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Di Mambro C, Yammine ML, Tamborrino PP, Giordano U, Righi D, Unolt M, Cantarutti N, Maiolo S, Albanese S, Carotti A, Amodeo A, Galletti L, Drago F. Long-Term Incidence of Arrhythmias in Extracardiac Conduit Fontan and Comparison Between Systemic Left and Right Ventricle. Europace 2024:euae097. [PMID: 38650062 DOI: 10.1093/europace/euae097] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2024] [Accepted: 02/16/2024] [Indexed: 04/25/2024] Open
Abstract
AIMS The extracardiac conduit-Fontan (ECC) has become the preferred technique for univentricular heart palliation, but there are currently no data on the incidence of long-term arrhythmias. This study investigated the incidence of arrhythmias and relation to single ventricle morphology in the long-term follow-up in ECC. METHODS AND RESULTS All patients with ECC performed in our Centre between 1987 and 2017 were included (minimum follow-up 5 years). Of 353 consecutive patients, 303 [57.8% males, aging 8-50 (median 20) years at last follow-up] were considered and divided into 2 groups depending on left (194 in Group 1) or right (109 in Group 2) ventricular morphology. Eighty-five (28%) experienced ≥1 arrhythmic complications, with early and late arrhythmias in 17 (5.6%) and 73 (24.1%) patients, respectively. Notably, late bradyarrhythmias occurred after 6 years in 21 (11%) patients in Group 1, and in 15 (13.8%) in Group 2 [p=0.48]. Late tachyarrhythmias occurred in 55 (18.2%) patients after 12 years: 33 (17%) in Group 1 and 22 (20.2%) patients in Group 2 [p=0.5]. Ventricular tachycardias were documented after 12.5 years in 14 (7.2%) patients of Group 1 and 15 (13.8%) of Group 2 [p=0.06] with a higher incidence in Group 2 during the follow-up [p=0.005]. CONCLUSION ECC is related to a significant arrhythmic risk in the long-term follow-up, higher than previously reported. Bradyarrhythmias occur earlier but are less frequent than tachyarrhythmias. Interestingly, patients with systemic right ventricle have a significantly higher incidence of ventricular tachycardias, especially in very long follow-up.
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Affiliation(s)
- Corrado Di Mambro
- Pediatric Cardiology and Cardiac Arrhythmias Complex Unit, Bambino Gesù Children's Hospital IRCCS (European Reference Network for Rare and Low Prevalence Complex Disease of the Heart-ERN GUARD-Heart)
| | - Marie Laure Yammine
- Pediatric Cardiology and Cardiac Arrhythmias Complex Unit, Bambino Gesù Children's Hospital IRCCS (European Reference Network for Rare and Low Prevalence Complex Disease of the Heart-ERN GUARD-Heart)
| | - Pietro Paolo Tamborrino
- Pediatric Cardiology and Cardiac Arrhythmias Complex Unit, Bambino Gesù Children's Hospital IRCCS (European Reference Network for Rare and Low Prevalence Complex Disease of the Heart-ERN GUARD-Heart)
| | - Ugo Giordano
- Sports Medicine Unit, Bambino Gesù Children's Hospital IRCCS, Rome, Italy
| | - Daniela Righi
- Pediatric Cardiology and Cardiac Arrhythmias Complex Unit, Bambino Gesù Children's Hospital IRCCS (European Reference Network for Rare and Low Prevalence Complex Disease of the Heart-ERN GUARD-Heart)
| | - Marta Unolt
- Pediatric Cardiology and Cardiac Arrhythmias Complex Unit, Bambino Gesù Children's Hospital IRCCS (European Reference Network for Rare and Low Prevalence Complex Disease of the Heart-ERN GUARD-Heart)
| | - Nicoletta Cantarutti
- Pediatric Cardiology and Cardiac Arrhythmias Complex Unit, Bambino Gesù Children's Hospital IRCCS (European Reference Network for Rare and Low Prevalence Complex Disease of the Heart-ERN GUARD-Heart)
| | - Stella Maiolo
- Pediatric Cardiology and Cardiac Arrhythmias Complex Unit, Bambino Gesù Children's Hospital IRCCS (European Reference Network for Rare and Low Prevalence Complex Disease of the Heart-ERN GUARD-Heart)
| | - Sonia Albanese
- Cardiac Surgery Unit, Bambino Gesù Children's Hospital IRCCS, Rome, Italy
| | - Adriano Carotti
- Cardiac Surgery Unit, Bambino Gesù Children's Hospital IRCCS, Rome, Italy
| | - Antonio Amodeo
- Heart Failure, Transplant and Mechanical Assist Device, Bambino Gesù Children's Hospital IRCCS, Rome, Italy
| | - Lorenzo Galletti
- Cardiac Surgery Unit, Bambino Gesù Children's Hospital IRCCS, Rome, Italy
| | - Fabrizio Drago
- Pediatric Cardiology and Cardiac Arrhythmias Complex Unit, Bambino Gesù Children's Hospital IRCCS (European Reference Network for Rare and Low Prevalence Complex Disease of the Heart-ERN GUARD-Heart)
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Fujita A, Shirozu K, Higashi M, Yamaura K. Anesthetic management in pregnant women with Fontan circulation: a case series. JA Clin Rep 2024; 10:25. [PMID: 38634932 PMCID: PMC11026315 DOI: 10.1186/s40981-024-00706-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2024] [Revised: 03/29/2024] [Accepted: 04/01/2024] [Indexed: 04/19/2024] Open
Abstract
BACKGROUND Given the advances in medicine, women with Fontan circulation are now reaching childbearing age. However, data on the mode of delivery and anesthetic management of these patients are limited. We report the cases of five pregnant women with Fontan circulation. CASE PRESENTATION The mean age at delivery was 28 ± 3 years, and the mean gestational period was 34 weeks and 3 days. Anticoagulation therapy was switched from warfarin and aspirin to continuous intravenous heparin. The modes of delivery were scheduled cesarean section (C/S) in one, emergency C/S in three, and vaginal delivery with epidural labor analgesia in one patient. Three patients underwent C/S under regional anesthesia; one received general anesthesia. The perinatal complications were heart failure, worsening valve regurgitation, and postoperative hematoma in three, four, and two patients, respectively. CONCLUSIONS For C/S in women with Fontan circulation, regional anesthesia should be considered. Epidural labor analgesia can help prevent the decrease in pulmonary blood flow due to straining. We initiated labor analgesia or C/S with regional anesthesia at the appropriate time in four patients.
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Affiliation(s)
- Ai Fujita
- Operating Rooms, Kyushu University Hospital, Fukuoka, Japan.
- Department of Anesthesiology, Fukuoka Children's Hospital, Kashiiteriha 5-1-1, Higashi-ku, Fukuoka, 813-0017, Japan.
| | - Kazuhiro Shirozu
- Department of Anesthesiology and Critical Care Medicine, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Midoriko Higashi
- Department of Anesthesiology and Critical Care Medicine, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Ken Yamaura
- Department of Anesthesiology and Critical Care Medicine, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
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Kratz T, Dauvergne J, Ruff R, Koch T, Breuer J, Asfour B, Herberg U, Bierbach B. In a porcine model of implantable pacemakers for pediatric unilateral diaphragm paralysis, the phrenic nerve is the best target. J Cardiothorac Surg 2024; 19:181. [PMID: 38580985 PMCID: PMC10996242 DOI: 10.1186/s13019-024-02707-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2023] [Accepted: 03/30/2024] [Indexed: 04/07/2024] Open
Abstract
BACKGROUND A frequent complication of Fontan operations is unilateral diaphragmatic paresis, which leads to hemodynamic deterioration of the Fontan circulation. A potential new therapeutic option is the unilateral diaphragmatic pacemaker. In this study, we investigated the most effective stimulation location for a potential fully implantable system in a porcine model. METHODS Five pigs (20.8 ± 0.95 kg) underwent implantation of a customized cuff electrode placed around the right phrenic nerve. A bipolar myocardial pacing electrode was sutured adjacent to the motor point and peripherally at the costophrenic angle (peripheral diaphragmatic muscle). The electrodes were stimulated 30 times per minute with a pulse duration of 200 µs and a stimulation time of 300 ms. Current intensity was the only variable changed during the experiment. RESULTS Effective stimulation occurred at 0.26 ± 0.024 mA at the phrenic nerve and 7 ± 1.22 mA at the motor point, a significant difference in amperage (p = 0.005). Even with a maximum stimulation of 10 mA at the peripheral diaphragm muscle, however, no effective stimulation was observed. CONCLUSION The phrenic nerve seems to be the best location for direct stimulation by a unilateral thoracic diaphragm pacemaker in terms of the required amperage level in a porcine model.
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Affiliation(s)
- Tobias Kratz
- Department of Paediatric Cardiology, University Hospital Bonn, Venusberg-Campus 1, 53127, Bonn, Germany.
| | - Jan Dauvergne
- Department of Paediatric Cardiology, University Hospital Bonn, Venusberg-Campus 1, 53127, Bonn, Germany
| | - Roman Ruff
- Fraunhofer IBMT, Institute for Biomedical Engineering, Sulzbach, Germany
| | - Timo Koch
- Fraunhofer IBMT, Institute for Biomedical Engineering, Sulzbach, Germany
| | - Johannes Breuer
- Department of Paediatric Cardiology, University Hospital Bonn, Venusberg-Campus 1, 53127, Bonn, Germany
| | - Boulos Asfour
- Department of Pediatric Cardiac Surgery, University Hospital Bonn, Bonn, Germany
| | - Ulrike Herberg
- Department of Paediatric Cardiology, University Hospital Bonn, Venusberg-Campus 1, 53127, Bonn, Germany
- Department of Pediatric Cardiology, University Hospital Aachen, Aachen, Germany
| | - Benjamin Bierbach
- Department of Pediatric Cardiac Surgery, University Hospital Bonn, Bonn, Germany
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Rajpal S, Rodriguez CP. High-Risk Congenital Heart Disease in Pregnancy. Methodist Debakey Cardiovasc J 2024; 20:24-35. [PMID: 38495662 PMCID: PMC10941697 DOI: 10.14797/mdcvj.1306] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2023] [Accepted: 01/03/2024] [Indexed: 03/19/2024] Open
Abstract
High-risk congenital heart disease (CHD) in pregnancy presents a complex clinical challenge. With improved medical care and increased survival rates, a growing population of adults with complex CHD are surviving to adulthood, including women of reproductive age. This chapter focuses on risk stratification and management of pregnant women with high-risk CHD, emphasizing the importance of considering both anatomical and physiological complexity. Maternal physiological changes, such as blood volume increase, cardiac output changes, and alterations in vascular resistance, can significantly impact high-risk CHD patients. Management of high-risk CHD in pregnancy necessitates a multidisciplinary approach and individualized care.
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Affiliation(s)
- Saurabh Rajpal
- The Ohio State University Wexner Medical Center, Columbus, Ohio, US
- Nationwide Children’s Hospital, Columbus, Ohio, US
| | - Carla P. Rodriguez
- Nationwide Children’s Hospital, Columbus, Ohio, US
- Boston Children’s Hospital and Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts, US
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Ravndal M, Idorn L, Nielsen KG, Hjortdal V. Lung Function in Fontan Patients Over a Ten-Year Period: Is the Fontan Circulation Impairing Lung Development? Pediatr Cardiol 2024; 45:500-512. [PMID: 38273050 PMCID: PMC10891202 DOI: 10.1007/s00246-023-03389-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/14/2023] [Accepted: 12/18/2023] [Indexed: 01/27/2024]
Abstract
Few studies have investigated how the Fontan circulation affects lung function, and no studies have investigated the development of lung function over longer time in these patients. We aimed to describe the development of lung function in Fontan patients over a 10-year period. Pulmonary function tests (PFT), including spirometry and diffusion capacity for Carbon Monoxide (DLCO) and Nitric Oxide (DLNO), were conducted in a Danish Fontan cohort in 2011 (PFT-I). In 2021, re-investigations were performed (PFT-II). We investigated changes in percent predicted (%pred) lung function from PFT-I to PFT-II. Patients were categorized into a pediatric group (age under 18 at PFT-I) and an adult group (age 18 or older at PFT-I). Out of the 81 patients completing PFT-I, 48 completed PFT-II. In the pediatric group (32 patients), there were significant declines in %pred forced expiratory volume in 1s (99.7 (92.4, 104.4)-89.3 (84.9, 97.2), p < 0,001), forced vital capacity (98.3 (87.8, 106.1)-96.7 (86.7, 100.6), p = 0.008), and alveolar volume (95.5 (89.5, 101.6)-89.5 (79.7, 93.2), p < 0.001). The corresponding measurements remained stable in the adult group. However, the median %pred DLNO significantly declined in the adult group (58.4 (53.3, 63.5)-53.7 (44.1, 57.3), p = 0.005). Over a 10-year period, several lung function parameters declined significantly in the younger Fontan patients, suggesting possible impairments in lung development during growth. The decline in %pred DLNO in the adult patient group indicates deterioration of the membrane component of diffusion capacity, implying that the Fontan circulation might negatively affect the alveolar membrane over time.
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Affiliation(s)
- Maren Ravndal
- Department of Cardiothoracic Surgery, Copenhagen University Hospital Rigshospitalet, Copenhagen, Denmark.
| | - Lars Idorn
- Section of Pediatric Cardiology, Department of Pediatrics and Adolescent Medicine, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - Kim Gjerum Nielsen
- Pediatric Pulmonary Service, Department of Pediatrics and Adolescent Medicine, Copenhagen University Hospital, Copenhagen, Denmark
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Vibeke Hjortdal
- Department of Cardiothoracic Surgery, Copenhagen University Hospital Rigshospitalet, Copenhagen, Denmark
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
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Butera G, Piccinelli E, Kolesnik A, Averin K, Seaman C, Castaldi B, Cuppini E, Fraisse A, Bautista-Rodriguez C, Hascoet S, D'Amore C, Baruteau AE, Blasco PB, Bianco L, Eicken A, Jones M, Kuo JA, Rajszys GB. Implantation of atrial flow regulator devices in patients with congenital heart disease and children with severe pulmonary hypertension or cardiomyopathy-an international multicenter case series. Front Cardiovasc Med 2024; 10:1332395. [PMID: 38288053 PMCID: PMC10822980 DOI: 10.3389/fcvm.2023.1332395] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2023] [Accepted: 12/22/2023] [Indexed: 01/31/2024] Open
Abstract
Background The Occlutech Atrial Flow Regulator (AFR) is a self-expandable double-disc nitinol device with a central fenestration. Its use has been approved in the adult population with heart failure and described for pulmonary hypertension (PH). Only case reports and small series have been published about its use in the paediatric population and for congenital heart disease (CHD). Objectives The authors sought to investigate the feasibility, safety, and short-term follow-up of AFR implantation in patients with CHD or children with PH or cardiomyopathy. Methods This is a multicenter retrospective study involving 10 centers worldwide. Patients of any age with CHD or patients aged < 18 years with PH or cardiomyopathy needing AFR implantation were included. Results A total of 40 patients underwent AFR implantation. The median age of the population at the time of the procedure was 58.5 months (IQR: 31.5-142.5) and the median weight was 17 kg (IQR: 10-46). A total of 26 (65.0%) patients had CHD, nine (22.5%) children, a cardiomyopathy, and five (12.5%), a structurally normal heart. The implantation success rate was 100%. There were two early and one late device thrombosis. Two patients (5.0%) with dilated cardiomyopathy on extracorporeal membrane oxygenator (ECMO) died during the hospital stay. At a median follow-up of 330 days (IQR: 125-593), 37 (92.5%) patients were alive. At follow-up, 20 patients improved their New York Heart Association (NYHA) class, 12 patients did not change their NYHA class, and one patient with idiopathic PH worsened. Conclusions AFR implantation in patients with CHD and children with severe PH or cardiomyopathy is promising and seems to have beneficial effects at short-term follow-up.
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Affiliation(s)
- Gianfranco Butera
- Cardiology, Cardiac Surgery and Heart Lung Transplantation, ERN GUARD HEART, Bambino Gesù Hospital and Research Institute, IRCCS, Rome, Italy
| | - Enrico Piccinelli
- Cardiology, Cardiac Surgery and Heart Lung Transplantation, ERN GUARD HEART, Bambino Gesù Hospital and Research Institute, IRCCS, Rome, Italy
- Department of Mechanical and Aerospace Engineering, Politecnico di Torino, Torino, Italy
| | - Adam Kolesnik
- Cardiovascular Interventions Laboratory, The Children’s Memorial Health Institute, Varsavia, Poland
| | - Kostantin Averin
- Division of Cardiology, Department of Pediatrics, Stollery Children’s Hospital, Edmonton, AB, Canada
| | - Cameron Seaman
- Division of Cardiology, Department of Pediatrics, Stollery Children’s Hospital, Edmonton, AB, Canada
| | - Biagio Castaldi
- Pediatric Cardiology Department, Padova University, Padova, Italy
| | - Elena Cuppini
- Pediatric Cardiology Department, Padova University, Padova, Italy
| | - Alain Fraisse
- Pediatric Cardiology Department, Royal Brompton Hospital, London, United Kingdom
| | | | - Sebastien Hascoet
- Pediatric Cardiology Department, Royal Brompton Hospital, London, United Kingdom
| | - Carmen D'Amore
- Epidemiology, Clinical Pathways and Clinical Risk Unit, Medical Direction, Bambino Gesù Children’s Hospital, IRCCS, Rome, Italy
| | - Alban-Elouen Baruteau
- Nantes Université, CHU Nantes, Department of Pediatric Cardiology and Pediatric Cardiac Surgery, FHU PreciCare, Nantes, France
| | - Pedro Betrián Blasco
- Pediatric Interventional Cardiology Unit, Vall d'Hebron Hospital, Barcellona, Spain
| | - Lisa Bianco
- Cardiology, Cardiac Surgery and Heart Lung Transplantation, ERN GUARD HEART, Bambino Gesù Hospital and Research Institute, IRCCS, Rome, Italy
- Pediatric Interventional Cardiology Unit, Vall d'Hebron Hospital, Barcellona, Spain
| | - Andreas Eicken
- Department of Congenital Heart Disease and Pediatric Cardiology, Deutsches Herzzentrum München, München, Germany
| | - Matthew Jones
- Department of Paediatric Cardiology and Adults with Congenital Heart Diseases, Evelina Children’s Hospital, London, United Kingdom
| | - James A. Kuo
- Division of Cardiology, Children’s Healthcare of Atlanta, Atlanta, GA, United States
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Peer SM. Reversing the Fontan paradox. Eur J Cardiothorac Surg 2024; 65:ezae012. [PMID: 38218719 DOI: 10.1093/ejcts/ezae012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/02/2024] [Accepted: 01/11/2024] [Indexed: 01/15/2024] Open
Affiliation(s)
- Syed Murfad Peer
- Division of Pediatric Cardiothoracic Surgery, University of Minnesota Masonic Children's Hospital, Minneapolis, MN, USA
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Haddad RN, Naggara O, Bonnet D, Malekzadeh-Milani S. Cerebral embolic protection during transcatheter stent expansion of restrictive extra-cardiac Fontan conduit. Cardiol Young 2024; 34:209-211. [PMID: 38031499 DOI: 10.1017/s1047951123004109] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/01/2023]
Abstract
We report a 20-year-old female patient (76 Kg/164 cm) with an extra-cardiac Fontan circulation who was referred to our institution for exertional dyspnoea and desaturation. The patient was diagnosed with a large calcified thrombus at the level of the Fontan fenestration, protruding inside the lumen of the conduit and reducing the diameter by half with a 3 mmHg pressure gradient. Transcatheter stent expansion of the obstructed extra-cardiac conduit was done with a 48 mm long XXL PTFE-covered Optimus-CVS® under temporary cerebral embolic protection with a TriGUARD-3™ deflection filter device (Keystone Heart). There was no procedural complication and the 3 months clinical outcomes are good.
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Affiliation(s)
- Raymond N Haddad
- M3C-Necker, Hôpital Universitaire Necker-Enfants malades, Assistance Publique-Hôpitaux de Paris (AP-HP), Paris, France
| | - Olivier Naggara
- Department of Pediatric Radiology, Hôpital Universitaire Necker-Enfants malades, Assistance Publique-Hôpitaux de Paris (AP-HP), Paris, France
- Department of Neuroradiology, GHU Paris Psychiatrie et Neurosciences, Sainte Anne Hospital - INSERM, Paris, France
- Université de Paris Cité, Paris, France
| | - Damien Bonnet
- M3C-Necker, Hôpital Universitaire Necker-Enfants malades, Assistance Publique-Hôpitaux de Paris (AP-HP), Paris, France
- Université de Paris Cité, Paris, France
| | - Sophie Malekzadeh-Milani
- M3C-Necker, Hôpital Universitaire Necker-Enfants malades, Assistance Publique-Hôpitaux de Paris (AP-HP), Paris, France
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Şişli E, Yıldırım C, Aka İB, Tuncer ON, Atay Y, Özbaran M, Pekkan K. Switching the Left and the Right Hearts: A Novel Bi-ventricle Mechanical Support Strategy with Spared Native Single-Ventricle. Ann Biomed Eng 2023; 51:2853-2872. [PMID: 37635154 DOI: 10.1007/s10439-023-03348-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2023] [Accepted: 08/09/2023] [Indexed: 08/29/2023]
Abstract
End-stage Fontan patients with single-ventricle (SV) circulation are often bridged-to-heart transplantation via mechanical circulatory support (MCS). Donor shortage and complexity of the SV physiology demand innovative MCS. In this paper, an out-of-the-box circulation concept, in which the left and right ventricles are switched with each other is introduced as a novel bi-ventricle MCS configuration for the "failing" Fontan patients. In the proposed configuration, the systemic circulation is maintained through a conventional mechanical ventricle assist device (VAD) while the venous circulation is delegated to the native SV. This approach spares the SV and puts it to a new use at the right-side providing the most-needed venous flow pulsatility to the failed Fontan circulation. To analyze its feasibility and performance, eight SV failure modes have been studied via an established multi-compartmental lumped parameter cardiovascular model (LPM). Here the LPM model is experimentally validated against the corresponding pulsatile mock-up flow loop measurements of a representative 15-year-old Fontan patient employing a clinically-approved VAD (Medtronic-HeartWare). The proposed surgical configuration maintained the healthy cardiac index (3-3.5 l/min/m2) and the normal mean systemic arterial pressure levels. For a failed SV with low ejection fraction (EF = 26%), representing a typical systemic Fontan failure, the proposed configuration enabled a ~ 28 mmHg amplitude in the venous/pulmonary waveforms and a 2 mmHg decrease in the central venous pressure (CVP) together with acceptable mean pulmonary artery pressures (17.5 mmHg). The pulmonary vascular resistance (PVR)-SV failure case provided a ~ 5 mmHg drop in the CVP, with venous/pulmonary pulsatility reaching to ~ 22 mmHg. For the high PVR failure case with a healthy SV (EF = 44%) pulmonary hypertension is likely to occur as expected. While this condition is routinely encountered during the heart transplantation and managed through pulmonary vasodilators a need for precise functional assessment of the spared failed-ventricle is recommended if utilized in the PVR failure mode. Comprehensive in vitro and in silico results encourage this novel concept as a low-cost, more physiological alternative to the conventional bi-ventricle MCS pending animal experiments.
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Affiliation(s)
- Emrah Şişli
- Pediatric Cardiovascular Surgery, Department of Cardiovascular Surgery, Osmangazi University Faculty of Medicine, Büyükdere District, Campus of Meşelik, Tepebaşı, 26480, Eskisehir, Turkey.
| | - Canberk Yıldırım
- Department of Biomedical Sciences and Engineering, Koç University, Istanbul, Turkey
| | - İbrahim Başar Aka
- Department of Mechatronics Engineering, İstanbul Bilgi University, Istanbul, Turkey
| | - Osman Nuri Tuncer
- Pediatric Cardiovascular Surgery, Department of Cardiovascular Surgery, Ege University Faculty of Medicine, Izmir, Turkey
| | - Yüksel Atay
- Pediatric Cardiovascular Surgery, Department of Cardiovascular Surgery, Ege University Faculty of Medicine, Izmir, Turkey
| | - Mustafa Özbaran
- Heart Transplantation, Department of Cardiovascular Surgery, Ege University Faculty of Medicine, Izmir, Turkey
| | - Kerem Pekkan
- Department of Mechanical Engineering, Koç University, Rumeli Feneri Campus, Sarıyer, Istanbul, Turkey.
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Venna A, Deshpande S, Downing T, John A, d'Udekem Y. Are dynamic measurements of central venous pressure in Fontan circulation during exercise or volume loading superior to resting measurements? Cardiol Young 2023:1-12. [PMID: 37981897 DOI: 10.1017/s1047951123003797] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/21/2023]
Abstract
BACKGROUND The main objective measure to assess the health of the Fontan circulation is the pressure measurement of the superior vena cava or pulmonary arteries. We reviewed the literature for benefits of measuring resting pressure in the Fontan circuit and explored whether dynamic measurement by volume loading or exercise has the potential to refine this diagnostic tool. METHODS PubMed was searched for articles showing a relationship between resting post-operative central venous pressure or pulmonary artery pressure and Fontan failure. Relationships between post-operative central venous pressure or pulmonary artery pressure and volume loading changes, such as during exercise or volume loading during cardiac catheterization, were also queried. RESULTS A total of 44 articles mentioned relationships between resting central venous pressure or pulmonary artery pressure and Fontan failure. Only 26 included an analysis between the variables and only seven of those articles found pressure to be predictive of Fontan failure. Ten articles examined the relationship between exercise or volume loading and outcomes and demonstrated a large individual variation of pressures under these dynamic conditions. CONCLUSIONS Based on current literature, there is not a lot of strong evidence to show that elevated resting central venous pressure or pulmonary artery pressure is predictive of Fontan failure. Some individuals experience dramatic increases in central venous pressure or pulmonary artery pressure under increased loading conditions with exercise or bolus fluid infusion, while others experience increases closer to that of a healthy control population. Further studies are needed to examine whether more dynamic and continuous monitoring of systemic venous pressures might better predict outcomes in patients with Fontan circulation.
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Affiliation(s)
- Alyssia Venna
- Division of Cardiac Surgery, Children's National Hospital, Washington, DC, USA
| | | | - Tacy Downing
- Division of Cardiology, Children's National Health System, Washington, DC, USA
| | - Anitha John
- Division of Cardiology, Children's National Health System, Washington, DC, USA
| | - Yves d'Udekem
- Division of Cardiac Surgery, Children's National Hospital, Washington, DC, USA
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Lanser CNG, van Poecke WHA, Scheffers LE, van den Berg LE, Helbing WA. Stress imaging in patients with a Fontan circulation: A systematic review. Int J Cardiol 2023; 391:131192. [PMID: 37479147 DOI: 10.1016/j.ijcard.2023.131192] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/11/2023] [Accepted: 07/14/2023] [Indexed: 07/23/2023]
Abstract
INTRODUCTION The aims of this study were to provide an overview of the cardiac stress response in Fontan patients and of the use, safety and clinical value of stress imaging in Fontan patients. METHODS Studies evaluating cardiac function using stress imaging in Fontan patients published up until 12 December 2021 were included in this review. RESULTS From 1603 potential studies, 32 studies met the inclusion criteria. In total, stress imaging tests of 728 Fontan patients were included. Cardiac function was most often measured using physical stress (61%), all other studies used dobutamine-induced stress. Stroke volume (SV) increased in most studies (71%), mean SV at rest ranged from 27 mL/m2 to 60 mL/m2 versus 27 mL/m2 to 101 mL/m2 during stress, and increased with an average of 4%. Ejection fraction increased in almost all studies, whereas both end-systolic volume and end-diastolic volume decreased during stress. Higher heart rates were obtained with physical stress (82-180) compared to dobutamine induced stress (73-128). Compared to controls, increases in heartrate and SV were lower and end-diastolic volume decreased abnormally in 75% of reporting studies. No major adverse events were reported. Poorer cardiac stress response was related to decreased exercise capacity and higher risk for long-term (adverse) outcomes in Fontan patients. DISCUSSION Cardiac stress response in Fontan patients differs from healthy subjects, reflected by lower increases in heart rate, diminished preload and decreased cardiac output, especially during higher levels of exercise. Stress imaging is safe, however the added clinical value needs to be investigated in more detail.
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Affiliation(s)
- Charlotte N G Lanser
- Department of Pediatrics, division of Pediatric Cardiology, Erasmus MC - Sophia Children's Hospital, Rotterdam, Netherlands
| | - Wessel H A van Poecke
- Department of Pediatrics, division of Pediatric Cardiology, Erasmus MC - Sophia Children's Hospital, Rotterdam, Netherlands
| | - Linda E Scheffers
- Department of Pediatrics, division of Pediatric Cardiology, Erasmus MC - Sophia Children's Hospital, Rotterdam, Netherlands
| | - Linda E van den Berg
- Department of Orthopedics and Sports Medicine, Erasmus MC - Sophia Children's Hospital, Rotterdam, Netherlands
| | - Willem A Helbing
- Department of Pediatrics, division of Pediatric Cardiology, Erasmus MC - Sophia Children's Hospital, Rotterdam, Netherlands; Department of Radiology, Erasmus MC - Sophia Children's Hospital, Rotterdam, Netherlands.
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12
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Scheffers LE, Helbing WA, Pereira T, Walet S, Utens EMWJ, Dulfer K, van den Berg LE. A 12-week lifestyle intervention: effects on fatigue, fear, and nutritional status in children with a Fontan circulation. Front Pediatr 2023; 11:1154015. [PMID: 38027302 PMCID: PMC10657862 DOI: 10.3389/fped.2023.1154015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/30/2023] [Accepted: 07/26/2023] [Indexed: 12/01/2023] Open
Abstract
Introduction Children and adolescents with a Fontan circulation are less physically active compared to healthy peers. In the current study, effects of a 12-week lifestyle intervention on fatigue, fears regarding exercise, caloric intake, rest energy expenditure (REE), and body composition were measured in children with a Fontan circulation. Methods This study was a semi-cross-over randomized controlled trial. The lifestyle intervention consisted of a 12-week high-weight resistance training (three supervised training sessions a week) supported by high-protein diet (>2 g/kg) and tailored recommended caloric intake. Fatigue (measured by the validated PedsQol Multidimensional Fatigue Scale), fears regarding exercise (measured on a fear thermometer), REE (measured using indirect calorimetry), caloric intake and body composition using air displacement plethysmography, and four-skinfold method were measured before and after the intervention and control period. Results Twenty-seven pediatric Fontan patients, median age 12.9 years (IQR: 10.5-16.2), of the included 28 patients successfully completed the program. Before training, both child- and parent-reported levels of fatigue were significantly worse on all domains (general, sleep/rest, and cognitive fatigue) compared to healthy peers. After training, parent-reported fatigue significantly improved on the general and cognitive fatigue domains [effect size +16 points (7-25), p < 0.001, and +10 points (2-17), p = 0.015, compared to the control period]. Before training, fear regarding exercise scored on the fear thermometer was low for both children and parents (median score 1 and 2, respectively, on a scale of 0-8). After training, child-reported fear decreased further compared to the control period [effect size -1.4 points (-2.3 to -0.6), p = 0.001]. At baseline, children had increased REE +12% compared to reference values, which did not change after exercise. Children ate an average of 637 calories below recommended intake based on REE, caloric deficit became smaller after the intervention, and protein intake increased compared to the control period [-388 calories (-674 to -102), p = 0.008, and +15 g (0.4-30), p = 0.044]. Body fat percentage did not change significantly. Conclusion A 12-week lifestyle intervention improved parent-reported fatigue symptoms in the children, further decreased child-reported fears, and increased caloric and protein intake.
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Affiliation(s)
- L. E. Scheffers
- Department of Paediatrics, Division of Paediatric Cardiology, Erasmus MC Sophia Children’s Hospital, Rotterdam, Netherlands
- Department of Paediatrics, Division of Gastroenterology, Erasmus MC Sophia Children’s Hospital, Rotterdam, Netherlands
- Respiratory Medicine and Allergology, Department of Paediatrics, University Medical Center, Erasmus MC Sophia Children’s Hospital, Rotterdam, Netherlands
- Department of Paediatrics, Center for Lysosomal and Metabolic Diseases, Erasmus MC, Rotterdam, Netherlands
| | - W. A. Helbing
- Department of Paediatrics, Division of Paediatric Cardiology, Erasmus MC Sophia Children’s Hospital, Rotterdam, Netherlands
| | - T. Pereira
- Department of Paediatrics, Division of Paediatric Cardiology, Erasmus MC Sophia Children’s Hospital, Rotterdam, Netherlands
| | - S. Walet
- Division of Dietetics, Department of Internal Medicine, Erasmus MC, Rotterdam, Netherlands
| | - E. M. W. J. Utens
- Department of Child and Adolescent Psychiatry/Psychology, Erasmus MC Sophia Children’s Hospital, Rotterdam, Netherlands
- Research Institute of Child Development and Education, University of Amsterdam, Amsterdam, Netherlands
- Department of Child and Adolescent Psychiatry, Amsterdam University Medical Center/Levvel, Amsterdam, Netherlands
| | - K. Dulfer
- Intensive Care Unit, Department of Paediatrics and Paediatric Surgery, Erasmus Medical Centre Sophia Children’s Hospital, Rotterdam, Netherlands
| | - L. E. van den Berg
- Department of Orthopedics and Sports Medicine, Erasmus MC, Rotterdam, Netherlands
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Hut T, Roest A, Gaillard D, Hazekamp M, van den Boogaard P, Lamb H, Kroft L, Jongbloed M, Westenberg J, Wentzel J, Rijnberg F, Kenjeres S. Virtual surgery to predict optimized conduit size for adult Fontan patients with 16-mm conduits. Interdiscip Cardiovasc Thorac Surg 2023; 37:ivad126. [PMID: 37522877 PMCID: PMC10686953 DOI: 10.1093/icvts/ivad126] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/25/2023] [Revised: 06/18/2023] [Accepted: 07/30/2023] [Indexed: 08/01/2023]
Abstract
OBJECTIVES Recent evidence suggests that conduits implanted in Fontan patients at the age of 2-4 years become undersized for adulthood. The objective of this study is to use computational fluid dynamic models to evaluate the effect of virtual expansion of the Fontan conduit on haemodynamics and energetics of the total cavopulmonary connection (TCPC) under resting conditions and increased flow conditions. METHODS Patient-specific, magnetic resonance imaging-based simulation models of the TCPC were performed during resting and increased flow conditions. The original 16-mm conduits were virtually enlarged to 3 new sizes. The proposed conduit sizes were defined based on magnetic resonance imaging-derived conduit flow in each patient. Flow efficiency was evaluated based on power loss, pressure drop and resistance and thrombosis risk was based on flow stagnation volume and relative residence time (RRT). RESULTS Models of 5 adult patients with a 16-mm extracardiac Fontan connection were simulated and subsequently virtually expanded to 24-32 mm depending on patient-specific conduit flow. Virtual expansion led to a 40-65% decrease in pressure gradient across the TCPC depending on virtual conduit size. Despite improved energetics of the entire TCPC, the pulmonary arteries remained a significant contributor to energy loss (60-73% of total loss) even after virtual surgery. Flow stagnation volume inside the virtual conduit and surface area in case of elevated RRT (>20/Pa) increased after conduit enlargement but remained negligible (flow stagnation <2% of conduit volume in rest, <0.5% with exercise and elevated RRT <3% in rest, <1% with exercise). CONCLUSIONS Virtual expansion of 16-mm conduits to 24-32 mm, depending on patient-specific conduit flow, in Fontan patients significantly improves TCPC efficiency while thrombosis risk presumably remains low.
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Affiliation(s)
- Tjerry Hut
- Department of Chemical Engineering, Faculty of Applied Sciences, Delft University of Technology and J.M. Burgers Centrum Research School for Fluid Mechanics, Delft, Netherlands
| | - Arno Roest
- Department of Pediatric Cardiology, Leiden University Medical Center, Leiden, Netherlands
| | - Duco Gaillard
- Department of Chemical Engineering, Faculty of Applied Sciences, Delft University of Technology and J.M. Burgers Centrum Research School for Fluid Mechanics, Delft, Netherlands
| | - Mark Hazekamp
- Department of Cardiothoracic Surgery, Leiden University Medical Center, Leiden, Netherlands
| | | | - Hildo Lamb
- Department of Radiology, Leiden University Medical Center, Leiden, Netherlands
| | - Lucia Kroft
- Department of Radiology, Leiden University Medical Center, Leiden, Netherlands
| | - Monique Jongbloed
- Department of Cardiology and Anatomy & Embryology, Leiden University Medical Center, Leiden, Netherlands
| | - Jos Westenberg
- Department of Radiology, Leiden University Medical Center, Leiden, Netherlands
| | - Jolanda Wentzel
- Department of Cardiology, Biomechanical Engineering, Erasmus MC, Rotterdam, Netherlands
| | - Friso Rijnberg
- Department of Cardiothoracic Surgery, Leiden University Medical Center, Leiden, Netherlands
| | - Sasa Kenjeres
- Department of Chemical Engineering, Faculty of Applied Sciences, Delft University of Technology and J.M. Burgers Centrum Research School for Fluid Mechanics, Delft, Netherlands
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d’Udekem Y, Kisamori E, Yerebakan C. We were wrong on the benefits of the extra-cardiac Fontan. Should we go back to the lateral tunnel? Interdiscip Cardiovasc Thorac Surg 2023; 37:ivad187. [PMID: 37991843 PMCID: PMC10686946 DOI: 10.1093/icvts/ivad187] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/27/2023] [Accepted: 11/21/2023] [Indexed: 11/24/2023]
Affiliation(s)
- Yves d’Udekem
- Division of Cardiovascular Surgery, Children’s National Heart Institute, Children’s National Hospital, Washington, DC, USA
| | - Eiri Kisamori
- Division of Cardiovascular Surgery, Children’s National Heart Institute, Children’s National Hospital, Washington, DC, USA
| | - Can Yerebakan
- Division of Cardiovascular Surgery, Children’s National Heart Institute, Children’s National Hospital, Washington, DC, USA
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15
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Ferrari MR, Schäfer M, Hunter KS, Di Maria MV. Central Venous Waveform Patterns in the Fontan Circulation Independently Contribute to the Prediction of Composite Survival. Pediatr Cardiol 2023:10.1007/s00246-023-03268-w. [PMID: 37773462 DOI: 10.1007/s00246-023-03268-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/03/2023] [Accepted: 08/07/2023] [Indexed: 10/01/2023]
Abstract
It is well appreciated that the Fontan circulation perturbs central venous hemodynamics, with elevated pressure being the clearest change associated with Fontan comorbidities, such as Fontan-associated liver disease (FALD) and protein-losing enteropathy (PLE). Our group has better quantity of these venous perturbations through single- and multi-location analyses of flow waveforms obtained from magnetic resonance imaging of Fontan patients. Here, we determine if such analyses, which yield principal components (PC) that describe flow features, are associated with Fontan survival. Patients with a Fontan circulation (N = 140) that underwent free-breathing and mechanically ventilated cardiac MRI were included in this study. Standard volumetric and functional hemodynamics, as well as flow analysis principal components, were subjected to univariate and bivariate Cox regression analyses to determine composite clinical outcome, including plastic bronchitis, PLE, and referral and receipt of transplant. Unsurprisingly, ventricular function measures of ejection fraction (EF; HR = 0.88, p < 0.0001), indexed end-systolic volume (ESVi; HR 1.02, p < 0.0001), and indexed end-diastolic volume (EDVi; HR = 1.02, p = 0.0007) were found as specific predictors of clinical events, with specificities uniformly > 0.75. Additionally a feature of IVC flow (PC2) indicating increased flow in systole was found as a highly sensitive predictor (HR = 0.851, p = 0.027, sensitivity 0.93). In bivariate prediction, combinations of ventricular function (EF, ESVi, EDVi) with this IVC flow feature yielded best overall prediction of composite outcome. This suggests that central venous waveform analysis relays additional information about Fontan patient survival and that coupling sensitive and specific measures in bivariate analysis is a useful approach for obtaining superior prediction of survival.
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Affiliation(s)
- Margaret R Ferrari
- Department of Bioengineering, University of Colorado Anschutz Medical Campus, Aurora, CO, 80045, USA
| | - Michal Schäfer
- Division of Cardiology, Heart Institute, Children's Hospital Colorado, University of Colorado Anschutz Medical Campus, 13123 East 16Th Ave, Aurora, CO, 80045, USA
| | - Kendall S Hunter
- Department of Bioengineering, University of Colorado Anschutz Medical Campus, Aurora, CO, 80045, USA
| | - Michael V Di Maria
- Division of Cardiology, Heart Institute, Children's Hospital Colorado, University of Colorado Anschutz Medical Campus, 13123 East 16Th Ave, Aurora, CO, 80045, USA.
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Ravndal M, Idorn L, Nielsen AKM, Kelly B, Nielsen KG, Nielsen DG, Hjortdal V. Exercise capacity in the Danish Fontan population remains stable after ten years of follow-up - is physical activity the key to success? Int J Cardiol 2023; 387:131137. [PMID: 37355241 DOI: 10.1016/j.ijcard.2023.131137] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/18/2023] [Revised: 05/30/2023] [Accepted: 06/20/2023] [Indexed: 06/26/2023]
Abstract
BACKGROUND Most Fontan patients have impaired exercise capacity, and a further decline in exercise capacity over time seems inevitable. However, few longitudinal studies exist, and there is a lack of data from newer eras. We aimed to describe the natural evolution of exercise capacity over a 10-year period in a contemporary, population-based cohort of Danish Fontan patients. METHODS The study was a nationwide, prospective study. A cardiopulmonary exercise test (CPET) was used to assess the exercise capacity. All Danish Fontan patients who participated in a national study in 2011 (CPET1), were invited to a follow-up visit in 2021 (CPET2). All patients who completed CPET1 and CPET2 with a respiratory exchange ratio over 1.0 were included. The main outcome was percent predicted VO2peak (%pred VO2peak). At the time of CPET2, patients filled out a questionnaire including questions regarding physical activity. RESULTS Seventy-seven patients completed both CPET1 and CPET2, and seventy patients completed the questionnaire. The time interval between the two CPETs was 10.4 ± 0.9 years. The median age was 15 years at CPET1 and 26 years at CPET2. The exercise capacity remained stable with a mean %pred VO2peak of 53.8 ± 11.3 at CPET1 and 55.6 ± 10.9 in CPET2 (p = 0.314). Higher levels of vigorous physical activity were associated with higher %pred VO2peak in CPET2 in a multivariate regression model. CONCLUSION The %pred VO2peak remained stable over a ten-year period in this population-based Fontan cohort. Higher levels of self-reported vigorous physical activity were associated with higher %pred VO2peak in the most recent CPET.
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Affiliation(s)
- Maren Ravndal
- Department of Cardiothoracic Surgery, Copenhagen University Hospital, Copenhagen, Denmark.
| | - Lars Idorn
- Department of Pediatrics and Adolescent Medicine, Copenhagen University Hospital, Copenhagen, Denmark
| | | | - Benjamin Kelly
- Department of Cardiothoracic and Vascular Surgery, Aarhus University Hospital, Aarhus, Denmark
| | - Kim Gjerum Nielsen
- Department of Pediatrics and Adolescent Medicine, Copenhagen University Hospital, Copenhagen, Denmark; Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | | | - Vibeke Hjortdal
- Department of Cardiothoracic Surgery, Copenhagen University Hospital, Copenhagen, Denmark; Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
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Cindik N, Gökdemir M, Varan B, Ulubay G, Ozkan M, Tokel NK. Comparison of serum N-terminal pro-brain natriuretic peptide levels, conventional echocardiography, exercise parameters, and dyssynchrony measurements in Fontan patients. Cardiol Young 2023; 33:1706-1712. [PMID: 37675568 DOI: 10.1017/s1047951123003256] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 09/08/2023]
Abstract
INTRODUCTION Little data are available concerning the methods used in the long-term follow-up of Fontan patients. We analyzed the association between serum N-terminal pro-brain natriuretic peptide levels, conventional echocardiography findings, exercise parameters, and dyssynchrony measurements in patients who underwent Fontan surgery. METHODS This study included 28 patients who underwent Fontan surgery (mean age 12.8 ± 4.36 years) and 27 healthy controls (mean age 12.5 ± 3.76 years). Echocardiography examinations and exercise tests were performed in both groups. The systemic ventricle was examined via echocardiography, dyssynchrony measurement was performed, the systemic ventricular myocardial performance index was calculated, and serum N-terminal pro-brain natriuretic peptide levels were measured for all subjects. RESULTS Lower cardiac output, stroke volume, maximal work, chronotropic index, maximal oxygen uptake, and higher N-terminal pro-brain natriuretic peptide levels were observed in the Fontan group than in the control group (p < 0.05). A negative correlation was found between physical exercise parameters and N-terminal pro-brain natriuretic peptide levels and dyssynchrony measurements. CONCLUSION Measurements of exercise capacity, serum N-terminal pro-brain natriuretic peptide levels, and dyssynchrony measurement were more valuable than conventional methods for assessing patients' clinical and functional status. Dyssynchrony measurements provided better information about ventricular status than did conventional echocardiography studies. While patients' systolic function determined by conventional echocardiography was normal, dyssynchrony measurements showed the opposite result. The negative relationship between serum N-terminal pro-brain natriuretic peptide levels, dyssynchrony measurements, and exercise capacity suggests that these parameters should be investigated further in Fontan patients.
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Affiliation(s)
- Nimet Cindik
- Department of Pediatric Cardiology, Baskent University, Konya, TR, Turkey
| | - Mahmut Gökdemir
- Department of Pediatric Cardiology, Baskent University, Konya, TR, Turkey
| | - Birgül Varan
- Pediatric cardiology, Baskent University Faculty of Medicine, Ankara, TR, Turkey
| | - Gaye Ulubay
- Department of Pulmonary Diseases, Baskent University Faculty of Medicine, Ankara, TR, Turkey
| | - Murat Ozkan
- Cardiovascular Surgery, Baskent University Faculty of Medicine, Ankara, TR, Turkey
| | - Niyazi Kürşad Tokel
- Pediatric cardiology, Baskent University Faculty of Medicine, Ankara, TR, Turkey
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Ishida H, Maeda J, Uchida K, Yamagishi H. Unique Pulmonary Hypertensive Vascular Diseases Associated with Heart and Lung Developmental Defects. J Cardiovasc Dev Dis 2023; 10:333. [PMID: 37623346 PMCID: PMC10455332 DOI: 10.3390/jcdd10080333] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2023] [Revised: 07/10/2023] [Accepted: 08/01/2023] [Indexed: 08/26/2023] Open
Abstract
Although pediatric pulmonary hypertension (PH) shares features and mechanisms with adult PH, there are also some significant differences between the two conditions. Segmental PH is a unique pediatric subtype of PH with unclear and/or multifactorial pathophysiological mechanisms, and is often associated with complex congenital heart disease (CHD), pulmonary atresia with ventricular septal defect, and aortopulmonary collateral arteries. Some cases of complex CHD, associated with a single ventricle after Fontan operation, show pathological changes in the small peripheral pulmonary arteries and pulmonary vascular resistance similar to those observed in pulmonary arterial hypertension (PAH). This condition is termed as the pediatric pulmonary hypertensive vascular disease (PPHVD). Recent advances in genetics have identified the genes responsible for PAH associated with developmental defects of the heart and lungs, such as TBX4 and SOX17. Targeted therapies for PAH have been developed; however, their effects on PH associated with developmental heart and lung defects remain to be established. Real-world data analyses on the anatomy, pathophysiology, genetics, and molecular biology of unique PPHVD cases associated with developmental defects of the heart and lungs, using nationwide and/or international registries, should be conducted in order to improve the treatments and prognosis of patients with these types of pediatric PH.
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Affiliation(s)
- Hidekazu Ishida
- Department of Pediatrics, Osaka University Graduate School of Medicine, 2-2 Yamadaoka, Suita 565-0871, Osaka, Japan;
| | - Jun Maeda
- Department of Cardiology, Tokyo Metropolitan Children’s Medical Center, 2-8-29 Musashidai, Fuchu 183-8561, Tokyo, Japan;
| | - Keiko Uchida
- Department of Pediatrics, Keio University of Medicine, 35 Shinanomachi, Shinjuku-ku 160-8582, Tokyo, Japan;
- Keio University Health Center, 4-1-1 Hiyoshi, Kohoku-ku, Yokohama 223-8521, Kanagawa, Japan
| | - Hiroyuki Yamagishi
- Department of Pediatrics, Keio University of Medicine, 35 Shinanomachi, Shinjuku-ku 160-8582, Tokyo, Japan;
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Kadoya T, Fujino M, Nakamura K, Sasaki T, Kawasaki Y, Yoshida Y, Suzuki T, Kanamoto N, Ehara E, Murakami Y. Successful perioperative management of pheochromocytoma in a patient with Fontan circulation. J Cardiol Cases 2023; 28:75-78. [PMID: 37521575 PMCID: PMC10382968 DOI: 10.1016/j.jccase.2023.04.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2022] [Revised: 03/15/2023] [Accepted: 04/11/2023] [Indexed: 08/01/2023] Open
Abstract
Pheochromocytoma (PCC) can adversely affect Fontan circulation. However, there are few reports on its perioperative management before and after PCC resection in Fontan patients. A 24-year-old female patient with congenitally corrected transposition of the great arteries, ventricular septal defect, and pulmonary atresia who had undergone Fontan palliation developed heart failure caused by PCC. The patient was pre-conditioned for PCC resection with heart failure treatment, alpha-blocker titration, and careful infusion, and had a good intraoperative and postoperative course with no complications. Postoperative catheter data showed improvements in systemic vascular resistance, cardiac output, and central venous pressure compared with preoperative data. There is no established preconditioning method for PCC resection in patients with Fontan circulation. Careful perioperative management based on an understanding of the features of the Fontan circulation can lead to better outcomes. Learning objective Pheochromocytoma (PCC) can occur in patients with Fontan circulation. Preoperative management and the PCC itself can adversely affect Fontan circulation, highlighting the importance of suspecting PCCs in Fontan patients based on symptoms such as heart failure, worsening arrhythmias, and headache, and emphasizing careful perioperative management.
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Affiliation(s)
- Takumi Kadoya
- Department of Pediatric Cardiology, Osaka City General Hospital, Osaka, Japan
| | - Mitsuhiro Fujino
- Department of Pediatric Cardiology, Osaka City General Hospital, Osaka, Japan
| | - Kae Nakamura
- Department of Pediatric Cardiology, Osaka City General Hospital, Osaka, Japan
| | - Takeshi Sasaki
- Department of Pediatric Cardiology, Osaka City General Hospital, Osaka, Japan
| | - Yuki Kawasaki
- Department of Pediatric Cardiology, Osaka City General Hospital, Osaka, Japan
| | - Yoko Yoshida
- Department of Pediatric Electrophysiology, Osaka City General Hospital, Osaka, Japan
| | - Tsugutoshi Suzuki
- Department of Pediatric Electrophysiology, Osaka City General Hospital, Osaka, Japan
| | - Naotetsu Kanamoto
- Department of Endocrinology, Osaka City General Hospital, Osaka, Japan
| | - Eiji Ehara
- Department of Pediatric Cardiology, Osaka City General Hospital, Osaka, Japan
| | - Yosuke Murakami
- Department of Pediatric Cardiology, Osaka City General Hospital, Osaka, Japan
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Rubinstein M, Zhu A, Mariani JA, Patel HC. Subcutaneous defibrillator use with unipolar pacemakers: Cautiously possible. Indian Pacing Electrophysiol J 2023; 23:126-129. [PMID: 37196770 PMCID: PMC10323176 DOI: 10.1016/j.ipej.2023.05.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2023] [Revised: 05/05/2023] [Accepted: 05/14/2023] [Indexed: 05/19/2023] Open
Abstract
Implantation of subcutaneous implantable cardioverter-defibrillator in a patient with existing unipolar pacemaker is against manufacturer recommendations. We report the case of a successful subcutaneous implantable cardioverter-defibrillator implantation in a patient with Fontan circulation and concomitant active unipolar pacing and present a summary of recommendations when considering subcutaneous implantable cardioverter-defibrillator implantation with unipolar pacing. Recommendations included: pre-procedure screening, rescreening during implantation and ventricular fibrillation induction, pacemaker programming, and post-procedure investigations.
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Affiliation(s)
| | - Angela Zhu
- Department of Cardiology, Heart Centre, Alfred Health, Melbourne, Australia
| | - Justin A Mariani
- Department of Cardiology, Heart Centre, Alfred Health, Melbourne, Australia; Heart Failure Research Laboratory, Baker Heart and Diabetes Institute, Melbourne, Australia; Central Clinical School, Monash University, Melbourne, Australia
| | - Hitesh C Patel
- Department of Cardiology, Heart Centre, Alfred Health, Melbourne, Australia; Heart Failure Research Laboratory, Baker Heart and Diabetes Institute, Melbourne, Australia; Central Clinical School, Monash University, Melbourne, Australia.
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Müller N, Herberg U, Breuer J, Kratz T, Härtel JA. Fitness to fly for children and adolescents after Fontan palliation. Front Cardiovasc Med 2023; 10:1170275. [PMID: 37424899 PMCID: PMC10326614 DOI: 10.3389/fcvm.2023.1170275] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2023] [Accepted: 06/02/2023] [Indexed: 07/11/2023] Open
Abstract
Introduction At cruising altitude, the cabin pressure of passenger aircraft needs to be adjusted and, therefore, the oxygen content is equivalent to ambient air at 2,500 masl, causing mild desaturation and a rising pulmonary vascular resistance (PVR) in healthy subjects. For Fontan patients with passive pulmonary perfusion, a rising PVR can cause serious medical problems. The purpose of this fitness to fly investigation (FTF) is to assess the risk of air travel for children and adolescents after Fontan palliation. Methods We investigated 21 Fontan patients [3-14y] in a normobaric hypoxic chamber at a simulated altitude of 2,500 m for 3 h. Oxygen saturation, heart rate, and regional tissue saturation in the forehead (NIRS) were measured continuously. Before entering the chamber, after 90 and 180 min in the hypoxic environment, blood gas analysis and echocardiography were performed. Results Heart rate and blood pressure did not show significant intraindividual changes. Capillary oxygen saturation (SaO2) decreased significantly after 90 min by a mean of 5.6 ± 2.87% without further decline. Lactate, pH, base excess, and tissue saturation in the frontal brain did not reach any critical values. In the case of open fenestration between the tunnel and the atrium delta, P did not increase, indicating stable pulmonary artery pressure. Conclusion All 21 children finished the investigation successfully without any adverse events, so flying short distance seems to be safe for most Fontan patients with good current health status. As the baseline oxygen saturation does not allow prediction of the maximum extent of desaturation and adaption to a hypoxic environment takes up to 180 min, the so-called hypoxic challenge test is not sufficient for these patients. Performing an FTF examination over a period of 180 min allows for risk assessment and provides safety to the patients and their families, as well as the airline companies.
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Affiliation(s)
- N. Müller
- Department for Pediatric Cardiology, Children’s Heart Center UK Bonn, University Hospital Bonn, Bonn, Germany
| | - U. Herberg
- Department for Pediatric Cardiology, Children’s Heart Center UK Bonn, University Hospital Bonn, Bonn, Germany
- Department for Pediatric Cardiology, University Hospital Aachen, Aachen, Germany
| | - J. Breuer
- Department for Pediatric Cardiology, Children’s Heart Center UK Bonn, University Hospital Bonn, Bonn, Germany
| | - T. Kratz
- Department for Pediatric Cardiology, Children’s Heart Center UK Bonn, University Hospital Bonn, Bonn, Germany
| | - J. A. Härtel
- Department for Pediatric Cardiology, Children’s Heart Center UK Bonn, University Hospital Bonn, Bonn, Germany
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22
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Taner T, Hilscher MB, Broda CR, Drenth JPH. Issues in multi-organ transplantation of the liver with kidney or heart in polycystic liver-kidney disease or congenital heart disease: Current practices and immunological aspects. J Hepatol 2023; 78:1157-1168. [PMID: 37208103 DOI: 10.1016/j.jhep.2023.02.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/28/2022] [Revised: 02/08/2023] [Accepted: 02/09/2023] [Indexed: 05/21/2023]
Abstract
Solid organ transplantation has become an integral part of the management of patients with end-stage diseases of the kidney, liver, heart and lungs. Most procedures occur in isolation, but multi-organ transplantation of the liver with either the kidney or heart has become an option. As more patients with congenital heart disease and cardiac cirrhosis survive into adulthood, particularly after the Fontan procedure, liver transplant teams are expected to face questions regarding multi-organ (heart-liver) transplantation. Similarly, patients with polycystic kidneys and livers may be managed by multi-organ transplantation. Herein, we review the indications and outcomes of simultaneous liver-kidney transplantation for polycystic liver-kidney disease, and discuss the indications, timing and procedural aspects of combined heart-liver transplantation. We also summarise the evidence for, and potential mechanisms underlying, the immunoprotective impact of liver allografts on the simultaneously transplanted organs.
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Affiliation(s)
- Timucin Taner
- Departments of Surgery & Immunology, Mayo Clinic, Rochester, MN, USA.
| | - Moira B Hilscher
- Division of Gastroenterology and Hepatology, Department of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Christopher R Broda
- Department of Pediatrics, Baylor College of Medicine/Texas Children's Hospital, Houston, TX, USA
| | - Joost P H Drenth
- Department of Gastroenterology and Hepatology, Radboud University, Nijmegen, the Netherlands
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23
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Putman R, Goldstein SA, Boyd B, Dotters-Katz S, Small M, Addae-Konadu KL. Sonographic Evaluation of the Placenta in Fontan Patients: A Case Series. J Ultrasound Med 2023; 42:1361-1365. [PMID: 36412992 DOI: 10.1002/jum.16135] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/27/2022] [Revised: 10/25/2022] [Accepted: 10/27/2022] [Indexed: 05/18/2023]
Abstract
Due to the advancements in pediatric cardiothoracic surgery and medical management, more individuals with congenital heart disease are reaching reproductive age. It is well established that individuals with Fontan circulation are at an increased risk for maternal and fetal adverse outcomes including maternal cardiovascular complications, hypertensive disorders of pregnancy, preterm birth, and fetal growth restriction. Early onset of poor placental health likely related to chronically elevated central venous pressure/low cardiac output inherited to Fontan circulation may play a role in the development of these outcomes. In this case series, we present second-trimester placental imaging findings and pregnancy outcomes of three individuals with Fontan circulation who delivered at a tertiary center in the Southeastern United States.
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Affiliation(s)
- Rachael Putman
- Department of Obstetrics and Gynecology, Duke University School of Medicine, Durham, North Carolina, USA
| | - Sarah A Goldstein
- Section of Cardiovascular Medicine, Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut, USA
| | - Brita Boyd
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, Duke University Medical Center, Durham, North Carolina, USA
| | - Sarah Dotters-Katz
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, Duke University Medical Center, Durham, North Carolina, USA
| | - Maria Small
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, Duke University Medical Center, Durham, North Carolina, USA
| | - Kateena L Addae-Konadu
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, The Southeast Permanente Medical Group, Atlanta, Georgia, USA
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24
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Lee GH, Koo HJ, Park KJ, Yang DH, Ha H. Characterization of baseline hemodynamics after the Fontan procedure: a retrospective cohort study on the comparison of 4D Flow MRI and computational fluid dynamics. Front Physiol 2023; 14:1199771. [PMID: 37304827 PMCID: PMC10248477 DOI: 10.3389/fphys.2023.1199771] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2023] [Accepted: 05/16/2023] [Indexed: 06/13/2023] Open
Abstract
Introduction: The aim of this study was to characterize the hemodynamics of Fontan patients using both four-dimensional flow magnetic resonance imaging (4D Flow MRI) and computational fluid dynamics (CFD). Methods: Twenty-nine patients (3.5 ± 0.5 years) who had undergone the Fontan procedure were enrolled, and the superior vena cava (SVC), left pulmonary artery (LPA), right pulmonary artery (RPA), and conduit were segmented based on 4D Flow MRI images. Velocity fields from 4D Flow MRI were used as boundary conditions for CFD simulations. Hemodynamic parameters such as peak velocity (Vmax), pulmonary flow distribution (PFD), kinetic energy (KE), and viscous dissipation (VD) were estimated and compared between the two modalities. Results and discussion: The Vmax, KE, VD, PFDTotal to LPA, and PFDTotal to RPA of the Fontan circulation were 0.61 ± 0.18 m/s, 0.15 ± 0.04 mJ, 0.14 ± 0.04 mW, 41.3 ± 15.7%, and 58.7 ± 15.7% from 4D Flow MRI; and 0.42 ± 0.20 m/s, 0.12 ± 0.05 mJ, 0.59 ± 0.30 mW, 40.2 ± 16.4%, and 59.8 ± 16.4% from CFD, respectively. The overall velocity field, KE, and PFD from the SVC were in agreement between modalities. However, PFD from the conduit and VD showed a large discrepancy between 4D Flow MRI and CFD, most likely due to spatial resolution and data noise. This study highlights the necessity for careful consideration when analyzing hemodynamic data from different modalities in Fontan patients.
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Affiliation(s)
- Gyu-Han Lee
- Department of Interdisciplinary Program in Biohealth-Machinery Convergence Engineering, Kangwon National University, Chuncheon, Republic of Korea
| | - Hyun Jung Koo
- Department of Radiology, Asan Medical Center, Research Institute of Radiology, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Kyung Jin Park
- Department of Radiology, Asan Medical Center, Research Institute of Radiology, University of Ulsan College of Medicine, Seoul, Republic of Korea
- Department of Electrical and Electronic Engineering, Yonsei University, Seoul, Republic of Korea
| | - Dong Hyun Yang
- Department of Radiology, Asan Medical Center, Research Institute of Radiology, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Hojin Ha
- Department of Smart Health Science and Technology, Kangwon National University, Chuncheon, Republic of Korea
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25
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Wittczak A, Dryżek P, Maciejewski M, Kula‐Mazurek A, Moszura T, Bikiewicz A, Bielecka‐Dabrowa A. Successful complex percutaneous intervention in patient with Fontan circulation and severe heart failure: A case report. Clin Case Rep 2023; 11:e7222. [PMID: 37151951 PMCID: PMC10155508 DOI: 10.1002/ccr3.7222] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2022] [Revised: 02/26/2023] [Accepted: 04/04/2023] [Indexed: 05/09/2023] Open
Abstract
We report the case of a successful complex percutaneous intervention in a patient with Fontan circulation and severe heart failure. The patient presented with cyanosis; Fontan conduit stenosis was detected, and the fenestration was patent. The complex interventional procedure allowed for a long-term stabilization of the patient's condition.
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Affiliation(s)
- Andrzej Wittczak
- Department of Cardiology and Congenital Diseases of AdultsPolish Mother's Memorial Hospital Research InstituteLodzPoland
| | - Paweł Dryżek
- Department of CardiologyPolish Mother's Memorial Hospital Research InstituteLodzPoland
| | - Marek Maciejewski
- Department of Cardiology and Congenital Diseases of AdultsPolish Mother's Memorial Hospital Research InstituteLodzPoland
| | - Anna Kula‐Mazurek
- Department of CardiologyPolish Mother's Memorial Hospital Research InstituteLodzPoland
| | - Tomasz Moszura
- Department of CardiologyPolish Mother's Memorial Hospital Research InstituteLodzPoland
| | - Agata Bikiewicz
- Department of Cardiology and Congenital Diseases of AdultsPolish Mother's Memorial Hospital Research InstituteLodzPoland
| | - Agata Bielecka‐Dabrowa
- Department of Cardiology and Congenital Diseases of AdultsPolish Mother's Memorial Hospital Research InstituteLodzPoland
- Department of Hypertension, Chair of Nephrology and HypertensionMedical University of LodzLodzPoland
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Marzullo R, Capestro A, Muçaj A, Piva T. Percutaneous rheolytic thrombectomy and cerebral embolic protection in a massive thrombosis of a fenestrated Fontan conduit: a case report. Eur Heart J Case Rep 2023; 7:ytad238. [PMID: 37215519 PMCID: PMC10199720 DOI: 10.1093/ehjcr/ytad238] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2022] [Revised: 02/05/2023] [Accepted: 05/04/2023] [Indexed: 05/24/2023]
Abstract
Background Clinical thromboembolism in Fontan patients is often a catastrophic event resulting in death and adverse long-term outcomes. The treatment of acute thromboembolic complications in these patients is very controversial. Case summary We describe the use of rheolytic thrombectomy in a Fontan patient with life-threatening pulmonary embolism, employing a cerebral protection system to reduce the risk of stroke through the fenestration. Discussion Rheolytic thrombectomy may be a successful alternative to systemic thrombolytic therapy and open surgical resection for the treatment of acute high-risk pulmonary embolism in the Fontan population. Embolic protection device to capture and remove thrombus/debris may be an innovative tool to reduce the risk of stroke through the fenestration while performing a percutaneous procedure in fenestrated Fontan patient.
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Affiliation(s)
| | - Alessandro Capestro
- Department of Pediatric and Congenital Cardiac Surgery and Cardiology, Azienda Ospedaliero-Universitaria—Ospedali Riuniti Ancona ‘Umberto I—G.M.Lancisi—G.Salesi’, Ancona, Italy
| | - Andi Muçaj
- Department of Cardiology, Azienda Ospedaliero-Universitaria—Ospedali Riuniti Ancona ‘Umberto I—G.M.Lancisi—G.Salesi’, Ancona, Italy
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27
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Ohsugi E, Kato R, Hosokawa Y, Oe K. Anesthetic management of cesarean hysterectomy using intra-aortic balloon occlusion in a patient with Fontan circulation and placenta increta: a case report. JA Clin Rep 2023; 9:20. [PMID: 37093334 PMCID: PMC10126174 DOI: 10.1186/s40981-023-00611-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2023] [Revised: 03/27/2023] [Accepted: 04/16/2023] [Indexed: 04/25/2023] Open
Abstract
BACKGROUND In patients with Fontan circulation, hemorrhage can cause life-threatening circulatory collapse, since Fontan circulation strongly depends on the preload. Furthermore, parturients with placenta accreta spectrum are at a high risk of rapid and massive hemorrhage. Herein, we report the case of an intra-aortic balloon occlusion used for a Fontan-palliated parturient with placenta increta with successful anesthetic management. CASE PRESENTATION A 35-year-old-female with Fontan circulation diagnosed with placenta increta underwent a cesarean hysterectomy. The main goal during anesthetic management was to maintain sufficient preload. Infrarenal intra-aortic balloon occlusion was used to reduce intraoperative hemorrhage. The hemodynamic changes caused were well tolerated in this case. CONCLUSIONS Intra-aortic balloon occlusion was used in a Fontan-palliated parturient with placenta increta with successful anesthetic management.
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Affiliation(s)
- Eriko Ohsugi
- Department of Anesthesiology, Showa University School of Medicine, 1-5-8 Hatanodai, Shinagawa-Ku, Tokyo, 142-8555, Japan.
| | - Rie Kato
- Department of Anesthesiology, Showa University School of Medicine, 1-5-8 Hatanodai, Shinagawa-Ku, Tokyo, 142-8555, Japan
| | - Yuki Hosokawa
- Department of Anesthesiology, Showa University School of Medicine, 1-5-8 Hatanodai, Shinagawa-Ku, Tokyo, 142-8555, Japan
| | - Katsunori Oe
- Department of Anesthesiology, Showa University School of Medicine, 1-5-8 Hatanodai, Shinagawa-Ku, Tokyo, 142-8555, Japan
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28
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Bigelow AM, Riggs KW, Morales DLS, Opotowsky AR, Lubert AM, Dillman JR, Veldtman GR, Heydarian HC, Trout AT, Cooper DS, Goldstein SL, Chin C, Palermo JJ, Ollberding NJ, Mays WA, Alsaied T. Isosorbide DiNitrate Effect on Hemodynamic Profile, Liver Stiffness, and Exercise Tolerance in Fontan Circulation (The NEET Clinical Trial). Pediatr Cardiol 2023:10.1007/s00246-023-03156-3. [PMID: 37084132 PMCID: PMC10119822 DOI: 10.1007/s00246-023-03156-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/04/2023] [Accepted: 03/27/2023] [Indexed: 04/22/2023]
Abstract
After Fontan operation, decreased venous capacitance and venoconstriction are adaptive mechanisms to maintain venous return and cardiac output. The consequent higher venous pressure may adversely impact end-organ function, exercise capacity and result in worse clinical outcomes. This pilot study evaluated the safety and effect of isosorbide dinitrate (ISDN), a venodilator, on exercise capacity, peripheral venous pressure (PVP), and liver stiffness in patients with Fontan circulation. In this prospective single-arm trial, 15 individuals with Fontan circulation were evaluated at baseline and after 4 weeks of therapeutic treatment with ISDN. Primary aims were to assess the safety of ISDN and the effect on maximal exercise. We also aimed to evaluate the effect of ISDN on ultrasound-assessed liver stiffness, markers of submaximal exercise, and PVP at rest and peak exercise. Repeated measures t-tests were used to assess change in variables of interest in response to ISDN. Mean age was 23.5 ± 9.2 years (range 11.2-39.0 years), and 10/15 (67%) were male. There was no statistically significant change in peak VO2 (1401 ± 428 to 1428 ± 436 mL/min, p = 0.128), but VO2 at the anaerobic threshold increased (1087 ± 313 to 1115 ± 302 mL/min, p = 0.03). ISDN was also associated with a lower peak exercise PVP (22.5 ± 4.5 to 20.6 ± 3.0 mmHg, p = 0.015). Liver stiffness was lower with ISDN, though the difference was not statistically significant (2.3 ± 0.4 to 2.1 ± 0.5 m/s, p = 0.079). Of the patients completing the trial, mild headache was common (67%), but there were no major adverse events. Treatment with ISDN for 4 weeks is well-tolerated in patients with a Fontan circulation. ISDN is associated with an increase in VO2 at anaerobic threshold, lower peak PVP, and a trend toward lower liver stiffness. Larger, longer duration studies will be necessary to define the impact of ISDN on clinical outcomes in the Fontan circulation.Clinical Trial Registration: URL: https://clinicaltrials.gov . Unique identifier: NCT04297241.
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Affiliation(s)
- Amee M Bigelow
- Department of Pediatrics, The Heart Institute, Cincinnati Children's Hospital Medical Center, University of Cincinnati College of Medicine, 3333 Burnet Drive, Cincinnati, OH, 45229, USA.
- Department of Pediatrics, The Heart Center, Nationwide Children's Hospital, The Ohio State University, 700 Children's Drive, Columbus, OH, 43205, USA.
| | - Kyle W Riggs
- Department of Pediatrics, The Heart Institute, Cincinnati Children's Hospital Medical Center, University of Cincinnati College of Medicine, 3333 Burnet Drive, Cincinnati, OH, 45229, USA
- Department of Cardiovascular and Thoracic Surgery, Northwell Health, Manhasset, NY, USA
| | - David L S Morales
- Department of Pediatrics, The Heart Institute, Cincinnati Children's Hospital Medical Center, University of Cincinnati College of Medicine, 3333 Burnet Drive, Cincinnati, OH, 45229, USA
| | - Alexander R Opotowsky
- Department of Pediatrics, The Heart Institute, Cincinnati Children's Hospital Medical Center, University of Cincinnati College of Medicine, 3333 Burnet Drive, Cincinnati, OH, 45229, USA.
| | - Adam M Lubert
- Department of Pediatrics, The Heart Institute, Cincinnati Children's Hospital Medical Center, University of Cincinnati College of Medicine, 3333 Burnet Drive, Cincinnati, OH, 45229, USA
| | - Jonathan R Dillman
- Department of Radiology, Cincinnati Children's Hospital Medical Center, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Gruschen R Veldtman
- Scottish Adult Congenital Cardiac Service and University of Glasgow, Institute of Cardiovascular Medicine and Sciences, Golden Jubilee Hospital, Glasgow, UK
| | - Haleh C Heydarian
- Department of Pediatrics, The Heart Institute, Cincinnati Children's Hospital Medical Center, University of Cincinnati College of Medicine, 3333 Burnet Drive, Cincinnati, OH, 45229, USA
| | - Andrew T Trout
- Department of Radiology, Cincinnati Children's Hospital Medical Center, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - David S Cooper
- Department of Pediatrics, The Heart Institute, Cincinnati Children's Hospital Medical Center, University of Cincinnati College of Medicine, 3333 Burnet Drive, Cincinnati, OH, 45229, USA
| | - Stuart L Goldstein
- Faculty of Medicine, Center for Acute Care Nephrology, Cincinnati Children's Hospital Medical Center, University of Cincinnati, Cincinnati, OH, USA
| | - Clifford Chin
- Department of Pediatrics, The Heart Institute, Cincinnati Children's Hospital Medical Center, University of Cincinnati College of Medicine, 3333 Burnet Drive, Cincinnati, OH, 45229, USA
| | - Joseph J Palermo
- Division of Pediatric Gastroenterology, Hepatology and Nutrition, Department of Pediatrics, University of Cincinnati, Cincinnati, OH, USA
| | - Nicholas J Ollberding
- Division of Biostatistics and Epidemiology, Department of Pediatrics, Cincinnati Children's Hospital Medical Center, University of Cincinnati, Cincinnati, OH, USA
| | - Wayne A Mays
- Department of Pediatrics, The Heart Institute, Cincinnati Children's Hospital Medical Center, University of Cincinnati College of Medicine, 3333 Burnet Drive, Cincinnati, OH, 45229, USA
| | - Tarek Alsaied
- Department of Pediatrics, The Heart Institute, Cincinnati Children's Hospital Medical Center, University of Cincinnati College of Medicine, 3333 Burnet Drive, Cincinnati, OH, 45229, USA
- Pittsburgh Children's Hospital Medical Center, The Heart and Vascular Institute, University of Pittsburgh, Pittsburgh, PA, USA
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Nederend M, Stoger JL, Egorova AD, Barge-Schaapveld DQCM, Jongbloed MRM. Genetic variant in the BRAF gene compatible with Noonan spectrum disorders in an adult Fontan patient with refractory protein losing enteropathy: a follow-up report. Eur Heart J Case Rep 2023; 7:ytad176. [PMID: 37123657 PMCID: PMC10141453 DOI: 10.1093/ehjcr/ytad176] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2022] [Revised: 03/22/2023] [Accepted: 04/04/2023] [Indexed: 05/02/2023]
Abstract
Background Patients with a univentricular heart form a morphological heterogenous group of patients at the most severe end of the congenital heart disease (CHD) spectrum. Over the past decades, more awareness and knowledge has been raised on the genetic contributions to CHD. To date, only a limited number of genes have been identified in the hypoplastic heart, mainly in left-sided hypoplasia. There is still much more to be elucidated in this field. Case summary Here, we present a follow-up report of a case of an adult patient after Fontan palliation, born with a.o. tricuspid atresia with hypoplastic right ventricle and pulmonary stenosis. This patient encountered a myriad of late sequalae involving multiple organ systems during the course of his young adult life, including refractory protein losing enteropathy (PLE). Concomitant extracardiac anomalies, in addition to the complex CHD and its complications, prompted for genetic evaluation. Whole exome sequencing showed a variant of uncertain significance in the BRAF gene [NM_004333.4:c.1897T > C p.(Tyr633His)], associated with Noonan spectrum disorders, that is also infamous for lymphoedema and PLE. The variant regards an evolutionarily highly conserved amino acid and is assumed pathogenic according to all prediction programmes. The mutation was most likely de novo. Discussion Genetic screening can provide new insights in the complex and varied phenotype of the (adult) Fontan patient and in the myriad of complications encountered. Adult CHD cardiologists should be aware of genetic syndromes underlying a CHD, concomitant extracardiac anomalies, and a complex clinical course with a broad spectrum of late sequelae.
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Affiliation(s)
- Marieke Nederend
- CAHAL, Center for Congenital Heart Disease Amsterdam Leiden, Leiden University Medical Center, Albinusdreef 2, 2333 ZA Leiden, The Netherlands
- Department of Cardiology, Leiden University Medical Center, Albinusdreef 2, 2333 ZA Leiden, The Netherlands
| | - J Lauran Stoger
- Department of Radiology, Leiden University Medical Center, Albinusdreef 2, 2333 ZA Leiden, The Netherlands
| | - Anastasia D Egorova
- CAHAL, Center for Congenital Heart Disease Amsterdam Leiden, Leiden University Medical Center, Albinusdreef 2, 2333 ZA Leiden, The Netherlands
- Department of Cardiology, Leiden University Medical Center, Albinusdreef 2, 2333 ZA Leiden, The Netherlands
| | - Daniela Q C M Barge-Schaapveld
- CAHAL, Center for Congenital Heart Disease Amsterdam Leiden, Leiden University Medical Center, Albinusdreef 2, 2333 ZA Leiden, The Netherlands
- Department of Clinical Genetics, Leiden University Medical Center, Albinusdreef 2, 2333 ZA Leiden, The Netherlands
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Tanaka Y, Sumie M, Hashimoto T, Osawa S, Karashima Y, Kandabashi T, Yamaura K. Anesthetic management of pheochromocytoma and paraganglioma for patients with Fontan circulation: a case series. JA Clin Rep 2023; 9:13. [PMID: 36897467 PMCID: PMC10006357 DOI: 10.1186/s40981-023-00605-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2023] [Revised: 03/02/2023] [Accepted: 03/03/2023] [Indexed: 03/11/2023] Open
Abstract
BACKGROUND Anesthetic management of pheochromocytoma and paraganglioma with Fontan circulation is challenging for physicians, with attention to cardiovascular physiology. CASE PRESENTATION We performed anesthetic management for pheochromocytoma and paraganglioma in three patients with Fontan circulation. We maintained intraoperative central venous pressure at preoperative level under fluid infusion and administrating nitric oxide to decrease pulmonary arterial resistance. We administered noradrenaline or vasopressin if low blood pressure was present despite adequate central venous pressure. Although noradrenaline is prevalent for the case of noradrenaline-secreting tumor especially after resection, we could maintain blood pressure to administrate vasopressin without increasing central venous pressure. Retroperitoneal laparoscopic approach which could avoid intra-abdominal adhesions might be selectable as case 3. CONCLUSIONS Sophisticated management is required for pheochromocytoma and paraganglioma with Fontan circulation.
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Affiliation(s)
- Yuto Tanaka
- Department of Anesthesiology and Critical Care Medicine, Kyushu University Hospital, 3-1-1 Maidashi, Higashi-Ku, Fukuoka, 812-8582, Japan.,Department of Anesthesia, Saiseikai Fukuoka General Hospital, 1-3-46 Tenjin, Chuo-Ku, Fukuoka, 810-0001, Japan
| | - Makoto Sumie
- Department of Anesthesiology and Critical Care Medicine, Kyushu University Hospital, 3-1-1 Maidashi, Higashi-Ku, Fukuoka, 812-8582, Japan. .,Department of Anesthesia, St. Mary's Hospital, 422 Tsubukuhonmachi, Kurume, Fukuoka, 830-8543, Japan.
| | - Takuma Hashimoto
- Department of Anesthesiology and Critical Care Medicine, Kyushu University Hospital, 3-1-1 Maidashi, Higashi-Ku, Fukuoka, 812-8582, Japan
| | - Sayaka Osawa
- Department of Critical Care, Kyushu University Hospital, 3-1-1 Maidashi, Higashi-Ku, Fukuoka, 812-8582, Japan
| | - Yuji Karashima
- Operating Rooms, Kyushu University Hospital, 3-1-1 Maidashi, Higashi-Ku, Fukuoka, 812-8582, Japan
| | - Tadashi Kandabashi
- Medical Information Center, Kyushu University Hospital, 3-1-1 Maidashi, Higashi-Ku, Fukuoka, 812-8582, Japan
| | - Ken Yamaura
- Department of Anesthesiology and Critical Care Medicine, Kyushu University Hospital, 3-1-1 Maidashi, Higashi-Ku, Fukuoka, 812-8582, Japan
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Haddad RN, Dautry R, Bonnet D, Malekzadeh-Milani S. Transvenous retrograde thoracic duct embolization for effective treatment of recurrent plastic bronchitis after fontan palliation. Catheter Cardiovasc Interv 2023; 101:863-869. [PMID: 36861752 DOI: 10.1002/ccd.30611] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/11/2022] [Revised: 01/08/2023] [Accepted: 02/21/2023] [Indexed: 03/03/2023]
Abstract
We report the case of a 5.5-year-old patient (16 kg/105 cm) who presented with plastic bronchitis (PB) refractory to conservative treatment 3 months after completion of Fontan palliation. Bi-inguinal transnodal fluoroscopy-guided lymphangiogram confirmed the chylous leak originating from the thoracic duct (TD) into the chest and did not opacify any central lymphatic vessel for direct transabdominal puncture. Retrograde transfemoral approach was adopted to catheterize the TD and selectively embolize its caudal portion using microcoils and liquid embolic adhesive. Recurrence of symptoms after 2 months indicated a redo catheterization to occlude the TD entirely using the same technique. The procedure was successful and the patient was discharged after 2 days with sustained clinical improvement at 24 months postoperative. In the context of refractory PB, end-to-end transvenous retrograde embolization of the TD appears to be an interesting alternative to more complex interventions such as transabdominal puncture, decompression, or surgical ligation of the TD.
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Affiliation(s)
- Raymond N Haddad
- M3C-Necker, Hôpital Universitaire Necker-Enfants Malades, Assistance Publique-Hôpitaux de Paris (AP-HP), Paris, France
| | - Raphael Dautry
- Department of Radiology, Hôpital Cochin, Assistance Publique-Hôpitaux de Paris (AP-HP), Paris, France
| | - Damien Bonnet
- M3C-Necker, Hôpital Universitaire Necker-Enfants Malades, Assistance Publique-Hôpitaux de Paris (AP-HP), Paris, France.,Université de Paris Cité, Paris, France
| | - Sophie Malekzadeh-Milani
- M3C-Necker, Hôpital Universitaire Necker-Enfants Malades, Assistance Publique-Hôpitaux de Paris (AP-HP), Paris, France
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Meinel K, Korak F, Dusleag M, Strini T, Baumgartner D, Burmas A, Sallmon H, Zieger B, Schlagenhauf A, Koestenberger M. Mild Acquired von Willebrand Syndrome and Cholestasis in Pediatric and Adult Patients with Fontan Circulation. J Clin Med 2023; 12. [PMID: 36769887 DOI: 10.3390/jcm12031240] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/24/2022] [Revised: 01/30/2023] [Accepted: 01/31/2023] [Indexed: 02/09/2023] Open
Abstract
Background: Hemodynamic alterations in Fontan patients (FP) are associated with hemostatic dysbalance and Fontan-associated liver disease. Studies of other hepatopathologies indicate an interplay between cholestasis, tissue factor (TF), and von Willebrand factor (VWF). Hence, we hypothesized a relationship between the accumulation of bile acids (BA) and these hemostatic factors in FP. Methods: We included 34 FP (Phenprocoumon n = 15, acetylsalicylic acid (ASA) n = 16). BA were assessed by mass spectrometry. TF activity and VWF antigen (VWF:Ag) were determined by chromogenic assays. VWF collagen-binding activity (VWF:CB) was assessed via ELISA. Results: Cholestasis was observed in 6/34 FP (total BA ≥ 10 µM). BA levels and TF activity did not correlate (p = 0.724). Cholestatic FP had lower platelet counts (p = 0.013) from which 5/6 FP were not treated with ASA. VWF:Ag levels were increased in 9/34 FP and significantly lower in FP receiving ASA (p = 0.044). Acquired von Willebrand syndrome (AVWS) was observed in 10/34-FP, with a higher incidence in cholestatic FP (4/6) (p = 0.048). Conclusions: Cholestasis is unexpectedly infrequent in FP and seems to be less frequent under ASA therapy. Therefore, ASA may reduce the risk of advanced liver fibrosis. FP should be screened for AVWS to avoid bleeding events, especially in cholestatic states.
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Taylor-LaPole AM, Colebank MJ, Weigand JD, Olufsen MS, Puelz C. A computational study of aortic reconstruction in single ventricle patients. Biomech Model Mechanobiol 2023; 22:357-77. [PMID: 36335184 DOI: 10.1007/s10237-022-01650-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2022] [Accepted: 10/12/2022] [Indexed: 11/06/2022]
Abstract
Patients with hypoplastic left heart syndrome (HLHS) are born with an underdeveloped left heart. They typically receive a sequence of surgeries that result in a single ventricle physiology called the Fontan circulation. While these patients usually survive into early adulthood, they are at risk for medical complications, partially due to their lower than normal cardiac output, which leads to insufficient cerebral and gut perfusion. While clinical imaging data can provide detailed insight into cardiovascular function within the imaged region, it is difficult to use these data for assessing deficiencies in the rest of the body and for deriving blood pressure dynamics. Data from patients used in this paper include three-dimensional, magnetic resonance angiograms (MRA), time-resolved phase contrast cardiac magnetic resonance images (4D-MRI) and sphygmomanometer blood pressure measurements. The 4D-MRI images provide detailed insight into velocity and flow in vessels within the imaged region, but they cannot predict flow in the rest of the body, nor do they provide values of blood pressure. To remedy these limitations, this study combines the MRA, 4D-MRI, and pressure data with 1D fluid dynamics models to predict hemodynamics in the major systemic arteries, including the cerebral and gut vasculature. A specific focus is placed on studying the impact of aortic reconstruction occurring during the first surgery that results in abnormal vessel morphology. To study these effects, we compare simulations for an HLHS patient with simulations for a matched control patient that has double outlet right ventricle (DORV) physiology with a native aorta. Our results show that the HLHS patient has hypertensive pressures in the brain as well as reduced flow to the gut. Wave intensity analysis suggests that the HLHS patient has irregular circulatory function during light upright exercise conditions and that predicted wall shear stresses are lower than normal, suggesting the HLHS patient may have hypertension.
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Sumie M, Kameyama N, Akasaka T, Tanaka Y, Ando T, Kandabashi T, Karashima Y, Yamaura K. Anesthetic management of hepatectomy for the patient with Fontan circulation: a case series. JA Clin Rep 2022; 8:94. [PMID: 36484931 PMCID: PMC9733739 DOI: 10.1186/s40981-022-00582-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2022] [Revised: 11/03/2022] [Accepted: 11/10/2022] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND Hepatectomy for patients with Fontan circulation consists of high central venous pressure and low pulmonary vascular resistance, and is challenging for physicians. CASE PRESENTATION We performed anesthetic management for hepatectomy in three patients with Fontan circulation. Massive bleeding and transfusion as well as careful management were needed. Open abdominal surgery had to be conducted instead of laparoscopic surgery for controlling bleeding in one case. We successfully performed general anesthesia using nitric oxide and inotropes while monitoring arterial pressure and central venous pressure in all the cases. CONCLUSIONS To maintain Fontan circulation during hepatectomy, it is important to manage central venous pressure and ensure appropriate circulatory volume.
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Affiliation(s)
- Makoto Sumie
- grid.411248.a0000 0004 0404 8415Department of Anesthesiology and Critical Care Medicine, Kyushu University Hospital, 3-1-1 Maidashi, Higashi-Ku, Fukuoka, 812-8582 Japan
| | - Nozomi Kameyama
- grid.411248.a0000 0004 0404 8415Department of Anesthesiology and Critical Care Medicine, Kyushu University Hospital, 3-1-1 Maidashi, Higashi-Ku, Fukuoka, 812-8582 Japan ,Department of Anesthesia, Takagi Hospital, 141-11 Sakemi, Okawa-Shi, Fukuoka, 831-0016 Japan
| | - Taiki Akasaka
- grid.411248.a0000 0004 0404 8415Department of Anesthesiology and Critical Care Medicine, Kyushu University Hospital, 3-1-1 Maidashi, Higashi-Ku, Fukuoka, 812-8582 Japan
| | - Yuto Tanaka
- grid.411248.a0000 0004 0404 8415Department of Anesthesiology and Critical Care Medicine, Kyushu University Hospital, 3-1-1 Maidashi, Higashi-Ku, Fukuoka, 812-8582 Japan ,grid.416599.60000 0004 1774 2406Department of Anesthesia, Saiseikai Fukuoka General Hospital, 1-3-46 Tenjin, Chuo-Ku, Fukuoka, 810-0001 Japan
| | - Taichi Ando
- grid.411248.a0000 0004 0404 8415Department of Anesthesiology and Critical Care Medicine, Kyushu University Hospital, 3-1-1 Maidashi, Higashi-Ku, Fukuoka, 812-8582 Japan
| | - Tadashi Kandabashi
- grid.411248.a0000 0004 0404 8415Medical Information Center, Kyushu University Hospital, 3-1-1 Maidashi, Higashi-Ku, Fukuoka, 812-8582 Japan
| | - Yuji Karashima
- grid.411248.a0000 0004 0404 8415Operating Rooms, Kyushu University Hospital, 3-1-1 Maidashi, Higashi-Ku, Fukuoka, 812-8582 Japan
| | - Ken Yamaura
- grid.411248.a0000 0004 0404 8415Department of Anesthesiology and Critical Care Medicine, Kyushu University Hospital, 3-1-1 Maidashi, Higashi-Ku, Fukuoka, 812-8582 Japan
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Zwischenberger JB, Breetz KA, Ballard-Croft C, Wang D. Failing Fontan cardiovascular support: Review. J Card Surg 2022; 37:5257-5261. [PMID: 36321714 PMCID: PMC9812883 DOI: 10.1111/jocs.17094] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2022] [Accepted: 09/17/2022] [Indexed: 11/06/2022]
Abstract
BACKGROUND Although all congenital heart defects (CHD) present unique challenges, univentricular CHD are especially challenging given the difficulty of passively perfusing pulmonary blood flow. Three surgical procedures are required within the first years of life, with the final completing a Fontan circulation in which the inferior vena cava is connected to the pulmonary artery and previously connected superior vena cava. This allows passive venous return to the pulmonary circulation then flow into the single ventricle for systemic circulation. METHODS Although a Fontan provides successful palliation for two to three decades, many complications can arise as pulmonary resistance must remain low to allow adequate forward flow. Eventually, the failing Fontan circulation requires temporary support as the patient awaits a heart transplant. We reviewed PubMed, Google Scholar, and U. Kentucky library for different techniques evaluated to support a failing Fontan circulation. RESULTS Multiple technologies have been developed as a bridge to transplant to decrease morbidity. Innovative types of extracorporeal membrane oxygenation, ventricular assist devices, and total artificial hearts have been attempted in laboratory settings as well as in Fontan patients with varying degrees of success. This article emphasizes the strengths and weaknesses of each technology in the context of Fontan physiology. CONCLUSION The end game for these patients remains a heart transplant. Without easy access to donors, each of the options discussed is a potential bridge to limit morbidity and mortality until a suitable donor heart becomes available.
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Affiliation(s)
| | | | | | - Dongfang Wang
- University of Kentucky, Department of Surgery, Division of Surgical Research
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36
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Voges I, Gabbert D. Reply to Van den Eyde et al. Eur J Cardiothorac Surg 2022; 62:6528952. [PMID: 35167668 DOI: 10.1093/ejcts/ezac092] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/17/2022] [Accepted: 01/28/2022] [Indexed: 01/07/2023] Open
Affiliation(s)
- Inga Voges
- Department of Congenital Heart Disease and Pediatric Cardiology, University Hospital Schleswig-Holstein, Kiel, Germany.,DZHK (German Centre for Cardiovascular Research), Partner Site Hamburg/Kiel/Lübeck, Kiel, Germany
| | - Dominik Gabbert
- Department of Congenital Heart Disease and Pediatric Cardiology, University Hospital Schleswig-Holstein, Kiel, Germany.,DZHK (German Centre for Cardiovascular Research), Partner Site Hamburg/Kiel/Lübeck, Kiel, Germany
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Van den Eynde J, Danford DA, Doshi A, Kutty S. Right ventricular dysfunction in hypoplastic left heart syndrome: superimposed effects of afterload and insulin resistance in puberty? Eur J Cardiothorac Surg 2022; 62:6528950. [PMID: 35167680 DOI: 10.1093/ejcts/ezac088] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/04/2022] [Accepted: 01/28/2022] [Indexed: 01/07/2023] Open
Affiliation(s)
- Jef Van den Eynde
- Helen B. Taussig Heart Center, The Johns Hopkins Hospital and School of Medicine, Baltimore, MD, USA.,Department of Cardiovascular Medicine, University Hospitals Leuven & Department of Cardiovascular Diseases, KU Leuven, Leuven, Belgium
| | - David A Danford
- Helen B. Taussig Heart Center, The Johns Hopkins Hospital and School of Medicine, Baltimore, MD, USA
| | - Ashish Doshi
- Helen B. Taussig Heart Center, The Johns Hopkins Hospital and School of Medicine, Baltimore, MD, USA
| | - Shelby Kutty
- Helen B. Taussig Heart Center, The Johns Hopkins Hospital and School of Medicine, Baltimore, MD, USA
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Verrall CE, Chen J, Yeh CH, Mackay MT, d'Udekem Y, Winlaw DS, Iyengar A, Ayer J, Gentles TL, Cordina R, Y-M Yang J. A diffusion MRI study of brain white matter microstructure in adolescents and adults with a Fontan circulation: Investigating associations with resting and peak exercise oxygen saturations and cognition. Neuroimage Clin 2022; 36:103151. [PMID: 35994923 DOI: 10.1016/j.nicl.2022.103151] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2022] [Revised: 08/09/2022] [Accepted: 08/10/2022] [Indexed: 12/14/2022]
Abstract
INTRODUCTION Adolescents and adults with a Fontan circulation are at risk of cognitive dysfunction; Attention and processing speed are notable areas of concern. Underlying mechanisms and brain alterations associated with worse long-term cognitive outcomes are not well determined. This study investigated brain white matter microstructure in adolescents and adults with a Fontan circulation and associations with resting and peak exercise oxygen saturations (SaO2), predicted maximal oxygen uptake during exercise (% pred VO2), and attention and processing speed. METHODS Ninety-two participants with a Fontan circulation (aged 13-49 years, ≥5 years post-Fontan completion) had diffusion MRI. Averaged tract-wise diffusion tensor imaging (DTI) metrics were generated for 34 white matter tracts of interest. Resting and peak exercise SaO2 and % pred VO2 were measured during cardiopulmonary exercise testing (CPET; N = 81). Attention and processing speed were assessed using Cogstate (N = 67 and 70, respectively). Linear regression analyses adjusted for age, sex, and intracranial volume were performed to investigate associations between i) tract-specific DTI metrics and CPET variables, and ii) tract-specific DTI metrics and attention and processing speed z-scores. RESULTS Forty-nine participants were male (53%), mean age was 23.1 years (standard deviation (SD) = 7.8 years). Mean resting and peak exercise SaO2 were 93.1% (SD = 3.6) and 90.1% (SD = 4.7), respectively. Mean attention and processing speed z-scores were -0.63 (SD = 1.07) and -0.72 (SD = 1.44), respectively. Resting SaO2 were positively associated with mean fractional anisotropy (FA) of the left corticospinal tract (CST) and right superior longitudinal fasciculus I (SLF-I) and negatively associated with mean diffusivity (MD) and radial diffusivity (RD) of the right SLF-I (p ≤ 0.01). Peak exercise SaO2 were positively associated with mean FA of the left CST and were negatively associated with mean RD of the left CST, MD of the left frontopontine tract, MD, RD and axial diffusivity (AD) of the right SLF-I, RD of the left SLF-II, MD, RD and AD of the right SLF-II, and MD and RD of the right SLF-III (p ≤ 0.01). Percent predicted VO2 was positively associated with FA of the left uncinate fasciculus (p < 0.01). Negative associations were identified between mean FA of the right arcuate fasciculus, right SLF-II and right SLF-III and processing speed (p ≤ 0.01). No significant associations were identified between DTI-based metrics and attention. CONCLUSION Chronic hypoxemia may have long-term detrimental impact on white matter microstructure in people living with a Fontan circulation. Paradoxical associations between processing speed and tract-specific DTI metrics could be suggestive of compensatory white matter remodeling. Longitudinal investigations focused on the mechanisms and trajectory of altered white matter microstructure and associated cognitive dysfunction in people with a Fontan circulation are required to better understand causal associations.
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Sagray E, Johnson JN, Schumacher KR, West S, Lowery RE, Simpson K. Protein-losing enteropathy recurrence after pediatric heart transplantation: Multicenter case series. Pediatr Transplant 2022; 26:e14295. [PMID: 35451219 DOI: 10.1111/petr.14295] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/13/2022] [Revised: 04/03/2022] [Accepted: 04/09/2022] [Indexed: 11/28/2022]
Abstract
BACKGROUND Protein-losing enteropathy (PLE) is a devastating complication of the Fontan circulation. Although orthotopic heart transplantation (HTx) typically results in resolution of PLE symptoms, isolated cases of PLE relapse have been described after HTx. METHODS Patients with Fontan-related PLE who had undergone HTx at participating centers and experienced relapse of PLE during follow-up were retrospectively identified. Available data related to pre- and post-HTx characteristics and PLE events were collected. RESULTS Eight patients from four different centers were identified. Median time from Fontan procedure to the development of PLE was 8 years, and median age at HTx was 17 years (range 7.7-21). In all patients, PLE resolved at a median time of 1 month after HTx (0.3-5). PLE recurrences occurred at a median time of 7.5 months after HTx (2-132). Each occurrence was associated with one or more significant clinical events; most commonly cellular- or antibody-mediated rejection; and less commonly graft dysfunction, infection, thrombosis, and posttransplant lymphoproliferative disease. PLE recurrences resolved after the successful treatment of the concomitant event, after a median time of 2 months in seven cases, while persisted and recurred in one patient in association with atypical mycobacterium infection and subsequent PTLD onset and relapses. Six patients were alive during follow-up at a median time of 4 years (1.3-22.5) after HTx. CONCLUSIONS This is the largest series of PLE recurrence after HTx. All cases were associated with one or more concomitant and significant clinical events. PLE typically resolved after resolution of the inciting clinical event.
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Affiliation(s)
- Ezequiel Sagray
- Division of Pediatric Cardiology, Department of Pediatric and Adolescent Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Jonathan N Johnson
- Division of Pediatric Cardiology, Department of Pediatric and Adolescent Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Kurt R Schumacher
- Division of Pediatric Cardiology, Department of Pediatrics, University of Michigan, Ann Arbor, Michigan, USA
| | - Shawn West
- Pediatric Cardiology, Children's Hospital of Pittsburgh, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Ray E Lowery
- Division of Pediatric Cardiology, Department of Pediatrics, University of Michigan, Ann Arbor, Michigan, USA
| | - Kathleen Simpson
- Division of Cardiology, Department of Pediatrics, Children's Hospital of Colorado, University of Colorado Denver, Aurora, Colorado, USA
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Nakae K, Ueno K, Shiokawa N, Takahashi Y, Kawamura J, Hazeki D, Imoto Y, Kawano Y. Pediatric Patients Undergoing a Fontan Operation or with a High RACHS-1 Score Require Monitoring for Chronic Kidney Disease in Early Childhood. Pediatr Cardiol 2022; 43:1020-1028. [PMID: 35028678 DOI: 10.1007/s00246-022-02817-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/19/2021] [Accepted: 01/06/2022] [Indexed: 11/25/2022]
Abstract
Although the number of pediatric patients with long-term survival following cardiac surgery is increasing, concerns regarding chronic kidney disease (CKD) after surgery are growing. We examined the frequency of and risk factors for pediatric CKD development in patients with congenital heart disease (CHD) at least 2 years after cardiac surgery. This was a cross-sectional study of 147 patients who underwent open-heart surgery for CHD at Kagoshima University Hospital from April 2010 to March 2017. Data on demographics, acute kidney injury after cardiac surgery, cyanotic heart disease, Fontan circulation, medications in the perioperative period, and Risk Adjustment for Congenital Heart Surgery-1 (RACHS-1) category were recorded. CKD was defined using the current classification system described in the National Kidney Foundation's Kidney Disease Outcomes Quality Initiative and assessed during early childhood within 2-3 years of cardiac surgery. Statistical analyses were performed using SPSS Statistics for Windows version 25.0. We consecutively enrolled 147 patients, of whom 22 (15.0%) had CKD, all with stage-2 severity. Among patients with CKD, a higher proportion underwent Fontan surgery (P < 0.001), a higher proportion had cyanotic heart disease (P = 0.009), and the RACHS-1 category was high (P = 0.003). Patients with CKD appeared more frequently than patients without CKD in RACHS-1 categories 3, 5, and 6. It is essential to evaluate renal function longitudinally and monitor for CKD, given that patients who underwent Fontan surgery or complicated surgery in infancy have a high rate of developing postoperative CKD in early childhood.
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Affiliation(s)
- Koji Nakae
- Department of Pediatrics, Kagoshima University Graduate School of Medical and Dental Sciences, 8-35-1 Sakuragaoka, Kagoshima, 890-8520, Japan.
| | - Kentaro Ueno
- Department of Pediatrics, Kagoshima University Graduate School of Medical and Dental Sciences, 8-35-1 Sakuragaoka, Kagoshima, 890-8520, Japan
| | - Naohiro Shiokawa
- Department of Pediatrics, Kagoshima University Graduate School of Medical and Dental Sciences, 8-35-1 Sakuragaoka, Kagoshima, 890-8520, Japan
| | - Yoshihiro Takahashi
- Department of Pediatrics, Kagoshima University Graduate School of Medical and Dental Sciences, 8-35-1 Sakuragaoka, Kagoshima, 890-8520, Japan
| | - Junpei Kawamura
- Department of Pediatrics, Kagoshima University Graduate School of Medical and Dental Sciences, 8-35-1 Sakuragaoka, Kagoshima, 890-8520, Japan
| | - Daisuke Hazeki
- Department of Pediatrics, Kagoshima University Graduate School of Medical and Dental Sciences, 8-35-1 Sakuragaoka, Kagoshima, 890-8520, Japan
| | - Yutaka Imoto
- Department of Cardiovascular and Gastroenterological Surgery, Kagoshima University Graduate School of Medical and Dental Sciences, Kagoshima, Japan
| | - Yoshifumi Kawano
- Department of Pediatrics, Kagoshima University Graduate School of Medical and Dental Sciences, 8-35-1 Sakuragaoka, Kagoshima, 890-8520, Japan
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Grosch IB, Andresen B, Diep LM, Diseth TH, Möller T. Quality of life and emotional vulnerability in a national cohort of adolescents living with Fontan circulation. Cardiol Young 2022; 32:874-82. [PMID: 34387177 DOI: 10.1017/S1047951121003188] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
INTRODUCTION To investigate quality of life and mental health after Fontan completion, we aimed to characterise outcomes in a representative group of adolescent patients. The study was part of the pre-transition clinical work-up in adolescents with Fontan-type palliation of univentricular CHD. The programme covers the entire paediatric Fontan patient population in Norway. METHODS Our cross-sectional study included 42 adolescents with Fontan circulation aged 15-18. We recruited a control group of 29 healthy peers. Quality of life was measured by the Pediatric Quality of Life Inventory Questionnaire, while mental health was assessed with the Strength and Difficulties Questionnaire. RESULTS Fontan patients scored lower than healthy controls on the Pediatric Quality of Life Inventory total (p = 0.004), the physical (p < 0.001) and social (p = 0.001) functioning subscale, and the Strength and Difficulties Questionnaire subscale of emotional symptoms (p = 0.035). Compared to two of the healthy teens (7%), seven patients (16%) in the Fontan group scored as having impaired mental health (p = 0.224). The female/male ratio for individuals with impaired health was 7:2 (p = 0.003). CONCLUSIONS Compared to healthy controls, adolescents after Fontan-type palliation in Norway have good health-related quality of life and mental health, despite having slightly lower score than healthy individuals, mainly in physical domains and school functioning. Compared to healthy controls and healthy teenagers, these adolescents have somewhat more emotional problems, and compared to male patients, female patients more often have impaired mental health.
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Hansson L, Sandberg C, Öhlund I, Lind T, Sthen Bergdahl M, Wiklund U, Rylander Hedlund E, Sjöberg G, Rydberg A. Vitamin D, liver-related biomarkers, and distribution of fat and lean mass in young patients with Fontan circulation. Cardiol Young 2022; 32:861-8. [PMID: 34338624 DOI: 10.1017/S1047951121003115] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
INTRODUCTION/AIM Young patients with Fontan circulation may have low serum 25-hydroxyvitamin D levels, an affected liver, and unhealthy body compositions. This study aimed to explore the association between vitamin D intake/levels, liver biomarkers, and body composition in young Fontan patients. METHOD We collected prospective data in 2017 to 2018, obtained with food-frequency questionnaires, biochemical analyses of liver biomarkers, and dual-energy X-ray absorptiometry scans in 44 children with Fontan circulation. Body compositions were compared to matched controls (n = 38). Linear regression analyses were used to investigate associations of biomarkers, leg pain, and lean mass on serum levels of 25-hydroxyvitamin D. Biomarkers were converted to z scores and differences were evaluated within the Fontan patients. RESULTS Our Fontan patients had a daily mean vitamin D intake of 9.9 µg and a mean serum 25-hydroxyvitamin D of 56 nmol/L. These factors were not associated with fat or lean mass, leg pain, or biomarkers of liver status. The Fontan patients had significantly less lean mass, but higher fat mass than controls. Male adolescents with Fontan circulation had a greater mean abdominal fat mass than male controls and higher cholesterol levels than females with Fontan circulation. CONCLUSION Vitamin D intake and serum levels were not associated with body composition or liver biomarkers in the Fontan group, but the Fontan group had lower lean mass and higher fat mass than controls. The more pronounced abdominal fat mass in male adolescents with Fontan circulation might increase metabolic risks later in life.
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Hara M, Hyodo A, Kimura H, Hiraki T. Transfenestration Doppler Assessment During Laparoscopic Pheochromocytoma Resection in a Patient With Fontan Circulation. J Cardiothorac Vasc Anesth 2022; 36:3655-3661. [PMID: 35659830 DOI: 10.1053/j.jvca.2022.04.046] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/09/2022] [Revised: 04/27/2022] [Accepted: 04/29/2022] [Indexed: 11/11/2022]
Affiliation(s)
- Masato Hara
- Department of Anesthesiology, Kurume University School of Medicine, Fukuoka, Japan.
| | - Ayako Hyodo
- Department of Anesthesiology, Kurume University School of Medicine, Fukuoka, Japan
| | - Hiroko Kimura
- Department of Anesthesiology, Kurume University School of Medicine, Fukuoka, Japan
| | - Teruyuki Hiraki
- Department of Anesthesiology, Kurume University School of Medicine, Fukuoka, Japan
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Kanngiesser LM, Freitag-Wolf S, Boroni Grazioli S, Gabbert DD, Hansen JH, Uebing AS, Voges I. Serial Assessment of Right Ventricular Deformation in Patients With Hypoplastic Left Heart Syndrome: A Cardiovascular Magnetic Resonance Feature Tracking Study. J Am Heart Assoc 2022; 11:e025332. [PMID: 35475354 PMCID: PMC9238584 DOI: 10.1161/jaha.122.025332] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background As right ventricular dysfunction is a major cause of adverse outcome in patients with hypoplastic left heart syndrome, the aim was to assess right ventricular function and deformation after Fontan completion by performing 2-dimensional cardiovascular magnetic resonance feature tracking in serial cardiovascular magnetic resonance studies. Methods and Results Cardiovascular magnetic resonance examinations of 108 patients with hypoplastic left heart syndrome (female: 31) were analyzed. Short-axis cine images were used for right ventricular volumetry. Two-dimensional cardiovascular magnetic resonance feature tracking was performed using long-axis and short-axis cine images to measure myocardial global longitudinal, circumferential, and radial strain. All patients had at least 2 cardiovascular magnetic resonance examinations after Fontan completion and 41 patients had 3 examinations. Global strain values and right ventricular ejection fraction decreased from the first to the third examination with a significant decline in global longitudinal strain from the first examination to the second examination (median, first, and third quartile: -18.8%, [-20.5;-16.5] versus -16.9%, [-19.3;-14.7]) and from the first to the third examination in 41 patients (-18.6%, [-20.9;-15.7] versus -15.8%, [-18.7;-12.6]; P-values <0.004). Right ventricular ejection fraction decreased significantly from the first to the third examination (55.4%, [49.8;59.3] versus 50.2%, [45.0;55.9]; P<0.002) and from the second to the third examination (53.8%, [47.2;58.7] versus 50.2%, [45.0;55.9]; P<0.0002). Conclusions Serial assessment of cardiovascular magnetic resonance studies in patients with hypoplastic left heart syndrome after Fontan completion demonstrates a significant reduction in global strain values and right ventricular ejection fraction at follow-up. The significant reduction in global longitudinal strain between the first 2 examinations with non-significant changes in right ventricular ejection fraction suggest that global longitudinal strain measured by 2-dimensional cardiovascular magnetic resonance feature tracking might be a superior technique for the detection of changes in myocardial function.
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Affiliation(s)
- Luca Mitch Kanngiesser
- Department of Congenital Heart Disease and Pediatric Cardiology University Hospital Schleswig-Holstein Kiel Germany
| | - Sandra Freitag-Wolf
- Institute of Medical Informatics and StatisticsKiel UniversityUniversity Hospital Schleswig-Holstein Kiel Germany
| | - Simona Boroni Grazioli
- Department of Congenital Heart Disease and Pediatric Cardiology University Hospital Schleswig-Holstein Kiel Germany
| | - Dominik Daniel Gabbert
- Department of Congenital Heart Disease and Pediatric Cardiology University Hospital Schleswig-Holstein Kiel Germany.,DZHK (German Centre for Cardiovascular Research)Partner Site Hamburg/Kiel/Lübeck Kiel Germany
| | - Jan Hinnerk Hansen
- Department of Congenital Heart Disease and Pediatric Cardiology University Hospital Schleswig-Holstein Kiel Germany.,DZHK (German Centre for Cardiovascular Research)Partner Site Hamburg/Kiel/Lübeck Kiel Germany
| | - Anselm Sebastian Uebing
- Department of Congenital Heart Disease and Pediatric Cardiology University Hospital Schleswig-Holstein Kiel Germany.,DZHK (German Centre for Cardiovascular Research)Partner Site Hamburg/Kiel/Lübeck Kiel Germany
| | - Inga Voges
- Department of Congenital Heart Disease and Pediatric Cardiology University Hospital Schleswig-Holstein Kiel Germany.,DZHK (German Centre for Cardiovascular Research)Partner Site Hamburg/Kiel/Lübeck Kiel Germany
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Abstract
PURPOSE OF REVIEW Establishing the Fontan circulation has led to improved survival in patients born with complex congenital heart diseases. Despite early success, the long-term course of Fontan patients is complicated by multi-organ dysfunction, mainly due to a combination of low resting and blunted exercise-augmented cardiac output as well as elevated central venous (Fontan) pressure. Similarly, despite absolute hemodynamic differences compared to the normal population with biventricular circulation, the "normal" ranges of hemodynamic parameters specific to age-appropriate Fontan circulation have not been well defined. With the ever-increasing population of patients requiring Fontan correction, it is of utmost importance that an acceptable range of hemodynamics in this highly complex patient cohort is better defined. RECENT FINDINGS Multiple publications have described hemodynamic limitations and potential management options in patients with Fontan circulation; however, an acceptable range of hemodynamic parameters in this patient population has not been well defined. Identification of "normal" hemodynamic parameters among patients with Fontan circulation will allow physicians to more objectively define indications for intervention, which is a necessary first step to eliminate institutional and regional heterogeneity in Fontan management and potentially improve long-term clinical outcomes.
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Latus H, Hofmann L, Gummel K, Khalil M, Yerebakan C, Waschulzik B, Schranz D, Voges I, Jux C, Reich B. Exercise-dependent changes in ventricular-arterial coupling and aortopulmonary collateral flow in Fontan patients: a real-time CMR study. Eur Heart J Cardiovasc Imaging 2022; 24:88-97. [PMID: 35045176 PMCID: PMC9762934 DOI: 10.1093/ehjci/jeac001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/27/2021] [Accepted: 01/07/2022] [Indexed: 12/24/2022] Open
Abstract
AIMS Inefficient ventricular-arterial (V-A) coupling has been described in Fontan patients and may result in adverse haemodynamics. A varying amount of aortopulmonary collateral (APC) flow is also frequently present that increases volume load of the single ventricle. The aim of the study was to assess changes in V-A coupling and APC flow during exercise CMR. METHODS AND RESULTS Eighteen Fontan patients (age 24 ± 3 years) and 14 controls (age 23 ± 4 years) underwent exercise CMR using a cycle ergometer. Ventricular volumetry and flow measurements in the ascending aorta (AAO), inferior (IVC), and superior (SVC) vena cava were assessed using real-time sequences during stepwise increases in work load. Measures of systemic arterial elastance Ea, ventricular elastance Ees, and V-A coupling (Ea/Ees) were assessed. APC flow was quantified as AAO - (SVC + IVC). Ea remained unchanged during all levels of exercise in both groups (P = 0.39 and P = 0.11). Ees increased in both groups (P = 0.001 and P < 0.001) with exercise but was lower in the Fontan group (P = 0.04). V-A coupling was impaired in Fontan patients at baseline (P = 0.04). Despite improvement during exercise (P = 0.002) V-A coupling remained impaired compared with controls (P = 0.001). Absolute APC flow in Fontan patients did not change during exercise even at maximum work load (P = 0.98). CONCLUSIONS Inefficient V-A coupling was already present at rest in Fontan patients and aggravated during exercise due to a limited increase in ventricular contractility which demonstrates the importance of a limited functional reserve of the single ventricle. APC flow remained unchanged suggesting no further increase in volume load during exercise.
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Affiliation(s)
- Heiner Latus
- Corresponding author. Tel: +49 89 1218 3011; Fax: +49 89 1218 3013. E-mail: ;
| | - Lucas Hofmann
- Pediatric Heart Center, Justus-Liebig University Hospital Giessen, Feulgenstr 10-12, 35385 Giessen, Germany
| | - Kerstin Gummel
- Pediatric Heart Center, Justus-Liebig University Hospital Giessen, Feulgenstr 10-12, 35385 Giessen, Germany
| | - Markus Khalil
- Pediatric Heart Center, Justus-Liebig University Hospital Giessen, Feulgenstr 10-12, 35385 Giessen, Germany
| | - Can Yerebakan
- Department of Cardiovascular Surgery, Children's National Hospital, Children's National Heart Institute, The George WashingtonUniversity School of Medicine and Health Sciences, 111 Michigan Ave NW, Washington, DC 20010, USA
| | - Birgit Waschulzik
- Institute for AI and Informatics Medicine, Technical University Munich, Ismaninger Str. 22, 81675 Munich, Germany
| | - Dietmar Schranz
- Pediatric Heart Center, Justus-Liebig University Hospital Giessen, Feulgenstr 10-12, 35385 Giessen, Germany
| | - Inga Voges
- Pediatric Heart Center, Justus-Liebig University Hospital Giessen, Feulgenstr 10-12, 35385 Giessen, Germany,Department of Congenital Heart Disease and Pediatric Cardiology, University Hospital Schleswig-Holstein, Arnold-Heller-Str 3, 24105 Kiel, Germany,DZHK (German Centre for Cardiovascular Research), Partner Site Hamburg/Kiel/Lübeck, Kiel, Germany
| | - Christian Jux
- Pediatric Heart Center, Justus-Liebig University Hospital Giessen, Feulgenstr 10-12, 35385 Giessen, Germany
| | - Bettina Reich
- Department of Pediatric Cardiology and Congenital Heart Disease, German Heart Centre, Technical University Munich, Lazarettstr. 36, 80636 Munich, Germany,Pediatric Heart Center, Justus-Liebig University Hospital Giessen, Feulgenstr 10-12, 35385 Giessen, Germany
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47
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Greenleaf CE, Lim ZN, Li W, LaPar DJ, Salazar JD, Corno AF. Impact on clinical outcomes from transcatheter closure of the Fontan fenestration: A systematic review and meta-analysis. Front Pediatr 2022; 10:915045. [PMID: 36268038 PMCID: PMC9576841 DOI: 10.3389/fped.2022.915045] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/07/2022] [Accepted: 08/26/2022] [Indexed: 11/25/2022] Open
Abstract
BACKGROUND Meta-analysis of the impact on clinical outcome from transcatheter closure of Fontan fenestration. METHODS Cochrane, Embase, MEDLINE, and Open-Gray were searched. Parameters such as changes in oxygen saturation, cavo-pulmonary pressure, maximum heart rate during exercise, exercise duration, and oxygen saturation after fenestration closure were pooled and statistical analysis performed. RESULTS Among 922 publications, 12 retrospective observational studies were included. The included studies involved 610 patients, of which 552 patients (90.5%) had a fenestration. Of those patients, 505 patients (91.5%) underwent attempt at trans-catheter closure. When it could be estimated, the pooled overall mean age at trans-catheter fenestration closure was 6.6 ± 7.4 years, and the mean follow-up time was 34.4 ± 10.7 months. There were 32 minor (6.3%) and 20 major (4.0%) complications during or after trans-catheter Fontan fenestration closure. The forest plots demonstrate that following fenestration closure, there was a significant increase in the mean arterial oxygen saturation of 7.9% (95% CI 6.4-9.4%, p < 0.01). There was also a significant increase in the mean cavo-pulmonary pressure of 1.4 mmHg (95% CI 1.0-1.8 mmHg, p < 0.01) following fenestration closure. The exercise parameters reported in 3 studies also favored closing the fenestration as well, yet the exercise duration increase of 1.7 min (95% CI 0.7-2.8 min, p < 0.01) after fenestration closure is probably clinically insignificant. CONCLUSION Late closure of a Fontan fenestration has the impact of improving resting oxygen saturation, exercise oxygen saturation, and a modest improvement of exercise duration. These clinical benefits, however, may be at the expense of tolerating slightly higher cavo-pulmonary mean pressures.
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Affiliation(s)
- Christopher E Greenleaf
- Pediatric and Congenital Cardiac Surgery, Children's Heart Institute, Memorial Hermann Children's Hospital, UTHealth, McGovern Medical School, Houston, TX, United States
| | - Zhia Ning Lim
- University College of London (UCL) Great Ormond Street Institute of Child Health, University College London, London, United Kingdom
| | - Wen Li
- Division of Clinical and Translational Sciences, Department of Internal Medicine, UTHealth, McGovern Medical School, Houston, TX, United States
| | - Damien J LaPar
- Pediatric and Congenital Cardiac Surgery, Children's Heart Institute, Memorial Hermann Children's Hospital, UTHealth, McGovern Medical School, Houston, TX, United States
| | - Jorge D Salazar
- Pediatric and Congenital Cardiac Surgery, Children's Heart Institute, Memorial Hermann Children's Hospital, UTHealth, McGovern Medical School, Houston, TX, United States
| | - Antonio F Corno
- Pediatric and Congenital Cardiac Surgery, Children's Heart Institute, Memorial Hermann Children's Hospital, UTHealth, McGovern Medical School, Houston, TX, United States
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Pyykkönen H, Rahkonen O, Ratia N, Lähteenmäki S, Tikkanen H, Piirilä P, Pitkänen-Argillander O. Exercise Prescription Enhances Maximal Oxygen Uptake and Anaerobic Threshold in Young Single Ventricle Patients with Fontan Circulation. Pediatr Cardiol 2022; 43:969-76. [PMID: 35106621 DOI: 10.1007/s00246-021-02806-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/03/2021] [Accepted: 12/17/2021] [Indexed: 11/08/2022]
Abstract
A modified Fontan procedure is performed to palliate single ventricle malformations. This hemodynamic arrangement sets systemic venous pressure unphysiologically high which predisposes the patient to severe long-term complications. As a means of self-care, exercise may ease transpulmonary flow. We investigated the effects of 6-month exercise prescription on pediatric Fontan patients. Eighteen stable Fontan patients (14 ± 2.6 years, 160.4 ± 11.3 cm, and 51.4 ± 14.4 kg) were recruited. Baseline fitness was assessed by physical activity questionnaire, body composition, cardiorespiratory performance, and muscle fitness tests. Exercise prescription was individually tailored for a 6-month training period at home. At entrance to the study, Fontan patients had lower than normal maximal oxygen uptake (VO2max) of 28. ± 5.9 ml/kg/min (61 ± 11% of normal). VO2max significantly correlated with weekly amount of habitual exercise and muscle mass of the lower limbs (p < 0.001 for both). After 6 months of training, the patients had improved their anaerobic threshold of 18 ± 3.5 vs 20 ± 4.8 ml/kg/min, p = 0.007, and workload tolerance of 119 ± 39 vs 132.4 ± 44 W, p = 0.001. At EUROFIT tests, the patient muscle fitness was below age-matched reference, but correlations existed between VO2max and lower limb muscle tests. Our patients with Fontan hemodynamics were able to positively respond to an exercise program by enhancing submaximal performance which should be beneficial for getting through daily activities. Future studies should correlate whether hemodynamic findings at Fontan completion influence physical activity and exercise reserves, and whether these predict predisposition to chronic complications.
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Hedlund E, Lundell B. Fontan circulation has improved life expectancy for infants born with complex heart disease over the last 50 years but has also resulted in significant morbidity. Acta Paediatr 2022; 111:11-16. [PMID: 34235784 DOI: 10.1111/apa.16023] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/22/2021] [Revised: 06/22/2021] [Accepted: 07/06/2021] [Indexed: 12/17/2022]
Abstract
The prognosis for infants born with complex heart disease improved dramatically with the introduction of the Fontan circulation 50 years ago. With today's carefully designed and staged operations to a Fontan circulation, life expectancy has increased and most children will survive into adult life. The Fontan circulation entails an unphysiological circulation with high risk for multiple organ system dysfunction. Neurodevelopmental disabilities with adverse psychosocial effects are prevalent. The Fontan circulation may eventually fail and necessitate heart transplantation. CONCLUSION: Fifty years development of the Fontan circulation to today's staged surgical procedures has improved survival but also revealed the burden of a high morbidity for a growing number of patients.
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Affiliation(s)
- Eva Hedlund
- Department of Women's and Children's Health Karolinska Institutet Stockholm Sweden
| | - Bo Lundell
- Department of Women's and Children's Health Karolinska Institutet Stockholm Sweden
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50
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Rychik J, Goldberg DJ, Rand E, Mancilla EE, Heimall J, Seivert N, Campbell D, O'Malley S, Dodds KM. A Path FORWARD: Development of a Comprehensive Multidisciplinary Clinic to Create Health and Wellness for the Child and Adolescent with a Fontan Circulation. Pediatr Cardiol 2022; 43:1175-1192. [PMID: 35604474 PMCID: PMC9125546 DOI: 10.1007/s00246-022-02930-z] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/22/2022] [Accepted: 04/28/2022] [Indexed: 12/19/2022]
Abstract
Today, it is anticipated most individuals diagnosed with single-ventricle malformation will survive surgical reconstruction through a successful Fontan operation. As greater numbers of patients survive, so has the recognition that individuals with Fontan circulation face a variety of challenges. The goal of a normal quality and duration of life will not be reached by all. The hurdles fall into a variety of domains. From a cardiovascular perspective, the Fontan circulation is fundamentally flawed by its inherent nature of creating a state of chronically elevated venous pressure and congestion, accompanied by a relatively low cardiac output. Ventricular dysfunction, atrioventricular valve regurgitation, and arrhythmia may directly impact cardiac performance and can progress with time. Problems are not limited to the cardiovascular system. Fontan circulatory physiology impacts a multitude of biological processes and health parameters outside the heart. The lymphatic circulation is under strain manifesting as variable degrees of protein-rich lymph loss and immune system dysregulation. Organ system dysfunction develops through altered perfusion profiles. Liver fibrosis is ubiquitous, and a process of systemic fibrogenesis in response to circulatory stressors may affect other organs as well. Somatic growth and development can be delayed. Behavioral and mental health problems are common, presenting as clinically important levels of anxiety and depression. Most striking is the high variability in prevalence and magnitude of these complications within the population, indicating the likelihood of additional factors enhancing or mitigating their emergence. We propose that optimal care for the individual with single ventricle and a Fontan circulation is ideally offered in a comprehensive multidisciplinary manner, with attention to elements that are beyond cardiac management alone. In this report, we share the concepts, our experiences, and perspectives on development of a clinic model-the "Fontan rehabilitation, wellness and resilience development" or FORWARD program. We provide insights into the mechanics of our multidisciplinary model of care and the benefits offered serving our growing population of individuals with a Fontan circulation and their families.
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Affiliation(s)
- Jack Rychik
- Division of Cardiology, Children's Hospital of Philadelphia, Philadelphia, USA.
- Department of Pediatrics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, USA.
- Fontan FORWARD Program, Cardiac Center at the Children's Hospital of Philadelphia, 3401 Civic Center Boulevard, Philadelphia, PA, 19104, USA.
| | - David J Goldberg
- Division of Cardiology, Children's Hospital of Philadelphia, Philadelphia, USA
- Department of Pediatrics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, USA
| | - Elizabeth Rand
- Division of Gastroenterology, Hepatology and Nutrition, Children's Hospital of Philadelphia, Philadelphia, USA
- Department of Pediatrics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, USA
| | - Edna E Mancilla
- Division of Endocrinology and Diabetes, Children's Hospital of Philadelphia, Philadelphia, USA
- Department of Pediatrics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, USA
| | - Jennifer Heimall
- Division of Allergy and Immunology, Children's Hospital of Philadelphia, Philadelphia, USA
- Department of Pediatrics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, USA
| | - Nicholas Seivert
- Department of Child and Adolescent Psychiatry, and Behavioral Sciences, Children's Hospital of Philadelphia, Philadelphia, USA
- Department of Psychiatry, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, USA
| | - Danielle Campbell
- Clinical Nutrition, Children's Hospital of Philadelphia, Philadelphia, USA
| | - Shannon O'Malley
- Division of Cardiology, Children's Hospital of Philadelphia, Philadelphia, USA
| | - Kathryn M Dodds
- Division of Cardiology, Children's Hospital of Philadelphia, Philadelphia, USA
- Department of Nursing at the University of Pennsylvania, Philadelphia, USA
- Fontan FORWARD Program, Cardiac Center at the Children's Hospital of Philadelphia, 3401 Civic Center Boulevard, Philadelphia, PA, 19104, USA
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