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Jalal Z, Langouet E, Dib N, Le-Quellenec S, Mostefa-Kara M, Martin A, Roubertie F, Thambo JB. Role and Applications of Experimental Animal Models of Fontan Circulation. J Clin Med 2024; 13:2601. [PMID: 38731130 PMCID: PMC11084605 DOI: 10.3390/jcm13092601] [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: 02/29/2024] [Revised: 04/17/2024] [Accepted: 04/26/2024] [Indexed: 05/13/2024] Open
Abstract
Over the last four decades, the Fontan operation has been the treatment of choice for children born with complex congenital heart diseases and a single-ventricle physiology. However, therapeutic options remain limited and despite ongoing improvements in initial surgical repair, patients still experience a multiplicity of cardiovascular complications. The causes for cardiovascular failure are multifactorial and include systemic ventricular dysfunction, pulmonary vascular resistance, atrioventricular valve regurgitation, arrhythmia, development of collaterals, protein-losing enteropathy, hepatic dysfunction, and plastic bronchitis, among others. The mechanisms leading to these late complications remain to be fully elucidated. Experimental animal models have been developed as preclinical steps that enable a better understanding of the underlying pathophysiology. They furthermore play a key role in the evaluation of the efficacy and safety of new medical devices prior to their use in human clinical studies. However, these experimental models have several limitations. In this review, we aim to provide an overview of the evolution and progress of the various types of experimental animal models used in the Fontan procedure published to date in the literature. A special focus is placed on experimental studies performed on animal models of the Fontan procedure with or without mechanical circulatory support as well as a description of their impact in the evolution of the Fontan design. We also highlight the contribution of animal models to our understanding of the pathophysiology and assess forthcoming developments that may improve the contribution of animal models for the testing of new therapeutic solutions.
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Affiliation(s)
- Zakaria Jalal
- Department of Pediatric and Adult Congenital Cardiology, University Hospital of Bordeaux, 33600 Pessac, France; (N.D.); (F.R.); (J.-B.T.)
- LIRYC Electrophysiology and Heart Modeling Institute, Fondation Bordeaux Université, 33600 Pessac, France
- Centre de Recherche Cardio-Thoracique de Bordeaux, INSERM U1045, 33600 Pessac, France
| | - Elise Langouet
- Department of Pediatric and Adult Congenital Cardiology Anesthesiology, University Hospital of Bordeaux, 33600 Pessac, France;
| | - Nabil Dib
- Department of Pediatric and Adult Congenital Cardiology, University Hospital of Bordeaux, 33600 Pessac, France; (N.D.); (F.R.); (J.-B.T.)
- LIRYC Electrophysiology and Heart Modeling Institute, Fondation Bordeaux Université, 33600 Pessac, France
- Centre de Recherche Cardio-Thoracique de Bordeaux, INSERM U1045, 33600 Pessac, France
| | | | - Mansour Mostefa-Kara
- Adult Congenital Heart Disease Medico-Surgical Unit, European Georges Pompidou Hospital, 75015 Paris, France;
| | - Amandine Martin
- Department of Cardiac Surgery, University Hospital, 97400 Saint-Denis, France;
| | - François Roubertie
- Department of Pediatric and Adult Congenital Cardiology, University Hospital of Bordeaux, 33600 Pessac, France; (N.D.); (F.R.); (J.-B.T.)
- LIRYC Electrophysiology and Heart Modeling Institute, Fondation Bordeaux Université, 33600 Pessac, France
- Centre de Recherche Cardio-Thoracique de Bordeaux, INSERM U1045, 33600 Pessac, France
| | - Jean-Benoît Thambo
- Department of Pediatric and Adult Congenital Cardiology, University Hospital of Bordeaux, 33600 Pessac, France; (N.D.); (F.R.); (J.-B.T.)
- LIRYC Electrophysiology and Heart Modeling Institute, Fondation Bordeaux Université, 33600 Pessac, France
- Centre de Recherche Cardio-Thoracique de Bordeaux, INSERM U1045, 33600 Pessac, France
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Pradegan N, Lena T, Tessari C, Gallo M, Tarzia V, Guariento A, Padalino M, Vida V, Gerosa G. Current Understanding and Future Directions of Transcatheter Devices to Assist Failing Fontan. JOURNAL OF THE SOCIETY FOR CARDIOVASCULAR ANGIOGRAPHY & INTERVENTIONS 2024; 3:101334. [PMID: 39130169 PMCID: PMC11307829 DOI: 10.1016/j.jscai.2024.101334] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 07/10/2023] [Revised: 01/06/2024] [Accepted: 01/22/2024] [Indexed: 08/13/2024]
Abstract
Even if the Fontan operation is the surgical treatment of choice in patients with univentricular physiology, it remains a palliative strategy. Consequently, when Fontan patients reach adulthood, the majority of them develop late clinical sequelae of a failing cavo-pulmonary circuit (eg, liver failure, protein-losing enteropathy, and arrhythmias). Although heart transplantation represents the gold standard to treat this condition, Fontan patients usually accede to this therapy late, when risk of mortality is significantly increased, and a shortage of donor hearts limits transplantation in this special population. Mechanical circulatory support is an emerging field, but it is still in the experimental stage. Current mechanical circulatory devices have been used in Fontan circulation but are associated with the need for high-risk redo surgery. Percutaneous pumps are an emerging field that is still under investigation, with multiple prototypes developed. This review aims to analyze the hemodynamic profile of the developed intravascular pumps and their application in the preclinical scenario in the Fontan circulation.
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Affiliation(s)
- Nicola Pradegan
- Cardiac Surgery Unit, Heart Transplant and MCS Program, Cardio-thoracic-vascular and Public Health Department, Padova University Hospital, Padova, Italy
| | - Tea Lena
- Cardiac Surgery Unit, Heart Transplant and MCS Program, Cardio-thoracic-vascular and Public Health Department, Padova University Hospital, Padova, Italy
| | - Chiara Tessari
- Cardiac Surgery Unit, Heart Transplant and MCS Program, Cardio-thoracic-vascular and Public Health Department, Padova University Hospital, Padova, Italy
| | - Michele Gallo
- Department of Cardiothoracic Surgery, University of Louisville, Louisville, Kentucky
| | - Vincenzo Tarzia
- Cardiac Surgery Unit, Cardio-Thoracic-Vascular and Public Health Department, University of Padova, Podova, Italy
| | - Alvise Guariento
- Pediatric Cardiac Surgery and Congenital Heart Disease Unit, Cardio-Thoracic-Vascular and Public Health Department, Padova University Hospital, Padova, Italy
| | - Massimo Padalino
- Pediatric Cardiac Surgery and Congenital Heart Disease Unit, Cardio-Thoracic-Vascular and Public Health Department, Padova University Hospital, Padova, Italy
| | - Vladimiro Vida
- Pediatric Cardiac Surgery and Congenital Heart Disease Unit, Cardio-Thoracic-Vascular and Public Health Department, Padova University Hospital, Padova, Italy
| | - Gino Gerosa
- Cardiac Surgery Unit, Heart Transplant and MCS Program, Cardio-thoracic-vascular and Public Health Department, Padova University Hospital, Padova, Italy
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Schumacher KR, Cedars A, Allen K, Goldberg D, Batazzi A, Reichle G, DiPaola F, Selewski D, Cousino M, Rosenthal DN. Achieving Consensus: Severity-Graded Definitions of Fontan-Associated Complications to Characterize Fontan Circulatory Failure. J Card Fail 2024:S1071-9164(24)00075-7. [PMID: 38452996 DOI: 10.1016/j.cardfail.2024.02.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2023] [Revised: 02/07/2024] [Accepted: 02/09/2024] [Indexed: 03/09/2024]
Abstract
BACKGROUND Fontan physiology leads to chronic changes in other organ systems that may affect long-term survival and the success of heart transplantation. Inadequate assessment and treatment of the extra-cardiac effects of Fontan may contribute to poor outcomes. Severity-graded/ordinal consensus definitions of Fontan complications are lacking, which limits understanding of how Fontan-specific morbidity affects patients' outcomes. METHODS AND RESULTS A panel of Fontan patient and physiology experts, including pediatric, adult congenital, heart failure, and critical-care cardiology as well as pediatric nephrology, hepatology and psychology, convened to develop definitions of Fontan complications. Definitions were created by using a severity-graded ordinal scale: grade 1, mild; grade 2, moderate; grade 3, severe; grade 4, disabling or life threatening. Following definition creation, a second panel of 21 experts in Fontan circulatory failure used a modified Delphi methodology to modify and vote on definitions until consensus (> 90% agreement without recommended further modification) was reached on final definitions. After 3 rounds of modifications and voting, consensus agreement was achieved on all Fontan-specific definitions. The defined complications and morbidities of Fontan include: anatomic Fontan pathway obstruction, cyanosis, systemic venous abnormalities resulting from venous insufficiency, atrial arrhythmia, ventricular arrhythmia, bradycardia, chronic pleural effusions, chronic ascites, protein-losing enteropathy, plastic bronchitis, hemoptysis and pulmonary hemorrhage, sleep apnea, Fontan-associated liver disease, portal and hepatic variceal disease, acute kidney injury affecting clinical treatment, polycythemia, thrombotic disease, recurrent or severe bacterial infection, skin atrophy, adrenal insufficiency, physical impact of previous stroke, mood/behavior disorder, and neurodevelopmental disorder. CONCLUSION Consensus and severity-graded definitions of Fontan-specific cardiac and extra-cardiac complications were achieved and are available for use in research. They will allow future robust analyses of Fontan patient outcomes.
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Affiliation(s)
- Kurt R Schumacher
- Congenital Heart Center, C.S. Mott Children's Hospital, University of Michigan, Detroit, MI.
| | | | - Kiona Allen
- Division of Pediatric Cardiology, Ann & Robert H. Lurie Children's Hospital of Chicago, Northwestern Feinberg School of Medicine, Evanston, IL
| | - David Goldberg
- University of Pennsylvania, Children's Hospital of Philadelphia, Philadelphia, PA
| | - Adrianna Batazzi
- Congenital Heart Center, C.S. Mott Children's Hospital, University of Michigan, Detroit, MI
| | - Garrett Reichle
- Congenital Heart Center, C.S. Mott Children's Hospital, University of Michigan, Detroit, MI
| | - Frank DiPaola
- University of Virginia, UVA Health Children's Health, Charlottesville, VA
| | - David Selewski
- Medical University of South Carolina, MUSC Children's Health, Charleston, SC
| | - Melissa Cousino
- Congenital Heart Center, C.S. Mott Children's Hospital, University of Michigan, Detroit, MI
| | - David N Rosenthal
- Stanford University, Lucille Packard Children's Hospital, Stanford, CA
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4
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Sakowitz S, Bakhtiyar SS, Ali K, Mallick S, Williamson C, Benharash P. Outcomes following major thoracoabdominal cancer resection in adults with congenital heart disease. PLoS One 2024; 19:e0295767. [PMID: 38165963 PMCID: PMC10760660 DOI: 10.1371/journal.pone.0295767] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2023] [Accepted: 11/28/2023] [Indexed: 01/04/2024] Open
Abstract
BACKGROUND While advances in medical and surgical management have allowed >97% of congenital heart disease (CHD) patients to reach adulthood, a growing number are presenting with non-cardiovascular malignancies. Indeed, adults with CHD are reported to face a 20% increase in cancer risk, relative to others, and cancer has become the fourth leading cause of death among this population. Surgical resection remains a mainstay in management of thoracoabdominal cancers. However, outcomes following cancer resection among these patients have not been well established. Thus, we sought to characterize clinical and financial outcomes following major cancer resections among adult CHD patients. METHODS The 2012-2020 National Inpatient Sample was queried for all adults (CHD or non-CHD) undergoing lobectomy, esophagectomy, gastrectomy, pancreatectomy, hepatectomy, or colectomy for cancer. To adjust for intergroup differences in baseline characteristics, entropy balancing was applied to generate balanced patient groups. Multivariable models were constructed to assess outcomes of interest. RESULTS Of 905,830 patients undergoing cancer resection, 1,480 (0.2%) had concomitant CHD. The overall prevalence of such patients increased from <0.1% in 2012 to 0.3% in 2012 (P for trend<0.001). Following risk adjustment, CHD was linked with greater in-hospital mortality (AOR 2.00, 95%CI 1.06-3.76), as well as a notable increase in odds of stroke (AOR 8.94, 95%CI 4.54-17.60), but no statistically significant difference in cardiac (AOR 1.33, 95%CI 0.69-2.59) or renal complications (AOR 1.35, 95%CI 0.92-1.97). Further, CHD was associated with a +2.39 day incremental increase in duration of hospitalization (95%CI +1.04-3.74) and a +$11,760 per-patient increase in hospitalization expenditures (95%CI +$4,160-19,360). CONCLUSIONS While a growing number of patients with CHD are undergoing cancer resection, they demonstrate inferior clinical and financial outcomes, relative to others. Novel screening, risk stratification, and perioperative management guidelines are needed for these patients to provide evidence-based recommendations for this complex and unique cohort.
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Affiliation(s)
- Sara Sakowitz
- Cardiovascular Outcomes Research Laboratories (CORELAB), University of California, Los Angeles, CA, United States of America
| | - Syed Shahyan Bakhtiyar
- Cardiovascular Outcomes Research Laboratories (CORELAB), University of California, Los Angeles, CA, United States of America
- Department of Surgery, University of Colorado, Aurora, CO, United States of America
| | - Konmal Ali
- Cardiovascular Outcomes Research Laboratories (CORELAB), University of California, Los Angeles, CA, United States of America
| | - Saad Mallick
- Cardiovascular Outcomes Research Laboratories (CORELAB), University of California, Los Angeles, CA, United States of America
| | - Catherine Williamson
- Cardiovascular Outcomes Research Laboratories (CORELAB), University of California, Los Angeles, CA, United States of America
| | - Peyman Benharash
- Cardiovascular Outcomes Research Laboratories (CORELAB), University of California, Los Angeles, CA, United States of America
- Department of Surgery, University of California, Los Angeles, CA, United States of America
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Amdani S, Auerbach SR, Bansal N, Chen S, Conway J, Silva JPDA, Deshpande SR, Hoover J, Lin KY, Miyamoto SD, Puri K, Price J, Spinner J, White R, Rossano JW, Bearl DW, Cousino MK, Catlin P, Hidalgo NC, Godown J, Kantor P, Masarone D, Peng DM, Rea KE, Schumacher K, Shaddy R, Shea E, Tapia HV, Valikodath N, Zafar F, Hsu D. Research Gaps in Pediatric Heart Failure: Defining the Gaps and Then Closing Them Over the Next Decade. J Card Fail 2024; 30:64-77. [PMID: 38065308 DOI: 10.1016/j.cardfail.2023.08.026] [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] [Received: 02/07/2023] [Revised: 08/18/2023] [Accepted: 08/19/2023] [Indexed: 01/13/2024]
Abstract
Given the numerous opportunities and the wide knowledge gaps in pediatric heart failure, an international group of pediatric heart failure experts with diverse backgrounds were invited and tasked with identifying research gaps in each pediatric heart failure domain that scientists and funding agencies need to focus on over the next decade.
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Affiliation(s)
- Shahnawaz Amdani
- Department of Pediatric Cardiology, Cleveland Clinic Children's, Cleveland, Ohio.
| | - Scott R Auerbach
- Division of Pediatric Cardiology, University of Colorado Anschutz Medical Campus, Aurora, Colorado
| | - Neha Bansal
- Division of Pediatric Cardiology, Mount Sinai Kravis Children's Hospital, Icahn School of Medicine, New York, New York
| | - Sharon Chen
- Division of Pediatric Cardiology, Lucile Packard Children's Hospital, Stanford University School of Medicine, Palo Alto, California
| | - Jennifer Conway
- Division of Pediatric Cardiology, Stollery Children's Hospital, Edmonton, Alberta, Canada
| | - Julie Pires DA Silva
- Division of Pediatric Cardiology, University of Colorado Anschutz Medical Campus, Aurora, Colorado
| | | | - Jessica Hoover
- Department of Pediatric Cardiology, Cleveland Clinic Children's, Cleveland, Ohio
| | - Kimberly Y Lin
- Division of Cardiology, Department of Pediatrics, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Shelley D Miyamoto
- Division of Pediatric Cardiology, University of Colorado Anschutz Medical Campus, Aurora, Colorado
| | - Kriti Puri
- Department of Pediatrics, Section of Pediatric Cardiology, Baylor College of Medicine/Texas Children's Hospital, Houston, Texas
| | - Jack Price
- Department of Pediatrics, Section of Pediatric Cardiology, Baylor College of Medicine/Texas Children's Hospital, Houston, Texas
| | - Joseph Spinner
- Department of Pediatrics, Section of Pediatric Cardiology, Baylor College of Medicine/Texas Children's Hospital, Houston, Texas
| | - Rachel White
- Division of Cardiology, Department of Pediatrics, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Joseph W Rossano
- Division of Cardiology, Department of Pediatrics, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - David W Bearl
- Department of Pediatric Cardiology, Monroe Carell Jr. Children's Hospital, Nashville, Tennessee
| | - Melissa K Cousino
- Department of Pediatrics, University of Michigan, C. S. Mott Children's Hospital, Ann Arbor, Michigan
| | - Perry Catlin
- Department of Psychology, Marquette University, Milwaukee, Wisconsin
| | - Nicolas Corral Hidalgo
- Division of Pediatric Cardiology, Children's Hospital at Montefiore, Albert Einstein College of Medicine, Bronx, New York
| | - Justin Godown
- Department of Pediatric Cardiology, Monroe Carell Jr. Children's Hospital, Nashville, Tennessee
| | - Paul Kantor
- Children's Hospital Los Angeles and the Keck School of Medicine of the University of Southern California, Los Angeles, California
| | - Daniele Masarone
- Heart Failure Unit, Department of Cardiology, AORN dei Colli-Monaldi Hospital Naples, Naples, Italy
| | - David M Peng
- Department of Pediatrics, University of Michigan, C. S. Mott Children's Hospital, Ann Arbor, Michigan
| | - Kelly E Rea
- Department of Pediatrics, University of Michigan, C. S. Mott Children's Hospital, Ann Arbor, Michigan
| | - Kurt Schumacher
- Department of Pediatrics, University of Michigan, C. S. Mott Children's Hospital, Ann Arbor, Michigan
| | - Robert Shaddy
- Children's Hospital Los Angeles and the Keck School of Medicine of the University of Southern California, Los Angeles, California
| | - Erin Shea
- Heart Failure Unit, Department of Cardiology, AORN dei Colli-Monaldi Hospital Naples, Naples, Italy
| | - Henry Valora Tapia
- Division of Pediatric Cardiology, University of Utah. Salt Lake City, Utah
| | - Nishma Valikodath
- Department of Pediatrics, Section of Pediatric Cardiology, Baylor College of Medicine/Texas Children's Hospital, Houston, Texas
| | - Farhan Zafar
- The Heart Institute, Cincinnati Children's Hospital Medical Center, College of Medicine, University of Cincinnati, Cincinnati, Ohio
| | - Daphne Hsu
- Division of Pediatric Cardiology, Children's Hospital at Montefiore, Albert Einstein College of Medicine, Bronx, New York
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Bakhtiyar SS, Sakowitz S, Ali K, Chervu N, Verma A, Si MS, Benharash P. Combined Heart-Liver vs Isolated Heart Transplantation in Adults With Congenital Heart Disease. Ann Thorac Surg 2023; 116:1260-1267. [PMID: 37059257 DOI: 10.1016/j.athoracsur.2023.04.007] [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: 01/20/2023] [Revised: 03/15/2023] [Accepted: 04/04/2023] [Indexed: 04/16/2023]
Abstract
BACKGROUND Despite an increasing number of adults with congenital heart disease undergoing combined heart-liver transplantation (CHLT), there is a paucity of literature analyzing posttransplant outcomes. We analyzed the incidence and outcomes of congenital heart disease patients undergoing CHLT compared with those undergoing isolated heart transplantation (HT). METHODS This was a retrospective analysis of all adult (≥18 years) congenital heart disease patients undergoing CHLT or HT between 2000 and 2020 in the Organ Procurement and Transplantation Network database. The primary outcome was death at 30 days and 1 year after transplantation. RESULTS Of 1214 recipients included for analysis, 92 (8%) underwent CHLT and 1122 (92%) underwent HT. Patients undergoing CHLT and HT were similar in the distribution of age, sex, and serum bilirubin. Upon adjusted analysis with HT as the reference, undergoing CHLT was associated with a similar hazard of 30-day mortality between 2000 and 2017 (hazard ratio [HR], 0.51; 95% CI, 0.12-2.08; P = .35) and 2018 and 2020 (HR, 2.32; 95% CI, 0.88-6.13; P = .09). Similarly, there was no difference in the hazard of 1-year mortality for patients undergoing CHLT between 2000 and 2017 (HR, 0.60; 95% CI, 0.22-1.63; P = .32) and 2018 and 2020 (HR, 1.52; 95% CI, 0.66-3.53; P = .33) compared with HT. CONCLUSIONS The number of adults undergoing CHLT continues to rise. Given comparable survival outcomes between CHLT and HT, our findings demonstrate the former as a viable option for complex congenital heart disease patients with failing cavopulmonary circulation and associated liver disease. Future studies should delineate factors associated with early hepatic dysfunction to help identify congenital heart disease patients that would benefit from CHLT.
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Affiliation(s)
- Syed Shahyan Bakhtiyar
- Cardiovascular Outcomes Research Laboratories, University of California, Los Angeles, Los Angeles, California
| | - Sara Sakowitz
- Cardiovascular Outcomes Research Laboratories, University of California, Los Angeles, Los Angeles, California
| | - Konmal Ali
- Cardiovascular Outcomes Research Laboratories, University of California, Los Angeles, Los Angeles, California
| | - Nikhil Chervu
- Cardiovascular Outcomes Research Laboratories, University of California, Los Angeles, Los Angeles, California
| | - Arjun Verma
- Cardiovascular Outcomes Research Laboratories, University of California, Los Angeles, Los Angeles, California
| | - Ming-Sing Si
- Division of Cardiac Surgery, Department of Surgery, University of California, Los Angeles, Los Angeles, California
| | - Peyman Benharash
- Cardiovascular Outcomes Research Laboratories, University of California, Los Angeles, Los Angeles, California; Division of Cardiac Surgery, Department of Surgery, University of California, Los Angeles, Los Angeles, California.
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Téllez L, Payancé A, Tjwa E, Del Cerro MJ, Idorn L, Ovroutski S, De Bruyne R, Verkade HJ, De Rita F, de Lange C, Angelini A, Paradis V, Rautou PE, García-Pagán JC. EASL-ERN position paper on liver involvement in patients with Fontan-type circulation. J Hepatol 2023; 79:1270-1301. [PMID: 37863545 DOI: 10.1016/j.jhep.2023.07.013] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/06/2023] [Accepted: 07/06/2023] [Indexed: 10/22/2023]
Abstract
Fontan-type surgery is the final step in the sequential palliative surgical treatment of infants born with a univentricular heart. The resulting long-term haemodynamic changes promote liver damage, leading to Fontan-associated liver disease (FALD), in virtually all patients with Fontan circulation. Owing to the lack of a uniform definition of FALD and the competitive risk of other complications developed by Fontan patients, the impact of FALD on the prognosis of these patients is currently debatable. However, based on the increasing number of adult Fontan patients and recent research interest, the European Association for The Study of the Liver and the European Reference Network on Rare Liver Diseases thought a position paper timely. The aims of the current paper are: (1) to provide a clear definition and description of FALD, including clinical, analytical, radiological, haemodynamic, and histological features; (2) to facilitate guidance for staging the liver disease; and (3) to provide evidence- and experience-based recommendations for the management of different clinical scenarios.
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Affiliation(s)
- Luis Téllez
- Gastroenterology and Hepatology Department, Hospital Universitario Ramón y Cajal, Madrid, Spain; Instituto Ramón y Cajal de Investigación Sanitaria (IRYCIS), CIBEREHD (Centro de Investigación Biomédica en Red Enfermedades Hepáticas y Digestivas), University of Alcalá, Madrid, Spain
| | - Audrey Payancé
- DHU Unity, Pôle des Maladies de l'Appareil Digestif, Service d'Hépatologie, Hôpital Beaujon, AP-HP, Clichy, France; Université Denis Diderot-Paris 7, Sorbonne Paris Cité, Paris, France
| | - Eric Tjwa
- Department of Gastroenterology and Hepatology, Radboud University Medical Center, Nijmegen, The Netherlands
| | - María Jesús Del Cerro
- Pediatric Cardiology Department, Hospital Universitario Ramón y Cajal, Madrid, Spain; Instituto Ramón y Cajal de Investigación Sanitaria (IRYCIS), University of Alcalá, Madrid, Spain
| | - Lars Idorn
- Department of Pediatrics, Section of Pediatric Cardiology, Rigshospitalet, Copenhagen, Denmark
| | - Stanislav Ovroutski
- Department of Congenital Heart Disease/Pediatric Cardiology, Deutsches Herzzentrum Berlin, Berlin, Germany
| | - Ruth De Bruyne
- Department of Pediatric Gastroenterology, Hepatology and Nutrition, Ghent University Hospital, Belgium
| | - Henkjan J Verkade
- Department of Pediatrics, Beatrix Children's Hospital/University Medical Center Groningen, The Netherlands
| | - Fabrizio De Rita
- Adult Congenital and Paediatric Heart Unit, Freeman Hospital, Newcastle Upon Tyne Hospitals NHS Foundation Trust, Newcastle Upon Tyne, UK
| | - Charlotte de Lange
- Department of Pediatric Radiology, Queen Silvia Childrens' Hospital, Sahlgrenska University Hospital, Behandlingsvagen 7, 41650 Göteborg, Sweden
| | - Annalisa Angelini
- Pathology of Cardiac Transplantation and Regenerative Medicine Unit, Department of Cardiac, Thoracic and Vascular Sciences and Public Health, University of Padua, Padua, Italy
| | - Valérie Paradis
- Centre de recherche sur l'inflammation, INSERM1149, Université Paris Cité, Paris, France; Pathology Department, Beaujon Hospital, APHP.Nord, Clichy, France
| | - Pierre Emmanuel Rautou
- AP-HP, Service d'Hépatologie, Hôpital Beaujon, DMU DIGEST, Centre de Référence des Maladies Vasculaires du Foie, FILFOIE, Clichy, France; Université Paris-Cité, Inserm, Centre de recherche sur l'inflammation, UMR 1149, Paris, France
| | - Juan Carlos García-Pagán
- Barcelona Hepatic Hemodynamic Laboratory, Liver Unit, Hospital Clínic, Institut de Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Departament de Medicina i Ciències de la Salut, University of Barcelona, Barcelona, Spain; CIBEREHD (Centro de Investigación Biomédica en Red Enfermedades Hepáticas y Digestivas), Health Care Provider of the European Reference Network on Rare Liver Disorders (ERN-Liver), Spain.
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8
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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] [Grants] [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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Chaudhry A, Selwyn J, Adams E, Bradley EA. Heart Failure in Complex Congenital Heart Disease of the Adult. Curr Cardiol Rep 2022; 24:1727-1735. [PMID: 36197543 PMCID: PMC9901216 DOI: 10.1007/s11886-022-01788-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 09/20/2022] [Indexed: 02/08/2023]
Abstract
PURPOSE OF REVIEW Adult congenital heart disease (ACHD) patients have demonstrated improved survival, especially those with severely complex disease, mainly single-ventricle/Fontan physiology and those with a systemic right ventricle. We describe the heart failure phenotypes of complex CHD, reversible causes for heart failure, and considerations for advanced therapy. RECENT FINDINGS While initially marketed for application to patients with acquired causes for heart failure, newer devices and technologies have started to be used in the ACHD population. After reversible causes for heart failure in CHD are addressed, it is reasonable to consider use of new device-based technologies and orthotopic heart transplant (OHT) for end-stage disease. New heart failure technology and organ transplant should carefully be considered and applied in complex ACHD, where there may be significant improvement in morbidity and mortality.
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Affiliation(s)
- Anisa Chaudhry
- Division of Cardiovascular Medicine, Penn State Heart and Vascular Institute, Pennsylvania State University College of Medicine, Penn State Milton S. Hershey Medical Center, Hershey, PA 17033, USA
| | - Julia Selwyn
- Department of Internal Medicine, Pennsylvania State University College of Medicine, Penn State Milton S. Hershey Medical Center, Hershey, PA, USA
| | - Elizabeth Adams
- Division of Cardiovascular Medicine, Penn State Heart and Vascular Institute, Pennsylvania State University College of Medicine, Penn State Milton S. Hershey Medical Center, Hershey, PA 17033, USA
| | - Elisa A. Bradley
- Division of Cardiovascular Medicine, Penn State Heart and Vascular Institute, Pennsylvania State University College of Medicine, Penn State Milton S. Hershey Medical Center, Hershey, PA 17033, USA,Department of Cellular and Molecular Physiology, Pennsylvania State University College of Medicine, Penn State Milton S. Hershey Medical Center, Hershey, PA, USA
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10
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Schleiger A, Kramer P, Sallmon H, Jentsch N, Pileckaite M, Danne F, Schafstedde M, Müller HP, Müller T, Tacke F, Jara M, Stockmann M, Berger F, Ovroutski S. Functional hepatic deterioration determined by 13C-methacetin breath test is associated with impaired hemodynamics and late Fontan failure in adults. Front Cardiovasc Med 2022; 9:952080. [PMID: 36158803 PMCID: PMC9489932 DOI: 10.3389/fcvm.2022.952080] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2022] [Accepted: 08/15/2022] [Indexed: 11/25/2022] Open
Abstract
Background Despite improved survival a substantial number of Fontan patients eventually develop late failure. Fontan-associated liver disease (FALD) is the most frequent end-organ dysfunction. Although impaired hemodynamics and Fontan failure correlate with FALD severity, no association between hepatic functional metabolic impairment and Fontan hemodynamics has been established. Hypothesis Metabolic liver function measured by liver maximum function capacity test (LiMAx®) correlates with Fontan hemodynamics and Fontan failure. Methods From 2020 to 2022, 58 adult Fontan patients [median age: 29.3 years, IQR (12.7), median follow-up time after Fontan operation: 23.2 years, IQR (8.7)] were analyzed in a cross-sectional study. Hemodynamic assessment included echocardiography, cardiopulmonary exercise testing and invasive hemodynamic evaluation. Fontan failure was defined based on commonly applied clinical criteria and our recently composed multimodal Fontan failure score. Results LiMAx® test revealed normal maximum liver function capacity in 40 patients (>315 μg/h*kg). In 18 patients a mild to moderate impairment was detected (140–314 μg/h*kg), no patient suffered from severe hepatic deterioration (≤ 139 μg/kg*h). Fontan failure was present in 15 patients. Metabolic liver function was significantly reduced in patients with increased pulmonary artery pressure (p = 0.041. r = −0.269) and ventricular end-diastolic pressure (p = 0.033, r = −0.325), respectively. In addition, maximum liver function capacity was significantly impaired in patients with late Fontan failure (289.0 ± 99.6 μg/kg*h vs. 384.5 ± 128.6 μg/kg*h, p = 0.007). Conclusion Maximum liver function capacity as determined by LiMAx® was significantly reduced in patients with late Fontan failure. In addition, elevated pulmonary artery pressure and end-diastolic ventricular pressure were associated with hepatic functional metabolic impairment.
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Affiliation(s)
- Anastasia Schleiger
- Department of Congenital Heart Disease/Pediatric Cardiology, Deutsches Herzzentrum Berlin, Berlin, Germany
- *Correspondence: Anastasia Schleiger
| | - Peter Kramer
- Department of Congenital Heart Disease/Pediatric Cardiology, Deutsches Herzzentrum Berlin, Berlin, Germany
| | - Hannes Sallmon
- Department of Congenital Heart Disease/Pediatric Cardiology, Deutsches Herzzentrum Berlin, Berlin, Germany
| | - Niklas Jentsch
- Department of Congenital Heart Disease/Pediatric Cardiology, Deutsches Herzzentrum Berlin, Berlin, Germany
| | - Marta Pileckaite
- Department of Congenital Heart Disease/Pediatric Cardiology, Deutsches Herzzentrum Berlin, Berlin, Germany
| | - Friederike Danne
- Department of Congenital Heart Disease/Pediatric Cardiology, Deutsches Herzzentrum Berlin, Berlin, Germany
| | - Marie Schafstedde
- Department of Congenital Heart Disease/Pediatric Cardiology, Deutsches Herzzentrum Berlin, Berlin, Germany
- Institute for Cardiovascular Computer-Assisted Medicine, Charité—Universitätsmedizin Berlin, Berlin, Germany
- Berlin Institute of Health, Charité-Universitätsmedizin Berlin, Berlin, Germany
| | - Hans-Peter Müller
- Charité Centre for Internal Medicine and Dermatology, Charité-Universitätsmedizin Berlin, Berlin, Germany
| | - Tobias Müller
- Department of Gastroenterology and Hepatology, Charité—Universitätsmedizin Berlin, Berlin, Germany
| | - Frank Tacke
- Department of Gastroenterology and Hepatology, Charité—Universitätsmedizin Berlin, Berlin, Germany
| | - Maximilian Jara
- Department of General, Visceral and Vascular Surgery, Charité—Universitätsmedizin Berlin, Berlin, Germany
| | - Martin Stockmann
- Department of General, Visceral and Vascular Surgery, Charité—Universitätsmedizin Berlin, Berlin, Germany
| | - Felix Berger
- Department of Congenital Heart Disease/Pediatric Cardiology, Deutsches Herzzentrum Berlin, Berlin, Germany
- Department of Pediatric Cardiology, Charité—Universitätsmedizin Berlin, Berlin, Germany
| | - Stanislav Ovroutski
- Department of Congenital Heart Disease/Pediatric Cardiology, Deutsches Herzzentrum Berlin, Berlin, Germany
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11
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Wald R, Mertens L. Hypoplastic Left Heart Syndrome Across the Lifespan: Clinical Considerations for Care of the Fetus, Child, and Adult. Can J Cardiol 2022; 38:930-945. [PMID: 35568266 DOI: 10.1016/j.cjca.2022.04.028] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2022] [Revised: 04/22/2022] [Accepted: 04/24/2022] [Indexed: 12/14/2022] Open
Abstract
Hypoplastic left heart syndrome (HLHS) is the most common anatomic lesion in children born with single ventricle physiology and is characterized by the presence of a dominant right ventricle and a hypoplastic left ventricle along with small left-sided heart structures. Diagnostic subgroups of HLHS reflect the extent of inflow and outflow obstruction at the aortic and mitral valves, specifically stenosis or atresia. If left unpalliated, HLHS is a uniformly fatal lesion in infancy. Following introduction of the Norwood operation, early survival has steadily improved over the past four decades, mirroring advances in operative and peri-operative management as well as reflecting refinements in patient surveillance and interstage clinical care. Notably, survival following staged palliation has increased from 0% to a 5-year survival of 60-65% for children in some centres. Despite the prevalence of HLHS in childhood with relatively favourable surgical outcomes in contemporary series, this cohort is only now reaching early adult life and longer-term outcomes have yet to be elucidated. In this article we focus on contemporary clinical management strategies for patients with HLHS across the lifespan, from fetal to adult life. Nomenclature and diagnostic considerations are discussed and current literature pertaining to putative genetic etiologies is reviewed. The spectrum of fetal and pediatric interventional strategies, both percutaneous and surgical, are described. Clinical, patient-reported and neurodevelopmental outcomes of HLHS are delineated. Finally, note is made of current areas of clinical uncertainty and suggested directions for future research are highlighted.
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Affiliation(s)
- Rachel Wald
- Labatt Family Heart Centre, Division of Cardiology, Hospital for Sick Children, Department of Pediatrics, University of Toronto, Toronto, Ontario, Canada; Peter Munk Cardiac Centre, Division of Cardiology, University Health Network, Department of Medicine,University of Toronto, Toronto, Ontario, Canada
| | - Luc Mertens
- Labatt Family Heart Centre, Division of Cardiology, Hospital for Sick Children, Department of Pediatrics, University of Toronto, Toronto, Ontario, Canada; Peter Munk Cardiac Centre, Division of Cardiology, University Health Network, Department of Medicine,University of Toronto, Toronto, Ontario, Canada
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12
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Hilscher MB, Wells ML, Venkatesh SK, Cetta F, Kamath PS. Fontan-associated liver disease. Hepatology 2022; 75:1300-1321. [PMID: 35179797 DOI: 10.1002/hep.32406] [Citation(s) in RCA: 21] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/27/2021] [Revised: 12/21/2021] [Accepted: 12/27/2021] [Indexed: 12/13/2022]
Affiliation(s)
- Moira B Hilscher
- Division of Gastroenterology and HepatologyDepartment of MedicineUniversity of PennsylvaniaPhiladelphiaPennsylvaniaUSA
| | - Michael L Wells
- Division of Abdominal ImagingDepartment of RadiologyMayo ClinicRochesterMinnesotaUSA
| | - Sudhakar K Venkatesh
- Division of Abdominal ImagingDepartment of RadiologyMayo ClinicRochesterMinnesotaUSA
| | - Frank Cetta
- Division of Pediatric CardiologyDepartment of Pediatric and Adolescent MedicineMayo ClinicRochesterMinnesotaUSA
| | - Patrick S Kamath
- Division of Gastroenterology and HepatologyDepartment of MedicineMayo ClinicRochesterMinnesotaUSA
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13
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Kramer P, Schleiger A, Schafstedde M, Danne F, Nordmeyer J, Berger F, Ovroutski S. A Multimodal Score Accurately Classifies Fontan Failure and Late Mortality in Adult Fontan Patients. Front Cardiovasc Med 2022; 9:767503. [PMID: 35360016 PMCID: PMC8960137 DOI: 10.3389/fcvm.2022.767503] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2021] [Accepted: 02/02/2022] [Indexed: 11/23/2022] Open
Abstract
Objectives Despite the outstanding success of the Fontan operation, it is a palliative procedure and a substantial number of patients experience late failure of the Fontan circulation. Clinical presentation and hemodynamic phenotypes of Fontan failure are considerably variable. While various parameters have been identified as risk factors for late Fontan failure, a feasible score to classify Fontan failure and possibly allow timely risk stratification is lacking. Here, we explored the possibility of developing a score based on hemodynamic, clinical and laboratory parameters to classify Fontan failure and mortality. Methods We performed a retrospective study in our cohort of adult Fontan patients from two institutions [n = 198, median follow-up after Fontan 20.3 (IQR 15.6–24.3) years], identifying those patients with clinical Fontan failure (n = 52, 26.3%). Various hemodynamic, echocardiographic, laboratory and clinical data were recorded and differences between patients with and without Fontan failure were analyzed. We composed a Fontan Failure Score containing 15 parameters associated with Fontan failure and/or mortality and assessed its accuracy to discriminate between patients with and without late Fontan failure as well as late mortality and survival. Results Late failure occurred at a median of 18.2 (IQR 9.1–21.1) years after Fontan completion. Mortality associated with Fontan failure was substantial (25/52, 48.1%) with freedom of death/transplantation/take-down of 64% at 5 years and 36% at 10 years after onset of Fontan failure, respectively. Patients with Fontan failure had a significantly higher median Fontan Failure Score compared to non-failing Fontan patients [8 points (IQR 5–10) vs. 2 points (IQR 1-5), p < 0.001]. The score accurately classifies Fontan failure as well as mortality as assessed with receiver operating characteristic analysis. Area under the curve of the Fontan Failure Score was 0.963 (95% CI 0.921; 0.985, p < 0.001) to discriminate failure and 0.916 (95% CI 0.873; 0.959, p < 0.001) to classify mortality. Conclusion We have developed an uncomplex yet remarkably accurate score to classify Fontan failure and late mortality in adult Fontan patients. Prospective validation and most likely refinement and calibration of the score in larger and preferably multi-institutional cohorts is required to assess its potential to predict the risk of Fontan failure and late mortality.
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Affiliation(s)
- Peter Kramer
- Department of Congenital Heart Disease/Pediatric Cardiology, German Heart Centre Berlin, Berlin, Germany
- *Correspondence: Peter Kramer
| | - Anastasia Schleiger
- Department of Congenital Heart Disease/Pediatric Cardiology, German Heart Centre Berlin, Berlin, Germany
| | - Marie Schafstedde
- Department of Congenital Heart Disease/Pediatric Cardiology, German Heart Centre Berlin, Berlin, Germany
- Institute for Cardiovascular Computer-Assisted Medicine, Charité - Universitätsmedizin Berlin, Berlin, Germany
- Berlin Institute of Health, Berlin, Germany
| | - Friederike Danne
- Department of Congenital Heart Disease/Pediatric Cardiology, German Heart Centre Berlin, Berlin, Germany
| | - Johannes Nordmeyer
- Department of Congenital Heart Disease/Pediatric Cardiology, German Heart Centre Berlin, Berlin, Germany
| | - Felix Berger
- Department of Congenital Heart Disease/Pediatric Cardiology, German Heart Centre Berlin, Berlin, Germany
- Department of Pediatric Cardiology, Charité - Universitätsmedizin Berlin, Campus Virchow-Klinikum, Berlin, Germany
- German Centre for Cardiovascular Research (DZHK), Partner Site Berlin, Berlin, Germany
| | - Stanislav Ovroutski
- Department of Congenital Heart Disease/Pediatric Cardiology, German Heart Centre Berlin, Berlin, Germany
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14
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Alsaied T, Rathod RH, Aboulhosn JA, Budts W, Anderson JB, Baumgartner H, Brown DW, Cordina R, D'udekem Y, Ginde S, Goldberg DJ, Goldstein BH, Lubert AM, Oechslin E, Opotowsky AR, Rychik J, Schumacher KR, Valente AM, Wright G, Veldtman GR. Reaching consensus for unified medical language in Fontan care. ESC Heart Fail 2021; 8:3894-3905. [PMID: 34190428 PMCID: PMC8497335 DOI: 10.1002/ehf2.13294] [Citation(s) in RCA: 36] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2020] [Revised: 02/03/2021] [Accepted: 02/19/2021] [Indexed: 02/04/2023] Open
Abstract
Aims The Fontan operation has resulted in improved survival in patients with single‐ventricle congenital heart disease. As a result, there is a growing population of teenagers and adults with a Fontan circulation. Many co‐morbidities have been increasingly recognized in this population due to the unique features of the Fontan circulation. Standardization of how Fontan co‐morbid conditions are defined will help facilitate understanding, consistency and interpretability of research and clinical experience. Unifying common language usage in Fontan is a critical precursor step for data comparison of research findings and clinical outcomes and ultimately accelerating improvements in management for this growing group of patients. This manuscript aimed to create unified definitions for morbidities seen after the Fontan palliation. Methods In association of many congenital heart disease organizations, this work used Delphi methodology to reach a broad consensus among recognized experts regarding commonly used terms in Fontan care and research. Each definition underwent at least three rounds of revisions to reach a final definition through surveys sent to experts in the field of single‐ventricle care. Results The process of reaching a consensus on multiple morbidities associated with the Fontan procedure is summarized in this manuscript. The different versions that preceded reaching the consensus are also presented in the Supporting Information. Table 1 represents the final definitions according to the consensus. Conclusions We propose the use of these definitions for clinical care, future research studies, registry development and clinical trials.
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Affiliation(s)
- Tarek Alsaied
- Heart Institute, Department of Pediatrics, Pittsburgh Children's Hospital Medical Center, Pittsburgh, PA, USA.,Heart Institute, Department of Pediatrics, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - Rahul H Rathod
- Department of Cardiology, Boston Children's Hospital, Boston, MA, USA
| | - Jamil A Aboulhosn
- Ahmanson/UCLA Adult Congenital Heart Disease Center, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA
| | - Werner Budts
- Division of Congenital and Structural Cardiology, University Hospitals Leuven, Leuven, Belgium
| | - Jeffrey B Anderson
- Heart Institute, Department of Pediatrics, Pittsburgh Children's Hospital Medical Center, Pittsburgh, PA, USA
| | - Helmut Baumgartner
- Department of Cardiology: Adult Congenital and Valvular Heart Disease, University Hospital Muenster, Muenster, Germany
| | - David W Brown
- Department of Cardiology, Boston Children's Hospital, Boston, MA, USA
| | - Rachael Cordina
- Adult Congenital Heart Disease Service and Pulmonary Hypertension Service, Royal Prince Alfred Hospital, Sydney, Australia
| | - Yves D'udekem
- Department of Cardiac Surgery and Children's National Heart Institute, Children's National Hospital, Washington, DC, USA
| | - Salil Ginde
- Division of Pediatric Cardiology, Department of Pediatrics, Medical College of Wisconsin, Milwaukee, WI, USA
| | - David J Goldberg
- Division of Cardiology, Department of Pediatrics, The Children's Hospital of Philadelphia, Perelman School of Medicine, University of Pennsylvania School of Medicine, Philadelphia, PA, USA
| | - Bryan H Goldstein
- Heart Institute, UPMC Children's Hospital of Pittsburgh, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Adam M Lubert
- Heart Institute, Department of Pediatrics, Pittsburgh Children's Hospital Medical Center, Pittsburgh, PA, USA
| | - Erwin Oechslin
- Congenital Cardiac Centre for Adults, Peter Munk Cardiac Centre, University Health Network, Toronto, Canada
| | - Alexander R Opotowsky
- Heart Institute, Department of Pediatrics, Pittsburgh Children's Hospital Medical Center, Pittsburgh, PA, USA
| | - Jack Rychik
- Division of Cardiology, Department of Pediatrics, The Children's Hospital of Philadelphia, Perelman School of Medicine, University of Pennsylvania School of Medicine, Philadelphia, PA, USA
| | - Kurt R Schumacher
- Congenital Heart Center, C.S. Mott Children's Hospital, University of Michigan, Ann Arbor, MI, USA
| | | | - Gail Wright
- Division of Cardiology, Department of Pediatrics, Stanford University School of Medicine, Santa Clara, CA, USA
| | - Gruschen R Veldtman
- Adult Congenital Heart Disease Service, Heart Centre, King Faisal Specialist Hospital and Research Centre, Riyadh, Saudi Arabia
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15
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Escher A, Strauch C, Hubmann EJ, Hübler M, Bortis D, Thamsen B, Mueller M, Kertzscher U, Thamsen PU, Kolar JW, Zimpfer D, Granegger M. A Cavopulmonary Assist Device for Long-Term Therapy of Fontan Patients. Semin Thorac Cardiovasc Surg 2021; 34:238-248. [PMID: 34166811 DOI: 10.1053/j.semtcvs.2021.06.016] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2021] [Accepted: 06/04/2021] [Indexed: 12/22/2022]
Abstract
Treatment of univentricular hearts remains restricted to palliative surgical corrections (Fontan pathway). The established Fontan circulation lacks a subpulmonary pressure source and is commonly accompanied by progressively declining hemodynamics. A novel cavopulmonary assist device (CPAD) may hold the potential for improved therapeutic management of Fontan patients by chronic restoration of biventricular equivalency. This study aimed at translating clinical objectives toward a functional CPAD with preclinical proof regarding hydraulic performance, hemocompatibility and electric power consumption. A prototype composed of hemocompatible titanium components, ceramic bearings, electric motors, and corresponding drive unit was manufactured for preclinical benchtop analysis: hydraulic performance in general and hemocompatibility characteristics in particular were analyzed in-silico (computational fluid dynamics) and validated in-vitro. The CPAD's power consumption was recorded across the entire operational range. The CPAD delivered pressure step-ups across a comprehensive operational range (0-10 L/min, 0-50 mm Hg) with electric power consumption below 1.5 W within the main operating range. In-vitro hemolysis experiments (N = 3) indicated a normalized index of hemolysis of 3.8 ± 1.6 mg/100 L during design point operation (2500 rpm, 4 L/min). Preclinical investigations revealed the CPAD's potential for low traumatic and thrombogenic support of a heterogeneous Fontan population (pediatric and adult) with potentially accompanying secondary disorders (e.g., elevated pulmonary vascular resistance or systemic ventricular insufficiency) at distinct physical activities. The low power consumption implied adequate settings for a small, fully implantable system with transcutaneous energy transfer. The successful preclinical proof provides the rationale for acute and chronic in-vivo trials aiming at the confirmation of laboratory findings and verification of hemodynamic benefit.
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Affiliation(s)
- Andreas Escher
- Biofluid Mechanics Laboratory, Institute for Imaging Science and Computational Modelling in Cardiovascular Medicine, Charité-Universitätsmedizin Berlin, Berlin, Germany; Department of Cardiac Surgery, Medical University of Vienna, Vienna, Austria
| | - Carsten Strauch
- Fachgebiet für Fluidsystemdynamik, Technische Universität Berlin, Berlin, Germany
| | - Emanuel J Hubmann
- Power Electronic Systems Laboratory, ETH Zurich, Zurich, Switzerland
| | - Michael Hübler
- University Heart & Vascular Center, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Dominik Bortis
- Power Electronic Systems Laboratory, ETH Zurich, Zurich, Switzerland
| | - Bente Thamsen
- Biofluid Mechanics Laboratory, Institute for Imaging Science and Computational Modelling in Cardiovascular Medicine, Charité-Universitätsmedizin Berlin, Berlin, Germany
| | - Marc Mueller
- Institute for Multiphase Processes, Leibniz University Hannover, Hannover, Germany
| | - Ulrich Kertzscher
- Biofluid Mechanics Laboratory, Institute for Imaging Science and Computational Modelling in Cardiovascular Medicine, Charité-Universitätsmedizin Berlin, Berlin, Germany
| | - Paul U Thamsen
- Fachgebiet für Fluidsystemdynamik, Technische Universität Berlin, Berlin, Germany
| | - Johann W Kolar
- Power Electronic Systems Laboratory, ETH Zurich, Zurich, Switzerland
| | - Daniel Zimpfer
- Department of Cardiac Surgery, Medical University of Vienna, Vienna, Austria
| | - Marcus Granegger
- Biofluid Mechanics Laboratory, Institute for Imaging Science and Computational Modelling in Cardiovascular Medicine, Charité-Universitätsmedizin Berlin, Berlin, Germany; Department of Cardiac Surgery, Medical University of Vienna, Vienna, Austria.
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16
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Considerations and experience driving expansion of combined heart-liver transplantation. Curr Opin Organ Transplant 2021; 25:496-500. [PMID: 32796180 DOI: 10.1097/mot.0000000000000804] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
PURPOSE OF REVIEW Heart transplantation concomitant with a liver transplant may be warranted when end-stage heart failure results in irreversible liver failure. Previously reported outcomes have been excellent yet the specific immunoprotective role of the liver allograft is not known. We review the current literature about the immunologic benefit for combined heart and liver transplantation (CHLT). RECENT FINDINGS The total number of combined heart and liver transplants continues to increase and accounts for approximately 25 cases per year. Familial amyloid polyneuropathy with cardiac cirrhosis is the most common indication for CHLT while adult congenital heart disease (CHD) with associated cirrhosis is increasing in frequency. The majority of recent registry data suggest a statistically equivalent to modestly improved survival advantage for CHLT compared with isolated heart transplantation. Direct mechanisms accounting for this survival advantage are not proven, but combined heart and liver transplants experience lower rates of acute cardiac rejection and cardiac allograft vasculopathy (CAV). SUMMARY Combined heart and liver transplants remain a small percentage of the total heart transplants worldwide, but the majority of recent literature confirms the safety and viability of this option for patients with end-stage heart and liver disease. Equivalent to modestly improved survival outcomes, lower rates of acute cardiac rejection and CAV warrant further investigation into the liver allograft's immunoprotective effect on the transplanted heart. The key mechanisms of tolerogenicity have important implications for surgical technique and immunosuppression requirements. Future directions include development of criteria for heart-liver transplant candidacy and identification of equitable allocation protocols.
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Abstract
Presently, with increasing survival of patients with congenital heart disease (CHD), pulmonary arterial hypertension (PAH) associated with CHD is commonly encountered in children and adults. This increased prevalence is seen despite significant advances in early diagnosis and surgical correction of patients with structural CHD. PAH is the cause of significant morbidity and mortality in these patients and comes in many forms. With the increased availability of targeted therapies for PAH, there is hope for improved hemodynamics, exercise capacity, quality of life, and possibly survival for these patients. There may also be opportunities for combined medical and interventional/surgical approaches for some.
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Affiliation(s)
- Erika B Rosenzweig
- Division of Pediatric Cardiology, Columbia University Irving Medical Center - New York Presbyterian Hospital, 3959 Broadway-CH-2N, New York, NY 10032, USA.
| | - Usha Krishnan
- Division of Pediatric Cardiology, Columbia University Irving Medical Center - New York Presbyterian Hospital, 3959 Broadway-CH-2N, New York, NY 10032, USA
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18
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Wang Y, Peng J, Rodefeld MD, Luan Y, Giridharan GA. A sensorless physiologic control strategy for continuous flow cavopulmonary circulatory support devices. Biomed Signal Process Control 2020. [DOI: 10.1016/j.bspc.2020.102130] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
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19
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Charla P, Karur GR, Yamamura K, Yoo SJ, Granton JT, Oechslin EN, Shah A, Benson LN, Honjo O, Mertens L, Alonso-Gonzalez R, Hanneman K, Wald RM. Augmentation of pulmonary blood flow and cardiac output by non-invasive external ventilation late after Fontan palliation. Heart 2020; 107:142-149. [PMID: 32748799 PMCID: PMC7788264 DOI: 10.1136/heartjnl-2020-316613] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/03/2020] [Revised: 05/20/2020] [Accepted: 05/26/2020] [Indexed: 11/10/2022] Open
Abstract
Objectives Although a life-preserving surgery for children with single ventricle physiology, the Fontan palliation is associated with striking morbidity and mortality with advancing age. Our primary objective was to evaluate the impact of non-invasive, external, thoraco-abdominal ventilation on pulmonary blood flow (PBF) and cardiac output (CO) as measured by cardiovascular magnetic resonance (CMR) imaging in adult Fontan subjects. Methods Adults with a dominant left ventricle post-Fontan palliation (lateral tunnel or extracardiac connections) and healthy controls matched by sex and age were studied. We evaluated vascular flows using phase-contrast CMR imaging during unassisted breathing, negative pressure ventilation (NPV) and biphasic ventilation (BPV). Measurements were made within target vessels (aorta, pulmonary arteries, vena cavae and Fontan circuit) at baseline and during each ventilation mode. Results Ten Fontan subjects (50% male, 24.5 years (IQR 20.8–34.0)) and 10 matched controls were studied. Changes in PBF and CO, respectively, were greater following BPV as compared with NPV. In subjects during NPV, PBF increased by 8% (Δ0.20 L/min/m2 (0.10–0.53), p=0.011) while CO did not change significantly (Δ0.17 L/min/m2 (−0.11–0.23), p=0.432); during BPV, PBF increased by 25% (Δ0.61 L/min/m2 (0.20–0.84), p=0.002) and CO increased by 16% (Δ0.47 L/min/m2 (0.21–0.71), p=0.010). Following BPV, change in PBF and CO were both significantly higher in subjects versus controls (0.61 L/min/m2 (0.2–0.84) vs −0.27 L/min/m2 (−0.55–0.13), p=0.001; and 0.47 L/min/m2 (0.21–0.71) vs 0.07 L/min/m2 (−0.47–0.33), p=0.034, respectively). Conclusion External ventilation acutely augments PBF and CO in adult Fontan subjects. Confirmation of these findings in larger populations with longer duration of ventilation and extended follow-up will be required to determine sustainability of haemodynamic effects.
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Affiliation(s)
- Pradeepkumar Charla
- Toronto Congenital Cardiac Center for Adults, Peter Munk Cardiac Center, University of Toronto, Toronto General Hospital, Toronto, Ontario, Canada
| | - Gauri Rani Karur
- Toronto Joint Department of Medical Imaging, University of Toronto, University Health Network, Toronto, Ontario, Canada
| | - Kenichiro Yamamura
- Toronto Congenital Cardiac Center for Adults, Peter Munk Cardiac Center, University of Toronto, Toronto General Hospital, Toronto, Ontario, Canada
| | - Shi-Joon Yoo
- Department of Diagnostic Imaging, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - John T Granton
- Toronto Congenital Cardiac Center for Adults, Peter Munk Cardiac Center, University of Toronto, Toronto General Hospital, Toronto, Ontario, Canada
| | - Erwin N Oechslin
- Toronto Congenital Cardiac Center for Adults, Peter Munk Cardiac Center, University of Toronto, Toronto General Hospital, Toronto, Ontario, Canada
| | - Ashish Shah
- Toronto Congenital Cardiac Center for Adults, Peter Munk Cardiac Center, University of Toronto, Toronto General Hospital, Toronto, Ontario, Canada
| | - Leland N Benson
- Division of Cardiology, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Osami Honjo
- Division of Cardiovascular Surgery, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Luc Mertens
- Division of Cardiology, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Rafael Alonso-Gonzalez
- Toronto Congenital Cardiac Center for Adults, Peter Munk Cardiac Center, University of Toronto, Toronto General Hospital, Toronto, Ontario, Canada
| | - Kate Hanneman
- Toronto Joint Department of Medical Imaging, University of Toronto, University Health Network, Toronto, Ontario, Canada
| | - Rachel M Wald
- Toronto Congenital Cardiac Center for Adults, Peter Munk Cardiac Center, University of Toronto, Toronto General Hospital, Toronto, Ontario, Canada .,Division of Cardiology, The Hospital for Sick Children, Toronto, Ontario, Canada
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20
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Ibe DO, Rapp JB, Whitehead KK, Otero HJ, Smith CL, Fogel MA, Biko DM. Pearls and Pitfalls in Pediatric Fontan Operation Imaging. Semin Ultrasound CT MR 2020; 41:442-450. [PMID: 32980091 DOI: 10.1053/j.sult.2020.05.009] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
Abstract
The Fontan operation or the total cavopulmonary connection is a palliative surgery for single ventricle congenital heart disease where the systemic venous return circumvents a pumping chamber and flows directly into the pulmonary circuit. With surgical and medical advances, there has been improvement in life expectancy of these patients, however, it has also resulted in unique complications from the physiology that requires diligent surveillance. A critical component relies on optimal imaging for diagnosis and treatment of these complications. This article describes the normal anatomy of the Fontan circulation, current imaging modalities and techniques, and frequently encountered complications seen when imaging the patients who have undergone Fontan palliation.
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Affiliation(s)
- Donald O Ibe
- Department of Radiology, Silhouette Diagnostic Consultants, Abuja, Nigeria
| | - Jordan B Rapp
- Department of Radiology, Children's Hospital of Philadelphia, Philadelphia, PA; Perelman School of Medicine at The University of Pennsylvania, Philadelphia, PA
| | - Kevin K Whitehead
- Perelman School of Medicine at The University of Pennsylvania, Philadelphia, PA; Division of Cardiology, Children's Hospital of Philadelphia, Philadelphia, PA
| | - Hansel J Otero
- Department of Radiology, Children's Hospital of Philadelphia, Philadelphia, PA; Division of Cardiology, Children's Hospital of Philadelphia, Philadelphia, PA
| | - Christopher L Smith
- Perelman School of Medicine at The University of Pennsylvania, Philadelphia, PA; Division of Cardiology, Children's Hospital of Philadelphia, Philadelphia, PA
| | - Mark A Fogel
- Perelman School of Medicine at The University of Pennsylvania, Philadelphia, PA; Division of Cardiology, Children's Hospital of Philadelphia, Philadelphia, PA
| | - David M Biko
- Department of Radiology, Children's Hospital of Philadelphia, Philadelphia, PA; Division of Cardiology, Children's Hospital of Philadelphia, Philadelphia, PA.
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21
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Ing RJ, Mclennan D, Twite MD, DiMaria M. Anesthetic Considerations for Fontan-Associated Liver Disease and the Failing Fontan Circuit. J Cardiothorac Vasc Anesth 2020; 34:2224-2233. [PMID: 32249074 DOI: 10.1053/j.jvca.2020.02.040] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/16/2018] [Revised: 02/19/2020] [Accepted: 02/23/2020] [Indexed: 12/13/2022]
Affiliation(s)
- Richard J Ing
- Department of Anesthesiology, Children's Hospital Colorado, Anschutz Medical Campus, Aurora, CO; School of Medicine, University of Colorado, Aurora, CO.
| | - Daniel Mclennan
- Stead Family Children's Hospital, University of Iowa, Iowa City, IA
| | - Mark D Twite
- Department of Anesthesiology, Children's Hospital Colorado, Anschutz Medical Campus, Aurora, CO; School of Medicine, University of Colorado, Aurora, CO
| | - Michael DiMaria
- Department of Anesthesiology, Children's Hospital Colorado, Anschutz Medical Campus, Aurora, CO; School of Medicine, University of Colorado, Aurora, CO
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22
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Broda CR, Downing TE, John AS. Diagnosis and management of the adult patient with a failing Fontan circulation. Heart Fail Rev 2020; 25:633-646. [DOI: 10.1007/s10741-020-09932-0] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
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23
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Poh C, Hornung T, Celermajer DS, Radford DJ, Justo RN, Andrews D, du Plessis K, Iyengar AJ, Winlaw D, d'Udekem Y. Modes of late mortality in patients with a Fontan circulation. Heart 2020; 106:1427-1431. [PMID: 32098807 DOI: 10.1136/heartjnl-2019-315862] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/28/2019] [Revised: 01/01/2020] [Accepted: 01/11/2020] [Indexed: 12/17/2022] Open
Abstract
OBJECTIVES The mechanisms of attrition of the Fontan population have been poorly characterised and it is unclear whether some of the deaths are potentially preventable. We analysed the circumstances of late death in patients with a Fontan circulation, with a special focus on identifying lesions amenable to intervention that may have contributed to the decline of their circulation. METHODS Between 1975 and 2018, a total of 105 patients from a Bi-National Registry died beyond 1 year after Fontan completion, at a median age of 18.6 (IQR 13.8-26.0) years old, 12.7 (IQR 6.0-19.3) years after Fontan completion. RESULTS A total of 105 patients died-63 patients (60%) with an atriopulmonary (AP) Fontan, 21 patients (20%) with a lateral tunnel (LT) and 21 patients (20%) with an extracardiac conduit (ECC). 72 patients (69%) were reviewed within 2 years preceding death, with 32% (23/72) deemed to be clinically well. Fontan circulatory failure was the most common cause of death in 42 patients (45%). Other causes of death included sudden death/arrhythmia (19%), perioperative death (12%), neurological complication (7%) and thromboembolism (7%). All patients with an LT or ECC who died from Fontan failure had at least one surgical defect that was amenable to intervention at time of death. CONCLUSIONS Conventional clinical surveillance has been insensitive in detecting a significant proportion of patients at risk of late death. Fontan circulatory failure contributes to half of the late deaths. Patients with an LT or ECC Fontan who died with a clinical picture of circulation failure may have potentially correctable lesions.
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Affiliation(s)
- Chin Poh
- Murdoch Childrens Research Institute, Parkville, Victoria, Australia .,Department of Paediatrics, University of Melbourne, Melbourne, Victoria, Australia
| | - Tim Hornung
- Green Lane Paediatric and Congenital Cardiac, Starship Hospital, Auckland, New Zealand
| | - David S Celermajer
- Department of Cardiology, Royal Prince Alfred Hospital, Camperdown, New South Wales, Australia
| | - Dorothy J Radford
- Adult Congenital Heart Unit, The Prince Charles Hospital, Brisbane, Brisbane, Queensland, Australia
| | - Robert N Justo
- Department of Paediatric Cardiology, Queensland Children's Hospital, Brisbane, Queensland, Australia
| | - David Andrews
- Princess Margaret Hospital, Perth, Western Australia, Australia
| | - Karin du Plessis
- Murdoch Childrens Research Institute, Parkville, Victoria, Australia
| | - Ajay J Iyengar
- Department of Cardiac Surgery, Royal Children's Hospital Melbourne, Parkville, Victoria, Australia
| | - David Winlaw
- Heart Centre for Children, The Children's Hospital at Westmead, Sydney, New South Wales, Australia
| | - Yves d'Udekem
- Murdoch Childrens Research Institute, Parkville, Victoria, Australia.,Department of Paediatrics, University of Melbourne, Melbourne, Victoria, Australia.,Heart Centre for Children, The Children's Hospital at Westmead, Sydney, New South Wales, Australia
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24
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Patino M, Chandrakantan A. Midgestational Fetal Procedures. CASE STUDIES IN PEDIATRIC ANESTHESIA 2019:197-201. [DOI: 10.1017/9781108668736.047] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 09/02/2023]
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25
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Acute Hemodynamic Effects of Negative Extrathoracic Pressure in Fontan Physiology. Pediatr Cardiol 2019; 40:1633-1637. [PMID: 31468061 DOI: 10.1007/s00246-019-02197-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/16/2019] [Accepted: 08/23/2019] [Indexed: 10/26/2022]
Abstract
We sought to assess acute hemodynamic changes after implementation of negative extrathoracic pressure (NEP) in spontaneously breathing ambulatory Fontan patients with symptomatic heart failure. We hypothesized that application of NEP would result in an acute decrease in pulmonary artery pressure. Ten patients with clinical evidence of Fontan failure underwent baseline hemodynamic catheterization while breathing spontaneously. Hemodynamic measurements were then repeated after 30 min of continuous NEP. After 30 min of continuous NEP, 4/10 patients had a decrease in their Fontan pressure by 2 mmHg and one patient had a decrease by 1 mmHg. There were three patients that had an increase in Fontan pressure by 2 mmHg. In 7/10 patients, indexed pulmonary vascular resistance decreased by an average of 31%. In symptomatic Fontan patients with a favorable hemodynamic response to NEP during catheterization, potential benefit of longer-term NEP to improve clinical status should be explored.
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26
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Garcia AM, Nakano SJ, Karimpour-Fard A, Nunley K, Blain-Nelson P, Stafford NM, Stauffer BL, Sucharov CC, Miyamoto SD. Phosphodiesterase-5 Is Elevated in Failing Single Ventricle Myocardium and Affects Cardiomyocyte Remodeling In Vitro. Circ Heart Fail 2019; 11:e004571. [PMID: 30354365 DOI: 10.1161/circheartfailure.117.004571] [Citation(s) in RCA: 29] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
Background Single ventricle (SV) congenital heart disease is fatal without intervention, and eventual heart failure is a major cause of morbidity and mortality. Although there are no proven medical therapies for the treatment or prevention of heart failure in the SV heart disease population, phosphodiesterase-5 inhibitors (PDE5i), such as sildenafil, are increasingly used. Although the pulmonary vasculature is the primary target of PDE5i therapy in patients with SV heart disease, the effects of PDE5i on the SV heart disease myocardium remain largely unknown. We sought to determine PDE5 expression and activity in the single right ventricle of SV heart disease patients relative to nonfailing controls and to determine whether PDE5 impacts cardiomyocyte remodeling using a novel serum-based in vitro model. Methods and Results PDE5 expression (n=9 nonfailing; n=7 SV heart disease), activity (n=8 nonfailing; n=9 SV heart disease), and localization (n=3 SV heart disease) were determined in explanted human right ventricle myocardium. PDE5 is expressed in SV heart disease cardiomyocytes, and PDE5 protein expression and activity are increased in SV heart disease right ventricle compared with nonfailing right ventricle. Isolated neonatal rat ventricular myocytes were treated for 72 hours with nonfailing or SV heart disease patient serum±sildenafil. Reverse transcription quantitative polymerase chain reaction (n=5 nonfailing; n=12 SV heart disease) and RNA sequencing (n=3 nonfailing; n=3 SV heart disease) were performed on serum-treated neonatal rat ventricular myocytes and demonstrated that treatment with SV heart disease sera results in pathological gene expression changes that are attenuated with PDE5i. Conclusions PDE5 is increased in failing SV heart disease myocardium, and pathological gene expression changes in SV heart disease serum-treated neonatal rat ventricular myocytes are abrogated by PDE5i. These results suggest that PDE5 represents an intriguing myocardial therapeutic target in this population.
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Affiliation(s)
- Anastacia M Garcia
- Division of Cardiology, Department of Pediatrics, University of Colorado Anschutz Medical Campus, Children's Hospital Colorado, Aurora (A.M.G., S.J.N., S.D.M.)
| | - Stephanie J Nakano
- Division of Cardiology, Department of Pediatrics, University of Colorado Anschutz Medical Campus, Children's Hospital Colorado, Aurora (A.M.G., S.J.N., S.D.M.)
| | | | - Karin Nunley
- Division of Cardiology, Department of Medicine (K.N., P.B.-N., N.M.S., B.L.S., C.C.S.)
| | - Penny Blain-Nelson
- Division of Cardiology, Department of Medicine (K.N., P.B.-N., N.M.S., B.L.S., C.C.S.)
| | - Natalie M Stafford
- Division of Cardiology, Department of Medicine (K.N., P.B.-N., N.M.S., B.L.S., C.C.S.)
| | - Brian L Stauffer
- Division of Cardiology, Department of Medicine (K.N., P.B.-N., N.M.S., B.L.S., C.C.S.)
| | - Carmen C Sucharov
- Division of Cardiology, Department of Medicine (K.N., P.B.-N., N.M.S., B.L.S., C.C.S.)
| | - Shelley D Miyamoto
- Division of Cardiology, Department of Pediatrics, University of Colorado Anschutz Medical Campus, Children's Hospital Colorado, Aurora (A.M.G., S.J.N., S.D.M.)
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27
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Granegger M, Thamsen B, Hubmann EJ, Choi Y, Beck D, Valsangiacomo Buechel E, Voutat M, Schweiger M, Meboldt M, Hübler M. A long-term mechanical cavopulmonary support device for patients with Fontan circulation. Med Eng Phys 2019; 70:9-18. [DOI: 10.1016/j.medengphy.2019.06.017] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2018] [Revised: 06/15/2019] [Accepted: 06/19/2019] [Indexed: 12/28/2022]
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28
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Commentary: Mechanical support for the subpulmonary circulation of Fontan physiology-A step in the right direction. J Thorac Cardiovasc Surg 2019; 158:1436-1437. [PMID: 31255340 DOI: 10.1016/j.jtcvs.2019.05.045] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/12/2019] [Accepted: 05/13/2019] [Indexed: 11/22/2022]
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29
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Peyton C. Protein-Losing Enteropathy and Plastic Bronchitis After the Fontan Operation. Crit Care Nurse 2019; 38:e5-e12. [PMID: 30504504 DOI: 10.4037/ccn2018784] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022]
Abstract
Protein-losing enteropathy and plastic bronchitis remain challenging to treat despite recent treatment advances. Protein-losing enteropathy and plastic bronchitis have been diagnosed in patients with cardiomyopathy, constrictive pericarditis, and congestive heart failure. This article focuses on patients with protein-losing enteropathy or plastic bronchitis following the Fontan procedure. Patients with single-ventricle physiology who have undergone the Fontan procedure are at risk for these conditions. Fontan physiology predisposes patients to chronically low cardiac output, increased central venous pressure, and congestive heart failure. These altered hemodynamics lead to increased mesenteric vascular resistance, resulting in venous hypertension and congestion in protein-losing enteropathy. Plastic bronchitis is a complex disease in which chronic high lymphatic pressures from Fontan physiology cause acellular bronchial casts to develop. These entities may also occur in patients with normal Fontan hemodynamics. This article also covers medical and surgical interventions for protein-losing enteropathy and plastic bronchitis. (Critical Care Nurse 2018;38[6]:e5-e12).
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Affiliation(s)
- Christine Peyton
- Christine Peyton is a clinical nurse specialist at the Heart Institute at Children's Hospital Colorado, Aurora, Colorado.
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30
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Granegger M, Valencia A, Quandt D, Dave H, Kretschmar O, Hübler M, Schweiger M. Approaches to Establish Extracardiac Total Cavopulmonary Connections in Animal Models—A Review. World J Pediatr Congenit Heart Surg 2019; 10:81-89. [DOI: 10.1177/2150135118802788] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Background: Long-term survival of patients with a single ventricle palliated with a Fontan procedure is still limited. No curative treatment options are available. To investigate the pathophysiology and potential treatment options, such as mechanical circulatory support (MCS), appropriate large animal models are required. The aim of this review was to analyze all full-text manuscripts presenting approaches for an extracardiac total cavopulmonary connection (TCPC) animal model to identify the feasibility and limitations in the acute and chronic setting. Methods: A literature search was performed for full-text publications presenting large animal models with extracardiac TCPCs on Pubmed and Embase. Out of 454 reviewed papers, 23 manuscripts fulfilled the inclusion criteria. Surgical procedures were categorized and hemodynamic changes at the transition from the biventricular to the univentricular condition analyzed. Results: Surgical procedures varied especially regarding coronary venous flow handling and anatomic shape of the TCPC. In most studies (n = 14), the main pulmonary artery was clamped and the coronary venous flow redirected by additional surgical interventions. Only in five reports, the caval veins were connected to the right pulmonary artery to create a true TCPC shape, whereas in all others (n = 18), the veins were connected to the main pulmonary artery. An elevated pulmonary vascular resistance was identified as a limiting hemodynamic factor for TCPC completion in healthy animals. Conclusions: A variety of acute TCPC animal models were successfully established with and without MCS, reflecting the most important hemodynamic features of a Fontan circulation; however, chronic animal models were not reported.
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Affiliation(s)
- Marcus Granegger
- Pediatric Cardiovascular Surgery, Pediatric Heart Center, Department of Surgery, University Children’s Hospital Zurich, Zurich, Switzerland
- Children’s Research Center, University Children’s Hospital Zurich, Zurich, Switzerland
| | - Anna Valencia
- Pediatric Cardiovascular Surgery, Pediatric Heart Center, Department of Surgery, University Children’s Hospital Zurich, Zurich, Switzerland
- Children’s Research Center, University Children’s Hospital Zurich, Zurich, Switzerland
| | - Daniel Quandt
- Children’s Research Center, University Children’s Hospital Zurich, Zurich, Switzerland
- Pediatric Cardiology, Pediatric Heart Center, Department of Surgery, University Children’s Hospital Zurich, Zurich, Switzerland
| | - Hitendu Dave
- Pediatric Cardiovascular Surgery, Pediatric Heart Center, Department of Surgery, University Children’s Hospital Zurich, Zurich, Switzerland
- Children’s Research Center, University Children’s Hospital Zurich, Zurich, Switzerland
| | - Oliver Kretschmar
- Children’s Research Center, University Children’s Hospital Zurich, Zurich, Switzerland
- Pediatric Cardiology, Pediatric Heart Center, Department of Surgery, University Children’s Hospital Zurich, Zurich, Switzerland
| | - Michael Hübler
- Pediatric Cardiovascular Surgery, Pediatric Heart Center, Department of Surgery, University Children’s Hospital Zurich, Zurich, Switzerland
- Children’s Research Center, University Children’s Hospital Zurich, Zurich, Switzerland
| | - Martin Schweiger
- Pediatric Cardiovascular Surgery, Pediatric Heart Center, Department of Surgery, University Children’s Hospital Zurich, Zurich, Switzerland
- Children’s Research Center, University Children’s Hospital Zurich, Zurich, Switzerland
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31
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Schidlow DN, Freud L, Friedman K, Tworetzky W. Fetal interventions for structural heart disease. Echocardiography 2018; 34:1834-1841. [PMID: 29287139 DOI: 10.1111/echo.13667] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
Fetal cardiac intervention (FCI) offers the potential to alter in utero anatomy and physiology. For aortic stenosis with evolving hypoplastic left heart syndrome and pulmonary atresia with intact ventricular septum with evolving hypoplastic right heart syndrome, FCI may result in maintenance of a biventricular circulation, thus avoiding single-ventricle palliation and its attendant complications. In the case of hypoplastic left heart syndrome with intact atrial septum, FCI may ameliorate in utero pathophysiology and portend a more favorable postnatal prognosis. In all cases, a detailed fetal echocardiographic assessment to identify the appropriate FCI candidate is essential. This article reviews the three aforementioned lesions for which FCI can be considered. The pathophysiology and rationale for intervention, echocardiographic assessment, patient selection criteria, and outcomes for each lesion will be reviewed. A primary focus will be the echocardiographic evaluation of each lesion.
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Affiliation(s)
- David N Schidlow
- Children's National Heart Institute, Children's National Medical Center, George Washington University School of Medicine and Health Sciences, Washington, DC, USA
| | - Lindsay Freud
- Division of Pediatric Cardiology, Columbia University Medical Center, New York-Presbyterian Morgan Stanley Children's Hospital, New York, NY, USA
| | - Kevin Friedman
- Department of Cardiology, Boston Children's Hospital, Boston, Massachusetts.,Department of Pediatrics, Harvard Medical School, Boston, Massachusetts
| | - Wayne Tworetzky
- Department of Cardiology, Boston Children's Hospital, Boston, Massachusetts.,Department of Pediatrics, Harvard Medical School, Boston, Massachusetts
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32
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Impact of Flow Differentials According to Cardiac and Respiratory Cycles on Three Types of Fontan Operation. Pediatr Cardiol 2018; 39:1144-1155. [PMID: 29671004 DOI: 10.1007/s00246-018-1872-1] [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: 11/08/2017] [Accepted: 03/22/2018] [Indexed: 10/17/2022]
Abstract
Few hemodynamic comparison studies on various types of Fontan operation have been reported. The objective of this study was to perform hemodynamic comparisons for flow size and volume in three types of Fontan operation: atriopulmonary connection (APC), lateral tunnel (LT), and extracardiac conduit (ECC). Forty patients with Fontan operation (8 with APC Fontan, 22 with LT Fontan, and 10 with ECC Fontan) were enrolled. Velocity time integral (VTI) and average peak velocity (APV) were assessed according to cardiac and respiratory cycles in SVC, IVC, hepatic vein, conduit, LPA, and RPA using direct intravenous Doppler echocardiography. During each cardiac cycle in APC, VTI and APV between inspiration and expiration did not show significant differences in SVC, IVC, HV, LPA, or RPA. During each cardiac cycle in LT and ECC, VTI and APV between inspiration and expiration showed significant differences in all native vessels. The gap between S and D wave in APC was the highest, followed by that in LT. It was the lowest in ECC regardless of inspiration or expiration. Hepatic reverse VTI and APV in APC showed significant decreases compared to those in VC and PA during inspiration and expiration. Flow size and volume in APC were more influenced by cardiac cycle. Those in LT were moderately influenced by both respiratory cycle and cardiac cycle while those in ECC were more influenced by respiratory cycle. APC Fontan has hemodynamic inefficiency with prominent reverse flow. However, total cavopulmonary connection (TCPC) Fontan has more hemodynamic efficiency without prominent reverse flows.
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33
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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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34
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Broda CR, Taylor DA, Adachi I. Progress in experimental and clinical subpulmonary assistance for Fontan circulation. J Thorac Cardiovasc Surg 2018; 156:1949-1956. [PMID: 29884497 DOI: 10.1016/j.jtcvs.2018.04.102] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/19/2017] [Revised: 04/09/2018] [Accepted: 04/24/2018] [Indexed: 11/15/2022]
Affiliation(s)
- Christopher R Broda
- Department of Pediatric Cardiology, Baylor College of Medicine/Texas Children's Hospital, Houston, Tex.
| | - Doris A Taylor
- Regenerative Medicine Research, Texas Heart Institute, Houston, Tex
| | - Iki Adachi
- Department of Congenital Heart Surgery, Baylor College of Medicine/Texas Children's Hospital, Houston, Tex
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35
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In Vitro Examination of the HeartWare CircuLite Ventricular Assist Device in the Fontan Connection. ASAIO J 2018; 63:482-489. [PMID: 28118264 DOI: 10.1097/mat.0000000000000521] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
The failing Fontan physiology may benefit from ventricular assist device (VAD) mechanical circulatory support, although a subpulmonary VAD placed at the Fontan connection has never successfully supported the Fontan circulation long term. The HeartWare CircuLite continuous flow VAD was examined for Fontan circulatory support in an in vitro mock circulation. The VAD was tested in three different scenarios: VAD in parallel, baffle restricted VAD in parallel, and VAD in series. Successful support was defined as simultaneous decrease in inferior vena cava (IVC) pressure of 5 mm Hg or more and an increase in cardiac output (CO) to 4.25 L/min or greater. The VAD in parallel scenario resulted in a CO decrease to 3.46 L/min and 2.22 mm Hg decrease in IVC pressure. The baffle restricted VAD in parallel scenario resulted in a CO increase to 3.9 L/min increase in CO and 20.5 mm Hg decrease in IVC pressure (at 90% restriction). The VAD in series scenario resulted in a CO of 1.75 L/min and 5.9 mm Hg decrease in IVC pressure. We successfully modeled chronic failing Fontan physiology using patient-specific hemodynamic and anatomic data. Although unsuccessful in supporting Fontan patients as defined here, the HeartWare CircuLite VAD demonstrates the possibility to reduce Fontan pressure and increase CO with a VAD in the Fontan connection. This study provides insight into pump performance and design issues when attempting to support Fontan circulation. Refinements in VAD design with specific parameters to help support this patient population is the subject of our future work.
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36
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Kotani Y, Chetan D, Zhu J, Saedi A, Zhao L, Mertens L, Redington AN, Coles J, Caldarone CA, Van Arsdell GS, Honjo O. Fontan Failure and Death in Contemporary Fontan Circulation: Analysis From the Last Two Decades. Ann Thorac Surg 2018; 105:1240-1247. [PMID: 29397930 DOI: 10.1016/j.athoracsur.2017.10.047] [Citation(s) in RCA: 31] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/25/2017] [Revised: 10/17/2017] [Accepted: 10/23/2017] [Indexed: 10/18/2022]
Abstract
BACKGROUND We sought to evaluate the incidence of Fontan failure or complication and its relation to death in patients having contemporary Fontan strategies over 2 decades. METHODS Five hundred patients who underwent Fontan completion (extracardiac, n = 326; lateral tunnel, n = 174) from 1985 to 2012 were reviewed. Patient characteristics, modes of Fontan failure/complication and death, and predictors for Fontan failure/complication and death were analyzed. RESULTS There were 23 early deaths (4.6%) and 17 late deaths (3.4%), with no early death since 2000. Survival has improved over time (p < 0.001). Twenty-three of 40 patients who died were identified as Fontan failure before death, including ventricular dysfunction (n = 14), pulmonary vascular dysfunction (n = 4), thromboembolism (n = 2), and arrhythmia (n = 4). Mode of death was circulatory failure (n = 18), multiorgan failure (n = 6), pulmonary failure (n = 3), cerebral/renal (n = 5), and sudden death (n = 4). Modes of failure/complication were directly (65%) or conceivably (10%) related to death in 30 of 40 patients (75%). Forty-eight percent of survivors had late Fontan complication(s). Five-year freedom from late Fontan complication was lower among patients who died compared with patients who survived (29.4% versus 53.3%, p < 0.001). Ventricular dysfunction (p = 0.001) and higher pulmonary artery pressures (p < 0.001) after Fontan were predictors for death. Longer cardiopulmonary bypass time (p = 0.032) and reinterventions (p < 0.001) were predictors for late Fontan complication. CONCLUSIONS Early death in the early era has been overcome. Yet the incidence and causes of late death remain unchanged. There was a strong causative relationship between the mode of Fontan failure/complication and death, indicating the importance of early recognition and treatment of Fontan failure/complication.
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Affiliation(s)
- Yasuhiro Kotani
- Division of Cardiovascular Surgery, Hospital for Sick Children, Toronto, Ontario, Canada; Department of Surgery, University of Toronto, Toronto, Ontario, Canada
| | - Devin Chetan
- Division of Cardiovascular Surgery, Hospital for Sick Children, Toronto, Ontario, Canada; Department of Surgery, University of Toronto, Toronto, Ontario, Canada
| | - Jiaquan Zhu
- Division of Cardiovascular Surgery, Hospital for Sick Children, Toronto, Ontario, Canada; Department of Surgery, University of Toronto, Toronto, Ontario, Canada
| | - Arezou Saedi
- Division of Cardiovascular Surgery, Hospital for Sick Children, Toronto, Ontario, Canada; Department of Surgery, University of Toronto, Toronto, Ontario, Canada
| | - Lisa Zhao
- Division of Cardiovascular Surgery, Hospital for Sick Children, Toronto, Ontario, Canada; Department of Surgery, University of Toronto, Toronto, Ontario, Canada
| | - Luc Mertens
- Division of Cardiology, Labatt Family Heart Center, Hospital for Sick Children, Toronto, Ontario, Canada; Department of Pediatrics, University of Toronto, Toronto, Ontario, Canada
| | - Andrew N Redington
- Division of Cardiology, Labatt Family Heart Center, Hospital for Sick Children, Toronto, Ontario, Canada; Department of Pediatrics, University of Toronto, Toronto, Ontario, Canada
| | - John Coles
- Division of Cardiovascular Surgery, Hospital for Sick Children, Toronto, Ontario, Canada; Department of Surgery, University of Toronto, Toronto, Ontario, Canada
| | - Christopher A Caldarone
- Division of Cardiovascular Surgery, Hospital for Sick Children, Toronto, Ontario, Canada; Department of Surgery, University of Toronto, Toronto, Ontario, Canada
| | - Glen S Van Arsdell
- Division of Cardiovascular Surgery, Hospital for Sick Children, Toronto, Ontario, Canada; Department of Surgery, University of Toronto, Toronto, Ontario, Canada
| | - Osami Honjo
- Division of Cardiovascular Surgery, Hospital for Sick Children, Toronto, Ontario, Canada; Department of Surgery, University of Toronto, Toronto, Ontario, Canada.
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Contemporary Outcomes of Combined Heart-Liver Transplant in Patients With Congenital Heart Disease. Transplantation 2018; 102:e67-e73. [DOI: 10.1097/tp.0000000000001978] [Citation(s) in RCA: 38] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
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Peer SM, Deatrick KB, Johnson TJ, Haft JW, Pagani FD, Ohye RG, Bove EL, Rojas-Peña A, Si MS. Mechanical Circulatory Support for the Failing Fontan: Conversion to Assisted Single Ventricle Circulation—Preliminary Observations. World J Pediatr Congenit Heart Surg 2018; 9:31-37. [DOI: 10.1177/2150135117733968] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
Background: Mechanical circulatory support (MCS) of a failing Fontan circulation remains challenging. We hypothesized that MCS can be provided by converting the Fontan circulation into a mechanically assisted single ventricle parallel circulation (MASVC). Methods: A porcine model of functionally univentricular circulation was created under cardiopulmonary bypass (CPB) by performing an atrial septectomy, tricuspid valvectomy, and interrupting antegrade pulmonary blood flow. A centrifugal flow pump was placed with inflow from the common atrium. Eight millimeter Dacron grafts anastomosed to the ascending aorta and main pulmonary artery supplied systemic (Qs) and pulmonary (Qp) blood flow. Ultrasonic flow probes were used to measure Qs and Qp after weaning from CPB. The Qp/Qs ratio was regulated using an adjustable clamp. Hemodynamic and laboratory data were recorded. Results: All four animals were successfully weaned from CPB onto the MASVC for a duration of two hours. Mechanically assisted single ventricle parallel circulation achieved satisfactory hemodynamics. As anticipated, the arterial oxygen saturation and partial pressure of oxygen in arterial blood were lower in the MASVC compared to baseline biventricular circulation. At the conclusion of the study, there was a trend towards a decrease in the mixed venous saturation with increasing oxygen extraction compared to the baseline. Serum lactate levels increased after weaning from CPB and did not return to baseline after two hours of support. Conclusion: Mechanically assisted single ventricle parallel circulation can be established in a single ventricle animal model. This strategy could potentially provide MCS of a single ventricle circulation. Studies with longer duration of support are required to assess adequacy of support and long-term sustainability.
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Affiliation(s)
- Syed M. Peer
- Department of Cardiac Surgery, University of Michigan Medical School, Ann Arbor, MI, USA
- Department of Pediatric Cardiac Surgery, University of Minnesota, Minneapolis, MN, USA
| | - Kristopher B. Deatrick
- Department of Cardiac Surgery, University of Michigan Medical School, Ann Arbor, MI, USA
| | - Thomas J. Johnson
- Department of Surgery-Section of Transplantation, ECMO Laboratory, University of Michigan Medical School, Ann Arbor, MI, USA
| | - Jonathan W. Haft
- Department of Cardiac Surgery, University of Michigan Medical School, Ann Arbor, MI, USA
| | - Francis D. Pagani
- Department of Cardiac Surgery, University of Michigan Medical School, Ann Arbor, MI, USA
| | - Richard G. Ohye
- Department of Cardiac Surgery, University of Michigan Medical School, Ann Arbor, MI, USA
| | - Edward L. Bove
- Department of Cardiac Surgery, University of Michigan Medical School, Ann Arbor, MI, USA
| | - Alvaro Rojas-Peña
- Department of Surgery-Section of Transplantation, ECMO Laboratory, University of Michigan Medical School, Ann Arbor, MI, USA
| | - Ming-Sing Si
- Department of Cardiac Surgery, University of Michigan Medical School, Ann Arbor, MI, USA
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Kratzert WB, Boyd EK, Schwarzenberger JC. Management of the Critically Ill Adult With Congenital Heart Disease. J Cardiothorac Vasc Anesth 2017; 32:1682-1700. [PMID: 29500124 DOI: 10.1053/j.jvca.2017.11.025] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/15/2017] [Indexed: 02/01/2023]
Abstract
Survival of adults with congenital heart disease (CHD) has improved significantly over the last 2 decades, leading to an increase in hospital and intensive care unit (ICU) admissions of these patients. Whereas most of the ICU admissions in the past were related to perioperative management, the incidence of medical emergencies from long-term sequelae of palliative or corrective surgical treatment of these patients is rising. Intensivists now are confronted with patients who not only have complex anatomy after congenital cardiac surgery, but also complex pathophysiology due to decades of living with abnormal cardiac anatomy and diseases of advanced age. Comorbidities affect all organ systems, including cognitive function, pulmonary and cardiovascular systems, liver, and kidneys. Critical care management requires an in-depth understanding of underlying anatomy and pathophysiology in order to apply contemporary concepts of adult ICU care to this population and optimize patient outcomes. In this review, the main CHD lesions and their common surgical management approaches are described, and the sequelae of CHD physiology are discussed. In addition, the effects of chronic comorbidities on the management of critically ill adults are explored, and the adjustments of current ICU management modalities and pharmacology to optimize care are discussed.
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Affiliation(s)
- Wolf B Kratzert
- Department of Anesthesiology and Perioperative Medicine, David Geffen School of Medicine at UCLA, Los Angeles, Los Angeles, CA.
| | - Eva K Boyd
- Department of Anesthesiology and Perioperative Medicine, David Geffen School of Medicine at UCLA, Los Angeles, Los Angeles, CA
| | - Johanna C Schwarzenberger
- Department of Anesthesiology and Perioperative Medicine, David Geffen School of Medicine at UCLA, Los Angeles, Los Angeles, CA
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Menon S, Chennapragada M, Ugaki S, Sholler GF, Ayer J, Winlaw DS. The Lymphatic Circulation in Adaptations to the Fontan Circulation. Pediatr Cardiol 2017; 38:886-892. [PMID: 28210768 DOI: 10.1007/s00246-017-1576-y] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/18/2016] [Accepted: 01/20/2017] [Indexed: 11/25/2022]
Abstract
Failing Fontan continues to be major problem for patients on the univentricular pathway. Failing Fontan is often complicated by chylothorax, plastic bronchitis and protein loosing enteropathy. The role of lymphatic circulation in Fontan circulation is still being researched. Newer imaging modalities give insight into the role of abnormal dilatation and retrograde flow in lymphatic channels post Fontan. Interventional strategies targeting abnormal lymphatic channels, provides an alternative management strategy for patients with failing Fontan. This review focuses on the role of lymphatic system in adaptations to Fontan circulation.
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Affiliation(s)
- Sabarinath Menon
- The Heart Centre for Children, The Children's Hospital at Westmead, Sydney, NSW, Australia
- Sree Chitra Tirunal Institute of Medical sciences and Technology, Thiruvananthapuram, Kerala, 695,011, India
- Sydney Children's Hospital Network, The Children's Hospital at Westmead, 212 Hawkesbury Road, Westmead, NSW, 2145, Australia
| | - Murthy Chennapragada
- Sydney Children's Hospital Network, The Children's Hospital at Westmead, 212 Hawkesbury Road, Westmead, NSW, 2145, Australia
- Discipline of Child and Adolescent Health, Sydney Medical School, University of Sydney, Camperdown, NSW, 2006, Australia
| | - Shinya Ugaki
- The Heart Centre for Children, The Children's Hospital at Westmead, Sydney, NSW, Australia
- Sydney Children's Hospital Network, The Children's Hospital at Westmead, 212 Hawkesbury Road, Westmead, NSW, 2145, Australia
| | - Gary F Sholler
- The Heart Centre for Children, The Children's Hospital at Westmead, Sydney, NSW, Australia
- Sydney Children's Hospital Network, The Children's Hospital at Westmead, 212 Hawkesbury Road, Westmead, NSW, 2145, Australia
- Discipline of Child and Adolescent Health, Sydney Medical School, University of Sydney, Camperdown, NSW, 2006, Australia
| | - Julian Ayer
- The Heart Centre for Children, The Children's Hospital at Westmead, Sydney, NSW, Australia
- Sydney Children's Hospital Network, The Children's Hospital at Westmead, 212 Hawkesbury Road, Westmead, NSW, 2145, Australia
- Discipline of Child and Adolescent Health, Sydney Medical School, University of Sydney, Camperdown, NSW, 2006, Australia
| | - David S Winlaw
- The Heart Centre for Children, The Children's Hospital at Westmead, Sydney, NSW, Australia.
- Sydney Children's Hospital Network, The Children's Hospital at Westmead, 212 Hawkesbury Road, Westmead, NSW, 2145, Australia.
- Discipline of Child and Adolescent Health, Sydney Medical School, University of Sydney, Camperdown, NSW, 2006, Australia.
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Strategies to Prevent Cast Formation in Patients with Plastic Bronchitis Undergoing Heart Transplantation. Pediatr Cardiol 2017; 38:1077-1079. [PMID: 28101662 DOI: 10.1007/s00246-017-1568-y] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/25/2016] [Accepted: 01/05/2017] [Indexed: 10/20/2022]
Abstract
Plastic bronchitis, a rare complication after Fontan palliation, carries a high morbidity and mortality risk. Heart transplantation is an effective treatment option, but casts may occur in the early post-operative period. We present a case series detailing peri-operative management strategies to minimize morbidity and mortality related to plastic bronchitis in patients undergoing heart transplantation. Patient 1 received no treatment pre-, intra-, or post-transplant for prevention of bronchial casts and developed severe respiratory acidosis 18 h following transplant. Emergent bronchoscopy was performed and a large obstructive cast was removed. The patient recovered and received inhaled tissue plasminogen activator (tPA) for 5 days. Patient 2 received inhaled tPA before, during, and for 5 days after transplantation and no bronchial casts developed. Patient 3 underwent intraoperative bronchoscopy just prior to implantation revealing no casts. The patient underwent non-urgent, preemptive bronchoscopy on post-transplant days 1, 3, and 4, removing several partially obstructive bronchial blood clots/casts, with no casts thereafter. Heart transplantation results in eventual resolution of plastic bronchitis. Residual bronchial casts can still be problematic in the peri-operative period. Airway clearance with inhaled tPA or bronchoscopy may prevent the need for prolonged mechanical ventilation and reduce post-operative morbidity in this unique population.
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Malik A, Hellinger JC, Servaes S, Schwartz MC, Keller MS, Epelman M. Prevalence of non-cardiovascular findings on CT angiography in children with congenital heart disease. Pediatr Radiol 2017; 47:267-279. [PMID: 27924361 DOI: 10.1007/s00247-016-3742-4] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/21/2016] [Revised: 09/30/2016] [Accepted: 10/27/2016] [Indexed: 12/21/2022]
Abstract
BACKGROUND CT angiography is gaining broader acceptance in the evaluation of children with known or suspected congenital heart disease. These studies include non-cardiovascular structures such as the mediastinum, lung parenchyma and upper abdominal organs. It is important to inspect all these structures for potential abnormalities that might be clinically important and, in some cases, may impact care plans. OBJECTIVE To determine the prevalence of non-cardiovascular findings in CT angiography of children with congenital heart disease. MATERIALS AND METHODS During 28 months, 300 consecutive children (170 males; mean age: 7.1 years, age range: 6 h-26 years), referred from a tertiary pediatric cardiology center, underwent clinically indicated CT angiography to evaluate known or suspected congenital heart disease. Slightly more than half (n = 169) of the patients were postoperative or post-intervention. Examinations were retrospectively reviewed, and non-cardiovascular findings were recorded and tabulated by organ system, congenital heart disease and operative procedure in conjunction with outcomes from medical charts. RESULTS Non-cardiovascular findings were identified in 83% (n = 250 / 300) of the studies for a total of 857 findings. In 221 patients (n = 73.7% of 300) a total of 813 non-cardiovascular findings were clinically significant, while in 9.7% (n = 29 / 300) of patients, 5.1% (n = 44 / 857) of the findings were nonsignificant. In 38.3% (n = 115 / 300) of patients with significant non-cardiovascular pathology, the findings were unexpected and directly impacted patient care plans. Commonly involved organs with non-cardiovascular findings were the lungs with 280 non-cardiovascular findings in 176 / 300 (58.7%) of patients, the airway with 139 non-cardiovascular findings in 103 / 300 (34.3%) of patients and the liver with 108 non-cardiovascular findings in 72 / 300 (24.0%) of patients. Syndromic associations were noted in 22% (n = 66 / 300) of the patients. CONCLUSION Non-cardiovascular findings are common in children with congenital heart disease who undergo CT angiography. Based upon our study population, if a child with congenital heart disease has a CT angiography, five out of six will have non-cardiovascular findings, while nearly three out of four (73.7%; 221 / 300) will have significant non-cardiovascular findings. Close attention to the non-cardiovascular structures in children with congenital heart disease presenting for a CT angiography is recommended as in nearly 40% of these children, findings were unexpected and directly altered patient care.
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Affiliation(s)
- Archana Malik
- Department of Radiology, The Children's Hospital of Philadelphia, Philadelphia, PA, USA.,Department of Radiology, St. Christopher's Hospital for Children, Philadelphia, PA, USA
| | - Jeffrey C Hellinger
- Department of Radiology, The Children's Hospital of Philadelphia, Philadelphia, PA, USA.,New York Cardiovascular Institute at Lenox Hill Radiology, New York, NY, USA
| | - Sabah Servaes
- Department of Radiology, The Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Mathew C Schwartz
- Department of Radiology, The Children's Hospital of Philadelphia, Philadelphia, PA, USA.,Sanger Heart and Vascular Institute, Levine Children's Hospital, Charlotte, NC, USA
| | - Marc S Keller
- Department of Radiology, The Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Monica Epelman
- Department of Radiology, The Children's Hospital of Philadelphia, Philadelphia, PA, USA. .,Department of Medical Imaging/Radiology, Nemours Children's Health System/Nemours Children's Hospital, 13535 Nemours Parkway, Orlando, FL, 32827, USA.
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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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Sakamoto T, Nagashima M, Hiramatsu T, Matsumura G, Park IS, Yamazaki K. Fontan circulation over 30 years. What should we learn from those patients? Asian Cardiovasc Thorac Ann 2016; 24:765-771. [DOI: 10.1177/0218492316667771] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
Background This study aimed to evaluate Fontan circulation which was observed over 30 years. Methods Forty patients who underwent a Fontan operation between 1974 and 1986 and survived (group S, n = 20) or died in the late period (group LD, n = 20) were evaluated. The median age at operation was 10 years (range 2–32 years). The diagnoses were tricuspid atresia in 21, single ventricle in 9, and others in 10. The Fontan procedure was a right atrium-pulmonary artery graft in 2, atriopulmonary connection in 28, and right atrium-right ventricle anastomosis in 10 (Björk in 4, graft in 6). Results Causes of late death were congestive heart failure in 6, sudden death in 4, arrhythmia in 4, and others in 6. Sixteen patients underwent reoperation 23.3 ± 6.5 years after Fontan. Cardiac catheterization was performed at 1 month and 12 years. There were no significant differences in central venous pressure, ventricular ejection fraction, or pulmonary vascular resistance between the two groups. However, changes in ventricular end-diastolic volume suggested volume and pressure overload in group LD. In group S, the latest chest radiographs showed cardiothoracic ratio 51.3% ± 7.6%, oxygen saturation 94% ± 2%, brain natriuretic peptide 153 ± 111 pg ċ mL−1, and Holter monitoring revealed sinus rhythm in 10 patients. New York Heart Association class was I in 12 patients, II in 6, and III in 2. Conclusions For long-term Fontan survival, timely total cavopulmonary connection conversion and medication to decrease ventricular volume and pressure load might be important.
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Affiliation(s)
- Takahiko Sakamoto
- Division of Pediatric Cardiovascular Surgery, The Heart Institute of Japan, Tokyo Women’s Medical University, Tokyo, Japan
- Department of Cardiovascular Surgery, The Heart Institute of Japan, Tokyo Women’s Medical University, Tokyo, Japan
| | - Mitsugi Nagashima
- Division of Pediatric Cardiovascular Surgery, The Heart Institute of Japan, Tokyo Women’s Medical University, Tokyo, Japan
- Department of Cardiovascular Surgery, The Heart Institute of Japan, Tokyo Women’s Medical University, Tokyo, Japan
| | - Takeshi Hiramatsu
- Division of Pediatric Cardiovascular Surgery, The Heart Institute of Japan, Tokyo Women’s Medical University, Tokyo, Japan
- Department of Cardiovascular Surgery, The Heart Institute of Japan, Tokyo Women’s Medical University, Tokyo, Japan
| | - Goki Matsumura
- Division of Pediatric Cardiovascular Surgery, The Heart Institute of Japan, Tokyo Women’s Medical University, Tokyo, Japan
- Department of Cardiovascular Surgery, The Heart Institute of Japan, Tokyo Women’s Medical University, Tokyo, Japan
| | - In-Sam Park
- Department of Pediatric Cardiology, The Heart Institute of Japan, Tokyo Women’s Medical University, Tokyo, Japan
| | - Kenji Yamazaki
- Department of Cardiovascular Surgery, The Heart Institute of Japan, Tokyo Women’s Medical University, Tokyo, Japan
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Devanagondi R, Suntharos P, Boyle GJ, Prieto LR. Protein Losing Enteropathy After Cardiac Transplantation Successfully Treated by Stent Implantation. World J Pediatr Congenit Heart Surg 2016; 8:754-757. [PMID: 27549730 DOI: 10.1177/2150135116658452] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Protein losing enteropathy (PLE) is a severe consequence of Fontan physiology that sometimes requires heart transplantation for definitive treatment. We describe transplant refractory PLE in a patient with heterotaxia and complex systemic and hepatic venous connections, successfully treated by transcatheter relief of multiple venous obstructions.
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Affiliation(s)
- Rajiv Devanagondi
- 1 Children's Heart Center, University of Rochester Medical Center, Rochester, NY, USA
| | - Patcharapong Suntharos
- 2 Center for Pediatric and Congenital Heart Disease, Cleveland Clinic Foundation, Cleveland, OH, USA
| | - Gerard J Boyle
- 2 Center for Pediatric and Congenital Heart Disease, Cleveland Clinic Foundation, Cleveland, OH, USA
| | - Lourdes R Prieto
- 2 Center for Pediatric and Congenital Heart Disease, Cleveland Clinic Foundation, Cleveland, OH, USA
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46
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Ferschl MB, Moon-Grady AJ, Rollins MD, Gilliss B, Schulman SR, Tulzer G, Stohl S, Ginosar Y. CASE 8—2016 Percutaneous Fetal Cardiac Intervention for Severe Aortic Stenosis and Evolving Hypoplastic Left-Heart Syndrome. J Cardiothorac Vasc Anesth 2016; 30:1118-28. [DOI: 10.1053/j.jvca.2016.03.155] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/09/2015] [Indexed: 11/11/2022]
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47
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Sharma S, Ruebner RL, Furth SL, Dodds KM, Rychik J, Goldberg DJ. Assessment of Kidney Function in Survivors Following Fontan Palliation. CONGENIT HEART DIS 2016; 11:630-636. [DOI: 10.1111/chd.12358] [Citation(s) in RCA: 44] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Affiliation(s)
- Sheena Sharma
- Division of Nephrology and; The Children's Hospital of Philadelphia; Philadelphia Pennsylvania USA
| | - Rebecca L Ruebner
- Division of Nephrology and; The Children's Hospital of Philadelphia; Philadelphia Pennsylvania USA
| | - Susan L Furth
- Division of Nephrology and; The Children's Hospital of Philadelphia; Philadelphia Pennsylvania USA
| | - Kathryn M Dodds
- Division of Cardiology; The Children's Hospital of Philadelphia; Philadelphia Pa USA
| | - Jack Rychik
- Division of Cardiology; The Children's Hospital of Philadelphia; Philadelphia Pa USA
| | - David J Goldberg
- Division of Cardiology; The Children's Hospital of Philadelphia; Philadelphia Pa USA
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Early and intermediate-term results of the extracardiac conduit total cavopulmonary connection for functional single-ventricle hearts. J Formos Med Assoc 2016; 115:318-24. [PMID: 26853857 DOI: 10.1016/j.jfma.2015.12.011] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2015] [Revised: 12/17/2015] [Accepted: 12/23/2015] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND/PURPOSE Fontan operation has evolved from atriopulmonary connection to total cavopulmonary connection (TCPC) due to its advantages in terms of hemodynamics and reduction of atrium-related complications. We analyzed the early and intermediate-term results of extracardiac conduit TCPC (EC-TCPC) procedure in patients with functional single ventricle to investigate the risk factors of surgical mortality and intermediate failure. METHODS Retrospective review of the medical records of 88 consecutive patients with functional single ventricle who underwent EC-TCPC from 2000 to 2013 was conducted. RESULTS The follow-up was 100% complete, ranging from 3 months to 13 years (mean 7.0 ± 3.8 years). There were two (2.3%) hospital and 18 (20.4%) late deaths. The estimated event-free survival rates at 1 year, 5 years, and 10 years were 90.6%, 89.3%, and 77.2%, respectively. On univariate analysis, fenestration was the only risk factor for surgical mortality (p = 0.027). On multivariate analysis, the significant atrioventricular valve regurgitation was the only risk factor for intermediate failure (p = 0.017). CONCLUSION The clinical results of EC-TCPC in patients with functional single ventricle were satisfactory. The patients who needed fenestration during operation had higher risk of surgical mortality. Significant atrioventricular valve regurgitation had negative impact on intermediate survival.
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Hill KD, Sampson MR, Li JS, Tunks RD, Schulman SR, Cohen-Wolkowiez M. Pharmacokinetics of intravenous sildenafil in children with palliated single ventricle heart defects: effect of elevated hepatic pressures. Cardiol Young 2016; 26:354-62. [PMID: 26197839 PMCID: PMC4591210 DOI: 10.1017/s1047951115000359] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
UNLABELLED Aims Sildenafil is frequently prescribed to children with single ventricle heart defects. These children have unique hepatic physiology with elevated hepatic pressures, which may alter drug pharmacokinetics. We sought to determine the impact of hepatic pressure on sildenafil pharmacokinetics in children with single ventricle heart defects. METHODS A population pharmacokinetic model was developed using data from 20 single ventricle children receiving single-dose intravenous sildenafil during cardiac catheterisation. Non-linear mixed effect modelling was used for model development, and covariate effects were evaluated based on estimated precision and clinical significance. RESULTS The analysis included a median (range) of 4 (2-5) pharmacokinetic samples per child. The final structural model was a two-compartment model for sildenafil with a one-compartment model for des-methyl-sildenafil (active metabolite), with assumed 100% sildenafil to des-methyl-sildenafil conversion. Sildenafil clearance was unaffected by hepatic pressure (clearance=0.62 L/hour/kg); however, clearance of des-methyl-sildenafil (1.94×(hepatic pressure/9)(-1.33) L/hour/kg) was predicted to decrease ~7-fold as hepatic pressure increased from 4 to 18 mmHg. Predicted drug exposure was increased by ~1.5-fold in subjects with hepatic pressures ⩾10 versus <10 mmHg (median area under the curve=533 versus 792 µg*h/L). Discussion Elevated hepatic pressure delays clearance of the sildenafil metabolite - des-methyl-sildenafil - and increases drug exposure. We speculate that this results from impaired biliary clearance. Hepatic pressure should be considered when prescribing sildenafil to children. These data demonstrate the importance of pharmacokinetic assessments in patients with unique cardiovascular physiology that may affect drug metabolism.
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Affiliation(s)
- Kevin D. Hill
- Department of Pediatrics, Duke University Medical Center, Durham, North Carolina, USA
- The Duke Clinical Research Institute, Durham, North Carolina, USA
| | - Mario R. Sampson
- The Duke Clinical Research Institute, Durham, North Carolina, USA
- University of North Carolina Eshelman School of Pharmacy, Chapel Hill, North Carolina, USA
| | - Jennifer S. Li
- The Duke Clinical Research Institute, Durham, North Carolina, USA
| | - Robert D. Tunks
- Department of Pediatrics, Duke University Medical Center, Durham, North Carolina, USA
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Sabri MR, Zolfi-Gol A, Ahmadi A, Haghjooy-Javanmard S. Effect of Tadalafil on Myocardial and Endothelial Function and Exercise Performance After Modified Fontan Operation. Pediatr Cardiol 2016. [PMID: 26215768 DOI: 10.1007/s00246-015-1238-x] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
Better postoperative management of patients who have undergone single ventricle (SV) Fontan procedure could potentially reduce long-term complications and improve the quality of life for patients. The present study determined the effect of tadalafil on myocardial and endothelial function and exercise performance after modified Fontan operation. Patients who had undergone SV modified Fontan operation were enrolled in this clinical trial. The demographic characteristics of the patients were recorded. Before administration of tadalafil and after the trial, ventricular function (MPI, EF, FS, E/A, VTI), exercise performance, and endothelial function were evaluated for sonographic and biochemical markers (FMD, IMT, ICAM, VCAM, NO) using echocardiography, exercise testing, vascular ultrasonography, and biochemical measurements, respectively. A single dose of tadalafil of 1 mg/kg was administered daily for 6 weeks, and the functional class of the patients before and after tadalafil was determined. A total of 15 patients completed this clinical trial. Tadalafil was shown to have a significant effect on myocardial function, exercise performance, and improvement in NYHA functional class (p < 0.05) of study population. It had no significant effect on the biochemical variables and endothelial function except for IMT (p > 0.05), which decreased significantly after tadalafil administration (p < 0.05). The findings indicate that tadalafil is a safe, well-tolerated agent for the use after modified Fontan operation to improve myocardial function and exercise performance and possibly reduce long-term morbidity and mortality of patients. More conclusive results could be obtained from further study with a larger sample size and long-term follow-up.
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Affiliation(s)
| | - Ali Zolfi-Gol
- Isfahan University of Medical Sciences, Isfahan, Iran.
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