child Department, Lausanne University Hospital, Lausanne, Switzerland
| | - Rafael Duran
- Department of Radiology and Interventional Radiology, Lausanne University Hospital, Lausanne, Switzerland
| | - René Pretre
- Department of Cardiac Surgery, Lausanne University Hospital, Lausanne, Switzerland
| | - Stefano Di Bernardo
- Pediatric Cardiology Unit, Women Mother and Child Department, Lausanne University Hospital, Lausanne, Switzerland
| |
Collapse
|
10
|
Laje P, Dori Y, Smith C, Pinto E, Taha D, Maeda K. Surgical Management of Central Lymphatic Conduction Disorders: A Review. J Pediatr Surg 2024; 59:281-289. [PMID: 37953163 DOI: 10.1016/j.jpedsurg.2023.10.039] [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: 10/08/2023] [Accepted: 10/11/2023] [Indexed: 11/14/2023]
Abstract
AIM Recent advances in lymphatic imaging allow understanding the pathophysiology of lymphatic central conduction disorders with great accuracy. This new imaging data is leading to a wide range of novel surgical interventions. We present here the state-of-the-art imaging technology and current spectrum of surgical procedures available for patients with these conditions. METHOD Descriptive report of the newest lymphatic imaging technology and surgical procedures and retrospective review of outcome data. RESULTS There are currently two high-resolution imaging modalities for the central lymphatic system: multi-access dynamic contrast-enhanced MR lymphangiogram (DCMRL) and central lymphangiography (CL). DCMRL is done by accessing percutaneously inguinal and mesenteric lymph nodes and periportal lymphatics vessels. DCMRL provides accurate anatomical and dynamic data on the progression, or lack thereof, of the lymphatic fluid throughout the central lymphatic system. CL is done by placing a catheter percutaneously in the thoracic duct (TD). Pleural effusions are managed by pleurectomy and intraoperative lymphatic glue embolization guided by CL. Anomalies of the TD are managed by TD-to-vein anastomosis and/or ligation of aberrant TD branches. Chylous ascites and organ-specific chylous leaks are managed by intraoperative glue embolization, surgical lymphocutaneous fistulas, and ligation of aberrant peripheral lymphatic channels, among several other procedures. CONCLUSION The surgical management of lymphatic conduction disorders is a new growing field within pediatric general surgery. Pediatric surgeons should be familiar with the newest imaging modalities of the lymphatic system and with the surgical options available for patients with these complex surgical conditions to provide prompt treatment or referral. LEVEL OF EVIDENCE V.
Collapse
Affiliation(s)
- Pablo Laje
- Center for Lymphatic Imaging and Intervention, Division of General, Thoracic and Fetal Surgery, Children's Hospital of Philadelphia, Philadelphia, USA.
| | - Yoav Dori
- Center for Lymphatic Imaging and Intervention, Division of General, Thoracic and Fetal Surgery, Children's Hospital of Philadelphia, Philadelphia, USA
| | - Christopher Smith
- Center for Lymphatic Imaging and Intervention, Division of General, Thoracic and Fetal Surgery, Children's Hospital of Philadelphia, Philadelphia, USA
| | - Erin Pinto
- Center for Lymphatic Imaging and Intervention, Division of General, Thoracic and Fetal Surgery, Children's Hospital of Philadelphia, Philadelphia, USA
| | - Dalal Taha
- Center for Lymphatic Imaging and Intervention, Division of General, Thoracic and Fetal Surgery, Children's Hospital of Philadelphia, Philadelphia, USA
| | - Katsuhide Maeda
- Center for Lymphatic Imaging and Intervention, Division of General, Thoracic and Fetal Surgery, Children's Hospital of Philadelphia, Philadelphia, USA
| |
Collapse
|
11
|
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.
Collapse
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
| |
Collapse
|
12
|
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.
Collapse
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.
| |
Collapse
|
13
|
Tomasulo CE, Dori Y, Smith CL. Understanding the next circulation: lymphatics and what the future holds. Curr Opin Cardiol 2023; 38:369-374. [PMID: 37195304 DOI: 10.1097/hco.0000000000001064] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/18/2023]
Abstract
PURPOSE OF REVIEW The lymphatic system was previously considered the forgotten circulation because of an absence of adequate options for imaging and intervention. However, recent advances over the last decade have improved management strategies for patients with lymphatic disease, including chylothorax, plastic bronchitis, ascites, and protein-losing enteropathy. RECENT FINDINGS New imaging modalities have enabled detailed visualization of lymphatic vessels to allow for a better understanding of the cause of lymphatic dysfunction in a variety of patient subsets. This sparked the development of multiple transcatheter and surgery-based techniques tailored to each patient based on imaging findings. In addition, the new field of precision lymphology has added medical management options for patients with genetic syndromes, who have global lymphatic dysfunction and typically do not respond as well to the more standard lymphatic interventions. SUMMARY Recent developments in lymphatic imaging have given insight into disease processes and changed the way patients are managed. Medical management has been enhanced and new procedures have given patients more options, leading to better long-term results.
Collapse
Affiliation(s)
| | - Yoav Dori
- Division of Cardiology, Jill and Mark Fishman Center for Lymphatic Disorders, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Christopher L Smith
- Division of Cardiology, Jill and Mark Fishman Center for Lymphatic Disorders, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| |
Collapse
|
14
|
Haddad RN, Dautry R, Bonnet D, Malekzadeh-Milani S. Transvenous retrograde thoracic duct embolization for effective treatment of recurrent plastic bronchitis after fontan palliation. Catheter Cardiovasc Interv 2023; 101:863-869. [PMID: 36861752 DOI: 10.1002/ccd.30611] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/11/2022] [Revised: 01/08/2023] [Accepted: 02/21/2023] [Indexed: 03/03/2023]
Abstract
We report the case of a 5.5-year-old patient (16 kg/105 cm) who presented with plastic bronchitis (PB) refractory to conservative treatment 3 months after completion of Fontan palliation. Bi-inguinal transnodal fluoroscopy-guided lymphangiogram confirmed the chylous leak originating from the thoracic duct (TD) into the chest and did not opacify any central lymphatic vessel for direct transabdominal puncture. Retrograde transfemoral approach was adopted to catheterize the TD and selectively embolize its caudal portion using microcoils and liquid embolic adhesive. Recurrence of symptoms after 2 months indicated a redo catheterization to occlude the TD entirely using the same technique. The procedure was successful and the patient was discharged after 2 days with sustained clinical improvement at 24 months postoperative. In the context of refractory PB, end-to-end transvenous retrograde embolization of the TD appears to be an interesting alternative to more complex interventions such as transabdominal puncture, decompression, or surgical ligation of the TD.
Collapse
Affiliation(s)
- Raymond N Haddad
- M3C-Necker, Hôpital Universitaire Necker-Enfants Malades, Assistance Publique-Hôpitaux de Paris (AP-HP), Paris, France
| | - Raphael Dautry
- Department of Radiology, Hôpital Cochin, Assistance Publique-Hôpitaux de Paris (AP-HP), Paris, France
| | - Damien Bonnet
- M3C-Necker, Hôpital Universitaire Necker-Enfants Malades, Assistance Publique-Hôpitaux de Paris (AP-HP), Paris, France.,Université de Paris Cité, Paris, France
| | - Sophie Malekzadeh-Milani
- M3C-Necker, Hôpital Universitaire Necker-Enfants Malades, Assistance Publique-Hôpitaux de Paris (AP-HP), Paris, France
| |
Collapse
|
15
|
Kamsheh AM, O'Connor MJ, Rossano JW. Management of circulatory failure after Fontan surgery. Front Pediatr 2022; 10:1020984. [PMID: 36425396 PMCID: PMC9679629 DOI: 10.3389/fped.2022.1020984] [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: 08/16/2022] [Accepted: 10/18/2022] [Indexed: 11/11/2022] Open
Abstract
With improvement in survival after Fontan surgery resulting in an increasing number of older survivors, there are more patients with a Fontan circulation experiencing circulatory failure each year. Fontan circulatory failure may have a number of underlying etiologies. Once Fontan failure manifests, prognosis is poor, with patient freedom from death or transplant at 10 years of only about 40%. Medical treatments used include traditional heart failure medications such as renin-angiotensin-aldosterone system blockers and beta-blockers, diuretics for symptomatic management, antiarrhythmics for rhythm control, and phosphodiesterase-5 inhibitors to decrease PVR and improve preload. These oral medical therapies are typically not very effective and have little data demonstrating benefit; if there are no surgical or catheter-based interventions to improve the Fontan circulation, patients with severe symptoms often require inotropic medications or mechanical circulatory support. Mechanical circulatory support benefits patients with ventricular dysfunction but may not be as useful in patients with other forms of Fontan failure. Transplant remains the definitive treatment for circulatory failure after Fontan, but patients with a Fontan circulation face many challenges both before and after transplant. There remains significant room and urgent need for improvement in the management and outcomes of patients with circulatory failure after Fontan surgery.
Collapse
Affiliation(s)
- Alicia M Kamsheh
- Division of Cardiology, Children's Hospital of Philadelphia, United States
| | - Matthew J O'Connor
- Division of Cardiology, Children's Hospital of Philadelphia, United States
| | - Joseph W Rossano
- Division of Cardiology, Children's Hospital of Philadelphia, United States
| |
Collapse
|