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Huynh E, Chernick R, Desai M. Francis Fontan (1929-2018): Pioneer pediatric cardiac surgeon. JOURNAL OF MEDICAL BIOGRAPHY 2024; 32:110-118. [PMID: 36069037 DOI: 10.1177/09677720221123322] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/15/2023]
Abstract
Up until the mid-1900s, tricuspid atresia - a birth defect of the tricuspid valve, was once categorized as a "death sentence." The challenge of achieving positive health outcomes for affected patients was compounded by a hesitancy to operate on children. The main concern was safely administering anesthesia to young patients who were going through a strenuous operation that was often poorly tolerated. Despite these assumed limitations, Francis Fontan, a pediatric cardiothoracic surgeon at the Hospital of Tondu in Bordeaux, was able to redirect blood flow from the superior and inferior vena cava to the pulmonary arteries in 1971, which elucidated the process of advancing clinical practice in medicine. With the support of mentors and a firm belief in this new technique, Fontan pioneered his eponymous procedure and ultimately paved the way for modern cardiovascular surgical techniques that helped to prolong the life of those with single functioning ventricles. The aim of this study is to examine the genesis and the evolution of the Fontan procedure to elucidate the process of advancing clinical practice in medicine by utilizing personal interviews, Fontan's works, associated primary and secondary sources in the context of 20th century cardiothoracic surgery and innovations.
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Affiliation(s)
| | | | - Manisha Desai
- Department of Anesthesiology and Perioperative Medicine, UMass Chan Medical School, Worcester, MA, USA
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2
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Overshoot of the Respiratory Exchange Ratio during Recovery from Maximal Exercise Testing in Young Patients with Congenital Heart Disease. CHILDREN 2023; 10:children10030521. [PMID: 36980079 PMCID: PMC10047014 DOI: 10.3390/children10030521] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/31/2022] [Revised: 03/02/2023] [Accepted: 03/04/2023] [Indexed: 03/09/2023]
Abstract
Introduction: The overshoot of the respiratory exchange ratio (RER) after exercise is reduced in patients with heart failure. Aim: The present study aimed to investigate the presence of this phenomenon in young patients with congenital heart disease (CHD), who generally present reduced cardiorespiratory fitness. Methods: In this retrospective study, patients with CHD underwent a maximal cardiopulmonary exercise testing (CPET) assessing the RER recovery parameters: the RER at peak exercise, the maximum RER value reached during recovery, the magnitude of the RER overshoot and the linear slope of the RER increase after the end of the exercise. Results: In total, 117 patients were included in this study. Of these, there were 24 healthy age-matched control subjects and 93 young patients with CHD (transposition of great arteries, Fontan procedure, aortic coarctation and tetralogy of Fallot). All patients presented a RER overshoot during recovery. Patients with CHD showed reduced aerobic capacity and cardiorespiratory efficiency during exercise, as well as a lower RER overshoot when compared to controls. RER magnitude was higher in the controls and patients with aortic coarctation when compared to those with transposition of great arteries, previous Fontan procedure, and tetralogy of Fallot. The RER magnitude was found to be correlated with the most relevant cardiorespiratory fitness and efficiency indices. Conclusions: The present study proposes new recovery indices for functional evaluation in patients with CHD. Thus, the RER recovery overshoots analysis should be part of routine CPET evaluation to further improve prognostic risk stratifications in patients with CHD.
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Alhabdan MS, Alzayer EA, Alawami MH, Khouqeer FA. Social life in adult patients after Fontan procedure. THE CARDIOTHORACIC SURGEON 2022. [DOI: 10.1186/s43057-022-00087-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022] Open
Abstract
Abstract
Background
Little is known about the social life in adult patients after Fontan palliation. The study aimed to assess the long-term social life of patients after Fontan surgery, including school achievement, employment, and marital status.
Results
We conducted a cross-sectional study on patients aged 18 years or above who had a Fontan operation for a single ventricle pathology. Our outcomes were the academic performance and marital and employment status of adult Fontan patients. Patients or their families were interviewed directly or by phone, and a set of questions were asked to address their educational level, employment, and marital status. Ninety-nine patients were included in the study. Their median age was 21 years (min–max: 18–41), and 60% were females (n= 59). The most common diagnoses were double inlet left ventricle (n= 24, 24%), tricuspid atresia (n= 21, 21%), and the unbalanced atrioventricular canal (n= 21, 21%). Fourteen patients (14%) were married, and 6 of them had children (two were females). Eleven percent were college graduates (either diploma or bachelor’s degree), and 47% were high school graduates.
Conclusions
Fontan operation could negatively affect the social life of the patients. It may affect employment patterns, educational levels, and marital status.
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4
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Selvanathan T, Smith JM, Miller SP, Field TS. Neurodevelopment and cognition across the lifespan in patients with single ventricle physiology: Abnormal brain maturation and accumulation of brain injuries. Can J Cardiol 2022; 38:977-987. [DOI: 10.1016/j.cjca.2022.02.009] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2021] [Revised: 01/19/2022] [Accepted: 02/01/2022] [Indexed: 02/08/2023] Open
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5
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Xu X, Lin JHI, Bais AS, Reynolds MJ, Tan T, Gabriel GC, Kondos Z, Liu X, Shiva SS, Lo CW. Mitochondrial Respiration Defects in Single-Ventricle Congenital Heart Disease. Front Cardiovasc Med 2021; 8:734388. [PMID: 34631832 PMCID: PMC8494974 DOI: 10.3389/fcvm.2021.734388] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2021] [Accepted: 08/16/2021] [Indexed: 02/04/2023] Open
Abstract
Background: Congenital heart disease (CHD) with single-ventricle (SV) physiology is now survivable with a three-stage surgical course ending with Fontan palliation. However, 10-year transplant-free survival remains at 39–50%, with ventricular dysfunction progressing to heart failure (HF) being a common sequela. For SV-CHD patients who develop HF, undergoing the surgical course would not be helpful and could even be detrimental. As HF risk cannot be predicted and metabolic defects have been observed in Ohia SV-CHD mice, we hypothesized that respiratory defects in peripheral blood mononuclear cells (PBMCs) may allow HF risk stratification in SV-CHD. Methods: SV-CHD (n = 20), biventricular CHD (BV-CHD; n = 16), or healthy control subjects (n = 22) were recruited, and PBMC oxygen consumption rate (OCR) was measured using the Seahorse Analyzer. Respiration was similarly measured in Ohia mouse heart tissue. Results: Post-Fontan SV-CHD patients with HF showed higher maximal respiratory capacity (p = 0.004) and respiratory reserve (p < 0.0001), parameters important for cell stress adaptation, while the opposite was found for those without HF (reserve p = 0.037; maximal p = 0.05). This was observed in comparison to BV-CHD or healthy controls. However, respiration did not differ between SV patients pre- and post-Fontan or between pre- or post-Fontan SV-CHD patients and BV-CHD. Reminiscent of these findings, heart tissue from Ohia mice with SV-CHD also showed higher OCR, while those without CHD showed lower OCR. Conclusion: Elevated mitochondrial respiration in PBMCs is correlated with HF in post-Fontan SV-CHD, suggesting that PBMC respiration may have utility for prognosticating HF risk in SV-CHD. Whether elevated respiration may reflect maladaptation to altered hemodynamics in SV-CHD warrants further investigation.
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Affiliation(s)
- Xinxiu Xu
- Department of Developmental Biology, School of Medicine, University of Pittsburgh, Pittsburgh, PA, United States
| | - Jiuann-Huey Ivy Lin
- Department of Developmental Biology, School of Medicine, University of Pittsburgh, Pittsburgh, PA, United States.,Department of Critical Care Medicine, School of Medicine, University of Pittsburgh, Pittsburgh, PA, United States
| | - Abha S Bais
- Department of Developmental Biology, School of Medicine, University of Pittsburgh, Pittsburgh, PA, United States
| | - Michael John Reynolds
- School of Medicine, Pittsburgh Heart, Lung, Vascular Medicine Institute, University of Pittsburgh, Pittsburgh, PA, United States
| | - Tuantuan Tan
- Department of Developmental Biology, School of Medicine, University of Pittsburgh, Pittsburgh, PA, United States
| | - George C Gabriel
- Department of Developmental Biology, School of Medicine, University of Pittsburgh, Pittsburgh, PA, United States
| | - Zoie Kondos
- Department of Developmental Biology, School of Medicine, University of Pittsburgh, Pittsburgh, PA, United States
| | - Xiaoqin Liu
- Department of Developmental Biology, School of Medicine, University of Pittsburgh, Pittsburgh, PA, United States
| | - Sruti S Shiva
- School of Medicine, Pittsburgh Heart, Lung, Vascular Medicine Institute, University of Pittsburgh, Pittsburgh, PA, United States.,Department of Pharmacology and Chemical Biology, School of Medicine, University of Pittsburgh, Pittsburgh, PA, United States
| | - Cecilia W Lo
- Department of Developmental Biology, School of Medicine, University of Pittsburgh, Pittsburgh, PA, United States
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6
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Fujita S, Oda S, Ono T, Sonoda H, Shiose A. Double valve replacement after ventricular assist device implantation in a Fontan patient. Ann Thorac Surg 2021; 113:e437-e439. [PMID: 34599908 DOI: 10.1016/j.athoracsur.2021.08.050] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/11/2021] [Accepted: 08/17/2021] [Indexed: 11/01/2022]
Abstract
Few reports have described the implantation and management of an implantable ventricular assist device in patients with functional uni-ventricular anatomy. We herein report a case who underwent HVAD implantation due to severe cardiac dysfunction and Fontan failure in the remote period following total cavo-pulmonary connection. Double valve replacement was subsequently required one year later due to repeated Fontan failure caused by the progression of aortic and atrioventricular regurgitation. The low-profile and saddle-shaped sewing cuff design of the MITRIS were beneficial for avoiding the HVAD inflow and atrioventricular valve interference in the less-dilated ventricle.
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Affiliation(s)
- Satoshi Fujita
- Department of Cardiovascular Surgery, Kyushu University Hospital, Fukuoka, Japan
| | - Shinichiro Oda
- Department of Cardiovascular Surgery, Kyushu University Hospital, Fukuoka, Japan
| | - Tomoyuki Ono
- Department of Cardiovascular Surgery, Kyushu University Hospital, Fukuoka, Japan
| | - Hiromichi Sonoda
- Department of Cardiovascular Surgery, Kyushu University Hospital, Fukuoka, Japan
| | - Akira Shiose
- Department of Cardiovascular Surgery, Kyushu University Hospital, Fukuoka, Japan.
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Girnius A, Zentner D, Valente AM, Pieper PG, Economy KE, Ladouceur M, Roos-Hesselink JW, Warshak C, Partington SL, Gao Z, Ollberding N, Faust M, Girnius S, Kaemmerer H, Nagdyman N, Cohen S, Canobbio M, Akagi T, Grewal J, Bradley E, Buber Y, Palumbo J, Walker N, Aboulhosn J, Oechslin E, Baumgartner H, Kurdi W, Book WM, Mulder BJM, Veldtman GR. Bleeding and thrombotic risk in pregnant women with Fontan physiology. Heart 2021; 107:1390-1397. [PMID: 33234672 PMCID: PMC10367127 DOI: 10.1136/heartjnl-2020-317397] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/27/2020] [Revised: 10/16/2020] [Accepted: 10/21/2020] [Indexed: 02/03/2023] Open
Abstract
BACKGROUND/OBJECTIVES Pregnancy may potentiate the inherent hypercoagulability of the Fontan circulation, thereby amplifying adverse events. This study sought to evaluate thrombosis and bleeding risk in pregnant women with a Fontan. METHODS We performed a retrospective observational cohort study across 13 international centres and recorded data on thrombotic and bleeding events, antithrombotic therapies and pre-pregnancy thrombotic risk factors. RESULTS We analysed 84 women with Fontan physiology undergoing 108 pregnancies, average gestation 33±5 weeks. The most common antithrombotic therapy in pregnancy was aspirin (ASA, 47 pregnancies (43.5%)). Heparin (unfractionated (UFH) or low molecular weight (LMWH)) was prescribed in 32 pregnancies (30%) and vitamin K antagonist (VKA) in 10 pregnancies (9%). Three pregnancies were complicated by thrombotic events (2.8%). Thirty-eight pregnancies (35%) were complicated by bleeding, of which 5 (13%) were severe. Most bleeds were obstetric, occurring antepartum (45%) and postpartum (42%). The use of therapeutic heparin (OR 15.6, 95% CI 1.88 to 129, p=0.006), VKA (OR 11.7, 95% CI 1.06 to 130, p=0.032) or any combination of anticoagulation medication (OR 13.0, 95% CI 1.13 to 150, p=0.032) were significantly associated with bleeding events, while ASA (OR 5.41, 95% CI 0.73 to 40.4, p=0.067) and prophylactic heparin were not (OR 4.68, 95% CI 0.488 to 44.9, p=0.096). CONCLUSIONS Current antithrombotic strategies appear effective at attenuating thrombotic risk in pregnant women with a Fontan. However, this comes with high (>30%) bleeding risk, of which 13% are life threatening. Achieving haemostatic balance is challenging in pregnant women with a Fontan, necessitating individualised risk-adjusted counselling and therapeutic approaches that are monitored during the course of pregnancy.
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Affiliation(s)
- Andrea Girnius
- Anesthesiology, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
| | - Dominica Zentner
- Department of Cardiology and Department of Genomic Medicine, Royal Melbourne Hospital, Melbourne, Victoria, Australia.,Faculty of Medicine, Dentistry and Health Sciences, University of Melbourne, Melbourne, Victoria, Australia
| | - Anne Marie Valente
- Brigham and Women's Hospital, Department of Medicine, Division of Cardiovascular Disease, Department of Cardiology Harvard Medical School, Boston, Massachusetts, USA
| | - Petronella G Pieper
- Department of Cardiology, University Medical Center Groningen, Groningen, The Netherlands
| | - Katherine E Economy
- Brigham and Women's Hospital, Department of Obstetrics and Gynecology, Division Maternal Fetal Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Magalie Ladouceur
- Cardiology, Hopital Europeen Georges Pompidou, Paris, France.,Pediatric Cardiology, Hopital Universitaire Necker-Enfants Malades, Paris, France
| | | | - Carri Warshak
- Obstetrics and Gynecology, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
| | - Sara L Partington
- Division of Cardiovascular Medicine, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA.,Division of Cardiology, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Zhiqian Gao
- Heart Institute, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
| | - Nicholas Ollberding
- Department of Pediatrics, Cincinnati Children's Hospital Medical Centre, Cincinnati, Ohio, USA.,Division of Biostatistics and Epidemiology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
| | - Michelle Faust
- Heart Institute, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
| | - Saulius Girnius
- Department of Hematology, Trihealth Cancer Institute, Cincinnati, Ohio, USA
| | | | | | - Scott Cohen
- Department of Cardiology, The Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | - Mary Canobbio
- School of Nursing, University of California Los Angeles, Los Angeles, California, USA
| | - Teiji Akagi
- Cardiovascular Medicine, Okayama University, Okayama, Japan
| | - Jasmine Grewal
- Cardiology, The University of British Columbia Faculty of Medicine, Vancouver, British Columbia, Canada
| | - Elisa Bradley
- Adult Congenital Heart Disease, The Ohio State University & Nationwide Children's Hospital, Nationwide Children's Hospital, Columbus, Ohio, USA
| | - Yonathan Buber
- Department of Medicine, Division of Cardiology, University of Washington School of Medicine, Seattle, Washington, USA
| | - Joseph Palumbo
- Haematology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
| | | | - Jamil Aboulhosn
- Ahmanson/UCLA ACHD Center, David Geffen School of Medicine at UCLA, Los Angeles, California, USA
| | - Erwin Oechslin
- Toronto Congenital Cardiac Centre for Adults, Peter Munk Cardiac Centre, University Heatlh Network and University of Toronto, Toronto, Ontario, Canada.,Bitove Family Professorship of Adult Congenital Heart Disease, Toronto General Hospital, Toronto, Ontario, Canada
| | - Helmut Baumgartner
- Department of Cardiology III: Adult Congenital and Valvular Heart Disease, University Hospital Muenster, Muenster, Albert Schweitzer Campus 1, Building A1, 48149 Muenster, Germany
| | - Wesam Kurdi
- King Faisal Specialist Hospital and Research Center, Riyadh, Saudi Arabia
| | - Wendy M Book
- Internal Medicine, Division of Cardiology, Emory University, Atlanta, Georgia, USA
| | | | - Gruschen R Veldtman
- Adult Congenital Heart Disease, King Faisal Specialist Hospital and Research Centre, Riyadh, Saudi Arabia
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8
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Hraska V, Mitchell ME, Woods RK, Hoffman GM, Kindel SJ, Ginde S. Innominate Vein Turn-down Procedure for Failing Fontan Circulation. Semin Thorac Cardiovasc Surg Pediatr Card Surg Annu 2021; 23:34-40. [PMID: 32354545 DOI: 10.1053/j.pcsu.2020.01.002] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2019] [Revised: 01/06/2020] [Accepted: 01/25/2020] [Indexed: 12/16/2022]
Abstract
After the Fontan, systemic venous hypertension induces pathophysiologic changes in the lymphatic system that can result in complications of pleural effusion, ascites, plastic bronchitis, and protein losing enteropathy. Advances in medical therapy and novel interventional approaches have not substantially improved the poor prognosis of these complications. A more physiological approach has been developed by decompression of the thoracic duct to the lower pressure common atrium with a concomitant increase of preload. Diverting the innominate vein to the common atrium increases the transport capacity of the thoracic duct, which in most patients enters the circulation at the left subclavian-jugular vein junction. Contrary to the fenestrated Fontan circulation, in which the thoracic duct is drained into the high pressure Fontan circulation, turn down of the innominate vein to the common atrium effectively decompresses the thoracic duct to the lower pressure system with "diastolic suctioning" of lymph. Innominate vein turn-down may be considered for medical-refractory post-Fontan lymphatic complications of persistent chylothorax, plastic bronchitis, and protein losing enteropathy. Prophylactic innominate vein turn-down may also be considered at time of the Fontan operation for patients that are higher risk for lymphatic complications.
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Affiliation(s)
- Viktor Hraska
- Division of Congenital Heart Surgery; Department of Surgery, Herma Heart Institute, Medical College of Wisconsin, Milwaukee, Wisconsin.
| | - Michael E Mitchell
- Division of Congenital Heart Surgery; Department of Surgery, Herma Heart Institute, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Ronald K Woods
- Division of Congenital Heart Surgery; Department of Surgery, Herma Heart Institute, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - George M Hoffman
- Department of Anesthesia, Herma Heart Institute, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Steven J Kindel
- Division of Pediatric Cardiology, Department of Pediatrics, Herma Heart Institute, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Salil Ginde
- Division of Pediatric Cardiology, Department of Pediatrics, Herma Heart Institute, Medical College of Wisconsin, Milwaukee, Wisconsin
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Khuong JN, Wilson TG, Iyengar AJ, d'Udekem Y. Acute and Chronic Kidney Disease Following Congenital Heart Surgery: A Review. Ann Thorac Surg 2020; 112:1698-1706. [PMID: 33310148 DOI: 10.1016/j.athoracsur.2020.10.054] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/14/2020] [Revised: 09/13/2020] [Accepted: 10/05/2020] [Indexed: 01/14/2023]
Abstract
BACKGROUND There is an increasing prevalence of chronic kidney disease in the population of adults currently living with congenital heart disease. A considerable proportion of children who undergo congenital heart surgery experience postoperative acute kidney injury. Whether there is an association between acute kidney injury after cardiac surgery in childhood and development of chronic kidney disease is unclear. METHODS Three electronic databases were searched to capture relevant studies exploring the relationship between acute kidney injury after congenital heart surgery in children and progression to chronic kidney disease. RESULTS A literature search identified a total of 212 research articles, 7 of which were selected for in-depth review. CONCLUSIONS There is a likely association between acute kidney injury in children undergoing congenital heart surgery and progression to chronic kidney disease. Research should be developed to mitigate factors contributing to postoperative acute kidney injury in neonates, infants, and children undergoing cardiac surgery. Better targeted follow-up protocols to monitor renal function in children undergoing cardiac surgery should be implemented. A universal definition for acute kidney injury and chronic kidney disease is needed to improve detection and research in this field.
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Affiliation(s)
- Jacqueline N Khuong
- Heart Research Group, Murdoch Children's Research Institute, Melbourne, Australia; Department of Paediatrics, Faculty of Medicine, University of Melbourne, Melbourne, Australia
| | - Thomas G Wilson
- Heart Research Group, Murdoch Children's Research Institute, Melbourne, Australia; Department of Paediatrics, Faculty of Medicine, University of Melbourne, Melbourne, Australia
| | - Ajay J Iyengar
- Heart Research Group, Murdoch Children's Research Institute, Melbourne, Australia; Department of Paediatrics, Faculty of Medicine, University of Melbourne, Melbourne, Australia
| | - Yves d'Udekem
- Division of Cardiac Surgery, Children's National Hospital, Washington, DC.
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10
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Reddy S, Handler SS, Wu S, Rabinovitch M, Wright G. Proceedings From the 2019 Stanford Single Ventricle Scientific Summit: Advancing Science for Single Ventricle Patients: From Discovery to Clinical Applications. J Am Heart Assoc 2020; 9:e015871. [PMID: 32188306 PMCID: PMC7428620 DOI: 10.1161/jaha.119.015871] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
Because of remarkable advances in survival over the past 40 years, the worldwide population of individuals with single ventricle heart disease living with Fontan circulation has grown to ≈70 000, with nearly half aged >18 years. Survival to at least 30 years of age is now achievable for 75% of Fontan patients. On the other hand, single ventricle patients account for the largest group of the 6000 to 8000 children hospitalized with circulation failure, with or without heart failure annually in the United States, with the highest in‐hospital mortality. Because there is little understanding of the underlying mechanisms of heart failure, arrhythmias, pulmonary and lymphatic vascular abnormalities, and other morbidities, there are no specific treatments to maintain long‐term myocardial performance or to optimize overall patient outcomes.
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Affiliation(s)
- Sushma Reddy
- Department of Pediatrics (Cardiology) Stanford University Palo Alto CA
| | | | - Sean Wu
- Department of Medicine (Cardiology) Stanford University Palo Alto CA
| | | | - Gail Wright
- Department of Pediatrics (Cardiology) Stanford University Palo Alto CA
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11
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Talwar S, Marathe SP, Choudhary SK, Airan B. Where are we after 50 years of the Fontan operation? Indian J Thorac Cardiovasc Surg 2020; 37:42-53. [PMID: 33584026 DOI: 10.1007/s12055-019-00906-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2019] [Revised: 11/02/2019] [Accepted: 11/08/2019] [Indexed: 01/11/2023] Open
Abstract
First introduced in 1971, the Fontan procedure is the final common destination for all patients with a functional single ventricle. The procedure itself has evolved tremendously over the last five decades. This review traces this journey and presents the importance, outcomes and future outlook of the procedure in the current era.
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Affiliation(s)
- Sachin Talwar
- Cardiothoracic Centre, All India Institute of Medical Sciences, New Delhi, India
- Department of Cardiothoracic and Vascular Surgery, All India Institute of Medical Sciences, Ansari Nagar, New Delhi, 110029 India
| | | | - Shiv Kumar Choudhary
- Cardiothoracic Centre, All India Institute of Medical Sciences, New Delhi, India
| | - Balram Airan
- Mahatma Gandhi Hospital, Mahatma Gandhi University of Medical Sciences Technology, Jaipur, India
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12
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Ruth ND, Drury NE, Bennett J, Kelly DA. Cardiac and Liver Disease in Children: Implications for Management Before and After Liver Transplantation. Liver Transpl 2020; 26:437-449. [PMID: 31872564 DOI: 10.1002/lt.25666] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/21/2018] [Accepted: 10/16/2019] [Indexed: 02/06/2023]
Abstract
There is close interaction between the functions of the liver and heart affecting the presentation, diagnosis, and outcome of acute and chronic cardiac and liver disease. Conditions affecting both organ systems should be considered when proposing transplantation because the interaction between cardiac disease and liver disease has implications for diagnosis, management, selection for transplantation, and, ultimately, for longterm outcomes after liver transplantation (LT). The combination of cardiac and liver disease is well recognized in adults but is less appreciated in pediatric patients. The focus of this review is to describe conditions affecting both the liver and heart and how they affect selection and management of LT in the pediatric population.
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Affiliation(s)
- Nicola D Ruth
- Liver Unit, Birmingham Women's & Children's Hospital, Birmingham, United Kingdom.,Institute of Infection and Immunity, University of Birmingham, Birmingham, United Kingdom
| | - Nigel E Drury
- Department of Paediatric Cardiac Surgery, Birmingham Women's & Children's Hospital, Birmingham, United Kingdom.,Institute of Cardiovascular Sciences, University of Birmingham, Birmingham, United Kingdom
| | - James Bennett
- Department of Anaesthesia, Birmingham Women's & Children's Hospital, Birmingham, United Kingdom.,Department of Anaesthesia, Queen Elizabeth Hospital Birmingham, Birmingham, United Kingdom
| | - Deirdre A Kelly
- Liver Unit, Birmingham Women's & Children's Hospital, Birmingham, United Kingdom.,Institute of Infection and Immunity, University of Birmingham, Birmingham, United Kingdom
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13
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Abstract
Objective: In recent years, attempting the biventricular pathway or biventricular conversions in patients with borderline ventricle has become a hot topic. However, inappropriate pursuit of biventricular repair in borderline candidates will lead to adverse clinical outcomes. Therefore, it is important to accurately assess the degree of ventricular development before operation and whether it can tolerate biventricular repair. This review evaluated ventricular development using echocardiography for a better prediction of biventricular repair in borderline ventricle. Data sources: Articles from January 1, 1990 to April 1, 2019 on biventricular repair in borderline ventricle were accessed from PubMed, using keywords including “borderline ventricle,” “congenital heart disease,” “CHD,” “echocardiography,” and “biventricular repair.” Study selection: Original articles and critical reviews relevant to the review's theme were selected. Results: Borderline left ventricle (LV): (1) Critical aortic stenosis: the Rhodes score, Congenital Heart Surgeons Society regression equation and another new scoring system was proposed to predict the feasibility of biventricular repair. (2) Aortic arch hypoplasia: the LV size and the diameter of aortic and mitral valve (MV) annulus should be taken into considerations for biventricular repair. (3) Right-dominant unbalanced atrioventricular septal defect (AVSD): atrioventricular valve index (AVVI), left ventricular inflow index (LVII), and right ventricle (RV)/LV inflow angle were the echocardiographic indices for biventricular repair. Borderline RV: (1) pulmonary atresia/intact ventricular septum (PA/IVS): the diameter z-score of tricuspid valve (TV) annulus, ratio of TV to MV diameter, RV inlet length z-score, RV area z-score, RV development index, and RV-TV index, etc. Less objective but more practical description is to classify the RV as tripartite, bipartite, and unipartite. The presence or absence of RV sinusoids, RV dependent coronary circulation, and the degree of tricuspid regurgitation should also be noted. (2) Left-dominant unbalanced AVSD: AVVI, LV, and RV volumes, whether apex forming ventricles were the echocardiographic indices for biventricular repair. Conclusions: Although the evaluation of echocardiography cannot guarantee the success of biventricular repair surgery, echocardiography can still provide relatively valuable basis for surgical decision making.
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14
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Contemporary Outcomes of the Fontan Operation: A Large Single-Institution Cohort. Ann Thorac Surg 2019; 108:1439-1446. [DOI: 10.1016/j.athoracsur.2019.05.039] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/22/2018] [Revised: 05/07/2019] [Accepted: 05/08/2019] [Indexed: 12/31/2022]
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15
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Diab SG, Godang K, Müller LO, Almaas R, Lange C, Brunvand L, Hansen KM, Myhre AG, Døhlen G, Thaulow E, Bollerslev J, Möller T. Progressive loss of bone mass in children with Fontan circulation. CONGENIT HEART DIS 2019; 14:996-1004. [DOI: 10.1111/chd.12848] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/29/2019] [Revised: 09/03/2019] [Accepted: 09/09/2019] [Indexed: 12/12/2022]
Affiliation(s)
- Simone Goa Diab
- Department of Pediatric Cardiology Oslo University Hospital Oslo Norway
| | - Kristin Godang
- Section of Specialized Endocrinology Oslo University Hospital Oslo Norway
| | - Lil‐Sofie Ording Müller
- Division of Radiology and Nuclear Medicine Section of Pediatric Radiology Oslo University Hospital Oslo Norway
| | - Runar Almaas
- Division of Pediatric and Adolescent Medicine Department of Pediatric Research Oslo University Hospital Oslo Norway
| | - Charlotte Lange
- Division of Radiology and Nuclear Medicine Section of Pediatric Radiology Oslo University Hospital Oslo Norway
| | - Leif Brunvand
- Department of Pediatric Cardiology Oslo University Hospital Oslo Norway
| | | | | | - Gaute Døhlen
- Department of Pediatric Cardiology Oslo University Hospital Oslo Norway
| | - Erik Thaulow
- Department of Pediatric Cardiology Oslo University Hospital Oslo Norway
- Institute of Clinical Medicine University of Oslo Oslo Norway
| | - Jens Bollerslev
- Section of Specialized Endocrinology Oslo University Hospital Oslo Norway
- Institute of Clinical Medicine University of Oslo Oslo Norway
| | - Thomas Möller
- Department of Pediatric Cardiology Oslo University Hospital Oslo Norway
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16
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Abstract
Half a century has passed since the original Fontan palliation. In the interim, surgical and medical advancements have allowed more single ventricle patients to reach Fontan and long-term survival for Fontan patients to improve significantly. However, the risk for Fontan failure and need for heart transplantation remains. In this article we discuss mechanisms of Fontan failure, risk factors and special considerations for Fontan patients in both medical and surgical management around heart transplantation and provide an updated review of survival for Fontan patients after heart transplantation.
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Affiliation(s)
- Amanda D McCormick
- Division of Pediatric Cardiology, C.S. Mott Children's Hospital, Ann Arbor, MI, USA
| | - Kurt R Schumacher
- Division of Pediatric Cardiology, C.S. Mott Children's Hospital, Ann Arbor, MI, USA
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17
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Abstract
OBJECTIVE To bring together stakeholders in the United Kingdom to establish national priorities for research in single-ventricle heart conditions. METHODS This study comprised two surveys and a workshop. The initial public online survey asked respondents up to three questions they would like answered for research. Responses were classified as unanswered, already answered, or unable to be answered by scientific research. In the follow-up survey, unanswered questions were divided into categories and respondents were asked to rank categories and questions by priority. A stakeholder workshop attended by patients, parents, healthcare professionals, researchers, and charities was held to determine the final list of research priorities. RESULTS A total of 128 respondents posed 344 research questions, of which 271 were classified as unanswered, and after removing duplicates, 204 questions remained, which were divided into 20 categories. In the second survey, 56 (49.1%) respondents successfully ranked categories and questions. A total of 39 participants attended the workshop, drawing up a list of 30 research priorities across nine priority categories. The nine priority categories are: Associated co-morbidities; Brain & neurodevelopment; Exercise; Fontan failure; Heart function; Living with a single ventricle heart condition; Management of the well-functioning Fontan circulation; Surgery & perioperative care; and Transplantation, mechanical support & novel therapies. CONCLUSIONS Through a multi-stage process, we engaged a wide range of interested parties to establish a list of research priorities in single-ventricle heart conditions. This provides a platform for clinicians, researchers, and funders in the United Kingdom and elsewhere to address the most important questions and improve outcomes in these rare but high-impact CHDs.
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18
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Heart beat but not respiration is the main driving force of the systemic venous return in the Fontan circulation. Sci Rep 2019; 9:2034. [PMID: 30765829 PMCID: PMC6376003 DOI: 10.1038/s41598-019-38848-5] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2018] [Accepted: 01/11/2019] [Indexed: 01/05/2023] Open
Abstract
The Fontan procedure provides relief from cyanosis in patients with univentricular hearts. A major clinical unmet need is to understand whether the venous flow patterns of the Fontan circulation lead to the development of congestive hepatopathy and other life-threatening complications. Currently, there is no consensus on whether heart beat or respiration is the main driving force of venous return and which one affects the periodic flow changes for the most (i. e., pulsatility). The present study, for the first time, quantified respiratory and cardiac components of the venous flow in the inferior vena cava (IVC) of 14 Fontan patients and 11 normal controls using a novel approach (“physio-matrix”). We found that in contrast to the normal controls, respiration in Fontan patients had a significant effect on venous flow pulsatility, and the ratio of respiration-dependent to the cardiac-dependent pulsatility was positively associated with the retrograde flow. Nevertheless, the main driving force of net IVC flow was the heart beat and not respiration. The separate analysis of the effects of respiration and heart beat provides new insights into the abnormal venous return patterns that may be responsible for adverse effects on liver and bowel of the patients with Fontan circulation.
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19
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Wang W, Hu X, Liao W, Rutahoile W, Malenka DJ, Zeng X, Yang Y, Feng P, Wen L, Huang W. The efficacy and safety of pulmonary vasodilators in patients with Fontan circulation: a meta-analysis of randomized controlled trials. Pulm Circ 2019; 9:2045894018790450. [PMID: 29972332 PMCID: PMC6348526 DOI: 10.1177/2045894018790450] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/22/2018] [Accepted: 07/02/2018] [Indexed: 11/17/2022] Open
Abstract
No previous meta-analysis has evaluated the efficacy and safety of pulmonary vasodilators in Fontan physiology. Recent relative trials have obtained conflicting results regarding improvements in peak oxygen consumption; the relatively small number of patients in each study may be a limiting factor. We aimed to evaluate the efficacy and safety of pulmonary vasodilators in Fontan patients. Relevant studies were identified by searching the PubMed, Embase, and Cochrane Library databases. Pooled outcomes were determined to assess the efficacy and safety of pulmonary vasodilators in Fontan patients. Nine randomized controlled studies involving 381 patients with Fontan circulation were included. Pulmonary vasodilator therapy led to significant improvement (mean difference = -0.39, 95% CI: [-0.72, -0.05]) in the New York Heart Association (NYHA) functional class. The 6-minute walking distance (6MWD) was significantly increased by 134 m (95% CI: [86.07, 181.94]), and the peak VO2 was also significantly improved (mean difference = 1.42 ml·(kg·min)-1, 95% CI: [0.21, 2.63]). Additionally, the mean pulmonary artery pressure (mPAP) was significantly reduced (mean difference = -2.25 mmHg, 95% CI: [-3.00, -1.50]). No significant change was found in mortality or in brain natriuretic peptide (BNP) or N-terminal pronatriuretic peptide (NT-proBNP). Four studies reported no side effects and good drug tolerance, and two studies reported mild adverse effects. The present meta-analysis indicated that pulmonary vasodilators (primarily the PDE-5 inhibitor and endothelin-1 receptor antagonist) significantly improved the hemodynamics of Fontan patients, reduced the NYHA functional class and increased the 6MWD. The peak oxygen consumption was also improved. No significant change was observed in mortality or in the BNP or NT-proBNP level. Overall, the pulmonary vasodilators were well tolerated. This finding needs to be confirmed in future studies.
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Affiliation(s)
- Wuwan Wang
- Department of Cardiology, the First Affiliated Hospital, Chongqing Medical University, Chongqing, China
| | - Xiankang Hu
- Chongqing Medical University, Chongqing, China
| | - Weitin Liao
- Chongqing Medical University, Chongqing, China
| | - W.H. Rutahoile
- Department of Cardiology, the First Affiliated Hospital, Chongqing Medical University, Chongqing, China
| | - David J. Malenka
- Section of Cardiovascular Medicine, Dartmouth-Hitchcock Medical Center, Lebanon, USA
| | - Xiaofang Zeng
- Department of Cardiology, the First Affiliated Hospital, Chongqing Medical University, Chongqing, China
| | - Yunjing Yang
- Department of Cardiology, the First Affiliated Hospital, Chongqing Medical University, Chongqing, China
| | - Panpan Feng
- Department of Cardiology, the First Affiliated Hospital, Chongqing Medical University, Chongqing, China
| | - Li Wen
- Department of Cardiology, the First Affiliated Hospital, Chongqing Medical University, Chongqing, China
| | - Wei Huang
- Department of Cardiology, the First Affiliated Hospital, Chongqing Medical University, Chongqing, China
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20
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Surveillance Testing and Preventive Care After Fontan Operation: A Multi-Institutional Survey. Pediatr Cardiol 2019; 40:110-115. [PMID: 30159585 DOI: 10.1007/s00246-018-1966-9] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/09/2018] [Accepted: 08/16/2018] [Indexed: 01/27/2023]
Abstract
More children with single ventricle heart disease are surviving after Fontan surgery. This circulation has pervasive effects on multiple organ systems and has unique modes of failure. Many centers have created multidisciplinary programs to care for these patients. Our aim was to survey such programs to better understand current approaches to care. We hypothesized that significant variability in surveillance testing strategy would be present. Eleven academic institutions with established Fontan care programs performing a combined estimated 300 Fontan surgeries per year, with a total population of 1500-2000 Fontan patients, were surveyed using a REDCap survey regarding surveillance testing and basic practice philosophies. Fontan care programs were structured both as consultative services (64%) and as the primary clinical team (9%). Electrocardiograms (73%) and echocardiograms (64%) were most commonly obtained annually. Serum studies, including complete blood count (73%), complete metabolic panel (73%), and Brain-type natriuretic peptide (54%), were most commonly obtained annually. Hepatic testing consisted of liver ultrasound in most centers, obtained biennially (45%) or > every 2 years (45%). Liver biopsy was not routinely recommended (54%). Neurodevelopmental outcomes were assessed at most institutions (54%), with a median frequency of every 3-4 years. There is considerable variability in the surveillance testing regimen and management strategy after a Fontan procedure at surveyed programs. There is an urgent need for surveillance guidelines to reduce variability, define quality metrics, streamline collaborative practice, and prospective research to better understand the complex adaptations of the body to Fontan physiology.
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21
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Zaki NC, Kelleman MS, James Parks W, Slesnick TC, McConnell ME, Oster ME. The utility of cardiac magnetic resonance imaging in post-Fontan surveillance. CONGENIT HEART DIS 2018; 14:140-146. [PMID: 30378262 DOI: 10.1111/chd.12692] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/24/2018] [Revised: 07/17/2018] [Accepted: 08/28/2018] [Indexed: 11/28/2022]
Abstract
OBJECTIVE Gated cardiac MRI offers the most detailed and accurate noninvasive method of assessing cardiac anatomy, particularly in patients with complex congenital heart disease. The proposed benefits of using cMRI as a routine screening tool in the Fontan population include early recognition of asymptomatic, postoperative anatomic and physiologic changes. In 2011, we therefore instituted at our center a recommended practice of cMRI screening in patients with Fontan physiology at 3 and 8 years post-Fontan operation. The purpose of this study was to determine the impact of this standardized practice of cMRI screening on the clinical management of a Fontan population. DESIGN We retrospectively reviewed charts from our institutional Fontan database to determine which patients were eligible for cMRI under the current guidelines and who underwent imaging from November 2002 to June 2015. We reviewed the frequency of cMRI and number of changes in management based on the results. Statistical significance was determined using a chi-square test. RESULTS There were 141 cMRIs performed on 121 patients who met inclusion criteria. The odds of a change in management were significantly greater after clinically indicated cMRI compared to screening cMRI (OR = 3.79, 95% CI: 1.48-9.66, P = .004). There were near significant odds of change in management if the cMRI occurred <8 years after Fontan regardless of whether it was for screening or clinically indicated purposes (OR = 2.43, 95% CI: 0.97-6.08, P = .052). The most frequent change in management was referral for catheterization with pulmonary artery angioplasty. CONCLUSIONS There is an important role for cMRI in routine surveillance of post-Fontan patients. Screening cMRI performed less than 8 years after Fontan palliation offers increased utility compared to studies performed later. The optimal timing of such imaging after Fontan palliation remains unclear.
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Affiliation(s)
- Neil C Zaki
- Emory University School of Medicine, Atlanta, Georgia.,Vanderbilt University School of Medicine, Nashville, Tennessee
| | | | - W James Parks
- Emory University School of Medicine, Atlanta, Georgia.,Children's Healthcare of Atlanta, Atlanta, Georgia
| | - Timothy C Slesnick
- Emory University School of Medicine, Atlanta, Georgia.,Children's Healthcare of Atlanta, Atlanta, Georgia
| | - Michael E McConnell
- Emory University School of Medicine, Atlanta, Georgia.,Children's Healthcare of Atlanta, Atlanta, Georgia
| | - Matthew E Oster
- Emory University School of Medicine, Atlanta, Georgia.,Children's Healthcare of Atlanta, Atlanta, Georgia
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22
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Smaś-Suska M, Róg B, Weryński P, Płazak W, Komar M, Olszowska M, Podolec P, Tomkiewicz-Pająk L. Long-Term Effects of Percutaneous Fenestration Following the Fontan Procedure in Adult Patients with Congenital Univentricular Heart. Med Sci Monit 2018; 24:3506-3513. [PMID: 29802801 PMCID: PMC5996839 DOI: 10.12659/msm.905786] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
Abstract
Background The Fontan procedure, performed for univentricular heart, may also include the technique of percutaneous fenestration to create a small atrial septal defect (ASD) and a right-to-left shunt. The aim of this study was to evaluate the long-term effects of fenestration in adult patients who had a Fontan procedure for univentricular heart. Material/Methods Fontan surgery was performed in 39 patients, including 19 (49%) patients with fenestration (Group I), and 20 (51%) patients without the fenestration procedure (Group II). Laboratory tests in both groups included echocardiography, plethysmography, cardiopulmonary exercise testing, and 24-hour Holter monitoring. Results Compared with patients in Group I, patients in Group II had a significantly increased level of N-terminal pro-brain natriuretic peptide (NT-proBNP) (p=0.04), alkaline phosphatase (ALP) (p=0.01) and a significant increase in frequency of atrial fibrillation (p=0.04). Patients in Group I had a significantly increased systemic ventricular ejection fraction (SVEF) (p=0.05) and increased heart rate (HR) (p=0.006), heart rate reserve (HRR) (p=0.02), ventilatory equivalent (VE) (p=0.01), and VO2 peak (p=0.05) on cardiopulmonary exercise testing (CPET). Renal, hematologic, and ventilatory parameters, and incidence of thromboembolism showed no significant differences between the groups. Conclusions Long-term follow-up of patients who underwent Fontan procedures with percutaneous fenestration had improved single ventricular function, lower NT-proBNP levels, improved exercise capacity, and reduced ALP levels. These findings indicate that percutaneous fenestration closure should be considered for adult patients who have undergone Fontan procedure for univentricular heart.
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Affiliation(s)
- Monika Smaś-Suska
- Departament of Cardiac and Vascular Diseases, Institute of Cardiology, Jagiellonian University Medical College, Cracow, Poland
| | - Beata Róg
- Outpatient Department of Cardiology and Cardiac Surgery, Institute of Cardiology, Jagiellonian University Medical College, Cracow, Poland
| | - Piotr Weryński
- Department of Pediatric Cardiology, Polish-American Institute of Pediatrics (PAIP), Jagiellonian University, Medical College, Cracow, Poland
| | - Wojciech Płazak
- Departament of Cardiac and Vascular Diseases, Institute of Cardiology, Jagiellonian University Medical College, Cracow, Poland
| | - Monika Komar
- Departament of Cardiac and Vascular Diseases, Institute of Cardiology, Jagiellonian University Medical College, Cracow, Poland
| | - Maria Olszowska
- Departament of Cardiac and Vascular Diseases, Institute of Cardiology, Jagiellonian University Medical College, Cracow, Poland
| | - Piotr Podolec
- Departament of Cardiac and Vascular Diseases, Institute of Cardiology, Jagiellonian University Medical College, Cracow, Poland
| | - Lidia Tomkiewicz-Pająk
- Departament of Cardiac and Vascular Diseases, Institute of Cardiology, Jagiellonian University Medical College, Cracow, Poland
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23
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Sinha L, Yerebakan C. The first integrated aortic turbine venous-assist system is born. J Thorac Cardiovasc Surg 2018; 156:304-305. [PMID: 29753509 DOI: 10.1016/j.jtcvs.2018.04.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/01/2018] [Accepted: 04/06/2018] [Indexed: 11/19/2022]
Affiliation(s)
- Lok Sinha
- Division of Cardiovascular Surgery, Children's National Heart Institute, Children's National Health System, The George Washington University School of Medicine and Health Sciences, Washington, DC
| | - Can Yerebakan
- Division of Cardiovascular Surgery, Children's National Heart Institute, Children's National Health System, The George Washington University School of Medicine and Health Sciences, Washington, DC.
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24
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Di Maria MV, Silverman L, Younoszai AK, Meyers ML, Capocelli KE, Narkewicz MR. Acoustic radiation force impulse of the liver after Fontan operation: Correlation with cardiopulmonary exercise test. CONGENIT HEART DIS 2018; 13:444-449. [PMID: 29473337 DOI: 10.1111/chd.12594] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/21/2017] [Revised: 01/03/2018] [Accepted: 01/19/2018] [Indexed: 12/11/2022]
Abstract
BACKGROUND The current management paradigm for children with single ventricle heart disease involves a series of palliative surgeries, culminating in the Fontan operation. This physiology results in a high central venous pressure, and in the setting of single ventricle heart disease, results in hepatic injury and fibrosis over time. Fontan-associated liver disease (FALD) is universally present in this cohort, and the current gold standard for diagnosis remains biopsy. Noninvasive assessments of liver fibrosis, such as ultrasound with elastography or acoustic radiation force impulse (ARFI), has been utilized in this cohort. The effect of poor cardiovascular efficiency, as measured by cardiopulmonary exercise test (CPET), on assessments of liver fibrosis remains poorly understood. METHODS Retrospective, cross-sectional study. Subjects were evaluated in a multidisciplinary clinic setting for patients who have undergone Fontan operation. CPETs, liver ultrasound with elastography (ARFI), and standard laboratory tests were performed as part of routine clinical care pathway. Statistical analysis included linear correlation. RESULTS There was a poor correlation between mean ARFI velocity and peak oxygen consumption (VO2max ) in this cohort (r = .20, P = NS). Similarly, there was poor correlation between ARFI and biomarkers of liver injury, time since Fontan operation and Fontan pressure. DISCUSSION ARFI had poor correlation with functional capacity after Fontan, as measured by VO2max obtained during CPET. While a single measurement of liver elastography was not associated with cardiopulmonary efficiency, longitudinal data may reveal an association.
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Affiliation(s)
- Michael V Di Maria
- Heart Institute, Children's Hospital Colorado, Department of Pediatrics, University of Colorado School of Medicine, Aurora, Colorado, USA
| | | | - Adel K Younoszai
- Heart Institute, Children's Hospital Colorado, Department of Pediatrics, University of Colorado School of Medicine, Aurora, Colorado, USA
| | - Mariana L Meyers
- Department of Radiology, Children's Hospital Colorado, University of Colorado School of Medicine, Aurora, Colorado, USA
| | - Kelley E Capocelli
- Department of Pathology, Children's Hospital Colorado, University of Colorado School of Medicine, Aurora, Colorado, USA
| | - Michael R Narkewicz
- Digestive Health Institute, Section of Pediatric Gastroenterology, Hepatology and Nutrition, Department of Pediatrics, University of Colorado School of Medicine, Aurora, Colorado, USA
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25
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Newburger JW, Sleeper LA, Gaynor JW, Hollenbeck-Pringle D, Frommelt PC, Li JS, Mahle WT, Williams IA, Atz AM, Burns KM, Chen S, Cnota J, Dunbar-Masterson C, Ghanayem NS, Goldberg CS, Jacobs JP, Lewis AB, Mital S, Pizarro C, Eckhauser A, Stark P, Ohye RG. Transplant-Free Survival and Interventions at 6 Years in the SVR Trial. Circulation 2018; 137:2246-2253. [PMID: 29437119 DOI: 10.1161/circulationaha.117.029375] [Citation(s) in RCA: 154] [Impact Index Per Article: 25.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/15/2017] [Accepted: 01/16/2018] [Indexed: 11/16/2022]
Abstract
BACKGROUND In the SVR trial (Single Ventricle Reconstruction), 1-year transplant-free survival was better for the Norwood procedure with right ventricle-to-pulmonary artery shunt (RVPAS) compared with a modified Blalock-Taussig shunt in patients with hypoplastic left heart and related syndromes. At 6 years, we compared transplant-free survival and other outcomes between the groups. METHODS Medical history was collected annually using medical record review, telephone interviews, and the death index. The cohort included 549 patients randomized and treated in the SVR trial. RESULTS Transplant-free survival for the RVPAS versus modified Blalock-Taussig shunt groups did not differ at 6 years (64% versus 59%, P=0.25) or with all available follow-up of 7.1±1.6 years (log-rank P=0.13). The RVPAS versus modified Blalock-Taussig shunt treatment effect had nonproportional hazards (P=0.009); the hazard ratio (HR) for death or transplant favored the RVPAS before stage II surgery (HR, 0.66; 95% confidence interval, 0.48-0.92). The effect of shunt type on death or transplant was not statistically significant between stage II to Fontan surgery (HR, 1.36; 95% confidence interval, 0.86-2.17; P=0.17) or after the Fontan procedure (HR, 0.76; 95% confidence interval, 0.33-1.74; P=0.52). By 6 years, patients with RVPAS had a higher incidence of catheter interventions (0.38 versus 0.23/patient-year, P<0.001), primarily because of more interventions between the stage II and Fontan procedures (HR, 1.72; 95% confidence interval, 1.00-3.03). Complications did not differ by shunt type; by 6 years, 1 in 5 patients had had a thrombotic event, and 1 in 6 had had seizures. CONCLUSIONS By 6 years, the hazards of death or transplant and catheter interventions were not different between the RVPAS versus modified Blalock-Taussig shunt groups. Children assigned to the RVPAS group had 5% higher transplant-free survival, but the difference did not reach statistical significance, and they required more catheter interventions. Both treatment groups have accrued important complications. CLINICAL TRIAL REGISTRATION URL: https://www.clinicaltrials.gov. Unique identifier: NCT00115934.
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Affiliation(s)
- Jane W Newburger
- Boston Children's Hospital and Harvard Medical School, MA (J.W.N., L.A.S., C.D.-M.).
| | - Lynn A Sleeper
- Boston Children's Hospital and Harvard Medical School, MA (J.W.N., L.A.S., C.D.-M.)
| | - J William Gaynor
- Children's Hospital of Philadelphia and University of Pennsylvania Medical School, Philadelphia (J.W.G.)
| | | | - Peter C Frommelt
- Children's Hospital of Wisconsin and Medical College of Wisconsin, Milwaukee (P.C.F., N.S.G.)
| | - Jennifer S Li
- North Carolina Consortium, Duke University, Durham (J.S.L.).,East Carolina University, Greenville, NC (J.S.L.).,Wake Forest University, Winston-Salem, NC (J.S.L.)
| | - William T Mahle
- Children's Healthcare of Atlanta and Emory University, GA (W.T.M.)
| | - Ismee A Williams
- Morgan Stanley Children's Hospital of New York-Presbyterian, Columbia College of Physicians and Surgeons, NY (I.A.W.)
| | - Andrew M Atz
- Medical University of South Carolina, Charleston (A.M.A.)
| | - Kristin M Burns
- National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, MD (KM.B.)
| | - Shan Chen
- New England Research Institutes, Watertown, MA (D.H.-P., S.C., P.S.)
| | - James Cnota
- Cincinnati Children's Medical Center, OH (J.C.)
| | | | - Nancy S Ghanayem
- Children's Hospital of Wisconsin and Medical College of Wisconsin, Milwaukee (P.C.F., N.S.G.)
| | - Caren S Goldberg
- University of Michigan Medical School, Ann Arbor (C.S.G., R.G.O.)
| | | | | | - Seema Mital
- Hospital for Sick Children, Toronto, Ontario, Canada (S.M.)
| | | | - Aaron Eckhauser
- Primary Children's Hospital and the University of Utah, Salt Lake City (A.E.)
| | - Paul Stark
- New England Research Institutes, Watertown, MA (D.H.-P., S.C., P.S.)
| | - Richard G Ohye
- University of Michigan Medical School, Ann Arbor (C.S.G., R.G.O.)
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26
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Hepatic Stiffness Using Shear Wave Elastography and the Related Factors for a Fontan Circulation. Pediatr Cardiol 2018; 39:57-65. [PMID: 28932977 DOI: 10.1007/s00246-017-1727-1] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/09/2017] [Accepted: 09/13/2017] [Indexed: 01/06/2023]
Abstract
Hepatic problems related to a Fontan circulation have been highlighted and elastography using ultrasound is a non-invasive tool that can measure the severity of hepatic stiffness. We investigated the hepatic stiffness using shear wave elastography (SWE) and related factors in patients with a Fontan circulation. This study enrolled 64 patients with a Fontan circulation who underwent cardiac catheterization and abdominal ultrasound from 2011 to 2015. The correlation between the laboratory tests, hemodynamic factors by cardiac catheterization, and SWE was evaluated. The patients were classified into non-cirrhotic level (≥ 2.0 m/s) and cirrhotic level (< 2.0 m/s) groups by the SWE value. The mean age was 17.6 years and the mean duration after the Fontan operation was 12.1 years. The mean value of SWE in patients (1.95 m/s) was higher than the normal (< 1.3 m/s). The SWE was higher in patients without than those with a fenestration (2.03 vs. 1.75 m/s, P = 0.003). In a multiple regression analysis between SWE and other factors, the CVP, fenestration, and lipoprotein Apo B had a significant correlation. In a multivariate analysis of cirrhotic level group, the CVP was the only significant factor. The hepatic stiffness had significantly progressed in most patients with a Fontan circulation. A low CVP and Fontan circulation with a fenestration might reduce the progression of the hepatic stiffness.
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27
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Cognitive Development of School-Age Hypoplastic Left Heart Syndrome Survivors: A Single Center Study. Pediatr Cardiol 2017; 38:1089-1096. [PMID: 28508919 DOI: 10.1007/s00246-017-1623-8] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/24/2017] [Accepted: 05/09/2017] [Indexed: 11/27/2022]
Abstract
Neurological and radiologic research results show an abnormal cerebral microstructure as well as abnormal neurodevelopment in patients treated for hypoplastic left heart syndrome. The aim of this study was to assess the varying cognitive performance these children have developed in dependence upon prenatal diagnosis, surgical techniques, surgical learning effects, anatomy, perfusion techniques, gender, pedagogic, and sociodemographic parameters in comparison to age-adjusted normative values. School-age children (6.3-16.9 years) with hypoplastic left heart syndrome, who were treated at the Children's heart Center Linz between 1997 and 2009, (n = 74), were surveyed in reference to cognitive achievements. 43 patients were examined prospectively by psychologists using the Wechsler intelligence scale for children IV in order to determine the respective total intelligence quotient index for each child's developmental stage. The mean index was 84.5 (percentile rank 26.4). The statistical spread and standard deviation ranged from a minimum of 40 to a maximum of 134 ± 20.8. The results for verbal comprehension, perceptual reasoning, and processing speed corresponded with total index results and were thus lower than the mean value of the normative values. The assessment of working memory showed results in the average. Prenatal diagnosis, type of lung perfusion, anatomy, and various cerebral perfusion techniques did not significantly affect the cognitive results of the patients. The results show that hypoplastic left heart syndrome patients can be successfully tutored formally as well as personally in cognitive areas, although when compared to healthy children, they showed lower results for intellectual area parameters.
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28
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Vaughn G, Moore J, Lamberti J, Canter C. Management of the failing Fontan: Medical, interventional and surgical treatment. PROGRESS IN PEDIATRIC CARDIOLOGY 2016. [DOI: 10.1016/j.ppedcard.2016.07.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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Hlavackova E, Liska M, Jicinska H, Navratil J, Litzman J. Secondary Combined Immunodeficiency in Pediatric Patients after the Fontan Operation: Three Case Reports. Int Arch Allergy Immunol 2016; 170:251-256. [PMID: 27685423 DOI: 10.1159/000449163] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2016] [Accepted: 08/16/2016] [Indexed: 11/19/2022] Open
Abstract
The Fontan operation or total cavopulmonal connection (TCPC) is a palliative surgical correction of rare and complex inborn cardiac malformations that are characterized by univentricular circulation. Protein-losing enteropathy (PLE) develops in 4-13% of patients after the Fontan procedure. Fontan-related PLE leads to secondary combined immunodeficiency marked by hypogammaglobulinemia and predominantly CD4+ lymphocytopenia. Here, we present 3 case reports of patients with secondary immunodeficiency after the Fontan operation. The severity of hypogammaglobulinemia correlated with the nature of the infectious complications; however, clinical manifestations of T cell deficiency such as severe viral or opportunistic infections were not observed. The clinical consequences of the secondary combined immunodeficiency were modified by immunoglobulin replacement treatment and antibiotic prophylaxis. Heart transplantation led to the resolution of PLE signs and the restitution of IgG levels in 1 transplanted patient. Our experience shows that the immunological follow-up was delayed in all 3 patients. We suggest that all patients should be followed regularly by a clinical immunologist after the Fontan surgery.
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Affiliation(s)
- Eva Hlavackova
- Department of Clinical Immunology and Allergology, St. Anne's University Hospital, Brno, Czech Republic
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Agarwal U, Smith AW, French KM, Boopathy AV, George A, Trac D, Brown ME, Shen M, Jiang R, Fernandez JD, Kogon BE, Kanter KR, Alsoufi B, Wagner MB, Platt MO, Davis ME. Age-Dependent Effect of Pediatric Cardiac Progenitor Cells After Juvenile Heart Failure. Stem Cells Transl Med 2016; 5:883-92. [PMID: 27151913 PMCID: PMC4922847 DOI: 10.5966/sctm.2015-0241] [Citation(s) in RCA: 54] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2015] [Accepted: 02/08/2016] [Indexed: 12/31/2022] Open
Abstract
To investigate the role of age of human pediatric cardiac progenitor cells (hCPCs) on ventricular remodeling, the authors injected neonate, infant, or child hCPCs into rats with right ventricular heart failure. Mechanisms including migration and proliferation assays, as suggested by computational modeling, showed improved chemotactic and proliferative capacity of neonatal hCPCs compared with infant or child hCPCs. Thus, the reparative potential of hCPCs is age-dependent. Children with congenital heart diseases have increased morbidity and mortality, despite various surgical treatments, therefore warranting better treatment strategies. Here we investigate the role of age of human pediatric cardiac progenitor cells (hCPCs) on ventricular remodeling in a model of juvenile heart failure. hCPCs isolated from children undergoing reconstructive surgeries were divided into 3 groups based on age: neonate (1 day to 1 month), infant (1 month to 1 year), and child (1 to 5 years). Adolescent athymic rats were subjected to sham or pulmonary artery banding surgery to generate a model of right ventricular (RV) heart failure. Two weeks after surgery, hCPCs were injected in RV musculature noninvasively. Analysis of cardiac function 4 weeks post-transplantation demonstrated significantly increased tricuspid annular plane systolic excursion and RV ejection fraction and significantly decreased wall thickness and fibrosis in rats transplanted with neonatal hCPCs compared with saline-injected rats. Computational modeling and systems biology analysis were performed on arrays and gave insights into potential mechanisms at the microRNA and gene level. Mechanisms including migration and proliferation assays, as suggested by computational modeling, showed improved chemotactic and proliferative capacity of neonatal hCPCs compared with infant/child hCPCs. In vivo immunostaining further suggested increased recruitment of stem cell antigen 1-positive cells in the right ventricle. This is the first study to assess the role of hCPC age in juvenile RV heart failure. Interestingly, the reparative potential of hCPCs is age-dependent, with neonatal hCPCs exerting the maximum beneficial effect compared with infant and child hCPCs. Significance Stem cell therapy for children with congenital heart defects is moving forward, with several completed and ongoing clinical trials. Although there are studies showing how children differ from adults, few focus on the differences among children. This study using human cardiac progenitor cells shows age-related changes in the reparative ability of cells in a model of pediatric heart failure and uses computational and systems biology to elucidate potential mechanisms.
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Affiliation(s)
- Udit Agarwal
- Wallace H. Coulter Department of Biomedical Engineering, Emory University and Georgia Institute of Technology, Atlanta, Georgia, USA Division of Cardiology, School of Medicine, Emory University, Atlanta, Georgia, USA
| | - Amanda W Smith
- Wallace H. Coulter Department of Biomedical Engineering, Emory University and Georgia Institute of Technology, Atlanta, Georgia, USA Division of Cardiology, School of Medicine, Emory University, Atlanta, Georgia, USA
| | - Kristin M French
- Wallace H. Coulter Department of Biomedical Engineering, Emory University and Georgia Institute of Technology, Atlanta, Georgia, USA Division of Cardiology, School of Medicine, Emory University, Atlanta, Georgia, USA
| | - Archana V Boopathy
- Wallace H. Coulter Department of Biomedical Engineering, Emory University and Georgia Institute of Technology, Atlanta, Georgia, USA Division of Cardiology, School of Medicine, Emory University, Atlanta, Georgia, USA
| | - Alex George
- Wallace H. Coulter Department of Biomedical Engineering, Emory University and Georgia Institute of Technology, Atlanta, Georgia, USA
| | - David Trac
- Wallace H. Coulter Department of Biomedical Engineering, Emory University and Georgia Institute of Technology, Atlanta, Georgia, USA
| | - Milton E Brown
- Wallace H. Coulter Department of Biomedical Engineering, Emory University and Georgia Institute of Technology, Atlanta, Georgia, USA Division of Cardiology, School of Medicine, Emory University, Atlanta, Georgia, USA
| | - Ming Shen
- Department of Pediatrics, School of Medicine, Emory University, Atlanta, Georgia, USA
| | - Rong Jiang
- Department of Pediatrics, School of Medicine, Emory University, Atlanta, Georgia, USA
| | - Janet D Fernandez
- Department of Cardiothoracic Surgery, School of Medicine, Emory University, Atlanta, Georgia, USA
| | - Brian E Kogon
- Children's Healthcare of Atlanta, Atlanta, Georgia, USA
| | - Kirk R Kanter
- Children's Healthcare of Atlanta, Atlanta, Georgia, USA
| | | | - Mary B Wagner
- Department of Pediatrics, School of Medicine, Emory University, Atlanta, Georgia, USA
| | - Manu O Platt
- Wallace H. Coulter Department of Biomedical Engineering, Emory University and Georgia Institute of Technology, Atlanta, Georgia, USA
| | - Michael E Davis
- Wallace H. Coulter Department of Biomedical Engineering, Emory University and Georgia Institute of Technology, Atlanta, Georgia, USA Division of Cardiology, School of Medicine, Emory University, Atlanta, Georgia, USA
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van Melle JP, Wolff D, Hörer J, Belli E, Meyns B, Padalino M, Lindberg H, Jacobs JP, Mattila IP, Berggren H, Berger RMF, Prêtre R, Hazekamp MG, Helvind M, Nosál M, Tlaskal T, Rubay J, Lazarov S, Kadner A, Hraska V, Fragata J, Pozzi M, Sarris G, Michielon G, di Carlo D, Ebels T. Surgical options after Fontan failure. Heart 2016; 102:1127-33. [DOI: 10.1136/heartjnl-2015-309235] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/24/2015] [Accepted: 03/03/2016] [Indexed: 11/04/2022] Open
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Whiteside W, Tan M, Ostlund RE, Yu S, Ma L, Rocchini A. Altered Cholesterol Metabolism and Hypocholesterolemia in Patients with Single Ventricle following Fontan Palliation. J Pediatr 2016; 171:73-7. [PMID: 26806364 PMCID: PMC5166701 DOI: 10.1016/j.jpeds.2015.12.038] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/10/2015] [Revised: 11/12/2015] [Accepted: 12/15/2015] [Indexed: 11/28/2022]
Abstract
OBJECTIVE To assess whether an abnormality in cholesterol absorption or synthesis may be associated with hypocholesterolemia in patients with single ventricle anatomy following Fontan palliation. STUDY DESIGN This is a cross-sectional study of 21 patients with hypocholesterolemia following Fontan procedure and age/sex-matched healthy controls, with median age of 13.4 (IQR 10.6-16.1) years. Laboratory values of several biomarkers, including phytosterols and 5-α-cholestanol (for cholesterol absorption) and lathosterol (for cholesterol biosynthesis), as well as cholesterol levels, inflammatory markers, and indices of liver function were compared between patients following Fontan procedure and controls. RESULTS The Fontan cohort had significantly lower total cholesterol (mean 117 ± SD 13.9, vs 128 ± 19.2 mg/dL, P = .03) and free cholesterol (35.5 ± 4.5 vs 39.2 ± 5.4 mg/dL, P = .02) compared with control patients. There was an increase in normalized 5-α-cholestanol (1.51 ± 0.6 vs 1.14 ± 0.37 μg/mL, P = .02), and a significantly lower lathosterol/5-α-cholestanol ratio (0.70 ± 0.38 vs 1.11 ± 0.76, P = .04). There was a strong correlation (r = 0.78, P < .0001) between lathosterol and cholesterol levels in the Fontan cohort, not seen in controls (r = 0.47, P = .04). The Fontan cohort also had significantly higher C-reactive protein, transaminases, total bilirubin, and gamma-glutamyl transferase levels. CONCLUSIONS Patients with hypocholesterolemia following Fontan procedure have evidence of increased cholesterol absorption and decreased cholesterol synthesis. As cholesterol absorption efficiency is a regulated process, this finding suggests an upregulation of cholesterol absorption as a result of decreased cholesterol production. In the setting of elevated liver indices and possible inflammation, this finding supports a growing body of data suggesting development of liver disease in patients receiving Fontan.
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Affiliation(s)
- Wendy Whiteside
- The Heart Institute, Cincinnati Children's Hospital Medical Center, Cincinnati, OH.
| | - Meng Tan
- Division of Metabolism Endocrinology and Diabetes, Department of Internal Medicine, University of Michigan, Ann Arbor, MI
| | - Richard E. Ostlund
- School of Medicine Division of Endocrinology, Metabolism & Lipid Research, Washington University, St. Louis, MO
| | - Sunkyung Yu
- Division of Pediatric Cardiology, Department of Pediatrics and Communicable Disease, University of Michigan, Ann Arbor, MI
| | - Lina Ma
- School of Medicine Division of Endocrinology, Metabolism & Lipid Research, Washington University, St. Louis, MO
| | - Albert Rocchini
- Division of Pediatric Cardiology, Department of Pediatrics and Communicable Disease, University of Michigan, Ann Arbor, MI
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Evans WN, Acherman RJ, Reardon LC, Ciccolo ML, Galindo A, Rothman A, Winn BJ, Yumiaco NS, Restrepo H. Fontan Outcomes and Pulmonary Blood Flow at Birth. Pediatr Cardiol 2016; 37:30-6. [PMID: 26187516 DOI: 10.1007/s00246-015-1234-1] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/24/2015] [Accepted: 07/09/2015] [Indexed: 12/18/2022]
Abstract
We previously noted, in a small group of post-Fontan patients, a possible association between hepatic fibrosis scores and the status of pulmonary blood flow at birth. To further explore this observation, we examined data from all Fontan patients seen in our center from July 2010 to March 2015. We identified 200 patients for analysis. Of the 200 patients, 56 underwent transvenous-hepatic biopsy. Of the 200 patients, 13 (6.5%) had protein-losing enteropathy. We divided both the 56 biopsy patients and the entire cohort of 200 patients into 4 groups: (1) unobstructed pulmonary blood flow at birth with functional left ventricles, (2) unobstructed pulmonary blood flow at birth with functional right ventricles, (3) obstructed pulmonary blood flow at birth with functional left ventricles, and (4) obstructed pulmonary blood flow at birth with functional right ventricles. Analysis of the 56 liver-biopsy patient groups showed median hepatic total-fibrosis scores for the 4 groups of 2 (0-6), 2 (0-8), 3 (2-6), and 4 (1-8), respectively, with statistical significance between groups 4 and 1 (p = 0.031). For the entire cohort of 200 patients, we analyzed the incidence of protein-losing enteropathy for each of the four groups and found protein-losing enteropathy percent occurrences of 0, 2.9, 8.8, and 16.1, respectively, with statistical significance between groups 4 and 2 (p = 0.031) and between groups 4 and 1 (p = 0.025). A history of obstructed pulmonary blood flow at birth, coupled with a functional right ventricle, may predict a poorer long-term Fontan outcome.
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Affiliation(s)
- William N Evans
- Children's Heart Center Nevada, 3006 S. Maryland Pkwy Ste. 690, Las Vegas, NV, 89109, USA. .,Division of Pediatric Cardiology, Department of Pediatrics, University of Nevada School of Medicine, 2040 W. Charleston Blvd Ste. 402, Las Vegas, NV, 89109, USA.
| | - Ruben J Acherman
- Children's Heart Center Nevada, 3006 S. Maryland Pkwy Ste. 690, Las Vegas, NV, 89109, USA.,Division of Pediatric Cardiology, Department of Pediatrics, University of Nevada School of Medicine, 2040 W. Charleston Blvd Ste. 402, Las Vegas, NV, 89109, USA
| | - Leigh C Reardon
- Children's Heart Center Nevada, 3006 S. Maryland Pkwy Ste. 690, Las Vegas, NV, 89109, USA.,UCLA Division of Cardiology and Division of Pediatric Cardiology, Ahmanson/UCLA Adult Congenital Heart Disease Center, 100 UCLA Medical Plaza, Suite 630, Los Angeles, CA, 90095, USA
| | - Michael L Ciccolo
- Children's Heart Center Nevada, 3006 S. Maryland Pkwy Ste. 690, Las Vegas, NV, 89109, USA.,Division of Pediatric Cardiology, Department of Pediatrics, University of Nevada School of Medicine, 2040 W. Charleston Blvd Ste. 402, Las Vegas, NV, 89109, USA
| | - Alvaro Galindo
- Children's Heart Center Nevada, 3006 S. Maryland Pkwy Ste. 690, Las Vegas, NV, 89109, USA.,Division of Pediatric Cardiology, Department of Pediatrics, University of Nevada School of Medicine, 2040 W. Charleston Blvd Ste. 402, Las Vegas, NV, 89109, USA
| | - Abraham Rothman
- Children's Heart Center Nevada, 3006 S. Maryland Pkwy Ste. 690, Las Vegas, NV, 89109, USA.,Division of Pediatric Cardiology, Department of Pediatrics, University of Nevada School of Medicine, 2040 W. Charleston Blvd Ste. 402, Las Vegas, NV, 89109, USA
| | - Brody J Winn
- Laboratory Medicine Consultants, 3059 S. Maryland Parkway, Suite 100, Las Vegas, NV, 89109, USA
| | - Noel S Yumiaco
- Laboratory Medicine Consultants, 3059 S. Maryland Parkway, Suite 100, Las Vegas, NV, 89109, USA
| | - Humberto Restrepo
- Children's Heart Center Nevada, 3006 S. Maryland Pkwy Ste. 690, Las Vegas, NV, 89109, USA.,Division of Pediatric Cardiology, Department of Pediatrics, University of Nevada School of Medicine, 2040 W. Charleston Blvd Ste. 402, Las Vegas, NV, 89109, USA
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Abstract
The Fontan operation is the final step of palliation for patients with a functionally single ventricle. Since its introduction in the 1970s, the Fontan surgery has become part of a successful surgical strategy that has improved single ventricle mortality. In recent years, we have become more aware of the limitations and long-term consequences of the Fontan physiology. Pulmonary vascular resistance plays an important role in total cavopulmonary circulation, and has been identified as a potential therapeutic target to mitigate Fontan sequelae. In this review, we will discuss the results of different pulmonary vasodilator trials and the use of pulmonary vasodilators as a treatment strategy for Fontan patients.
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Schneck E, Mann V, Körner C, Jost A, Thul J, Engel JB, Müller MF. [Patient with a Fontan circulation undergoing caesarean section: Anesthesiological management]. Anaesthesist 2015; 64:532-9. [PMID: 26159666 DOI: 10.1007/s00101-015-0047-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2015] [Revised: 05/07/2015] [Accepted: 05/12/2015] [Indexed: 11/29/2022]
Abstract
Adults suffering from congenital heart diseases (CHD) represent a challenge to anesthesiologists because of the diverse pathologies, complex pathophysiology and special treatment strategies. Due to improved therapeutic options for CHD, patient quality of life and life expectancy is increasing, leaving them as a growing population including pregnant patients with CHD. This article presents the main principles of the pathophysiology and anesthesiological management of pregnant patients living with a Fontan circulation based on a case report, which was complicated by an aortic coarctation and atonic uterine hemorrhage.
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Affiliation(s)
- E Schneck
- Klinik für Anästhesiologie und operative Intensivmedizin, Universitätsklinikum Gießen und Marburg, Standort Gießen, Sektion Kinderherzzentrum, Rudolf-Buchheim-Str. 7, 35392, Gießen, Deutschland,
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Transcoronary infusion of cardiac progenitor cells in hypoplastic left heart syndrome: Three-year follow-up of the Transcoronary Infusion of Cardiac Progenitor Cells in Patients With Single-Ventricle Physiology (TICAP) trial. J Thorac Cardiovasc Surg 2015; 150:1198-1207, 1208.e1-2. [PMID: 26232942 DOI: 10.1016/j.jtcvs.2015.06.076] [Citation(s) in RCA: 85] [Impact Index Per Article: 9.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/23/2015] [Revised: 05/26/2015] [Accepted: 06/14/2015] [Indexed: 12/15/2022]
Abstract
OBJECTIVES Our aim was to assess midterm safety and clinical outcomes of intracoronary infusion of cardiosphere-derived cells (CDCs) after staged palliation in patients with hypoplastic left heart syndrome (HLHS). METHODS In this prospective, controlled study, 14 consecutive patients with HLHS who were undergoing 2- or 3-stage surgical palliations were assigned to receive intracoronary CDC infusion 1 month after cardiac surgery (n = 7), followed by 7 patients allocated to a control group with standard care alone. The primary end point was to assess procedural feasibility and safety; the secondary end point was to evaluate cardiac function and heart failure status through 36-month follow-up. RESULTS No complications, including tumor formation, were reported within 36 months after CDC infusion. Echocardiography showed significantly greater improvement in right ventricular ejection fraction (RVEF) in infants receiving CDCs than in controls at 36 months (+8.0% ± 4.7% vs +2.2% ± 4.3%; P = .03). These cardiac function improvements resulted in reduced brain natriuretic peptide levels (P = .04), lower incidence of unplanned catheter interventions (P = .04), and higher weight-for-age z score (P = .02) at 36 months relative to controls. As independent predictors of treatment responsiveness, absolute changes in RVEF at 36 months were negatively correlated with age, weight-for-age z score, and RVEF at CDC infusion. CONCLUSIONS Intracoronary CDC infusion after staged procedure in patients with HLHS is safe and improves RVEF, which persists during 36-month follow-up. This therapeutic strategy may enhance somatic growth and reduce incidence of heart failure.
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