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Furuta K. What we know and need to know about Fontan-associated liver disease. Hepatol Res 2024. [PMID: 39012801 DOI: 10.1111/hepr.14095] [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: 07/18/2024]
Affiliation(s)
- Kunimaro Furuta
- Department of Gastroenterology and Hepatology, Osaka University Graduate School of Medicine, Suita, Japan
- Department of Gastroenterology and Hepatology, Ikeda City Hospital, Ikeda, Japan
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2
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Hansen S, Gilroy R, Lindsay I, Doty JR, Butschek RA, Danford CJ. A Meta-Analysis of Cumulative Incidence of Hepatocellular Carcinoma After the Fontan Operation. Dig Dis Sci 2024:10.1007/s10620-024-08470-1. [PMID: 38867097 DOI: 10.1007/s10620-024-08470-1] [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: 12/04/2023] [Accepted: 04/30/2024] [Indexed: 06/14/2024]
Abstract
BACKGROUND Hepatic complications are increasingly recognized after the Fontan operation. The development of hepatocellular carcinoma (HCC) is associated with high mortality when diagnosed, but its incidence and risk factors are poorly understood. We conducted a systematic review and meta-analysis of the cumulative incidence of HCC after Fontan and associated risk factors. METHODS We searched PubMed, CINAHL, and MEDLINE databases for articles reporting the cumulative incidence of HCC after Fontan operation on March 21, 2023. A single-arm random effects meta-analysis was conducted to assess cumulative incidence at 10, 20, and 30 years after Fontan. Meta-analysis of the difference of the medians was used to assess the influence of risk factors on the development of HCC. RESULTS Four studies including a total of 1320 patients reported cumulative incidence. The cumulative incidence of HCC at 10, 20, and 30 years after Fontan was 0% (95% CI 0.00-0.01), 2% (0.01-0.06), and 7% (0.03-0.17) respectively. Seven studies including 6,250 patients reported overall incidence of HCC and associated risk factors. At a median 18.4 (IQR 11.9-24.9) years of follow-up, incidence of HCC was 2% (0.01-0.04). Only use of anticoagulation was associated with a lower risk of HCC (RR 0.3, 95% CI 0.1-0.88). DISCUSSION By 30 years after Fontan, cumulative incidence of HCC is high (7%). Risk of HCC development prior to 10 years post-Fontan is low (0%), though the decision to defer HCC surveillance in this period may require future investigation based on larger studies. Screening with ultrasound every 6 months starting 20 years post-Fontan is reasonable, however, further research regarding timing, cost-effectiveness, additional risk factors associated with HCC risk, and different screening modalities is required.
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Affiliation(s)
- Sophie Hansen
- School of Biological Sciences, University of Utah, Salt Lake City, UT, 84132, USA
- Transplant Services, Intermountain Medical Center, 5171 Cottonwood St. #210, Murray, UT, 84107, USA
| | - Richard Gilroy
- Transplant Services, Intermountain Medical Center, 5171 Cottonwood St. #210, Murray, UT, 84107, USA
| | - Ian Lindsay
- Division of Cardiovascular Medicine, University of Utah, Salt Lake City, UT, 84132, USA
| | - John R Doty
- Cardiovascular and Thoracic Surgery, Intermountain Medical Center, Murray, UT, 84107, USA
| | - Ross A Butschek
- Intermountain Medical Center, Heart Institute, Murray, UT, 84107, USA
| | - Christopher J Danford
- Transplant Services, Intermountain Medical Center, 5171 Cottonwood St. #210, Murray, UT, 84107, USA.
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3
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Hitawala AA, Gopalakrishna H, Mironova M, Livinski AA, Wright EC, Downing T, Ito S, Fisher SD, Cedars AM, John AS, Heller T. Meta-analysis: Incidence of cirrhosis and hepatocellular carcinoma in patients with Fontan palliation. Aliment Pharmacol Ther 2024; 59:1020-1032. [PMID: 38497159 DOI: 10.1111/apt.17952] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/10/2023] [Revised: 12/10/2023] [Accepted: 03/03/2024] [Indexed: 03/19/2024]
Abstract
BACKGROUND AND AIMS The Fontan palliation is the final stage of surgery for many children born with univentricular physiology. Almost all Fontan patients develop liver fibrosis which may eventually lead to cirrhosis and hepatocellular carcinoma (HCC). These are important causes of morbidity and mortality in these patients. We performed a systematic review and meta-analysis to assess the incidence of cirrhosis and HCC in Fontan patients and stratify it based on time since surgery. METHODS A literature search of seven databases identified 1158 records. Studies reporting the number of cirrhosis and HCC cases in Fontan patients and time since Fontan surgery were included. In the cirrhosis cohort, we included only those studies where all patients underwent liver biopsy. RESULTS A total of 23 studies were included: 12 and 13 studies in the cirrhosis and HCC cohorts, respectively, with two studies included in both cohorts. The incidence of cirrhosis was 0.97 per 100 patient-years (95% CI 0.57-1.63), with the incidence and cumulative incidence ≥20 years post Fontan surgery being 1.61 per 100 patient-years (95% CI 1.24-2.08) and 32.2% (95% CI 25.8%-39.4%), respectively. The incidence of HCC was 0.12 per 100 patient-years (95% CI 0.07-0.21), with the incidence and cumulative incidence ≥20 years post Fontan surgery being 0.20 per 100 patient-years (95% CI 0.12-0.35) and 3.9% (95% CI 2.2%-6.8%), respectively. Only about 70% of patients with HCC (20/28) had underlying cirrhosis. CONCLUSION The incidence of cirrhosis and HCC increases over time, especially at ≥20 years post Fontan surgery. Studies are needed to further identify at-risk patients in order to streamline surveillance for these highly morbid conditions.
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Affiliation(s)
- Asif A Hitawala
- Liver Disease Branch, National Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health, Bethesda, Maryland, USA
| | - Harish Gopalakrishna
- Liver Disease Branch, National Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health, Bethesda, Maryland, USA
| | - Maria Mironova
- Liver Disease Branch, National Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health, Bethesda, Maryland, USA
| | - Alicia A Livinski
- National Institutes of Health Library, Office of Research Services, Office of the Director, National Institutes of Health, Bethesda, Maryland, USA
| | - Elizabeth C Wright
- Office of the Director, National Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health, Bethesda, Maryland, USA
| | - Tacy Downing
- Division of Pediatric Cardiology, Children's National Hospital, Washington, DC, USA
| | - Seiji Ito
- Division of Pediatric Cardiology, Children's National Hospital, Washington, DC, USA
| | - Stacy D Fisher
- Adult Congenital Heart Disease Center, Johns Hopkins Heart and Vascular Institute, Baltimore, Maryland, USA
| | - Ari M Cedars
- Adult Congenital Heart Disease Center, Johns Hopkins Heart and Vascular Institute, Baltimore, Maryland, USA
| | - Anitha S John
- Division of Pediatric Cardiology, Children's National Hospital, Washington, DC, USA
| | - Theo Heller
- Translational Hepatology Section, Liver Disease Branch, National Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health, Bethesda, Maryland, USA
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4
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Kim YY, Lluri G, Haeffele C, Daugherty T, Krasuski RA, Serfas JD, de Freitas RA, Porlier A, Lubert AM, Wu FM, Valente AM, Krieger EV, Buber J, Rodriguez FH, Gaignard S, Saraf A, Hindes M, Earing MG, Lewis MJ, Rosenbaum MS, Zaidi AN, Hopkins K, Bradley EA, Cedars AM, Ko JL, Franklin WJ, Frederickson A, Ginde S, Grewal J, Nyman A, Min J, Schluger C, Rand E, Rosenthal BE, Hilscher M, Rychik J, Hoteit MA. Hepatocellular carcinoma in survivors after Fontan operation: a case-control study. Eur Heart J 2024; 45:1477-1480. [PMID: 38085593 DOI: 10.1093/eurheartj/ehad788] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/30/2023] [Accepted: 11/16/2023] [Indexed: 01/25/2024] Open
Affiliation(s)
- Yuli Y Kim
- Division of Cardiology, Hospital of the University of Pennsylvania, Perelman Center for Advanced Medicine, 2nd Floor E. Pavilion, 3400 Civic Center Boulevard, Philadelphia, PA 19104, USA
- Division of Cardiology, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Gentian Lluri
- Ahmanson/UCLA Adult Congenital Heart Disease Center, Division of Cardiology, Department of Medicine, University of California Los Angeles, Los Angeles, CA, USA
| | | | - Tami Daugherty
- Division of Cardiovascular Medicine, Stanford Medicine, Stanford, CA, USA
| | | | | | - R Andrew de Freitas
- Division of Pediatric Cardiology, Anne & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL, USA
| | - Avaliese Porlier
- Division of Pediatric Cardiology, Anne & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL, USA
| | - Adam M Lubert
- Cincinnati Children's Hospital Heart Institute, Department of Pediatrics, University of Cincinnati, Cincinnati, OH, USA
| | - Fred M Wu
- Division of Cardiology, Department of Medicine, Brigham and Women's Hospital, Boston, MA, USA
- Department of Cardiology, Boston Children's Hospital, Boston, MA, USA
| | - Anne Marie Valente
- Division of Cardiology, Department of Medicine, Brigham and Women's Hospital, Boston, MA, USA
- Department of Cardiology, Boston Children's Hospital, Boston, MA, USA
| | - Eric V Krieger
- University of Washington Medical Center, University of Washington School of Medicine, Seattle, WA, USA
- Seattle Children's Hospital, Seattle, WA, USA
| | - Jonathan Buber
- University of Washington Medical Center, University of Washington School of Medicine, Seattle, WA, USA
| | | | - Scott Gaignard
- Department of Pediatrics, Emory University, Atlanta, GA, USA
| | - Anita Saraf
- Department of Pediatrics, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Morgan Hindes
- Department of Pediatrics, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | | | - Matthew J Lewis
- Division of Cardiology, Columbia University Irving Medical Center, NewYork, NY, USA
| | - Marlon S Rosenbaum
- Division of Cardiology, Columbia University Irving Medical Center, NewYork, NY, USA
| | - Ali N Zaidi
- Mount Sinai Adult Congenital Heart Disease Center, Mount Sinai Heart, NewYork, NY, USA
| | - Kali Hopkins
- Mount Sinai Adult Congenital Heart Disease Center, Mount Sinai Heart, NewYork, NY, USA
| | - Elisa A Bradley
- Division of Cardiovascular Medicine, The Ohio State University, Columbus, OH, USA
| | - Ari M Cedars
- Department of Pediatrics, Johns Hopkins Department of Medicine, Baltimore, MD, USA
| | - Jong L Ko
- Department of Pediatrics, Johns Hopkins Department of Medicine, Baltimore, MD, USA
| | - Wayne J Franklin
- Division of Pediatric Cardiology, Phoenix Children's Hospital, Phoenix, AZ, USA
- Department of Child Health, University of Arizona College of Medicine-Phoenix, Phoenix, AZ, USA
| | - Abby Frederickson
- Division of Pediatric Cardiology, Phoenix Children's Hospital, Phoenix, AZ, USA
| | - Salil Ginde
- Department of Pediatrics, Children's Hospital of Wisconsin, Milwaukee, WI, USA
| | - Jasmine Grewal
- Division of Cardiology, St.Paul's Hospital, University of British Columbia, Vancouver, BC, Canada
| | - Annique Nyman
- Division of Cardiology, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Jungwon Min
- Department of Biomedical and Health Informatics, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Charlotte Schluger
- Department of Biomedical and Health Informatics, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Elizabeth Rand
- Division of Hepatology, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Benjamin E Rosenthal
- Department of Medicine, Hospital of the University of Pennsylvania, Philadelphia, PA, USA
| | - Moira Hilscher
- Division of Hepatology, Hospital of the University of Pennsylvania, Philadelphia, PA, USA
| | - Jack Rychik
- Division of Cardiology, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Maarouf A Hoteit
- Division of Hepatology, Hospital of the University of Pennsylvania, Philadelphia, PA, USA
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Karazisi C, Dellborg M, Mellgren K, Giang KW, Skoglund K, Eriksson P, Mandalenakis Z. Outcomes after cancer diagnosis in children and adult patients with congenital heart disease in Sweden: a registry-based cohort study. BMJ Open 2024; 14:e083237. [PMID: 38631823 PMCID: PMC11029300 DOI: 10.1136/bmjopen-2023-083237] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/14/2023] [Accepted: 04/04/2024] [Indexed: 04/19/2024] Open
Abstract
OBJECTIVE Patients with congenital heart disease (CHD) have an increased cancer risk. The aim of this study was to determine cancer-related mortality in CHD patients compared with non-CHD controls, compare ages at cancer diagnosis and death, and explore the most fatal cancer diagnoses. DESIGN Registry-based cohort study. SETTING AND PARTICIPANTS CHD patients born between 1970 and 2017 were identified using Swedish Health Registers. Each was matched by birth year and sex with 10 non-CHD controls. Included were those born in Sweden with a cancer diagnosis. RESULTS Cancer developed in 758 out of 67814 CHD patients (1.1%), with 139 deaths (18.3%)-of which 41 deaths occurred in patients with genetic syndromes. Cancer was the cause of death in 71.9% of cases. Across all CHD patients, cancer accounted for 1.8% of deaths. Excluding patients with genetic syndromes and transplant recipients, mortality risk between CHD patients with cancer and controls showed no significant difference (adjusted HR 1.17; 95% CI 0.93 to 1.49). CHD patients had a lower median age at cancer diagnosis-13.0 years (IQR 2.9-30.0) in CHD versus 24.6 years (IQR 8.6-35.1) in controls. Median age at death was 15.1 years (IQR 3.6-30.7) in CHD patients versus 18.5 years (IQR 6.1-32.7) in controls. The top three fatal cancer diagnoses were ill-defined, secondary and unspecified, eye and central nervous system tumours and haematological malignancies. CONCLUSIONS Cancer-related deaths constituted 1.8% of all mortalities across all CHD patients. Among CHD patients with cancer, 18.3% died, with cancer being the cause in 71.9% of cases. Although CHD patients have an increased cancer risk, their mortality risk post-diagnosis does not significantly differ from non-CHD patients after adjustements and exclusion of patients with genetic syndromes and transplant recipients. However, CHD patients with genetic syndromes and concurrent cancer appear to be a vulnerable group.
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Affiliation(s)
- Christina Karazisi
- Department of Molecular and Clinical Medicine, University of Gothenburg, Goteborg, Sweden
- Department of Medicine, Geriatrics and Emergency Medicine, Region Västra Götaland, Sahlgrenska University Hospital, Goteborg, Sweden
| | - Mikael Dellborg
- Department of Molecular and Clinical Medicine, University of Gothenburg, Goteborg, Sweden
- Department of Medicine, Geriatrics and Emergency Medicine, Region Västra Götaland, Sahlgrenska University Hospital, Goteborg, Sweden
- Adult Congenital Heart Disease Unit, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Karin Mellgren
- Department of Pediatric Oncology, Sahlgrenska University Hospital, Goteborg, Sweden
| | - Kok Wai Giang
- Department of Molecular and Clinical Medicine, University of Gothenburg, Goteborg, Sweden
- Department of Medicine, Geriatrics and Emergency Medicine, Region Västra Götaland, Sahlgrenska University Hospital, Goteborg, Sweden
| | - Kristofer Skoglund
- Department of Molecular and Clinical Medicine, University of Gothenburg, Goteborg, Sweden
| | - Peter Eriksson
- Department of Molecular and Clinical Medicine, University of Gothenburg, Goteborg, Sweden
- Department of Medicine, Geriatrics and Emergency Medicine, Region Västra Götaland, Sahlgrenska University Hospital, Goteborg, Sweden
- Adult Congenital Heart Disease Unit, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Zacharias Mandalenakis
- Department of Molecular and Clinical Medicine, University of Gothenburg, Goteborg, Sweden
- Department of Medicine, Geriatrics and Emergency Medicine, Region Västra Götaland, Sahlgrenska University Hospital, Goteborg, Sweden
- Adult Congenital Heart Disease Unit, Sahlgrenska University Hospital, Gothenburg, Sweden
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Ohuchi H, Mori A, Kurosaki K, Shiraishi I, Nakai M. Prevalence and clinical correlates and characteristics of "Super Fontan". Am Heart J 2023; 263:93-103. [PMID: 37211285 DOI: 10.1016/j.ahj.2023.05.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/17/2022] [Revised: 04/21/2023] [Accepted: 05/15/2023] [Indexed: 05/23/2023]
Abstract
BACKGROUND Super-Fontan (SF) is an excellent phenotype of patients with Fontan circulation and normal exercise capacity. This study aimed to clarify the prevalence and clinical correlates and characteristics of SF. METHODS We reviewed 404 Fontan patients who had undergone cardiopulmonary exercise testing, and the results were compared with clinical profiles. RESULTS Seventy-seven (19%) patients had SF, and the postoperative prevalence at 5, 10, 15, 20, and ≥ 25 years was 16 (35%), 30 (39%), 18 (19%), 13 (14%), and 0 (0%), respectively. Compared with non-SF, SF patients were younger (P < .001) and were mostly men (P < .05). SF was characterized by a current high arterial blood pressure and oxygen saturation (SaO2), low systemic ventricle (SV) end-diastolic pressure, favorable body composition, superior pulmonary function, preserved hepatorenal and hemostatic functions, and better glucose tolerance (P < .05-.001). Pre-Fontan better SV function, low pulmonary artery resistance, and high SaO2 were associated with current SF (P < .05-.01). Furthermore, positive trajectory of exercise capacity and high daily activity during childhood were associated with current adult SF (P < .05). During the follow-up, 25 patients died, and 74 patients were unexpectedly hospitalized. There was no death in the SF group, and the rate of hospitalization was 67% lower than that of the non-SF group (P < .01-.001). CONCLUSIONS The prevalence of SF gradually decreased over time. SF was characterized by preserved multi-end-organ function and an excellent prognosis. Pre-Fontan hemodynamics and post-Fontan childhood daily activity were associated with being adult SF.
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Affiliation(s)
- Hideo Ohuchi
- Department of Pediatric Cardiology, National Cerebral and Cardiovascular Center, Osaka, Japan; Adult Congenital Heart Disease Center, National Cerebral and Cardiovascular Center, Osaka, Japan
| | - Aki Mori
- Department of Pediatric Cardiology, National Cerebral and Cardiovascular Center, Osaka, Japan; Adult Congenital Heart Disease Center, National Cerebral and Cardiovascular Center, Osaka, Japan
| | - Kenichi Kurosaki
- Department of Pediatric Cardiology, National Cerebral and Cardiovascular Center, Osaka, Japan
| | - Isao Shiraishi
- Department of Pediatric Cardiology, National Cerebral and Cardiovascular Center, Osaka, Japan
| | - Michikazu Nakai
- Department of Medical and Health Information Management, National Cerebral and Cardiovascular Center, Osaka, Japan
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Ishida H, Maeda J, Uchida K, Yamagishi H. Unique Pulmonary Hypertensive Vascular Diseases Associated with Heart and Lung Developmental Defects. J Cardiovasc Dev Dis 2023; 10:333. [PMID: 37623346 PMCID: PMC10455332 DOI: 10.3390/jcdd10080333] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2023] [Revised: 07/10/2023] [Accepted: 08/01/2023] [Indexed: 08/26/2023] Open
Abstract
Although pediatric pulmonary hypertension (PH) shares features and mechanisms with adult PH, there are also some significant differences between the two conditions. Segmental PH is a unique pediatric subtype of PH with unclear and/or multifactorial pathophysiological mechanisms, and is often associated with complex congenital heart disease (CHD), pulmonary atresia with ventricular septal defect, and aortopulmonary collateral arteries. Some cases of complex CHD, associated with a single ventricle after Fontan operation, show pathological changes in the small peripheral pulmonary arteries and pulmonary vascular resistance similar to those observed in pulmonary arterial hypertension (PAH). This condition is termed as the pediatric pulmonary hypertensive vascular disease (PPHVD). Recent advances in genetics have identified the genes responsible for PAH associated with developmental defects of the heart and lungs, such as TBX4 and SOX17. Targeted therapies for PAH have been developed; however, their effects on PH associated with developmental heart and lung defects remain to be established. Real-world data analyses on the anatomy, pathophysiology, genetics, and molecular biology of unique PPHVD cases associated with developmental defects of the heart and lungs, using nationwide and/or international registries, should be conducted in order to improve the treatments and prognosis of patients with these types of pediatric PH.
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Affiliation(s)
- Hidekazu Ishida
- Department of Pediatrics, Osaka University Graduate School of Medicine, 2-2 Yamadaoka, Suita 565-0871, Osaka, Japan;
| | - Jun Maeda
- Department of Cardiology, Tokyo Metropolitan Children’s Medical Center, 2-8-29 Musashidai, Fuchu 183-8561, Tokyo, Japan;
| | - Keiko Uchida
- Department of Pediatrics, Keio University of Medicine, 35 Shinanomachi, Shinjuku-ku 160-8582, Tokyo, Japan;
- Keio University Health Center, 4-1-1 Hiyoshi, Kohoku-ku, Yokohama 223-8521, Kanagawa, Japan
| | - Hiroyuki Yamagishi
- Department of Pediatrics, Keio University of Medicine, 35 Shinanomachi, Shinjuku-ku 160-8582, Tokyo, Japan;
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Shiraishi J, Itoh S, Tomino T, Yoshiya S, Nagao Y, Kayashima H, Harada N, Sakamoto I, Tsutsui H, Yoshizumi T. Surgical treatment of hepatocellular carcinoma after Fontan operation: three case reports and review of the literature. Clin J Gastroenterol 2023:10.1007/s12328-023-01795-w. [PMID: 37046144 DOI: 10.1007/s12328-023-01795-w] [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: 02/06/2023] [Accepted: 03/27/2023] [Indexed: 04/14/2023]
Abstract
We herein describe three patients with Fontan-associated liver disease who developed hepatocellular carcinoma (HCC). The first patient was a 28-year-old woman who had undergone the Fontan operation (FO) at the age of 4 years. She was diagnosed with HCC (cT4aN0M0, Stage IVA, UICC 8th edition), for which she underwent extended posterior right sectionectomy and partial hepatectomy of S2. She developed recurrence of peritoneal dissemination after 12 months, and she was alive 18 months after surgery. The second patient was a 43-year-old man who had undergone the FO at the age of 3 years. He was diagnosed with HCC (cT2N0M0, Stage II), for which he underwent laparoscopic-assisted partial hepatectomy of S3. He remained free from recurrent HCC for 17 months. The third patient was a 21-year-old woman who had undergone the FO at the age of 3 years. She was diagnosed with HCC (cT3N0M0, Stage III), for which she underwent laparoscopic-assisted partial hepatectomy of S2 and S4. She remained free from recurrent HCC for 30 months. We reviewed 18 surgical cases of HCC arising from Fontan-associated liver disease, including our 3 cases, and found that a high preoperative alpha-fetoprotein concentration might be a predictor of HCC recurrence.
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Affiliation(s)
- Jin Shiraishi
- Department of Surgery and Science, Graduate School of Medical Sciences, Kyushu University, 3-1-1, Maidashi, Higashi-ku, Fukuoka, 812-8582, Japan
| | - Shinji Itoh
- Department of Surgery and Science, Graduate School of Medical Sciences, Kyushu University, 3-1-1, Maidashi, Higashi-ku, Fukuoka, 812-8582, Japan.
| | - Takahiro Tomino
- Department of Surgery and Science, Graduate School of Medical Sciences, Kyushu University, 3-1-1, Maidashi, Higashi-ku, Fukuoka, 812-8582, Japan
| | - Shohei Yoshiya
- Department of Surgery and Science, Graduate School of Medical Sciences, Kyushu University, 3-1-1, Maidashi, Higashi-ku, Fukuoka, 812-8582, Japan
| | - Yoshihiro Nagao
- Department of Surgery and Science, Graduate School of Medical Sciences, Kyushu University, 3-1-1, Maidashi, Higashi-ku, Fukuoka, 812-8582, Japan
| | - Hiroto Kayashima
- Department of Surgery and Science, Graduate School of Medical Sciences, Kyushu University, 3-1-1, Maidashi, Higashi-ku, Fukuoka, 812-8582, Japan
| | - Noboru Harada
- Department of Surgery and Science, Graduate School of Medical Sciences, Kyushu University, 3-1-1, Maidashi, Higashi-ku, Fukuoka, 812-8582, Japan
| | - Ichiro Sakamoto
- Department of Cardiovascular Medicine, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Hiroyuki Tsutsui
- Department of Cardiovascular Medicine, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Tomoharu Yoshizumi
- Department of Surgery and Science, Graduate School of Medical Sciences, Kyushu University, 3-1-1, Maidashi, Higashi-ku, Fukuoka, 812-8582, Japan
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9
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Abdominal lymphatic pathway in Fontan circulation using non-invasive magnetic resonance lymphangiography. Heart Vessels 2023; 38:581-587. [PMID: 36318300 DOI: 10.1007/s00380-022-02196-8] [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: 07/06/2022] [Accepted: 10/20/2022] [Indexed: 11/07/2022]
Abstract
Lymphatic congestion is known to play an important role in the development of late Fontan complications. This study aimed to (1) develop a gadolinium ethoxybenzyl diethylenetriamine pentaacetic acid (Gd-EOB-DTPA) contrast three-dimensional heavily T2-weighed MR technique that can detect abnormal lymphatic pathway in the abdomen while simultaneously evaluating hepatocellular carcinoma (HCC) and to (2) propose a new classification of abnormal abdominal lymphatic pathway using a non-invasive method in adults with Fontan circulation. Twenty-seven adults with Fontan circulation who underwent Gd-EOB-DTPA abdominal MR imaging were prospectively enrolled in this study. We proposed MR lymphangiography that suppresses the vascular signal on heavily T2-weighted imaging after EOB contrast. The patients were classified as follows: grade 1 with almost no lymphatic pathway, grade 2 with a lymphatic pathway mainly around the bile duct and liver surface, and grade 3 with a lymphatic pathway mainly around the vertebral body and inferior vena cava. The grade 3 group showed the lowest oxygen saturation level, highest central venous pressure, highest incidence of massive ascites, HCC, and focal nodular hyperplasia. This group also tended to have patients with the oldest age and highest cardiac index; however, the difference was not statistically significant. As for the blood test, the grade 3 group showed the lowest platelet count and serum albumin level and the highest fibrosis-4 index. A novel technique, Gd-EOB-DTPA MR lymphangiography, can detect abnormal abdominal lymphatic pathways in Fontan circulation, which can reflect the severity of failing Fontan.
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10
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de Lange C, Möller T, Hebelka H. Fontan-associated liver disease: Diagnosis, surveillance, and management. Front Pediatr 2023; 11:1100514. [PMID: 36937979 PMCID: PMC10020358 DOI: 10.3389/fped.2023.1100514] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/16/2022] [Accepted: 02/09/2023] [Indexed: 03/06/2023] Open
Abstract
The Fontan operation is a lifesaving procedure for patients with functional single-ventricle congenital heart disease, where hypoplastic left heart syndrome is the most frequent anomaly. Hemodynamic changes following Fontan circulation creation are now increasingly recognized to cause multiorgan affection, where the development of a chronic liver disease, Fontan-associated liver disease (FALD), is one of the most important morbidities. Virtually, all patients with a Fontan circulation develop liver congestion, resulting in fibrosis and cirrhosis, and most patients experience childhood onset. FALD is a distinctive type of congestive hepatopathy, and its pathogenesis is thought to be a multifactorial process driven by increased nonpulsatile central venous pressure and decreased cardiac output, both of which are inherent in the Fontan circulation. In the advanced stage of liver injury, complications of portal hypertension often occur, and there is a risk of developing secondary liver cancer, reported at young age. However, FALD develops with few clinical symptoms, a surprisingly variable degree of severity in liver disease, and with little relation to poor cardiac function. The disease mechanisms and modifying factors of its development are still not fully understood. As one of the more important noncardiac complications of the Fontan circulation, FALD needs to be diagnosed in a timely manner with a structured monitoring scheme of disease development, early detection of malignancy, and determination of the optimal time point for transplantation. There is also a clear need for consensus on the best surveillance strategy for FALD. In this regard, imaging plays an important role together with clinical scoring systems, biochemical workups, and histology. Patients operated on with a Fontan circulation are generally followed up in cardiology units. Ultimately, the resulting multiorgan affection requires a multidisciplinary team of healthcare personnel to address the different organ complications. This article discusses the current concepts, diagnosis, and management of FALD, with special emphasis on the role of different imaging techniques in the diagnosis and monitoring of disease progression, as well as current recommendations for liver disease surveillance.
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Affiliation(s)
- Charlotte de Lange
- Department of Pediatric Radiology, Queen Silvia Children's Hospital, Sahlgrenska University Hospital, Gothenburg, Sweden
- Institution of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Thomas Möller
- Department of Pediatric Cardiology, Oslo University Hospital, Oslo, Norway
| | - Hanna Hebelka
- Department of Pediatric Radiology, Queen Silvia Children's Hospital, Sahlgrenska University Hospital, Gothenburg, Sweden
- Institution of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
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11
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Jou J, Li J, Kaldas FM. Combined hepatocellular carcinoma-cholangiocarcinoma in a patient with Fontan-associated liver disease. BMJ Case Rep 2022; 15:e250590. [PMID: 36343983 PMCID: PMC9644299 DOI: 10.1136/bcr-2022-250590] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
Abstract
We present a rare case of combined hepatocellular carcinoma-cholangiocarcinoma in a woman with a history of univentricular congenital heart disease requiring multiple corrective operations including Fontan procedure. During workup for elevated alpha fetal protein, a right hepatic lobe lesion was identified with biopsy showing poorly differentiated hepatocellular carcinoma. She underwent successful segment 5 liver resection. Final pathology demonstrated combined hepatocellular carcinoma-cholangiocarcinoma. She was treated with gemcitabine/oxaliplatin adjuvant chemotherapy and had no evidence of recurrent disease at her 12-month follow-up. To our knowledge, this is the first case reported in of successful treatment of this rare malignancy in the setting of Fontan-associated liver disease and highlights the importance of a robust screening protocol in this patient population. Semiannual screening for the development of primary liver malignancy should start by 10 years post-Fontan and continue until heart-liver transplantation may be performed. It is important to note that cirrhosis is not a pre-requisite for the development of hepatocellular carcinoma or cholangiocarcinoma in these patients.
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Affiliation(s)
- Jonathan Jou
- Department of Surgery, University of Illinois College of Medicine, Chicago, Illinois, USA
| | - Jennifer Li
- Department of Surgery, University of California Los Angeles, Los Angeles, California, USA
| | - Fady M Kaldas
- Department of Surgery, University of California Los Angeles, Los Angeles, California, USA
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12
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Ohuchi H, Kawata M, Uemura H, Akagi T, Yao A, Senzaki H, Kasahara S, Ichikawa H, Motoki H, Syoda M, Sugiyama H, Tsutsui H, Inai K, Suzuki T, Sakamoto K, Tatebe S, Ishizu T, Shiina Y, Tateno S, Miyazaki A, Toh N, Sakamoto I, Izumi C, Mizuno Y, Kato A, Sagawa K, Ochiai R, Ichida F, Kimura T, Matsuda H, Niwa K. JCS 2022 Guideline on Management and Re-Interventional Therapy in Patients With Congenital Heart Disease Long-Term After Initial Repair. Circ J 2022; 86:1591-1690. [DOI: 10.1253/circj.cj-22-0134] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Affiliation(s)
- Hideo Ohuchi
- Department of Pediatric Cardiology and Adult Congenital Heart Disease, National Cerebral and Cardiovascular Center
| | - Masaaki Kawata
- Division of Pediatric and Congenital Cardiovascular Surgery, Jichi Children’s Medical Center Tochigi
| | - Hideki Uemura
- Congenital Heart Disease Center, Nara Medical University
| | - Teiji Akagi
- Department of Cardiovascular Medicine, Okayama University Graduate School of Medicine Dentistry and Pharmaceutical Sciences
| | - Atsushi Yao
- Division for Health Service Promotion, University of Tokyo
| | - Hideaki Senzaki
- Department of Pediatrics, International University of Health and Welfare
| | - Shingo Kasahara
- Department of Cardiovascular Surgery, Okayama University Graduate School of Medicine Dentistry and Pharmaceutical Sciences
| | - Hajime Ichikawa
- Department of Pediatric Cardiovascular Surgery, National Cerebral and Cardiovascular Center
| | - Hirohiko Motoki
- Department of Cardiovascular Medicine, Shinshu University School of Medicine
| | - Morio Syoda
- Department of Cardiology, Tokyo Women’s Medical University
| | - Hisashi Sugiyama
- Department of Pediatric Cardiology, Seirei Hamamatsu General Hospital
| | - Hiroyuki Tsutsui
- Department of Cardiovascular Medicine, Kyushu University Graduate School of Medical Sciences
| | - Kei Inai
- Department of Pediatric Cardiology and Adult Congenital Cardiology, Tokyo Women’s Medical University
| | - Takaaki Suzuki
- Department of Pediatric Cardiac Surgery, Saitama Medical University
| | | | - Syunsuke Tatebe
- Department of Cardiovascular Medicine, Tohoku University Graduate School of Medicine
| | - Tomoko Ishizu
- Cardiovascular Division, Faculty of Medicine, University of Tsukuba
| | - Yumi Shiina
- Cardiovascular Center, St. Luke’s International Hospital
| | - Shigeru Tateno
- Department of Pediatrics, Chiba Kaihin Municipal Hospital
| | - Aya Miyazaki
- Division of Congenital Heart Disease, Department of Transition Medicine, Shizuoka General Hospital
| | - Norihisa Toh
- Department of Cardiovascular Medicine, Okayama University Graduate School of Medicine Dentistry and Pharmaceutical Sciences
| | - Ichiro Sakamoto
- Department of Cardiovascular Medicine, Kyushu University Graduate School of Medical Sciences
| | - Chisato Izumi
- Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center
| | - Yoshiko Mizuno
- Faculty of Nursing, Tokyo University of Information Sciences
| | - Atsuko Kato
- Department of Pediatric Cardiology, National Cerebral and Cardiovascular Center
| | - Koichi Sagawa
- Department of Pediatric Cardiology, Fukuoka Children’s Hospital
| | - Ryota Ochiai
- Department of Adult Nursing, Yokohama City University
| | - Fukiko Ichida
- Department of Pediatrics, International University of Health and Welfare
| | - Takeshi Kimura
- Department of Cardiovascular Medicine, Kyoto University Graduate School of Medicine
| | | | - Koichiro Niwa
- Department of Cardiology, St. Luke’s International Hospital
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Liver nodules after the Fontan operation: role of the computerised tomography scan. Cardiol Young 2022; 32:930-935. [PMID: 34365989 DOI: 10.1017/s1047951121003309] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Currently, there is an increasing prevalence of liver nodules in patients following the Fontan operation. The appropriate non-invasive modalities have been applied to assess a diagnosis of Fontan-associated liver disease. The aims of this study were to determine the prevalence and associated factors for the presence of liver nodules using CT scan. A cross-sectional study of 34 patients older than 15 years of age was recruited. Ultrasound upper abdomen, ultrasound liver elastography, and CT scan of the upper abdomen were performed after the Fontan operation. The median age of patients was 20 years (range 14-36 years). The median age at the Fontan operation was 7 years (range 5-17 years) and the duration after the Fontan operation was 12 years (range 4-22 years). The prevalence of liver nodules was 62% as detected by CT scans. Hepatic vein pressure in patients with liver nodules was significantly higher than in those without liver nodules. Hepatic vein pressure above 13 mmHg was a factor associated with liver nodules. There was little agreement between the ultrasound of the upper abdomen and CT scan of the upper abdomen in the evaluation of liver nodules. Hepatic pressure was the only associated factor for the occurrence of liver nodules in patients following the Fontan operation. The prevalence of liver nodules was very high after the Fontan operation. The upper abdomen CT scan should be performed for the surveillance of liver nodules in every Fontan patient over the age of 15 years.
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Laparoscopic hysterectomy for endometrial cancer after the Fontan procedure: The first case report. Int Cancer Conf J 2021; 11:41-45. [DOI: 10.1007/s13691-021-00513-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2021] [Accepted: 10/04/2021] [Indexed: 12/24/2022] Open
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Ohuchi H, Hayama Y, Nakajima K, Kurosaki K, Shiraishi I, Nakai M. Incidence, Predictors, and Mortality in Patients With Liver Cancer After Fontan Operation. J Am Heart Assoc 2021; 10:e016617. [PMID: 33538186 PMCID: PMC7955326 DOI: 10.1161/jaha.120.016617] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Background Liver cancer (LC) is a serious late complication after the Fontan operation. However, the incidence, predictors, and prognosis remain unknown. The purpose of our study was to determine these clinical characteristics. Methods and Results We assessed liver function in 339 consecutive patients who had undergone the Fontan procedure from 2005 to 2019. LC was histologically diagnosed in 10 patients after a median period of 2.9 years (range: 0.3–13.8; median age: 29.9 years [range: 14.4–41.5 years]; overall median post–Fontan procedure follow‐up: 25.6 years [range: 13–32.1 years]), and the annual incidence was 0.89%. Over the entire post‐Fontan follow‐up period, the annual incidences of new‐onset LC in the second, third, and fourth decades were 0.14%, 0.43%, and 8.83%, respectively. The patients with LC had longer follow‐up periods, higher levels of AFP (α‐fetoprotein), and higher values of liver fibrosis indices (P<0.01–0.0001). Moreover, all indices were predictive of new‐onset LC (P<0.01–0.0001). The LC treatments were surgical resection (n=3), transarterial chemoembolization (n=3), radiofrequency ablation (n=2), and hospice care (n=2). During a median follow‐up of 9.4 months, 4 patients died; the survival rate at 1 year was 60%, and it was better among asymptomatic patients (P<0.01). Conclusions The LC incidence rapidly increased ≥30 years after the Fontan procedure, and liver fibrosis indices and AFP were predictive of new‐onset LC. These LC‐predictive markers should be monitored closely and mandatorily for early LC detection and better prognosis.
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Affiliation(s)
- Hideo Ohuchi
- Pediatric CardiologyNational Cerebral and Cardiovascular CenterSuitaOsakaJapan
- Adult Congenital Heart DiseaseNational Cerebral and Cardiovascular CenterSuitaOsakaJapan
| | - Yohsuke Hayama
- Pediatric CardiologyNational Cerebral and Cardiovascular CenterSuitaOsakaJapan
| | - Kimiko Nakajima
- Pediatric CardiologyNational Cerebral and Cardiovascular CenterSuitaOsakaJapan
| | - Kenichi Kurosaki
- Pediatric CardiologyNational Cerebral and Cardiovascular CenterSuitaOsakaJapan
| | - Isao Shiraishi
- Pediatric CardiologyNational Cerebral and Cardiovascular CenterSuitaOsakaJapan
| | - Michikazu Nakai
- Center for Cerebral and Cardiovascular Disease InformationNational Cerebral and Cardiovascular CenterSuitaOsakaJapan
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