1
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Dib N, Chaix MA, Samuel M, Hermann Honfo S, Hamilton RM, Aboulhosn J, Broberg CS, Cohen S, Cook S, Dore A, Jameson SM, Fournier A, Ibrahim R, Kay J, Mongeon FP, Opotowsky AR, Zaidi A, Poirier N, Khairy P. Cardiovascular Outcomes in Fontan Patients With Right vs Left Univentricular Morphology: A Multicenter Study. JACC. ADVANCES 2024; 3:100871. [PMID: 38939676 PMCID: PMC11198647 DOI: 10.1016/j.jacadv.2024.100871] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/22/2023] [Revised: 11/27/2023] [Accepted: 01/02/2024] [Indexed: 06/29/2024]
Abstract
Background There is a paucity of data on long-term outcomes after Fontan palliation in patients with a dominant morphological univentricular right (uRV) vs left (uLV) ventricle. Objectives The purpose of this study was to compare the incidence of atrial arrhythmias, thromboembolic events, cardiac transplantation, and death following Fontan palliation in patients with uRV vs uLV. Methods The Alliance for Adult Research in Congenital Cardiology conducted a multicenter retrospective cohort study on patients with total cavopulmonary connection Fontan palliation across 12 centers in North America. All components of the composite outcome, that is, atrial arrhythmias, thromboembolic events, cardiac transplantation, and death, were reviewed and classified by a blinded adjudicating committee. Time-to-event analyses were performed that accounted for competing risks. Results A total of 384 patients were followed for 10.5 ± 5.9 years. The composite outcome occurred in 3.7 vs 1.7 cases per 100 person-years for uRV (N = 171) vs uLV (N = 213), respectively (P < 0.001). In multivariable analyses, uRV conferred a >2-fold higher risk of the composite outcome (HR: 2.17, 95% CI: 1.45-3.45, P < 0.001). In secondary analyses of components of the primary outcome, uRV was significantly associated with a greater risk of cardiac transplantation or death (HR: 9.09, 95% CI: 2.17-38.46, P < 0.001) and atrial arrhythmias (HR: 2.17, 95% CI: 1.20-4.00, P = 0.010) but not thromboembolic events (HR: 1.64, 95% CI: 0.86-3.16, P = 0.131). Conclusions Fontan patients with uRV vs uLV morphology have a higher incidence of adverse cardiovascular events, including atrial arrhythmia, cardiac transplantation, and all-cause mortality.
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Affiliation(s)
- Nabil Dib
- Montreal Heart Institute, Université de Montréal, Quebec, Canada
| | - Marie-A. Chaix
- Montreal Heart Institute, Université de Montréal, Quebec, Canada
| | - Michelle Samuel
- Montreal Heart Institute, Université de Montréal, Quebec, Canada
| | | | | | - Jamil Aboulhosn
- Ahmanson/UCLA Adult Congenital Heart Program, University of California, Los Angeles, USA
| | - Craig S. Broberg
- Knight Cardiovascular Institute, Oregon Health and Science University, Portland, USA
| | - Scott Cohen
- The Wisconsin Adult Congenital Heart (WAtCH) Program, Medical College of Wisconsin, Milwaukee, USA
| | - Stephen Cook
- The Philadelphia Adult Congenital Heart Center, Children's Hospital of Pittsburgh, Pittsburgh, USA
| | - Annie Dore
- Montreal Heart Institute, Université de Montréal, Quebec, Canada
| | - Susan M. Jameson
- Adult Congenital Heart Program, Stanford University, Palo Alto, USA
| | - Anne Fournier
- Hôpital Sainte-Justine, Université de Montréal, Montreal, Canada
| | - Reda Ibrahim
- Montreal Heart Institute, Université de Montréal, Quebec, Canada
| | - Joseph Kay
- Division of Cardiology, University of Colorado Denver, Aurora, USA
| | | | - Alexander R. Opotowsky
- Boston Adult Congenital Heart Service, Boston Children's Hospital and Brigham and Women's Hospital, Harvard Medical School, Boston, USA
| | - Ali Zaidi
- Nationwide Children's Hospital, Ohio State University, Columbus, USA
| | - Nancy Poirier
- Montreal Heart Institute, Université de Montréal, Quebec, Canada
| | - Paul Khairy
- Montreal Heart Institute, Université de Montréal, Quebec, Canada
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2
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Omori T, Kuwajima K, Rader F, Siegel RJ, Shiota T. Implication of Right Atrial Pressure Estimated by Echocardiography in Patients with Severe Tricuspid Regurgitation. J Am Soc Echocardiogr 2023; 36:1170-1177. [PMID: 37356676 DOI: 10.1016/j.echo.2023.06.009] [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: 05/11/2023] [Revised: 06/14/2023] [Accepted: 06/17/2023] [Indexed: 06/27/2023]
Abstract
BACKGROUND Little is known about how tightly right atrial pressure (RAP) is associated with prognosis in patients with severe tricuspid regurgitation (TR). The aim of this study was to investigate the association of RAP estimated by echocardiography (RAP-echo) with cardiovascular events in patients with severe TR. METHODS Two hundred forty outpatients (median age, 75 years; 130 women) who underwent two-dimensional transthoracic echocardiography and were diagnosed with severe TR were retrospectively studied. According to RAP-echo using the diameter of the inferior vena cava and its response to a sniff, patients were classified into two groups: low or middle and high RAP-echo. Cardiovascular events were defined as cardiovascular death and admission for heart failure. RESULTS During follow-up (median, 428 days; range, 87-1,229 days), 64 patients experienced cardiovascular events. By multivariate analysis, high RAP-echo was independently associated with cardiovascular events (hazard ratio, 2.46; 95% CI, 1.17-5.18). Also, jugular venous distention and leg edema were not independently associated with cardiovascular events. CONCLUSIONS The significant and stronger association of RAP-echo with clinical outcome compared with estimates of RAP on physical examination suggests that recognition of high RAP-echo can be a valuable surrogate for the clinical management of severe TR patients.
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Affiliation(s)
- Taku Omori
- Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, California
| | - Ken Kuwajima
- Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, California
| | - Florian Rader
- Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, California; Department of Medicine, University of California, Los Angeles, Los Angeles, California
| | - Robert J Siegel
- Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, California; Department of Medicine, University of California, Los Angeles, Los Angeles, California
| | - Takahiro Shiota
- Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, California; Department of Medicine, University of California, Los Angeles, Los Angeles, California.
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3
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Meyer Z, Haas N, Mühlberg R, Braun A, Fischer M, Mandilaras G. Transient liver elastography in the follow-up of Fontan patients: results of a nation wide survey in Germany. Front Pediatr 2023; 11:1194641. [PMID: 37711600 PMCID: PMC10499538 DOI: 10.3389/fped.2023.1194641] [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: 03/27/2023] [Accepted: 07/24/2023] [Indexed: 09/16/2023] Open
Abstract
Introduction Fontan-palliated patients are at risk for the development of Fontan-associated liver disease (FALD). Currently, there is no consensus on how to stage FALD. Transient elastography (TE) is a rapid, non-invasive method to assess FALD and liver fibrosis. Method To assess the availability and conditions of using TE to monitor liver disease in Fontan patients in german centers for pediatric cardiology and to propose the introduction of a standardized national protocol for the monitoring of liver disease, we developed a questionnaire. Results In total, 95 valid questionnaires were collected. Only 20% of the centers offer the TE investigation directly. Most of the centers transfer the patients to another department or center (40%) or didńt offer TE (40%). In only 2.6% of the centers TE is performed directly by the cardiologist. Most of the centers transfer the patients to a other department. In 29.2% TE is performed only at a certain age of the patients and in 27.7% it is performed if the patients present symptoms of failing Fontan. In only 13.9% of the centers TE is proposed in all the Fontan patients on a routine basis. Most often TE is performed only from the beginning of the adolescence. In the majority of answers it was not known if the patients are fasting for the examination (68%) or not and if the TE examination had to be performed in a specific breathing phase during TE (Inspiration/Expiration, 90%). In the majority, TE is not offered routinely (46.9%). Discussion To date in Germany, TE is only used in a few numbers of centers specialized in Fontan follow-up. A standardized protocol to use TE is currently not existing. With regard to the feasibility of the examination, it is evident that TE is a quick, cheap and easy method to distinguish between cases with and without progressive FALD. This makes TE a useful and prognostic tool for screening of liver disease and to failing Fontan circulation. Conclusion We propose a systematic TE evaluation of possible liver congestion and fibrosis, as a part of the routine follow-up of Fontan patients.
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Affiliation(s)
- Zora Meyer
- Ludwig Maximilian University of Munich, Munich, Germany
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4
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Hur MH, Kim H, Lee JH. Hepatocellular carcinoma diagnosed in a patient who had Fontan operation 30 years ago: a case report. JOURNAL OF LIVER CANCER 2022; 22:188-193. [PMID: 37383407 PMCID: PMC10035737 DOI: 10.17998/jlc.2022.08.17] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/26/2022] [Revised: 08/11/2022] [Accepted: 08/17/2022] [Indexed: 06/30/2023]
Abstract
The Fontan operation is performed in patients with a single ventricle. As the systemic venous return is directly connected to the pulmonary circulation during this procedure, chronic hepatic congestion is induced, leading to Fontan-associated liver disease (FALD) including liver cirrhosis and hepatocellular carcinoma (HCC). In this report, we present a case of HCC diagnosed in a patient who underwent the Fontan operation 30 years ago. The patient underwent regular surveillance for FALD, which revealed a 4 cm-sized hepatic mass with elevated serum alpha-fetoprotein. After surgical treatment, there was no evidence of HCC recurrence during 3 years of follow-up. As the risk of HCC and Fontan-associated liver cirrhosis increases with the duration elapsed since the operation, regular surveillance should be emphasized. Serial follow-up of serum alpha-fetoprotein levels and abdominal imaging are necessary to achieve early and accurate diagnosis of HCC in post-Fontan patients.
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Affiliation(s)
- Moon Haeng Hur
- Department of Internal Medicine and Liver Research Institute, Seoul National University College of Medicine, Seoul, Korea
| | - Haeryoung Kim
- Department of Pathology, Seoul National University College of Medicine, Seoul, Korea
| | - Jeong-Hoon Lee
- Department of Internal Medicine and Liver Research Institute, Seoul National University College of Medicine, Seoul, Korea
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5
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Willmann S, Ince I, Ahsman M, Coboeken K, Zhang Y, Thelen K, Kubitza D, Zannikos P, Zhou W, Pina LM, Post T, Lippert J. Model‐informed bridging of rivaroxaban doses for thromboprophylaxis in pediatric patients aged 9 years and older with congenital heart disease. CPT Pharmacometrics Syst Pharmacol 2022; 11:1111-1121. [PMID: 35665486 PMCID: PMC9381895 DOI: 10.1002/psp4.12830] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2022] [Revised: 05/09/2022] [Accepted: 05/23/2022] [Indexed: 12/04/2022] Open
Abstract
Rivaroxaban is approved in various regions for the treatment of acute venous thromboembolism (VTE) in children aged between 0 and 18 years and was recently investigated for thromboprophylaxis in children aged between 2 and 8 years (with body weights <30 kg) with congenital heart disease who had undergone the Fontan procedure. In the absence of clinical data, rivaroxaban doses for thromboprophylaxis in post‐Fontan children aged 9 years and older or ≥30 kg were derived by a bridging approach that used physiologically‐based pharmacokinetic (PBPK) and population pharmacokinetic (popPK) models based on pharmacokinetic (PK) data from 588 pediatric patients and from adult patients who received 10 mg once daily for thromboprophylaxis after major orthopedic surgeries as a reference. Both models showed a tendency toward underestimating rivaroxaban exposure in post‐Fontan patients aged between 2 and 5 years but accurately described rivaroxaban PK in post‐Fontan patients aged between 5 and 8 years. Under the assumption that hepatic function is not impaired in post‐Fontan patients, PBPK and popPK simulations indicated that half of the rivaroxaban doses for the same body weight given to pediatric patients treated for acute VTE would yield in pediatric post‐Fontan patients exposures similar to the exposure observed in adult patients receiving 10 mg rivaroxaban once daily for thromboprophylaxis. Simulation‐derived doses (7.5 mg rivaroxaban once daily for body weights 30–<50 kg and 10 mg once daily for body weights ≥50 kg) were therefore included in the recent US label of rivaroxaban for thromboprophylaxis in children aged 2 years and older with congenital heart disease who have undergone the Fontan procedure.
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Affiliation(s)
- Stefan Willmann
- Bayer AG, Research & Development, Pharmaceuticals Wuppertal/Leverkusen Germany
| | - Ibrahim Ince
- Bayer AG, Research & Development, Pharmaceuticals Wuppertal/Leverkusen Germany
| | - Maurice Ahsman
- Leiden Experts on Advanced Pharmacokinetics and Pharmacodynamics Leiden The Netherlands
| | - Katrin Coboeken
- Bayer AG, Research & Development, Pharmaceuticals Wuppertal/Leverkusen Germany
| | - Yang Zhang
- Bayer AG, Research & Development, Pharmaceuticals Wuppertal/Leverkusen Germany
| | - Kirstin Thelen
- Bayer AG, Research & Development, Pharmaceuticals Wuppertal/Leverkusen Germany
| | - Dagmar Kubitza
- Bayer AG, Research & Development, Pharmaceuticals Wuppertal/Leverkusen Germany
| | - Peter Zannikos
- Janssen Research & Development, LLC Raritan New Jersey USA
| | - Wangda Zhou
- Janssen Research & Development, LLC Raritan New Jersey USA
| | | | - Teun Post
- Leiden Experts on Advanced Pharmacokinetics and Pharmacodynamics Leiden The Netherlands
| | - Jörg Lippert
- Bayer AG, Research & Development, Pharmaceuticals Wuppertal/Leverkusen Germany
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6
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Herrmann JE, Selamet Tierney ES. Exercise Capacity and Training Programs in Paediatric Fontan Patients: A Systematic Review. CJC PEDIATRIC AND CONGENITAL HEART DISEASE 2022; 1:108-118. [PMID: 37970491 PMCID: PMC10642096 DOI: 10.1016/j.cjcpc.2022.04.005] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/10/2022] [Accepted: 04/19/2022] [Indexed: 11/17/2023]
Abstract
Background Exercise training programs can effectively enhance exercise capacity in adults with congenital heart disease, including Fontan patients. However, few studies have explored the impact of exercise training exclusively on paediatric Fontan cohorts. This study systematically reviews exercise capacity in paediatric Fontan patients and the impact of training programs on their cardiovascular health. Methods Medline and Embase were searched for articles published between January 1990 and November 2021. Studies were included in which data could be analyzed discretely for patients who had undergone the Fontan procedure and were ≤20 years old at the time of study. Cardiopulmonary exercise parameters were extracted from all studies, and training protocols were collected from training programs. Results The studies demonstrated that Fontan patients exhibit significantly diminished peak exercise capacity relative to healthy peers. We identified 9 training programs that exclusively studied Fontan patients ≤20 years. The programs ranged from 6 weeks to 12 months in duration, with 8 programs incorporating aerobic activity and 1 focused only on inspiratory muscle training. At least 1 measure of maximal or submaximal exercise capacity improved significantly within each program in which statistical analysis was performed, with no reported adverse events. There were 2 additional training programs in which the patients were predominantly (>65%), but not exclusively, Fontan patients. Conclusions Overall, the results indicate that exercise training programs can safely and effectively improve at least 1 measure of exercise capacity in paediatric Fontan patients.
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Affiliation(s)
- Jessica E. Herrmann
- Department of Pediatrics/Cardiology, Stanford University School of Medicine, Stanford, California, USA
| | - Elif Seda Selamet Tierney
- Department of Pediatrics/Cardiology, Stanford University School of Medicine, Stanford, California, USA
- Division of Pediatric Cardiology, Lucile Packard Children’s Hospital, Palo Alto, California, USA
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7
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Pollak U, Abarbanel I, Salem Y, Serraf AE, Mishaly D. Dominant Ventricular Morphology and Early Postoperative Course After the Fontan Procedure. World J Pediatr Congenit Heart Surg 2022; 13:346-352. [PMID: 35446208 PMCID: PMC9024023 DOI: 10.1177/21501351221081246] [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] [Indexed: 11/16/2022]
Abstract
Background Single ventricle heart disease comprises a wide variety of critical heart defects that lead to the provision of systemic cardiac output by one dominant ventricle. It requires staged surgical palliation that culminates in Fontan circulation. Dominant ventricular morphology in single ventricle patients reportedly has an impact on postoperative morbidity and mortality with varying results. The objectives of this study were to examine the association between ventricular morphology and the early postoperative course after the Fontan procedure. Methods A retrospective cohort study in a tertiary referral pediatric medical center that included 98 consecutive patients who underwent Fontan procedure between October 2009 and May 2016. Postoperative outcomes were compared between patients with left ventricular morphology and those with right ventricular morphology (crude effect and regression analysis). Results Patients with right ventricular morphology had longer postoperative hospitalizations compared to patients with left ventricular morphology (26.5 days vs 18.2 days, respectively, P = .028), higher postoperative maximal vasoactive-inotropic scores (25.6 vs 12.4, P = .02), higher serum lactate levels (7.7 mmol/L vs 6.4 mmol/L, P = .03), higher proportions of ventilation throughout 24 h or more (16 patients [38%] vs 8 patients [14%], P = .009), higher proportions of ventricular dysfunction (12 patients [29%] vs 5 patients [9%], P = .0001), and lower blood oxygen saturation levels at discharge (87% vs 92%, P = .03). Conclusions The Fontan procedure in patients with right ventricular morphology is associated with longer postoperative hospitalization and worse early postoperative characteristics (ventricular dysfunction and atrioventricular valve regurgitation) as well as higher rates of early, transient signs of sub-optimal postoperative hemodynamics compared to those with left ventricular morphology.
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Affiliation(s)
- Uri Pollak
- Pediatric Cardiac Critical Care Unit, Hadassah University Medical Center, Jerusalem, Israel.,Pediatric Cardiology, Hadassah University Medical Center, Jerusalem, Israel.,Pediatric Extracorporeal Support Program, Hadassah University Medical Center, Jerusalem, Israel.,58884The Hebrew University Hadassah Medical School, Jerusalem, Israel
| | - Inbar Abarbanel
- The Sackler Faculty of Medicine, 58408Tel Aviv University, Tel Aviv, Israel
| | - Yishay Salem
- The Sackler Faculty of Medicine, 58408Tel Aviv University, Tel Aviv, Israel.,Pediatric Cardiology, Edmond J. Safra International Congenital Heart Center, 146925The Edmond and Lily Safra Children's Hospital, The Chaim Sheba Medical Center, Tel Hashomer, Israel
| | - Alain E Serraf
- The Sackler Faculty of Medicine, 58408Tel Aviv University, Tel Aviv, Israel.,Pediatric and Congenital Cardiac Surgery, Edmond J. Safra International Congenital Heart Center, The Edmond and Lily Safra Children's Hospital, 26744The Chaim Sheba Medical Center, Tel Hashomer, Israel
| | - David Mishaly
- The Sackler Faculty of Medicine, 58408Tel Aviv University, Tel Aviv, Israel.,Pediatric and Congenital Cardiac Surgery, Edmond J. Safra International Congenital Heart Center, The Edmond and Lily Safra Children's Hospital, 26744The Chaim Sheba Medical Center, Tel Hashomer, Israel
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8
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Predictors of Poor Functional Status in Adult Fontan Patients Living at Moderate Altitude. Pediatr Cardiol 2021; 42:1757-1765. [PMID: 34143227 DOI: 10.1007/s00246-021-02660-8] [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: 03/28/2021] [Accepted: 06/08/2021] [Indexed: 10/21/2022]
Abstract
Patients who have undergone Fontan palliation have reduced exercise tolerance measured by maximal oxygen consumption (VO2 max). Declining exercise capacity is associated with increased morbidity and mortality. The impact of hemodynamics and other variables on this population's functional status is not well understood. This study sought to identify variables that predict low VO2 max in Fontan patients living at moderate altitude (5,000-8,000 feet). We performed a retrospective cohort study of 44 adult Fontan patients living at moderate altitude who had undergone cardiopulmonary exercise testing (CPET) and cardiac catheterization. We evaluated hemodynamic parameters measured during catheterization, imaging results, and laboratory studies for correlation with VO2 max measured during CPET. Our study cohort (median age 30 years, 52% female) had exercise impairment with mean VO2 max of 21.6 mL/kg/min. Higher trans-pulmonary gradient (TPG) (p < 0.001) and mean pulmonary artery (PA) pressure (p = 0.013) were predictors of lower maximal and submaximal VO2. Higher BNP values correlated with lower VO2 max (p = 0.01). Platelet count, GGT, albumin, and pulmonary vasodilator therapy did not correlate with VO2 max. None of the studied variables were associated with higher minute ventilation to peak carbon dioxide production (VE/VCO2 slope) or change in VO2 max over time. In conclusion, higher TPG and mean PA pressure predicted lower exercise tolerance amongst our cohort of adult Fontan patients living at moderate altitude. Future studies are needed to determine if these clinical variables represent viable therapeutic targets that could result in improved exercise tolerance and outcomes in patients with Fontan circulation.
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9
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Strobel AM, Alblaihed L. Cardiac Emergencies in Kids. Emerg Med Clin North Am 2021; 39:605-625. [PMID: 34215405 DOI: 10.1016/j.emc.2021.04.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Encountering a child with congenital heart disease after surgical palliation in the emergency department, specifically the single-ventricle or ventricular assist device, without a basic familiarity of these surgeries can be extremely anxiety provoking. Knowing what common conditions or complications may cause these children to visit the emergency department and how to stabilize will improve the chance for survival and is the premise for this article, regardless of practice setting.
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Affiliation(s)
- Ashley M Strobel
- Department of Emergency Medicine, University of Minnesota Medical School, Hennepin County Medical Center, University of Minnesota Masonic Children's Hospital, 701 South Park Avenue R2.123, Minneapolis, MN 55414, USA.
| | - Leen Alblaihed
- Department of Emergency Medicine, University of Maryland School of Medicine, University of Maryland Upper Chesapeake Medical System, 500 Upper Chesapeake Drive, Bel Air, MD 21014, USA
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10
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Grandfils S, Dewandre PY, Bonnet P, Radermecker MA, Nisolle M, Kridelka F, Emonts P. Pregnancy and delivery in a patient with a Fontan circulation and primary ciliary dyskinesia: A case report. J Gynecol Obstet Hum Reprod 2021; 50:102184. [PMID: 34119700 DOI: 10.1016/j.jogoh.2021.102184] [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: 01/05/2021] [Revised: 05/30/2021] [Accepted: 06/07/2021] [Indexed: 10/21/2022]
Abstract
A patient had primary ciliary dyskinesia with a complex cardiac malformation. As a child, she had benefited from a Fontan surgery to maintain a proper cardiac function. In such patients, whether it is safe to become pregnant is controversial. This case illustrates the possibility of carrying a pregnancy to term and providing a vaginal birth if a rigorous preconception consultation is performed to ensure care by a multidisciplinary specialized team, and the patient is properly informed of the risks.
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Affiliation(s)
- Sébastien Grandfils
- Department of Gynecology and Obstetrics. CHU of Liege, University Hospital of Liege, 600 Rue de Gaillarmont, Liege 4032, Belgium.
| | | | | | - Marc André Radermecker
- Department of Anatomy, University of Liege, Belgium; Department of cardiovascular surgery, CHU of Liege, Belgium
| | - Michelle Nisolle
- Department of Gynecology and Obstetrics, CHU of Liege - CHR de la Citadelle Liege, Belgium
| | - Frédéric Kridelka
- Department of Gynecology and Obstetrics. CHU of Liege, University Hospital of Liege, 600 Rue de Gaillarmont, Liege 4032, Belgium
| | - Patrick Emonts
- Department of Gynecology and Obstetrics. CHU of Liege, University Hospital of Liege, 600 Rue de Gaillarmont, Liege 4032, Belgium; Department of Gynecology and Obstetrics, CHU of Liege - CHR de la Citadelle Liege, Belgium
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11
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van den Bosch E, Bossers SSM, Kamphuis VP, Boersma E, Roos-Hesselink JW, Breur JMPJ, Ten Harkel ADJ, Kapusta L, Bartelds B, Roest AAW, Kuipers IM, Blom NA, Koopman LP, Helbing WA. Associations Between Blood Biomarkers, Cardiac Function, and Adverse Outcome in a Young Fontan Cohort. J Am Heart Assoc 2021; 10:e015022. [PMID: 33624507 PMCID: PMC8174257 DOI: 10.1161/jaha.119.015022] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Background Patients who have undergone the Fontan procedure are at high risk of circulatory failure. In an exploratory analysis we aimed to determine the prognostic value of blood biomarkers in a young cohort who have undergone the Fontan procedure. Methods and Results In multicenter prospective studies patients who have undergone the Fontan procedure underwent blood sampling, cardiopulmonary exercise testing, and stress cardiac magnetic resonance imaging. Several biomarkers including NT-proBNP (N-terminal pro-B-type natriuretic peptide), GDF-15 (growth differentiation factor 15), Gal-3 (galectin-3), ST2 (suppression of tumorigenicity 2), DLK-1 (protein delta homolog 1), FABP-4 (fatty acid-binding protein 4), IGFBP-1 (insulin-like growth factor-binding protein 1), IGFBP-7, MMP-2 (matrix metalloproteinase 2), and vWF (von Willebrand factor) were assessed in blood at 9.6 (7.1-12.1) years after Fontan completion. After this baseline study measurement, follow-up information was collected on the incidence of adverse cardiac events, including cardiac death, out of hospital cardiac arrest, heart transplantation (listing), cardiac reintervention (severe events), hospitalization, and cardioversion/ablation for arrhythmias was collected and the relation with blood biomarkers was assessed by Cox proportional hazard analyses. The correlation between biomarkers and other clinical parameters was evaluated. We included 133 patients who have undergone the Fontan procedure, median age 13.2 (25th, 75th percentile 10.4-15.9) years, median age at Fontan 3.2 (2.5-3.9) years. After a median follow-up of 6.2 (4.9-6.9) years, 36 (27.1%) patients experienced an event of whom 13 (9.8%) had a severe event. NT-proBNP was associated with (all) events during follow-up and remained predictive after correction for age, sex, and dominant ventricle (hazard ratio, 1.89; CI, 1.32-2.68). The severe event-free survival was better in patients with low levels of GDF-15 (P=0.005) and vWF (P=0.008) and high levels of DLK-1 (P=0.041). There was a positive correlation (β=0.33, P=0.003) between DLK-1 and stress cardiac magnetic resonance imaging functional reserve. Conclusions NT-proBNP, GDF-15, vWF, DLK-1, ST-2 FABP-4, and IGFBP-7 levels relate to long-term outcome in young patients who have undergone the Fontan procedure.
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Affiliation(s)
- Eva van den Bosch
- Division of Pediatric Cardiology Department of Pediatrics Erasmus University Medical Center Rotterdam The Netherlands.,Department of Radiology Erasmus University Medical Center Rotterdam The Netherlands.,Netherlands Heart Institute Utrecht The Netherlands
| | - Sjoerd S M Bossers
- Division of Pediatric Cardiology Department of Pediatrics Erasmus University Medical Center Rotterdam The Netherlands.,Department of Radiology Erasmus University Medical Center Rotterdam The Netherlands
| | - Vivian P Kamphuis
- Netherlands Heart Institute Utrecht The Netherlands.,Division of Pediatric Cardiology Department of Pediatrics Leiden University Medical Center The Netherlands
| | - Eric Boersma
- Department of Cardiology Erasmus University Medical Center Rotterdam The Netherlands
| | | | - Johannes M P J Breur
- Department of Pediatric Cardiology University Medical Center Utrecht Utrecht The Netherlands
| | - Arend D J Ten Harkel
- Division of Pediatric Cardiology Department of Pediatrics Leiden University Medical Center The Netherlands
| | - Livia Kapusta
- Department of Pediatric Cardiology Sourasky Medical Center Tel Aviv University Tel Aviv Israel.,Division of Pediatric Cardiology Department of Pediatrics Radboud University Medical Center Nijmegen The Netherlands
| | - Beatrijs Bartelds
- Division of Pediatric Cardiology Department of Pediatrics Erasmus University Medical Center Rotterdam The Netherlands
| | - Arno A W Roest
- Division of Pediatric Cardiology Department of Pediatrics Leiden University Medical Center The Netherlands
| | - Irene M Kuipers
- Division of Pediatric Cardiology Department of Pediatrics Academic Medical Center Amsterdam The Netherlands
| | - Nico A Blom
- Division of Pediatric Cardiology Department of Pediatrics Leiden University Medical Center The Netherlands.,Division of Pediatric Cardiology Department of Pediatrics Academic Medical Center Amsterdam The Netherlands
| | - Laurens P Koopman
- Division of Pediatric Cardiology Department of Pediatrics Erasmus University Medical Center Rotterdam The Netherlands
| | - Willem A Helbing
- Division of Pediatric Cardiology Department of Pediatrics Erasmus University Medical Center Rotterdam The Netherlands.,Department of Radiology Erasmus University Medical Center Rotterdam The Netherlands.,Division of Pediatric Cardiology Department of Pediatrics Radboud University Medical Center Nijmegen The Netherlands
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12
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Rodriguez DS, Mao C, Mahle WT, Kanter KR, Alazraki A, Braithwaite K, Rytting H, Caltharp S, Magliocca JF, Romero R. Pretransplantation and Post-Transplantation Liver Disease Assessment in Adolescents Undergoing Isolated Heart Transplantation for Fontan Failure. J Pediatr 2021; 229:78-85.e2. [PMID: 32976893 DOI: 10.1016/j.jpeds.2020.09.044] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/18/2020] [Revised: 08/17/2020] [Accepted: 09/17/2020] [Indexed: 02/07/2023]
Abstract
OBJECTIVE To describe the assessment of Fontan-associated liver disease and determine the clinical and imaging measures that may identify hepatic morbidity risk in isolated heart transplantation candidates and trend those measures post-isolated heart transplantation. STUDY DESIGN Retrospective analysis of pre-isolated heart transplantation and post-isolated heart transplantation Fontan-associated liver disease (FALD) status using blood tests, magnetic resonance imaging (MRI), and liver biopsy analysis within 6 months before isolated heart transplantation and 12 months after isolated heart transplantation in 9 consecutive patients with Fontan. Pre- and post-isolated heart transplantation standard laboratory values; varices, ascites, splenomegaly, thrombocytopenia (VAST) score; Fontan liver MRI score; liver biopsy scores; Model for End-stage Liver Disease (MELD); MELD excluding the International Normalized Ratio (MELD-XI); AST to platelet ratio index, and cardiac catheterization data were compared. RESULTS Pretransplantation maximum MELD and MELD-XI was 15 and 16, respectively. Central venous pressures and VAST scores decreased significantly post-transplantation. In 5 paired studies, Fontan liver MRI score maximum was 10 pretransplantation and decreased significantly post-transplantation. Arterially enhancing nodules on MRI persisted in 2 patients post-transplantation. Pretransplantation and post-transplantation liver biopsy scores did not differ in 4 paired biopsy specimens. CONCLUSIONS Patients with FALD and MELD <15, MELD-XI <16, Fontan liver MRI score <10, and VAST score ≤2 can have successful short-term isolated heart transplantation outcomes. Liver MRI and VAST scores improved post-transplantation. Post-transplantation liver biopsy scores did not change significantly. Pretransplantation liver biopsy demonstrating fibrosis alone should not exclude consideration of isolated heart transplantation. The persistence of hepatic vascular remodeling and fibrosis post-isolated heart transplantation suggests that continued surveillance for hepatic complications post-transplantation for patients with Fontan is reasonable.
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Affiliation(s)
- Dellys Soler Rodriguez
- Division of Pediatric Gastroenterology, Hepatology, and Nutrition, Children's Healthcare of Atlanta, Emory University School of Medicine, Atlanta, GA
| | - Chad Mao
- Sibley Heart Center, Children's Healthcare of Atlanta, Emory University School of Medicine, Atlanta, GA
| | - William T Mahle
- Sibley Heart Center, Children's Healthcare of Atlanta, Emory University School of Medicine, Atlanta, GA
| | - Kirk R Kanter
- Division of Cardiothoracic Surgery, Children's Healthcare of Atlanta, Emory University School of Medicine, Atlanta, GA
| | - Adina Alazraki
- Division of Pediatric Radiology, Children's Healthcare of Atlanta, Emory University School of Medicine, Atlanta, GA
| | - Kiery Braithwaite
- Division of Pediatric Radiology, Children's Healthcare of Atlanta, Emory University School of Medicine, Atlanta, GA
| | - Heather Rytting
- Department of Pathology, Children's Healthcare of Atlanta, Emory University School of Medicine, Atlanta, GA
| | - Shelley Caltharp
- Department of Pathology, Children's Healthcare of Atlanta, Emory University School of Medicine, Atlanta, GA
| | - Joseph F Magliocca
- Transplant Section, Department of Surgery, Children's Healthcare of Atlanta, Emory University School of Medicine, Atlanta, GA
| | - René Romero
- Division of Pediatric Gastroenterology, Hepatology, and Nutrition, Children's Healthcare of Atlanta, Emory University School of Medicine, Atlanta, GA.
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13
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Akiyama K, Itatani K, Wu IY, Tachibana Y, Obata Y, Nakajima Y, Yamagishi M, Takayama H, Sawa T. Difference in Intraventricular Vortex Between the Single Right Ventricle and Single Left Ventricle. J Cardiothorac Vasc Anesth 2020; 35:2242-2243. [PMID: 33250432 DOI: 10.1053/j.jvca.2020.11.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/01/2020] [Accepted: 11/03/2020] [Indexed: 11/11/2022]
Affiliation(s)
- Koichi Akiyama
- Department of Cardiothoracic Surgery, Columbia University Medical Center, NY
| | - Keiichi Itatani
- Department of Cardiovascular Surgery, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - Isaac Y Wu
- Department of Anesthesiology, Columbia University Medical Center, NY
| | - Yosuke Tachibana
- Department of Anesthesiology, Yodogawa Christian Hospital, Osaka, Japan
| | - Yurie Obata
- Department of Anesthesiology, Yodogawa Christian Hospital, Osaka, Japan
| | - Yasufumi Nakajima
- Department of Anesthesiology, Kansai Medical University, Hirakata, Japan
| | - Masaaki Yamagishi
- Department of Cardiovascular Surgery, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - Hiroo Takayama
- Department of Cardiothoracic Surgery, Columbia University Medical Center, NY
| | - Teiji Sawa
- Department of Anesthesiology, Kyoto Prefectural University of Medicine, Kyoto, Japan
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14
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Bockeria L, Carrel T, Lemaire A, Makarenko V, Kim A, Shatalov K, Cox M, Svanidze O. Total cavopulmonary connection with a new restorative vascular graft: results at 2 years. J Thorac Dis 2020; 12:4168-4173. [PMID: 32944328 PMCID: PMC7475567 DOI: 10.21037/jtd-19-739] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/03/2022]
Abstract
Background To present a 2-year follow-up regarding safety and hemodynamic performance of a new restorative vascular graft used as extracardiac cavo-pulmonary connection in patients with univentricular congenital heart malformations. Methods The graft was implanted in five patients (aged 4–12 years) as extracardiac connection between the inferior vena cava and the pulmonary artery. The conduit consists of a bioabsorbable polymer-based implant able to generate endogenous tissue restoration leading to a fully functional neo-vessel while the polymer progressively absorbs. All patients have reached more than 24 months following surgery and underwent echocardiography and magnetic resonance imaging. Results All patients are doing well at 24 months follow-up, with no graft-related serious adverse events. Transthoracic echocardiography demonstrated adequate function of the conduit in all patients while magnetic resonance imaging showed anatomical and functional stability of the restorative grafts. Conclusions The new restorative conduit has been successfully used for the second step of the Fontan procedure as extracardiac total cavopulmonary connection. The results are promising because they suggest that complete transformation of a bioabsorbable polymer and replacement through endogenous tissue may represent a major advantage in the treatment of congenital heart disease patients. Further monitoring will allow to evaluate the long-term behavior of this new graft, in terms of clinical and hemodynamic performance, thrombogenicity and ability to grow.
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Affiliation(s)
- Leo Bockeria
- Department of Cardiovascular Surgery, Bakulev Center, Moscow, Russia
| | - Thierry Carrel
- Department of Cardiovascular Surgery, University of Bern, Bern, Switzerland
| | | | | | - Alex Kim
- Department of Cardiovascular Surgery, Bakulev Center, Moscow, Russia
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15
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Tseng SY, Siddiqui S, Di Maria MV, Hill GD, Lubert AM, Kutty S, Opotowsky AR, Possner M, Morales DLS, Quintessenza JA, Alsaied T. Atrioventricular Valve Regurgitation in Single Ventricle Heart Disease: A Common Problem Associated With Progressive Deterioration and Mortality. J Am Heart Assoc 2020; 9:e015737. [PMID: 32419552 PMCID: PMC7429008 DOI: 10.1161/jaha.119.015737] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
The Fontan procedure has provided patients with single ventricle physiology extended survival into adulthood and in many cases has improved their quality of life. Atrioventricular valve regurgitation (AVVR) is common in single ventricle patients and is associated with increased risk of mortality. AVVR is more common in patients with a systemic tricuspid or common atrioventricular valve but is generally progressive irrespective of underlying valve morphology. AVVR can be attributable to diverse structural and functional abnormalities at multiple levels of the valvar apparatus, as well as ventricular dysfunction and dilation. Multiple imaging modalities including recent advances in 3‐dimensional echocardiography and cross‐sectional imaging have been used to further understand AVVR. Surgery to address AVVR must be tailored to the underlying mechanism and the timing of surgical repair should be chosen carefully. In this review, we discuss the etiologies, treatment options, surgical timing, and outcomes of valve repair or replacement for AVVR in patients with single ventricle congenital heart disease, with a focus on those with a Fontan circulation as AVVR is associated with increased risk for Fontan failure and mortality. In‐depth understanding of the current literature will help guide clinicians in their approach and management of AVVR in this population.
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Affiliation(s)
- Stephanie Y Tseng
- Department of Pediatrics The Heart Institute Cincinnati Children's Hospital Medical Center University of Cincinnati College of Medicine Cincinnati OH
| | - Saira Siddiqui
- Department of Pediatrics The Heart Institute Cincinnati Children's Hospital Medical Center University of Cincinnati College of Medicine Cincinnati OH
| | - Michael V Di Maria
- Department of Pediatrics Heart Institute Children's Hospital Colorado University of Colorado School of Medicine Aurora CO
| | - Garick D Hill
- Department of Pediatrics The Heart Institute Cincinnati Children's Hospital Medical Center University of Cincinnati College of Medicine Cincinnati OH
| | - Adam M Lubert
- Department of Pediatrics The Heart Institute Cincinnati Children's Hospital Medical Center University of Cincinnati College of Medicine Cincinnati OH
| | - Shelby Kutty
- Taussig Heart Center The Johns Hopkins Hospital Baltimore MD
| | - Alexander R Opotowsky
- Department of Pediatrics The Heart Institute Cincinnati Children's Hospital Medical Center University of Cincinnati College of Medicine Cincinnati OH.,Department of Cardiology Boston Children's Hospital Boston MA USA
| | - Mathias Possner
- Division of Cardiology Department of Medicine University of Washington School of Medicine Seattle WA USA
| | - David L S Morales
- Department of Pediatrics The Heart Institute Cincinnati Children's Hospital Medical Center University of Cincinnati College of Medicine Cincinnati OH
| | - James A Quintessenza
- Department of Pediatrics The Heart Institute Cincinnati Children's Hospital Medical Center University of Cincinnati College of Medicine Cincinnati OH
| | - Tarek Alsaied
- Department of Pediatrics The Heart Institute Cincinnati Children's Hospital Medical Center University of Cincinnati College of Medicine Cincinnati OH
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16
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CT and MR imaging findings of the livers in adults with Fontan palliation: an observational study. Abdom Radiol (NY) 2020; 45:188-202. [PMID: 31471707 DOI: 10.1007/s00261-019-02119-8] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
PURPOSE To describe liver imaging findings and complications on computed tomography (CT) or magnetic resonance imaging (MRI) in adults with Fontan palliation and investigate whether imaging features show correlations with clinical and physiological parameters. METHODS Our Institutional Review Board approved this retrospective study. Two blinded abdominal radiologists reviewed abdominal CT (n = 21) and MRI (n = 16) images between September 2011 and October 2017 in 37 adults (median age 27 years, interquartile range 21-36 years, 14 males [38%]) with a Fontan palliation (median post-Fontan duration 22 years, interquartile range 19-28 years). Correlation between CT/MRI findings and clinical parameters including laboratory results within 6 months of CT/MRI examinations was assessed by Spearman's rank correlation coefficient. RESULTS Lobulated hepatic surface and blunt hepatic edge were seen in 92% (34/37) and 95% (35/37) of patients, respectively. Surface nodularity was noted in 32% (12/37). In 7 patients, there were 11 hepatic nodules which showed arterial-phase hyperenhancement and washout. Among them, 2 were biopsy-proven hepatocellular carcinomas (HCCs), and the remaining 9 were focal nodular hyperplasia (FNH)-like nodules. Suprahepatic inferior vena cava (IVC) diameter showed positive correlations with post-Fontan duration (p < 0.01), serum gamma-glutamyl transferase (p < 0.01), and total bilirubin (p < 0.01). CONCLUSION The livers in post-Fontan adults show a unique morphology of blunt edge and lobulating surface with occasional nodularity. There is a diagnostic challenge in distinguishing HCCs from FNH-like nodules in post-Fontan population due to overlapping imaging findings. Suprahepatic IVC diameter is a potentially useful imaging marker that reflects hepatic dysfunction in Fontan palliation.
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17
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Gordon-Walker TT, Bove K, Veldtman G. Fontan-associated liver disease: A review. J Cardiol 2019; 74:223-232. [DOI: 10.1016/j.jjcc.2019.02.016] [Citation(s) in RCA: 60] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/13/2019] [Accepted: 02/21/2019] [Indexed: 02/07/2023]
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18
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Pollak U, Ruderman T, Borik-Chiger S, Mishaly D, Serraf A, Vardi A. Transfusion-related acute hepatic injury following postoperative platelets administration in pediatric patients undergoing the Fontan procedure. CONGENIT HEART DIS 2019; 14:968-977. [PMID: 31343842 DOI: 10.1111/chd.12825] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/02/2019] [Revised: 05/11/2019] [Accepted: 07/08/2019] [Indexed: 11/30/2022]
Abstract
OBJECTIVE The final common pathway of single ventricle patients is the Fontan procedure. Among the immediate postoperative complications is acute hepatic injury presented by marked elevation of liver enzymes (alanine transaminase [ALT] and aspartate transaminase [AST]). We aimed to determine the contribution of blood products transfusion to acute hepatic injury. DESIGN Single center retrospective cohort study. SETTING Pediatric Cardiac Intensive Care Unit at a tertiary medical center. PATIENTS Ninety-nine pediatric patients undergoing the Fontan procedure between January 2009 and December 2016. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Out of the four types of blood products, transfusion of platelets was found to significantly affect postoperative levels of ALT and AST. Additional factors included postoperative administration of sodium bicarbonate, decreased flow through the Fontan canal and decreased urine output. Preoperative pulmonary artery pressure and pulmonary vascular resistance, cardiopulmonary bypass time, aortic cross-clamp time, amount of postoperative bleeding, and vasoactive-inotropic score did not influence liver enzymes levels CONCLUSIONS: In pediatric Fontan patients, platelets transfusions contribute to an acute hepatic injury. The relation between platelets and transfusion-related acute lung injury (TRALI) has been well described, but this is the first time it is being described in regard to acute hepatic injury (TRAHI). Changing platelet transfusion strategy could decrease morbidity in Fontan patients but further research is needed.
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Affiliation(s)
- Uri Pollak
- Pediatric Cardiac Critical Care Unit, Hadassah University Medical Center, Jerusalem, Israel.,Pediatric Cardiology, Hadassah University Medical Center, Jerusalem, Israel.,Pediatric Extracorporeal Support Program, Hadassah University Medical Center, Jerusalem, Israel.,The Hebrew University Hadassah Medical School, Jerusalem, Israel
| | - Tatyana Ruderman
- The Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Sharon Borik-Chiger
- The Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel.,Pediatric Cardiology, Edmond J Safra International Congenital Heart Center, The Edmond and Lily Safra Children's Hospital, Chaim Sheba Medical Center, Tel Hashomer, Israel
| | - David Mishaly
- The Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel.,Pediatric and Congenital Cardiac Surgery, Edmond J Safra International Congenital Heart Center, The Edmond and Lily Safra Children's Hospital, Chaim Sheba Medical Center, Tel Hashomer, Israel
| | - Alain Serraf
- The Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel.,Pediatric and Congenital Cardiac Surgery, Edmond J Safra International Congenital Heart Center, The Edmond and Lily Safra Children's Hospital, Chaim Sheba Medical Center, Tel Hashomer, Israel
| | - Amir Vardi
- The Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel.,Pediatric Cardiac Intensive Care Unit, Edmond J Safra International Congenital Heart Center, The Edmond and Lily Safra Children's Hospital, Chaim Sheba Medical Center, Tel Hashomer, Israel
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19
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Kamphuis VP, Elbaz MSM, van den Boogaard PJ, Kroft LJM, Lamb HJ, Hazekamp MG, Jongbloed MRM, Blom NA, Helbing WA, Roest AAW, Westenberg JJM. Stress increases intracardiac 4D flow cardiovascular magnetic resonance -derived energetics and vorticity and relates to VO 2max in Fontan patients. J Cardiovasc Magn Reson 2019; 21:43. [PMID: 31340834 PMCID: PMC6657113 DOI: 10.1186/s12968-019-0553-4] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2019] [Accepted: 06/14/2019] [Indexed: 12/04/2022] Open
Abstract
BACKGROUND We hypothesize that dobutamine-induced stress impacts intracardiac hemodynamic parameters and that this may be linked to decreased exercise capacity in Fontan patients. Therefore, the purpose of this study was to assess the effect of pharmacologic stress on intraventricular kinetic energy (KE), viscous energy loss (EL) and vorticity from four-dimensional (4D) Flow cardiovascular magnetic resonance (CMR) imaging in Fontan patients and to study the association between stress response and exercise capacity. METHODS Ten Fontan patients underwent whole-heart 4D flow CMR before and during 7.5 μg/kg/min dobutamine infusion and cardiopulmonary exercise testing (CPET) on the same day. Average ventricular KE, EL and vorticity were computed over systole, diastole and the total cardiac cycle (vorticity_volavg cycle, KEavg cycle, ELavg cycle). The relation to maximum oxygen uptake (VO2 max) from CPET was tested by Pearson's correlation or Spearman's rank correlation in case of non-normality of the data. RESULTS Dobutamine stress caused a significant 88 ± 52% increase in KE (KEavg cycle: 1.8 ± 0.5 vs 3.3 ± 0.9 mJ, P < 0.001), a significant 108 ± 49% increase in EL (ELavg cycle: 0.9 ± 0.4 vs 1.9 ± 0.9 mW, P < 0.001) and a significant 27 ± 19% increase in vorticity (vorticity_volavg cycle: 3441 ± 899 vs 4394 ± 1322 mL/s, P = 0.002). All rest-stress differences (%) were negatively correlated to VO2 max (KEavg cycle: r = - 0.83, P = 0.003; ELavg cycle: r = - 0.80, P = 0.006; vorticity_volavg cycle: r = - 0.64, P = 0.047). CONCLUSIONS 4D flow CMR-derived intraventricular kinetic energy, viscous energy loss and vorticity in Fontan patients increase during pharmacologic stress and show a negative correlation with exercise capacity measured by VO2 max.
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Affiliation(s)
- Vivian P. Kamphuis
- Department of Pediatrics division of Pediatric Cardiology, Leiden University Medical Center, Leiden, the Netherlands
- Netherlands Heart Institute, Utrecht, The Netherlands
| | - Mohammed S. M. Elbaz
- Department of Radiology Feinberg School of Medicine, Northwestern University, Chicago, USA
| | | | - Lucia J. M. Kroft
- Department of Radiology, Leiden University Medical Center, Leiden, the Netherlands
| | - Hildo J. Lamb
- Department of Radiology, Leiden University Medical Center, Leiden, the Netherlands
| | - Mark G. Hazekamp
- Department of Cardiothoracic Surgery, Leiden University Medical Center, Leiden, the Netherlands
| | | | - Nico A. Blom
- Department of Pediatrics division of Pediatric Cardiology, Leiden University Medical Center, Leiden, the Netherlands
- Department of Pediatrics division of Pediatric Cardiology, Academic Medical Center, Amsterdam, the Netherlands
| | - Willem A. Helbing
- Department of Pediatrics, division of Pediatric Cardiology, Erasmus Medical Center, Rotterdam, the Netherlands
- Department of Pediatrics division of Pediatric Cardiology, Radboud university Medical Center, Nijmegen, the Netherlands
| | - Arno A. W. Roest
- Department of Pediatrics division of Pediatric Cardiology, Leiden University Medical Center, Leiden, the Netherlands
| | - Jos J. M. Westenberg
- Department of Radiology Feinberg School of Medicine, Northwestern University, Chicago, USA
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20
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Pina LM, Dong X, Zhang L, Samtani MN, Michelson AD, Justino H, Bonnet D, Harris KC, Jefferies J, McCrindle BW, Li JS. Rivaroxaban, a direct Factor Xa inhibitor, versus acetylsalicylic acid as thromboprophylaxis in children post-Fontan procedure: Rationale and design of a prospective, randomized trial (the UNIVERSE study). Am Heart J 2019; 213:97-104. [PMID: 31132584 DOI: 10.1016/j.ahj.2019.04.009] [Citation(s) in RCA: 25] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/15/2018] [Accepted: 04/16/2019] [Indexed: 11/19/2022]
Abstract
BACKGROUND The Fontan procedure is the final step of the 3-stage palliative procedure commonly performed in children with single ventricle physiology. Thrombosis remains an important complication in children after this procedure. To date, guideline recommendations for the type and duration of thromboprophylaxis after Fontan surgery are mainly based on extrapolation of knowledge gained from adults at risk for thrombosis in other clinical settings. Warfarin is being used off-label, and because of its multiple interactions with other drugs and food, a new alternative is highly desirable. Rivaroxaban, a direct Factor Xa inhibitor with a predictable pharmacokinetic profile, is a candidate to address this medical need. STUDY DESIGN The UNIVERSE study is a prospective, open-label, active-controlled, multicenter study in children 2 to 8 years of age who have single ventricle physiology and had the Fontan procedure within the 4 months preceding enrollment. This study consists of 2 parts. In Part A, rivaroxaban pharmacokinetics, pharmacodynamics, safety, and tolerability are assessed to validate the pediatric dosing selected. In Part B, safety and efficacy of rivaroxaban versus acetylsalicylic acid are evaluated for thromboprophylaxis in children post-Fontan procedure. Children in each part will receive study drug for 12 months. Part A has been completed with 12 children enrolled. Enrollment into Part B is currently ongoing. CONCLUSIONS The UNIVERSE study aims to provide dosing, pharmacokinetics/pharmacodynamics, safety, and efficacy information on the use of rivaroxaban, an oral anticoagulant, versus acetylsalicylic acid, an antiplatelet agent, in children with single ventricle physiology after the Fontan procedure.
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Affiliation(s)
| | - Xiangwen Dong
- Janssen Research and Development, LLC., Raritan, NJ 08869
| | - Liping Zhang
- Janssen Research and Development, LLC., Raritan, NJ 08869
| | | | | | | | | | - Kevin C Harris
- Children's Heart Centre, BC Children's Hospital, Vancouver, BC V6H 3N1, Canada
| | - John Jefferies
- The Heart Institute, Cincinnati Children's Hospital Medical Centre, Cincinnati, OH 45229
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21
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Michel M, Zlamy M, Entenmann A, Pichler K, Scholl-Bürgi S, Karall D, Geiger R, Salvador C, Niederwanger C, Ohuchi H. Impact of the Fontan Operation on Organ Systems. Cardiovasc Hematol Disord Drug Targets 2019; 19:205-214. [PMID: 30747084 DOI: 10.2174/1871529x19666190211165124] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2018] [Revised: 01/09/2019] [Accepted: 01/29/2019] [Indexed: 02/06/2023]
Abstract
In patients having undergone the Fontan operation, besides the well discussed changes in the cardiac, pulmonary and gastrointestinal system, alterations of further organ systems including the hematologic, immunologic, endocrinological and metabolic are reported. As a medical adjunct to Fontan surgery, the systematic study of the central role of the liver as a metabolizing and synthesizing organ should allow for a better understanding of the pathomechanism underlying the typical problems in Fontan patients, and in this context, the profiling of endocrinological and metabolic patterns might offer a tool for the optimization of Fontan follow-up, targeted monitoring and specific adjunct treatment.
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Affiliation(s)
- Miriam Michel
- Department of Pediatrics III, Division of Cardiology, Pulmology, Allergology, and Cystic Fibrosis, Innsbruck Medical University, Anichstraße 35, 6020 Innsbruck, Austria
| | - Manuela Zlamy
- Department of Pediatrics I, Innsbruck Medical University, Anichstraße 35, 6020 Innsbruck, Austria
| | - Andreas Entenmann
- Department of Pediatrics I, Innsbruck Medical University, Anichstraße 35, 6020 Innsbruck, Austria
| | - Karin Pichler
- Department of Pediatrics, Vienna Medical University, Währinger Gürtel 16, 1090 Vienna, Austria
| | - Sabine Scholl-Bürgi
- Department of Pediatrics I, Innsbruck Medical University, Anichstraße 35, 6020 Innsbruck, Austria
| | - Daniela Karall
- Department of Pediatrics I, Innsbruck Medical University, Anichstraße 35, 6020 Innsbruck, Austria
| | - Ralf Geiger
- Department of Pediatrics III, Division of Cardiology, Pulmology, Allergology, and Cystic Fibrosis, Innsbruck Medical University, Anichstraße 35, 6020 Innsbruck, Austria
| | - Christina Salvador
- Department of Pediatrics I, Innsbruck Medical University, Anichstraße 35, 6020 Innsbruck, Austria
| | - Christian Niederwanger
- Department of Pediatrics I, Innsbruck Medical University, Anichstraße 35, 6020 Innsbruck, Austria
| | - Hideo Ohuchi
- Department for Pediatric Cardiology, National Cerebral and Cardiovascular Center, 5-7-1 Fujishiro-dai, Suita, Osaka 565-8565, Japan
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22
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Erikssen G, Aboulhosn J, Lin J, Liestøl K, Estensen ME, Gjesdal O, Skulstad H, Døhlen G, Lindberg HL. Survival in patients with univentricular hearts: the impact of right versus left ventricular morphology. Open Heart 2018; 5:e000902. [PMID: 30364544 PMCID: PMC6196969 DOI: 10.1136/openhrt-2018-000902] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/11/2018] [Revised: 08/02/2018] [Accepted: 08/22/2018] [Indexed: 12/17/2022] Open
Abstract
Objective Patients with univentricular hearts (UVH) have high mortality despite modern treatment, and better methods to identify patients at highest risk are needed. We wanted to improve risk stratification in patients with UVH by focusing on the prognostic significance of single right versus single left ventricular morphology (SRV vs SLV). Methods All 395 patients with UVH operated at our centre were prospectively included from 1972 to 2016 (195 SRV, 166 SLV, 34 mixed or indeterminate ventricular morphology). Diagnoses, UVH morphology, types of all operations and time and causes of death or heart transplantation (HTX) were recorded. The primary endpoint was death or HTX. Results Among the 111 non-Fontan patients, 88 died (SRV 62 vs SLV 20; p<0.0001), 32 due to heart failure (SRV 23 vs SLV 5; p=0.0012). Twenty-five years of cumulative SRV versus SLV survival among the 284 Fontan patients (41 deaths/HTX) was 66.9% vs 87.9% (p=0.0027), partly explained by more deaths/HTX due to heart failure among patients with SRV (p=0.0006). Survival in patients with SRV with and without hypoplastic left heart syndrome (HLHS) was similar. SRV versus SLV was a strong predictor of death/HTX in multivariable proportional hazards analyses (RR 3.3, 95% CI 1.6 to 6.6). Conclusion SRV versus SLV is a strong short-term and long-term predictor of survival among patients with UVH, mainly explained by higher rates of death/HTX due to heart failure in the SRV group. Our findings apply to patients with SRV both with and without HLHS.
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Affiliation(s)
- Gunnar Erikssen
- ACHD Unit, Department of Cardiology, Oslo University Hospital Rikshospitalet, Oslo, Norway
| | - Jamil Aboulhosn
- Ahmanson/UCLA Adult Congenital Heart Disease Center, UCLA Medical Plaza, Los Angeles, California, USA
| | - Jeannette Lin
- Ahmanson/UCLA Adult Congenital Heart Disease Center, UCLA Medical Plaza, Los Angeles, California, USA
| | - Knut Liestøl
- Department of Informatics, University of Oslo, Oslo, Norway
| | - Mette E Estensen
- ACHD Unit, Department of Cardiology, Oslo University Hospital Rikshospitalet, Oslo, Norway
| | - Ola Gjesdal
- ACHD Unit, Department of Cardiology, Oslo University Hospital Rikshospitalet, Oslo, Norway
| | - Helge Skulstad
- Faculty of Medicine, Institute of Clinical Medicine, University of Oslo, Oslo, Norway
| | - Gaute Døhlen
- Department of Pediatric Cardiology, Oslo University Hospital, Oslo, Norway
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Udholm S, Aldweib N, Hjortdal VE, Veldtman GR. Prognostic power of cardiopulmonary exercise testing in Fontan patients: a systematic review. Open Heart 2018; 5:e000812. [PMID: 30057765 PMCID: PMC6059270 DOI: 10.1136/openhrt-2018-000812] [Citation(s) in RCA: 43] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/23/2018] [Revised: 04/03/2018] [Accepted: 04/24/2018] [Indexed: 11/04/2022] Open
Abstract
Objective Exercise impairment is common in Fontan patients. Our aim is to systematically review previous literature to determine the prognostic value of exercise capacity in older adolescent and adult Fontan patients with respect to late outcome. Additionally, we reviewed the determinants of exercise capacity in Fontan patients and changes in exercise capacity over time. Methods PubMed, CINAHL, Embase, The Cochrane Library and Scopus were searched systematically for studies reporting exercise capacity and late outcome such as mortality, cardiac transplantation and hospitalisation. Studies were eligible for inclusion if more than 30 patients were included and mean age was ≥16 years. Results Four thousand and seven hundred and twenty-two studies were identified by the systematic search. Seven studies fulfilled the inclusion and exclusion criteria. The total number of patients was 1664 adult Fontan patients. There were 149 deaths and 35 heart transplantations. All eligible studies were retrospective cohort studies. The correlation between exercise capacity and late outcome was identified, and HRs were reported. Conclusion In Fontan patients, the best predictors of death and transplantation were a decline in peak VO2, heart rate variables and exercise oscillatory ventilation. Peak VO2 was not strongly predictive of mortality or hospitalisation in Fontan patients. Several variables were strong and independent predictors of hospitalisation and morbidity.
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Affiliation(s)
- Sebastian Udholm
- Department of Cardiothoracic and Vascular Surgery, Aarhus University Hospital, Aarhus, Denmark
| | - Nael Aldweib
- Cardiovascular Medicine Department, Allegheny General Hospital, Pittsburgh, Pennsylvania, USA
| | | | - Gruschen R Veldtman
- Adult Congenital Heart Disease Program, Heart Institute, Cincinnati Children's Hospital Medical Centre, Cincinnati, Ohio, USA
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Kim TH, Yang HK, Jang HJ, Yoo SJ, Khalili K, Kim TK. Abdominal imaging findings in adult patients with Fontan circulation. Insights Imaging 2018; 9:357-367. [PMID: 29623675 PMCID: PMC5991003 DOI: 10.1007/s13244-018-0609-2] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2017] [Revised: 02/04/2018] [Accepted: 02/12/2018] [Indexed: 12/12/2022] Open
Abstract
Abstract The Fontan procedures, designed to treat paediatric patients with functional single ventricles, have markedly improved the patient’s survival into adulthood. The physiology of the Fontan circuit inevitably increases systemic venous pressure, which may lead to multi-system organ failure in the long-term follow-up. Fontan-associated liver disease (FALD) can progress to liver cirrhosis with signs of portal hypertension. Focal nodular hyperplasia-like nodules commonly develop in FALD. Imaging surveillance is often performed to monitor the progression of FALD and to detect hepatocellular carcinoma, which infrequently develops in FALD. Other abdominal abnormalities in post-Fontan patients include protein losing enteropathy and pheochromocytoma/paraganglioma. Given that these abdominal abnormalities are critical for patient management, it is important for radiologists to become familiar with the abdominal abnormalities that are common in post-Fontan patients on cross-sectional imaging. Teaching points • Fontan procedure for functional single ventricle has improved patient survival into adulthood. • Radiologists should be familiar with unique imaging findings of Fontan-associated liver disease. • Focal nodular hyperplasia-like nodules commonly develop in Fontan-associated liver disease. • Hepatocellular carcinoma, protein-losing enteropathy, pheochromocytoma/paraganglioma may develop. Electronic supplementary material The online version of this article (10.1007/s13244-018-0609-2) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Tae-Hyung Kim
- Department of Radiology, Seoul National University Hospital, 101 Daehak-ro, Jongno-gu, Seoul, 03080, South Korea.,Department of Radiology, Seoul National University College of Medicine, 103 Daehak-ro, Jongnogu, Seoul, 03080, South Korea
| | - Hyun Kyung Yang
- Department of Medical Imaging, Toronto General Hospital, 585 University Avenue, Toronto, ON, M5G 2N2, Canada
| | - Hyun-Jung Jang
- Department of Medical Imaging, Toronto General Hospital, 585 University Avenue, Toronto, ON, M5G 2N2, Canada
| | - Shi-Joon Yoo
- Department of Diagnostic Imaging, Hospital for Sick Children, 555 University Avenue, Toronto, ON, M5J2L4, Canada
| | - Korosh Khalili
- Department of Medical Imaging, Toronto General Hospital, 585 University Avenue, Toronto, ON, M5G 2N2, Canada
| | - Tae Kyoung Kim
- Department of Medical Imaging, Toronto General Hospital, 585 University Avenue, Toronto, ON, M5G 2N2, Canada.
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Kverneland LS, Kramer P, Ovroutski S. Five decades of the Fontan operation: A systematic review of international reports on outcomes after univentricular palliation. CONGENIT HEART DIS 2018; 13:181-193. [DOI: 10.1111/chd.12570] [Citation(s) in RCA: 61] [Impact Index Per Article: 10.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/28/2017] [Revised: 11/08/2017] [Accepted: 12/08/2017] [Indexed: 11/28/2022]
Affiliation(s)
- Laura S. Kverneland
- Department of Internal Medicine; Herlev Hospital; Copenhagen Denmark
- Department of Congenital Heart Disease/Pediatric Cardiology; German Heart Center Berlin; Berlin Germany
| | - Peter Kramer
- Department of Congenital Heart Disease/Pediatric Cardiology; German Heart Center Berlin; Berlin Germany
| | - Stanislav Ovroutski
- Department of Congenital Heart Disease/Pediatric Cardiology; German Heart Center Berlin; Berlin Germany
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26
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A potentially curative fetal intervention for hypoplastic left heart syndrome. Med Hypotheses 2018; 110:132-137. [PMID: 29317056 DOI: 10.1016/j.mehy.2017.12.001] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2017] [Revised: 11/26/2017] [Accepted: 12/01/2017] [Indexed: 11/21/2022]
Abstract
Hypoplastic left heart syndrome (HLHS) encapsulates a spectrum of complex congenital cardiovascular malformations involving varying degrees of underdevelopment of the left-sided heart structures. However, despite improved survival rates since the introduction of staged surgical reconstruction, treatment options for HLHS remain palliative rather than curative. A major limiting factor in the development of definitive curative therapy for HLHS is an incomplete understanding of its pathogenesis. Currently, the aetiology HLHS is best conceptualised by the 'flow theory' of cardiogenesis, which states that normal cardiac development is reliant on the interrelationship of normal flow patterns of blood through the developing heart, and appropriate growth of the cardiac valves and myocardium. Thus, congenital cardiac malformations, such as HLHS, are thought to arise when these two processes are incorrectly coupled in utero. The rationale for the hypothesis proposed herein rests upon the flow theory of cardiogenesis. Morphological studies of HLHS indicate that, although underdeveloped, all left-sided cardiac structures are present and anatomically correct. Further, of the various structural abnormalities that can occur within the spectrum of HLHS, the presence of a ventricular septal defect (VSD) is rare. The rarity of a VSD within the morphological spectrum of HLHS suggests the syndrome may not develop in the presence of a functionally significant VSD. Presumably, the presence of a functional VSD establishes a communication between the two ventricles during cardiac development, and preserves the normal pressure-flow-dependent growth of the left ventricular (LV) myocardium, despite inflow/outflow valve defects. It is proposed that surgical creation of a VSD in utero will 'rescue' the LV of hearts with left-sided valvular deformities that render them susceptible to the development of HLHS later in gestation. In evaluating this hypothesis, potential techniques for surgical creation of a VSD in utero are offered. These techniques are based on already established catheter-based in utero interventions, and conventional postnatal percutaneous procedures for VSD creation. Further discussion is also offered on techniques to avoid, and manage, potential complications (i.e. conduction system damage) of the proposed technique(s). Finally, if VSD creation in utero is indeed practically feasible, and successfully establishes the hypothesised hemodynamic and myocardial growth normalisation within the abnormally developing LV, the clinical implications are profound. This procedure may hold a potential cure for almost every sub-type of HLHS.
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Kovacikova L, Krasnanova V, Skrak P, Zahorec M, Kantorova A, Semberova J, Bacharova L. Immune Abnormalities in Patients With Single Ventricle Circulation Precede the Fontan Procedure. World J Pediatr Congenit Heart Surg 2017; 8:672-682. [PMID: 29187105 DOI: 10.1177/2150135117732529] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
BACKGROUND Immune abnormalities are common in Fontan patients with protein-losing enteropathy. Limited data exist on immune function of other patients with single ventricle circulation. METHODS This prospective cohort study evaluated immunologic characteristics of children with single ventricle circulation from neonatal age up to early post-Fontan period. RESULTS Low leukocyte counts were observed in half of the patients prior to bidirectional Glenn and Fontan surgery. Total lymphocyte counts were below normal range in 36% to 63% of patients across all groups except patients following Fontan procedure who had normal counts. Typical lymphocyte subpopulation patterns were (1) high counts of total and helper T lymphocytes (CD3+ and CD4+ cells), low B lymphocytes (CD19+ cells), and increased CD4/CD8 ratio in neonates and (2) low T lymphocytes (CD3+, CD4+, CD8+ cells) with high natural killer cells (CD16+) and B lymphocytes (CD19+ cells) in other groups. Low preoperative total lymphocyte counts were associated with longer intensive care unit stay in patients after bidirectional Glenn and Fontan procedure ( P = .03 and P = .01, respectively) and low leukocyte counts with higher incidence of pleural effusions and chylothorax after Fontan procedure ( P = .005 and P = .002, respectively). CONCLUSIONS Single ventricle patients display several immunological abnormalities. Beyond the neonatal age, an immune pattern includes CD3+, CD4+, CD8+ lymphopenia, and CD16+ and CD19+ lymphocytosis. B-cell lymphocytosis compensates T-cell lymphopenia, producing normal total lymphocyte counts in patients early after Fontan surgery. Low preoperative total lymphocyte counts may be associated with longer postoperative intensive care unit stay in patients with bidirectional Glenn and Fontan procedure and leukopenia with pleural effusions in Fontan patients.
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Affiliation(s)
- Lubica Kovacikova
- 1 Pediatric Cardiac Intensive Care Unit, National Institute of Cardiovascular Diseases, Limbova 1, Bratislava, Slovakia
| | - Veronika Krasnanova
- 1 Pediatric Cardiac Intensive Care Unit, National Institute of Cardiovascular Diseases, Limbova 1, Bratislava, Slovakia
| | - Peter Skrak
- 1 Pediatric Cardiac Intensive Care Unit, National Institute of Cardiovascular Diseases, Limbova 1, Bratislava, Slovakia
| | - Martin Zahorec
- 1 Pediatric Cardiac Intensive Care Unit, National Institute of Cardiovascular Diseases, Limbova 1, Bratislava, Slovakia
| | - Andrea Kantorova
- 2 Department of Pediatric Cardiac Surgery, National Institute of Cardiovascular Diseases, Limbova 1, Bratislava, Slovakia
| | - Jana Semberova
- 3 Department of Laboratory Medicine, Children Faculty Hospital, Limbova 1, Bratislava, Slovakia
| | - Ljuba Bacharova
- 4 Department of Biophotonics, International Laser Center Bratislava, Ilkovičova 3, Bratislava, Slovakia
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28
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Buendía-Fuentes F, Melero-Ferrer JL, Plaza-López D, Rueda-Soriano J, Osa-Saez A, Aguero J, Calvillo-Batllés P, Fonfria-Esparcia C, Ballesta-Cuñat A, Martí-Bonmatí L, Martínez-Dolz L. Noninvasive Liver Assessment in Adult Patients With Fontan Circulation Using Acoustic Radiation Force Impulse Elastography and Hepatic Magnetic Resonance Imaging. World J Pediatr Congenit Heart Surg 2017; 9:22-30. [PMID: 29103357 DOI: 10.1177/2150135117732674] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Abstract
BACKGROUND Patients who have undergone the Fontan procedure are at risk of developing hepatic dysfunction. However, broad recommendations regarding liver monitoring are limited. The purpose of this study was to characterize the frequency of liver disease in adult Fontan patients using multimodality imaging (hepatic magnetic resonance imaging [MRI], acoustic radiation force impulse [ARFI] elastography, or hepatic ultrasound). METHODS In a prospective cross-sectional analysis of adult patients palliated with a Fontan procedure, hepatic MRI, ARFI, and hepatic ultrasound were used to assess for liver disease. The protocol compared (1) varying prevalence of liver disease based on each imaging technique, (2) agreement between different techniques, and (3) association between noninvasive imaging diagnosis of liver disease and clinical variables, including specific liver disease biomarkers. RESULTS Thirty-seven patients were enrolled. The ARFI results showed high wave propagation velocity in 35 patients (94.6%). All patients had some abnormality in the hepatic MRI. Specifically, 8 patients (21.6%) showed signs of chronic liver disease, 10 patients (27%) had significant liver fibrosis, and 27 patients (73%) had congestion. No correlation was found between liver stiffness measured as propagation velocity and hepatic MRI findings. Only 7 patients had an abnormal hepatic ultrasound study. CONCLUSIONS There is an inherent liver injury in adult Fontan patients. Signs of liver disease were observed in most patients by both hepatic MRI and ARFI elastography but not by ultrasound imaging. Increased liver stiffness did not identify specific disease patterns from MRI, supporting the need for multimodality imaging to characterize liver disease in Fontan patients.
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Affiliation(s)
- F Buendía-Fuentes
- 1 Department of Cardiology, Arnau de Vilanova Hospital, Valencia, Spain
| | - J L Melero-Ferrer
- 2 Adult Congenital Heart Disease Unit, Department of Cardiology, La Fe University Hospital, Valencia, Spain
| | - D Plaza-López
- 2 Adult Congenital Heart Disease Unit, Department of Cardiology, La Fe University Hospital, Valencia, Spain
| | - J Rueda-Soriano
- 2 Adult Congenital Heart Disease Unit, Department of Cardiology, La Fe University Hospital, Valencia, Spain
| | - A Osa-Saez
- 2 Adult Congenital Heart Disease Unit, Department of Cardiology, La Fe University Hospital, Valencia, Spain
| | - J Aguero
- 2 Adult Congenital Heart Disease Unit, Department of Cardiology, La Fe University Hospital, Valencia, Spain
| | | | | | - A Ballesta-Cuñat
- 4 Department of Hepatology, La Fe University Hospital, Valencia, Spain
| | - L Martí-Bonmatí
- 3 Department of Radiology, La Fe University Hospital, Valencia, Spain
| | - L Martínez-Dolz
- 2 Adult Congenital Heart Disease Unit, Department of Cardiology, La Fe University Hospital, Valencia, Spain
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29
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Muthusami P, Yoo SJ, Chaturvedi R, Gill N, Windram J, Schantz D, Prsa M, Caro-Dominguez P, Seed M, Grosse-Wortmann L, Ling SC, Chavhan GB. Splanchnic, Thoracoabdominal, and Cerebral Blood Flow Volumes in Healthy Children and Young Adults in Fasting and Postprandial States: Determining Reference Ranges by Using Phase-Contrast MR Imaging. Radiology 2017; 285:231-241. [DOI: 10.1148/radiol.2017162114] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Affiliation(s)
- Prakash Muthusami
- From the Department of Diagnostic Imaging (P.M., S.J.Y., N.T., J.W., D.S., M.P., P.C.D., M.S., L.G.W., G.B.C.), Division of Cardiology, Department of Pediatrics (S.J.Y., R.C., J.W., D.S., M.P., M.S., L.G.W.), and Division of Gastroenterology, Hepatology, and Nutrition (S.C.L.), the Hospital For Sick Children, 555 University Ave, Toronto, ON, Canada M5G 1X8; and Departments of Medical Imaging (P.M., S.J.Y., P.C.D., M.S., L.G.W., G.B.C.), and Pediatrics (R.C., S.C.L.), University of Toronto, Toronto, Canada
| | - Shi-Joon Yoo
- From the Department of Diagnostic Imaging (P.M., S.J.Y., N.T., J.W., D.S., M.P., P.C.D., M.S., L.G.W., G.B.C.), Division of Cardiology, Department of Pediatrics (S.J.Y., R.C., J.W., D.S., M.P., M.S., L.G.W.), and Division of Gastroenterology, Hepatology, and Nutrition (S.C.L.), the Hospital For Sick Children, 555 University Ave, Toronto, ON, Canada M5G 1X8; and Departments of Medical Imaging (P.M., S.J.Y., P.C.D., M.S., L.G.W., G.B.C.), and Pediatrics (R.C., S.C.L.), University of Toronto, Toronto, Canada
| | - Rajiv Chaturvedi
- From the Department of Diagnostic Imaging (P.M., S.J.Y., N.T., J.W., D.S., M.P., P.C.D., M.S., L.G.W., G.B.C.), Division of Cardiology, Department of Pediatrics (S.J.Y., R.C., J.W., D.S., M.P., M.S., L.G.W.), and Division of Gastroenterology, Hepatology, and Nutrition (S.C.L.), the Hospital For Sick Children, 555 University Ave, Toronto, ON, Canada M5G 1X8; and Departments of Medical Imaging (P.M., S.J.Y., P.C.D., M.S., L.G.W., G.B.C.), and Pediatrics (R.C., S.C.L.), University of Toronto, Toronto, Canada
| | - Navjot Gill
- From the Department of Diagnostic Imaging (P.M., S.J.Y., N.T., J.W., D.S., M.P., P.C.D., M.S., L.G.W., G.B.C.), Division of Cardiology, Department of Pediatrics (S.J.Y., R.C., J.W., D.S., M.P., M.S., L.G.W.), and Division of Gastroenterology, Hepatology, and Nutrition (S.C.L.), the Hospital For Sick Children, 555 University Ave, Toronto, ON, Canada M5G 1X8; and Departments of Medical Imaging (P.M., S.J.Y., P.C.D., M.S., L.G.W., G.B.C.), and Pediatrics (R.C., S.C.L.), University of Toronto, Toronto, Canada
| | - Jonathan Windram
- From the Department of Diagnostic Imaging (P.M., S.J.Y., N.T., J.W., D.S., M.P., P.C.D., M.S., L.G.W., G.B.C.), Division of Cardiology, Department of Pediatrics (S.J.Y., R.C., J.W., D.S., M.P., M.S., L.G.W.), and Division of Gastroenterology, Hepatology, and Nutrition (S.C.L.), the Hospital For Sick Children, 555 University Ave, Toronto, ON, Canada M5G 1X8; and Departments of Medical Imaging (P.M., S.J.Y., P.C.D., M.S., L.G.W., G.B.C.), and Pediatrics (R.C., S.C.L.), University of Toronto, Toronto, Canada
| | - Daryl Schantz
- From the Department of Diagnostic Imaging (P.M., S.J.Y., N.T., J.W., D.S., M.P., P.C.D., M.S., L.G.W., G.B.C.), Division of Cardiology, Department of Pediatrics (S.J.Y., R.C., J.W., D.S., M.P., M.S., L.G.W.), and Division of Gastroenterology, Hepatology, and Nutrition (S.C.L.), the Hospital For Sick Children, 555 University Ave, Toronto, ON, Canada M5G 1X8; and Departments of Medical Imaging (P.M., S.J.Y., P.C.D., M.S., L.G.W., G.B.C.), and Pediatrics (R.C., S.C.L.), University of Toronto, Toronto, Canada
| | - Milan Prsa
- From the Department of Diagnostic Imaging (P.M., S.J.Y., N.T., J.W., D.S., M.P., P.C.D., M.S., L.G.W., G.B.C.), Division of Cardiology, Department of Pediatrics (S.J.Y., R.C., J.W., D.S., M.P., M.S., L.G.W.), and Division of Gastroenterology, Hepatology, and Nutrition (S.C.L.), the Hospital For Sick Children, 555 University Ave, Toronto, ON, Canada M5G 1X8; and Departments of Medical Imaging (P.M., S.J.Y., P.C.D., M.S., L.G.W., G.B.C.), and Pediatrics (R.C., S.C.L.), University of Toronto, Toronto, Canada
| | - Pablo Caro-Dominguez
- From the Department of Diagnostic Imaging (P.M., S.J.Y., N.T., J.W., D.S., M.P., P.C.D., M.S., L.G.W., G.B.C.), Division of Cardiology, Department of Pediatrics (S.J.Y., R.C., J.W., D.S., M.P., M.S., L.G.W.), and Division of Gastroenterology, Hepatology, and Nutrition (S.C.L.), the Hospital For Sick Children, 555 University Ave, Toronto, ON, Canada M5G 1X8; and Departments of Medical Imaging (P.M., S.J.Y., P.C.D., M.S., L.G.W., G.B.C.), and Pediatrics (R.C., S.C.L.), University of Toronto, Toronto, Canada
| | - Mike Seed
- From the Department of Diagnostic Imaging (P.M., S.J.Y., N.T., J.W., D.S., M.P., P.C.D., M.S., L.G.W., G.B.C.), Division of Cardiology, Department of Pediatrics (S.J.Y., R.C., J.W., D.S., M.P., M.S., L.G.W.), and Division of Gastroenterology, Hepatology, and Nutrition (S.C.L.), the Hospital For Sick Children, 555 University Ave, Toronto, ON, Canada M5G 1X8; and Departments of Medical Imaging (P.M., S.J.Y., P.C.D., M.S., L.G.W., G.B.C.), and Pediatrics (R.C., S.C.L.), University of Toronto, Toronto, Canada
| | - Lars Grosse-Wortmann
- From the Department of Diagnostic Imaging (P.M., S.J.Y., N.T., J.W., D.S., M.P., P.C.D., M.S., L.G.W., G.B.C.), Division of Cardiology, Department of Pediatrics (S.J.Y., R.C., J.W., D.S., M.P., M.S., L.G.W.), and Division of Gastroenterology, Hepatology, and Nutrition (S.C.L.), the Hospital For Sick Children, 555 University Ave, Toronto, ON, Canada M5G 1X8; and Departments of Medical Imaging (P.M., S.J.Y., P.C.D., M.S., L.G.W., G.B.C.), and Pediatrics (R.C., S.C.L.), University of Toronto, Toronto, Canada
| | - Simon C. Ling
- From the Department of Diagnostic Imaging (P.M., S.J.Y., N.T., J.W., D.S., M.P., P.C.D., M.S., L.G.W., G.B.C.), Division of Cardiology, Department of Pediatrics (S.J.Y., R.C., J.W., D.S., M.P., M.S., L.G.W.), and Division of Gastroenterology, Hepatology, and Nutrition (S.C.L.), the Hospital For Sick Children, 555 University Ave, Toronto, ON, Canada M5G 1X8; and Departments of Medical Imaging (P.M., S.J.Y., P.C.D., M.S., L.G.W., G.B.C.), and Pediatrics (R.C., S.C.L.), University of Toronto, Toronto, Canada
| | - Govind B. Chavhan
- From the Department of Diagnostic Imaging (P.M., S.J.Y., N.T., J.W., D.S., M.P., P.C.D., M.S., L.G.W., G.B.C.), Division of Cardiology, Department of Pediatrics (S.J.Y., R.C., J.W., D.S., M.P., M.S., L.G.W.), and Division of Gastroenterology, Hepatology, and Nutrition (S.C.L.), the Hospital For Sick Children, 555 University Ave, Toronto, ON, Canada M5G 1X8; and Departments of Medical Imaging (P.M., S.J.Y., P.C.D., M.S., L.G.W., G.B.C.), and Pediatrics (R.C., S.C.L.), University of Toronto, Toronto, Canada
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Sathananthan G, Harris L, Nair K. Ventricular Arrhythmias in Adult Congenital Heart Disease: Mechanisms, Diagnosis, and Clinical Aspects. Card Electrophysiol Clin 2017; 9:213-223. [PMID: 28457236 DOI: 10.1016/j.ccep.2017.02.004] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/07/2023]
Abstract
The risk of ventricular arrhythmias in the adult congenital heart disease population increases with age. The mechanism, type, and frequency vary depending on the complexity of the defect, whether it has been repaired, and the type and timing of repair. Risk stratification for sudden death in patients with congenital heart disease is often challenging. Current recommendations provide a useful guide for management of these patients and risk stratification continues to evolve. Internal cardiac defibrillator implantation is often challenging due to limited transvenous access, often resulting in the need for epicardial or subcutaneous devices.
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Affiliation(s)
- Gnalini Sathananthan
- Department of Cardiology, Peter Munk Cardiac Centre, University Health Network, University of Toronto, 585 University Avenue, Toronto, ON M5G 2N2, Canada
| | - Louise Harris
- Department of Cardiology, Peter Munk Cardiac Centre, University Health Network, University of Toronto, 585 University Avenue, Toronto, ON M5G 2N2, Canada
| | - Krishnakumar Nair
- Department of Cardiology, Peter Munk Cardiac Centre, University Health Network, University of Toronto, 585 University Avenue, Toronto, ON M5G 2N2, Canada.
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Alsaied T, Bokma JP, Engel ME, Kuijpers JM, Hanke SP, Zuhlke L, Zhang B, Veldtman GR. Predicting long-term mortality after Fontan procedures: A risk score based on 6707 patients from 28 studies. CONGENIT HEART DIS 2017; 12:393-398. [DOI: 10.1111/chd.12468] [Citation(s) in RCA: 37] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/31/2016] [Revised: 12/29/2016] [Accepted: 03/29/2017] [Indexed: 11/28/2022]
Affiliation(s)
- Tarek Alsaied
- Children's Heart Institute; Cincinnati Children's Hospital Medical Center; Cincinnati Ohio USA
| | - Jouke P. Bokma
- Department of Cardiology, Academic Medical Center, Amsterdam; Interuniversity Cardiology Institute of the Netherlands, Netherlands Heart Institute; Utrecht The Netherlands
| | - Mark E. Engel
- Department of Medicine, Groote Schuur Hospital, The Cardiac Clinic, Department of Medicine; Groote Schuur Hospital and University of Cape Town; Cape Town South Africa
| | - Joey M. Kuijpers
- Department of Cardiology, Academic Medical Center, Amsterdam; Interuniversity Cardiology Institute of the Netherlands, Netherlands Heart Institute; Utrecht The Netherlands
| | - Samuel P. Hanke
- Children's Heart Institute; Cincinnati Children's Hospital Medical Center; Cincinnati Ohio USA
| | - Liesl Zuhlke
- Department of Pediatrics; Red Cross War Memorial Children's Hospital and University of Cape Town; Cape Town South Africa
| | - Bin Zhang
- Division of Biostatistics and Epidemiology; Cincinnati Children's Hospital Medical Center; Cincinnati Ohio USA
| | - Gruschen R. Veldtman
- Adolescent and Adult Congenital Program, Children's Heart Institute; Cincinnati Children's Hospital Medical Center; Cincinnati Ohio USA
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32
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Bruse JL, Giusti G, Baker C, Cervi E, Hsia TY, Taylor AM, Schievano S. Statistical Shape Modeling for Cavopulmonary Assist Device Development: Variability of Vascular Graft Geometry and Implications for Hemodynamics. J Med Device 2017; 11. [PMID: 28479938 DOI: 10.1115/1.4035865] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022] Open
Abstract
Patients born with a single functional ventricle typically undergo three-staged surgical palliation in the first years of life, with the last stage realizing a cross-like total cavopulmonary connection (TCPC) of superior and inferior vena cavas (SVC and IVC) with both left and right pulmonary arteries, allowing all deoxygenated blood to flow passively back to the lungs (Fontan circulation). Even though within the past decades more patients survive into adulthood, the connection comes at the prize of deficiencies such as chronic systemic venous hypertension and low cardiac output, which ultimately may lead to Fontan failure. Many studies have suggested that the TCPC's inherent insufficiencies might be addressed by adding a cavopulmonary assist device (CPAD) to provide the necessary pressure boost. While many device concepts are being explored, few take into account the complex cardiac anatomy typically associated with TCPCs. In this study, we focus on the extra cardiac conduit vascular graft connecting IVC and pulmonary arteries as one possible landing zone for a CPAD and describe its geometric variability in a cohort of 18 patients that had their TCPC realized with a 20mm vascular graft. We report traditional morphometric parameters and apply statistical shape modeling to determine the main contributors of graft shape variability. Such information may prove useful when designing CPADs that are adapted to the challenging anatomical boundaries in Fontan patients. We further compute the anatomical mean 3D graft shape (template graft) as a representative of key shape features of our cohort and prove this template graft to be a significantly better approximation of population and individual patient's hemodynamics than a commonly used simplified tube geometry. We therefore conclude that statistical shape modeling results can provide better models of geometric and hemodynamic boundary conditions associated with complex cardiac anatomy, which in turn may impact on improved cardiac device development.
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Affiliation(s)
- Jan L Bruse
- Centre for Cardiovascular Imaging, UCL Institute of Cardiovascular Science & Great Ormond Street Hospital for Children
| | - Giuliano Giusti
- Centre for Cardiovascular Imaging, UCL Institute of Cardiovascular Science & Great Ormond Street Hospital for Children
| | - Catriona Baker
- Centre for Cardiovascular Imaging, UCL Institute of Cardiovascular Science & Great Ormond Street Hospital for Children
| | - Elena Cervi
- Centre for Cardiovascular Imaging, UCL Institute of Cardiovascular Science & Great Ormond Street Hospital for Children
| | - Tain-Yen Hsia
- Centre for Cardiovascular Imaging, UCL Institute of Cardiovascular Science & Great Ormond Street Hospital for Children
| | - Andrew M Taylor
- Centre for Cardiovascular Imaging, UCL Institute of Cardiovascular Science & Great Ormond Street Hospital for Children
| | - Silvia Schievano
- Centre for Cardiovascular Imaging, UCL Institute of Cardiovascular Science & Great Ormond Street Hospital for Children
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Hilscher MB, Johnson JN, Cetta F, Driscoll DJ, Poterucha JJ, Sanchez W, Connolly HM, Kamath PS. Surveillance for liver complications after the Fontan procedure. CONGENIT HEART DIS 2017; 12:124-132. [DOI: 10.1111/chd.12446] [Citation(s) in RCA: 48] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/26/2016] [Revised: 11/01/2016] [Accepted: 12/26/2016] [Indexed: 12/30/2022]
Affiliation(s)
- Moira B. Hilscher
- Department of Medicine/Division of Gastroenterology and Hepatology; Mayo Clinic; Rochester Minnesota USA
| | - Jonathan N. Johnson
- Department of Pediatrics and Adolescent Medicine/Division of Pediatric Cardiology; Mayo Clinic; Rochester Minnesota USA
- Department of Cardiovascular Diseases; Mayo Clinic; Rochester Minnesota USA
| | - Frank Cetta
- Department of Pediatrics and Adolescent Medicine/Division of Pediatric Cardiology; Mayo Clinic; Rochester Minnesota USA
- Department of Cardiovascular Diseases; Mayo Clinic; Rochester Minnesota USA
| | - David J. Driscoll
- Department of Pediatrics and Adolescent Medicine/Division of Pediatric Cardiology; Mayo Clinic; Rochester Minnesota USA
- Department of Cardiovascular Diseases; Mayo Clinic; Rochester Minnesota USA
| | - John J. Poterucha
- Department of Medicine/Division of Gastroenterology and Hepatology; Mayo Clinic; Rochester Minnesota USA
| | - William Sanchez
- Department of Medicine/Division of Gastroenterology and Hepatology; Mayo Clinic; Rochester Minnesota USA
| | - Heidi M. Connolly
- Department of Cardiovascular Diseases; Mayo Clinic; Rochester Minnesota USA
| | - Patrick S. Kamath
- Department of Medicine/Division of Gastroenterology and Hepatology; Mayo Clinic; Rochester Minnesota USA
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Monteiro R, Dob D, Cauldwell M, Gatzoulis M. Anaesthetic management of parturients with univentricular congenital heart disease and the Fontan operation. Int J Obstet Anesth 2016; 28:83-91. [DOI: 10.1016/j.ijoa.2016.08.004] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/06/2016] [Revised: 07/19/2016] [Accepted: 08/22/2016] [Indexed: 11/26/2022]
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Hegde S, Hsiao A. Improving the Fontan: Pre-surgical planning using four dimensional (4D) flow, bio-mechanical modeling and three dimensional (3D) printing. PROGRESS IN PEDIATRIC CARDIOLOGY 2016. [DOI: 10.1016/j.ppedcard.2016.07.012] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
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Alsaied T, Bokma JP, Engel ME, Kuijpers JM, Hanke SP, Zuhlke L, Zhang B, Veldtman GR. Factors associated with long-term mortality after Fontan procedures: a systematic review. Heart 2016; 103:104-110. [DOI: 10.1136/heartjnl-2016-310108] [Citation(s) in RCA: 91] [Impact Index Per Article: 11.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/05/2016] [Revised: 10/13/2016] [Accepted: 10/18/2016] [Indexed: 12/16/2022] Open
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Chiu SN, Wang JK, Lu CW, Wu KL, Tseng WC, Wu MH. Electrophysiology Study for Complex Supraventricular Tachycardia in Congenital Heart Disease Patients With Single-Ventricle Physiology. J Am Heart Assoc 2016; 5:e004504. [PMID: 27799231 PMCID: PMC5210343 DOI: 10.1161/jaha.116.004504] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/16/2016] [Accepted: 10/07/2016] [Indexed: 12/01/2022]
Abstract
BACKGROUND Supraventricular tachycardia (SVT) is common in complex congenital heart disease (CCHD) patients with single-ventricle physiology and may cause hemodynamic deterioration. We reported the outcomes of catheter ablation for such complex SVT in these single-ventricle CCHD patients. METHODS AND RESULTS Patients with single-ventricle physiology (defined as CCHD patients) who received electrophysiology studies and catheter ablation between 1995 and 2015 were studied. We enrolled 30 CCHD patients (18 with right atrial isomerism, 5 with left atrial isomerism, and 7 with other CCHDs; 17 male, 13 female). The age of onset of clinical SVT was 6.7 years (±4.7 years). Electrophysiology studies and ablation were performed at age 7.1 years (±3.9 years); body weight was 20.7 kg (±10.0 kg). Twin atrioventricular nodes were present in 60% of patients (right atrial isomerism, 72.2%; left atrial isomerism, 40%; other CCHDs, 42.9%). Manifested preexcitation was noted in 10% of patients. SVT was induced in 21 patients. Twin atrioventricular nodal reentrant tachycardia was the most common (57.1%), followed by atrioventricular reentrant tachycardia (28.6%), junctional tachycardia (14.3%), and atrioventricular nodal reentrant tachycardia (9.5%). Multiple arrhythmias were common (33.3%), particularly in patients with atrioventricular reentrant tachycardia (50%). Ablation successfully eliminated SVT in 12 of 14 patients (85.7%), with a recurrence rate of 16.7% during 6 years of follow-up. CONCLUSIONS Transcatheter ablation of complex SVT substrates, including minor atrioventricular node of twin atrioventricular nodal reentrant tachycardia, accessory pathways of atrioventricular reentrant tachycardia, and a slow pathway of atrioventricular nodal reentrant tachycardia, is effective in CCHD patients. The limitations are limited vascular access and the risk of atrioventricular block.
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Affiliation(s)
- Shuenn-Nan Chiu
- Department of Pediatrics, National Taiwan University Hospital and National Taiwan University Children Hospital, Taipei, Taiwan
| | - Jou-Kou Wang
- Department of Pediatrics, National Taiwan University Hospital and National Taiwan University Children Hospital, Taipei, Taiwan
| | - Chun-Wei Lu
- Department of Pediatrics, National Taiwan University Hospital and National Taiwan University Children Hospital, Taipei, Taiwan
| | - Kun-Lang Wu
- Department of Pediatrics, Changhua Christian Hospital, Changhua, Taiwan
| | - Wei-Chieh Tseng
- Department of Pediatrics, National Taiwan University Hospital and National Taiwan University Children Hospital, Taipei, Taiwan
| | - Mei-Hwan Wu
- Department of Pediatrics, National Taiwan University Hospital and National Taiwan University Children Hospital, Taipei, Taiwan
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Rajabzadeh-Oghaz H, Firoozabadi B, Saidi MS, Monjezi M, Navabi Shirazi MA, Malakan Rad E. Pulsatile blood flow in total cavopulmonary connection: a comparison between Y-shaped and T-shaped geometry. Med Biol Eng Comput 2016; 55:213-224. [DOI: 10.1007/s11517-016-1499-4] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2014] [Accepted: 03/26/2016] [Indexed: 11/30/2022]
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Broomall E, McBride ME, Deal BJ, Ducharme-Crevier L, Shaw A, Mazwi M, Backer CL, Mongé MC, Costello J, Marino BS, DeFreitas A, Wainwright MS. Posterior Circulation Ischemia or Occlusion in Five Adults With Failing Fontan Circulation. Ann Thorac Surg 2016; 101:2315-20. [PMID: 27016841 DOI: 10.1016/j.athoracsur.2016.01.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/16/2015] [Revised: 11/24/2015] [Accepted: 01/04/2016] [Indexed: 10/22/2022]
Abstract
BACKGROUND Palliative procedures performed before the Fontan procedure may require ligation of the subclavian arteries, thereby affecting flow to the vertebral arteries. In adults with functionally univentricular heart disease, the implications of altered brainstem vascular anatomy for perioperative management of failing Fontan circulation are not known. METHODS We identified abnormal posterior circulation anatomy in an adult patient with failing Fontan circulation who experienced a brainstem stroke after Fontan conversion. We then changed our clinical practice to include detailed preoperative neurologic evaluation of adults with univentricular heart disease and failing Fontan circulation. Here, we report the clinical and neuroimaging findings in 5 consecutive patients before and after this change in practice. RESULTS Five patients ages 28 to 42 years had Fontan procedures performed in childhood, and underwent either Fontan conversion or cardiac transplantation. Patient 1 experienced an episode of decreased cerebral perfusion pressure on postoperative day 3, and experienced an ischemic brainstem stroke causing transient locked-in syndrome. A change in practice was made, and patients 2, 3, and 4 were evaluated preoperatively by the neurocritical care service. These patients then had higher target blood pressures perioperatively and no neurologic injury. Patient 5 was evaluated for symptoms consistent with subclavian steal. Neuroimaging in 3 patients was abnormal, with atrophic vertebral arteries, an occluded vertebral artery, and retrograde perfusion of a vertebral artery. CONCLUSIONS In adults with failing Fontan circulation there is a potential for neurologic complications as a result of venous congestion with elevated central venous pressures, and aberrant posterior circulation. The patient's history and brain imaging may be used to identify at-risk patients and to tailor perioperative management during Fontan conversion or heart transplantation to mitigate the risk for brainstem ischemia.
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Affiliation(s)
- Eileen Broomall
- Division of Neurology, Department of Pediatrics, Ann & Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, Illinois; Ruth D. & Ken M. Davee Pediatric Neurocritical Care Program, Ann & Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Mary E McBride
- Division of Cardiology, Department of Pediatrics, Ann & Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Barbara J Deal
- Division of Cardiology, Department of Pediatrics, Ann & Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Laurence Ducharme-Crevier
- Division of Neurology, Department of Pediatrics, Ann & Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, Illinois; Ruth D. & Ken M. Davee Pediatric Neurocritical Care Program, Ann & Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Alexandra Shaw
- Division of Neurology, Department of Pediatrics, Ann & Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Mjaye Mazwi
- Division of Cardiology, Department of Pediatrics, Ann & Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Carl L Backer
- Department of Cardiovascular Thoracic Surgery, Ann & Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Michael C Mongé
- Department of Cardiovascular Thoracic Surgery, Ann & Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - John Costello
- Division of Cardiology, Department of Pediatrics, Ann & Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Bradley S Marino
- Division of Cardiology, Department of Pediatrics, Ann & Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Andrew DeFreitas
- Division of Cardiology, Department of Pediatrics, Ann & Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Mark S Wainwright
- Division of Neurology, Department of Pediatrics, Ann & Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, Illinois; Ruth D. & Ken M. Davee Pediatric Neurocritical Care Program, Ann & Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, Illinois.
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Ortiz-Vázquez M, Espinoza-Blanco O, Ramírez-Marroquín S, Calderón-Colmenero J, García-Montes JA, Cervantes-Salazar J. [Comparison between patients undergoing Fontan operation with or without cardiopulmonary bypass]. ARCHIVOS DE CARDIOLOGIA DE MEXICO 2016; 86:1-10. [PMID: 26830073 DOI: 10.1016/j.acmx.2015.12.001] [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: 02/24/2014] [Revised: 12/03/2015] [Accepted: 12/06/2015] [Indexed: 11/17/2022] Open
Abstract
Fontan operation is the final palliative stage of patients with univentricular hearts. Cardiopulmonary bypass (CPB) decreases ventricular performance and increases pulmonary artery pressures in the post operative recovery period. It seems that Fontan operation performed without CPB decreases short term morbidity and intra hospitalary length of stay. OBJETIVE Compare outcome in Fontan patients who have undergone surgery with or without CPB. METHOD This is a retrospective review of patients undergoing Fontan operation from january 2009 to december 2012. Patients were grouped according to CPB use and comparative analyses were done. RESULTS Ten patients were operated without CPB use. There was a discrepancy between age in both groups, being younger in the no CPB group. Around 80% of patients in both groups had a staged procedure. A 18mm graft was used in half of the cases; a fenestration was created in all cases. Length of stay was equal in both groups, there was less need of pharmacologic support and nitric oxide use in patients without CPB use. No deaths were reported also in this group. At folllow up, most patients had a class i functional status. CONCLUSIONS In our experience, Fontan operation without CPB has similar outcomes compared with CPB use.
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Affiliation(s)
- Marlo Ortiz-Vázquez
- Cirugía de Malformaciones Congénitas del Corazón, Instituto Nacional de Cardiología Dr. Ignacio Chávez, Facultad de Medicina, División de estudios de posgrado, UNAM, México, D.F., México
| | - Osbaldo Espinoza-Blanco
- Cirugía de Malformaciones Congénitas del Corazón, Instituto Nacional de Cardiología Dr. Ignacio Chávez, Facultad de Medicina, División de estudios de posgrado, UNAM, México, D.F., México
| | - Samuel Ramírez-Marroquín
- Cirugía de Malformaciones Congénitas del Corazón, Instituto Nacional de Cardiología Dr. Ignacio Chávez, Facultad de Medicina, División de estudios de posgrado, UNAM, México, D.F., México
| | - Juan Calderón-Colmenero
- Cirugía de Malformaciones Congénitas del Corazón, Instituto Nacional de Cardiología Dr. Ignacio Chávez, Facultad de Medicina, División de estudios de posgrado, UNAM, México, D.F., México
| | - Jose Antonio García-Montes
- Cirugía de Malformaciones Congénitas del Corazón, Instituto Nacional de Cardiología Dr. Ignacio Chávez, Facultad de Medicina, División de estudios de posgrado, UNAM, México, D.F., México
| | - Jorge Cervantes-Salazar
- Cirugía de Malformaciones Congénitas del Corazón, Instituto Nacional de Cardiología Dr. Ignacio Chávez, Facultad de Medicina, División de estudios de posgrado, UNAM, México, D.F., México.
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Rajabzadeh Oghaz H, Firoozabadi B, Saidi M, Monjezi M, Navabi Shirazi M, Malakan Rad E. Evaluation of a novel extra-cardiac Fontan procedure with implantation of a biocompatible membrane. Ing Rech Biomed 2015. [DOI: 10.1016/j.irbm.2015.06.006] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Mechanical Circulatory Support of a Univentricular Fontan Circulation with a Continuous Axial-Flow Pump in a Piglet Model. ASAIO J 2015; 61:196-201. [DOI: 10.1097/mat.0000000000000172] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
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Nasr VG, Kussman BD. Advances in the Care of Adults With Congenital Heart Disease. Semin Cardiothorac Vasc Anesth 2014; 19:175-86. [DOI: 10.1177/1089253214563989] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
The significant decline in mortality among children and adolescents with congenital heart disease (CHD) is associated with an increasing prevalence of CHD in adults, particularly those with moderate to severe defects. As a significant percentage of adolescents and young adults are lost to follow-up in the transition from pediatric to adult care, they may present for elective procedures with substantial CHD-associated morbidity. In addition to the specific cardiac defect, the procedures performed, and the current pathophysiological status, several factors should be considered when managing the adult with CHD. These include the type of setting (adult vs pediatric institution); surgeon (pediatric vs adult cardiac surgeon); coexisting diseases associated with CHD, such as coronary artery disease, hepatic dysfunction, renal dysfunction, cerebrovascular accidents, myopathy, and coagulation disorders; acquired diseases of aging; pregnancy; and psychosocial functioning. The current status of the management of common and important congenital cardiac defects is also described.
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Affiliation(s)
- Ra-Id Abdulla
- Section of Pediatric Cardiology, Rush University, Chicago, USA,
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Liang F, Sughimoto K, Matsuo K, Liu H, Takagi S. Patient-specific assessment of cardiovascular function by combination of clinical data and computational model with applications to patients undergoing Fontan operation. INTERNATIONAL JOURNAL FOR NUMERICAL METHODS IN BIOMEDICAL ENGINEERING 2014; 30:1000-1018. [PMID: 24753499 DOI: 10.1002/cnm.2641] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/15/2013] [Revised: 11/01/2013] [Accepted: 03/22/2014] [Indexed: 06/03/2023]
Abstract
The assessment of cardiovascular function is becoming increasingly important for the care of patients with single-ventricle defects. However, most measurement methods available in the clinical setting cannot provide a separate measure of cardiac function and loading conditions. In the present study, a numerical method has been proposed to compensate for the limitations of clinical measurements. The main idea was to estimate the parameters of a cardiovascular model by fitting model simulations to patient-specific clinical data via parameter optimization. Several strategies have been taken to establish a well-posed parameter optimization problem, including clinical data-matched model development, parameter selection based on an extensive sensitivity analysis, and proper choice of parameter optimization algorithm. The numerical experiments confirmed the ability of the proposed parameter optimization method to uniquely determine the model parameters given an arbitrary set of clinical data. The method was further tested in four patients undergoing the Fontan operation. Obtained results revealed a prevalence of ventricular abnormalities in the patient cohort and at the same time demonstrated the presence of marked inter-patient differences and preoperative to postoperative changes in cardiovascular function. Because the method allows a quick assessment and makes use of clinical data available in clinical practice, its clinical application is promising.
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Affiliation(s)
- Fuyou Liang
- SJTU-CU International Cooperative Research Center, School of Naval Architecture, Ocean and Civil Engineering, Shanghai Jiao Tong University, 800 Dongchuan Road, Shanghai, 200240, China
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Kung E, Perry JC, Davis C, Migliavacca F, Pennati G, Giardini A, Hsia TY, Marsden A. Computational modeling of pathophysiologic responses to exercise in Fontan patients. Ann Biomed Eng 2014; 43:1335-47. [PMID: 25260878 DOI: 10.1007/s10439-014-1131-4] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2014] [Accepted: 09/19/2014] [Indexed: 11/29/2022]
Abstract
Reduced exercise capacity is nearly universal among Fontan patients. Although many factors have emerged as possible contributors, the degree to which each impacts the overall hemodynamics is largely unknown. Computational modeling provides a means to test hypotheses of causes of exercise intolerance via precisely controlled virtual experiments and measurements. We quantified the physiological impacts of commonly encountered, clinically relevant dysfunctions introduced to the exercising Fontan system via a previously developed lumped-parameter model of Fontan exercise. Elevated pulmonary arterial pressure was observed in all cases of dysfunction, correlated with lowered cardiac output (CO), and often mediated by elevated atrial pressure. Pulmonary vascular resistance was not the most significant factor affecting exercise performance as measured by CO. In the absence of other dysfunctions, atrioventricular valve insufficiency alone had significant physiological impact, especially under exercise demands. The impact of isolated dysfunctions can be linearly summed to approximate the combined impact of several dysfunctions occurring in the same system. A single dominant cause of exercise intolerance was not identified, though several hypothesized dysfunctions each led to variable decreases in performance. Computational predictions of performance improvement associated with various interventions should be weighed against procedural risks and potential complications, contributing to improvements in routine patient management protocol.
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Affiliation(s)
- Ethan Kung
- Mechanical Engineering Department, Clemson University, Clemson, SC, 29634, USA
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Elder RW, McCabe NM, Veledar E, Kogon BE, Jokhadar M, Rodriguez FH, McConnell ME, Book WM. Risk factors for major adverse events late after Fontan palliation. CONGENIT HEART DIS 2014; 10:159-68. [PMID: 25130602 DOI: 10.1111/chd.12212] [Citation(s) in RCA: 56] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 07/04/2014] [Indexed: 11/26/2022]
Abstract
OBJECTIVE Risk factors for major adverse events late after Fontan palliation are unknown. Prior studies have suggested ventricular function and morphology as important risk factors. The aim of this study is to (1) characterize the late major adverse event profile in adult Fontan patients and (2) identify additional risk factors that may contribute to adverse outcomes. DESIGN AND SETTING A retrospective review of all adult patients >15 years post-Fontan seen at a tertiary academic center was conducted. Clinical, laboratory, cardiac data, and abdominal imaging were collected via chart review. Major adverse events (death, cardiac transplantation, or listing) were identified, and timing of events was plotted using Kaplan-Meier methods. Univariate and multivariate logistic regression was used to determine independent predictors of late-term events. RESULTS A total of 123 adult Fontan patients were identified (mean time post-Fontan 22.4 years [±4.4]). Major adverse events occurred in 19/123 patients (15%). In this 15-year survivor cohort, transplant-free survival rates were 94.6%, 82.9%, and 59.8% at 20, 25, and 30 years postoperation, respectively. Modes of death were Fontan failure with preserved function (4), congestive heart failure with decreased function (2), sudden death (2), thromboembolic event (1), post-Fontan conversion (2), and posttransplant (2). No differences in adverse outcomes were found based on morphology of the systemic ventricle, Fontan type, or systolic ventricular function. On the other hand, features of portal hypertension (OR 19.0, CI 4.7-77.3, P < .0001), presence of a pacemaker (OR 13.4, CI 2.6-69.8, P = .002), and systemic oxygen desaturation (OR 0.86, CI 0.75-0.98, P = .02) were risk factors for major adverse events in the multivariate analysis. CONCLUSIONS In adult Fontan patients surviving >15 years post-Fontan, portal hypertension, oxygen desaturation, and need for pacemaker were predictive of adverse events. Traditional measures may not predict late-term outcomes in adult survivors; further study of the liver's role in late outcomes is warranted.
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Affiliation(s)
- Robert W Elder
- Section of Cardiology, Pediatrics and Internal Medicine, Yale School of Medicine, New Haven, Conn, USA
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Secchi F, Resta EC, Di Leo G, Petrini M, Messina C, Carminati M, Sardanelli F. Segmentation of cardiac magnetic resonance cine images of single ventricle: including or excluding the accessorial ventricle? Int J Cardiovasc Imaging 2014; 30:1117-24. [PMID: 24801178 DOI: 10.1007/s10554-014-0438-4] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/15/2014] [Accepted: 04/28/2014] [Indexed: 10/25/2022]
Abstract
Our aim was to compare two different approaches for segmentation of single ventricle (SV) on cardiac magnetic resonance (CMR) cine images. We retrospectively studied 30 consecutive patients (23 males; aged 27 ± 10 years) with a treated SV who underwent 1.5-T CMR using ECG-triggered axial true-FISP, HASTE and cine true-FISP sequences. We classified patients for visceroatrial situs, cardiac axis orientation, ventricular loop, morphology of SV and position of great arteries. One experienced reader segmented cine images twice, firstly including only the systemic ventricle, secondly including both systemic and accessorial ventricles. Ejection fraction (EF), indexed end-diastolic volume (EDVI), end-systolic volume (ESVI), and stroke volume (SVI) were calculated. Data were presented as medians and interquartile intervals. Four patients presented dextrocardia and one patient mesocardia. Two had situs ambiguus with asplenia and one situs ambiguus with polisplenia. Four patients showed right morphology of the SV and three levo-ventricle loop. We found 14 levo-trasposition of great arteries (TGA), 4 levo-malposition of great arteries (MGA), four dextro-MGA, two dextro-TGA, and one inverted vessel position. When segmenting only the systemic ventricle, EDVI (mL/m2) was 65 (50-91), when segmenting both ventricles 76 (58-110) (P < 0.001); ESVI (mL/m2) was 32 (24-45) and 45 (33-60), respectively (P < 0.001); EF (%) was 49 (43-57) and 33 (24-47), respectively (P = 0.003); SVI (mL/m2) was 34 (17-48) and 33 (24-47) (P = 0.070). The inclusion of the accessorial ventricle in the segmentation of SV produce a biased lower EF showing a very low contribution to the pump function.
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Affiliation(s)
- Francesco Secchi
- Radiology Unit, IRCCS Policlinico San Donato, Piazza Malan 2, 20097, San Donato Milanese, Italy,
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McCrindle BW, Zak V, Breitbart RE, Mahony L, Shrader P, Lai WW, Burns KM, Colan SD, Williams RV, Goldberg D, Hill KD, Khaikin S, Atz AM. The relationship of patient medical and laboratory characteristics to changes in functional health status in children and adolescents after the Fontan procedure. Pediatr Cardiol 2014; 35:632-40. [PMID: 24264999 PMCID: PMC3959245 DOI: 10.1007/s00246-013-0831-0] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/16/2013] [Accepted: 10/26/2013] [Indexed: 10/26/2022]
Abstract
Despite hypothesized concerns about deterioration beginning in adolescence, longitudinal data and associated factors regarding standardized assessment of physical functioning are not available for Fontan patients. Parents who participated in the Fontan Cross-Sectional Study completed the Child Health Questionnaire at 2 time points for 245 subjects ages 6-18 years. Associations between change in Physical Functioning Summary Score and baseline patient, medical, and laboratory characteristics (mean age 9.5 ± 1.7 years) and follow-up patient and medical characteristics (mean age 16.2 ± 1.6 years) were determined by regression analyses. During a mean of 6.7 ± 0.4 years, a small (not clinically important) but statistically significant decrease in score from 46.2 ± 11.7 to 44.5 ± 12.1 (p < 0.03) was noted. Subjects with higher baseline scores had a greater decrease in score (r = -0.48; p < 0.001). A multivariable model of patient and medical characteristics (R(2) = 0.11) showed that a greater decrease in score was significantly associated with interim development of asthma (n = 13; parameter estimate [PE] -6.6; p < 0.05) or other chronic respiratory, lung, or breathing problems (n = 13; PE -12.5; p < 0.001) and the presence of protein-losing enteropathy at any time (n = 12; PE -9.4; p = 0.006). Change in score was not significantly associated with baseline laboratory measures of exercise capacity and ventricular characteristics and function. Therefore, although physical functioning may be stable during adolescence for many Fontan patients, deterioration occurs in some in association with respiratory conditions and protein-losing enteropathy. Further longitudinal study is necessary to better understand the relationship between clinical morbidities and functional health status as these patients transition into adulthood.
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Affiliation(s)
| | - Victor Zak
- New England Research Institutes, Watertown, MA
| | | | - Lynn Mahony
- University of Texas Southwestern Medical Center, Dallas, TX
| | | | - Wyman W. Lai
- Columbia University Medical Center, New York, NY
| | | | | | | | | | | | - Svetlana Khaikin
- University of Toronto, The Hospital for Sick Children, Toronto, Canada
| | - Andrew M. Atz
- Medical University of South Carolina, Charleston, SC
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Ibrahim L. Mid-term outcome of Egyptian children post univentricular repair (experience of single center). EGYPTIAN PEDIATRIC ASSOCIATION GAZETTE 2014. [DOI: 10.1016/j.epag.2013.12.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022] Open
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