Third trimester predictors of interventional timing and accuracy of fetal anticipatory guidance in tetralogy of Fallot: A multi-center study

OBJECTIVE

The objective was to evaluate and improve accuracy of anticipatory counseling regarding neonatal intervention for prenatally diagnosed tetralogy of Fallot (TOF) by assessing new and previously published predictors of neonatal intervention.

METHODS

This is a multi-center, retrospective study from three centers of 112 fetal TOF patients undergoing third trimester fetal echocardiograms from 2004 to 2017. Additional cardiac defects requiring neonatal intervention were excluded. Fetal echocardiographic, clinical, and consultation data were compared between neonatal and late intervention. Optimal echocardiographic values were determined.

RESULTS

Twenty-six infants (23%) required neonatal intervention. Those infants had significantly different pulmonary valve (PV) z-scores, PV:aortic valve (AoV) ratios, PV:AoV z-score differences (absolute difference between z-scores), and increased likelihood of abnormal ductal flow. Counseling during fetal echocardiogram regarding interventional timing was accurate for 50% needing neonatal intervention and 86% undergoing late intervention (P = .002). The best neonatal intervention predictors were PV:AoV ratio of <0.6 and counseling for neonatal intervention. PV:AoV z-score difference ≥5 provided 89% negative predictive value for excluding patients from neonatal repair.

CONCLUSIONS

Third trimester fetal echocardiograms can predict interventional timing. The best predictors of neonatal intervention are PV:AoV ratio <0.6, PV:AoV z-score difference ≥5, and cardiologist counseling that neonatal intervention was likely.

Biomarkers of fibrosis and portal hypertension in Fontan-associated liver disease in children and adults

BACKGROUND

Fontan-associated liver disease (FALD) refers to structural and functional changes of the liver caused by the physiology of the Fontan palliation. Currently, liver biopsy is the gold standard to assess liver fibrosis of FALD.

AIM

Investigate biomarkers correlating with severity of liver biopsy fibrosis in FALD.

METHODS

A retrospective study of post-Fontan patients ≥ 10 years of age who underwent liver biopsy was conducted. Advanced liver disease (ALD) was defined as bridging fibrosis and/or cirrhosis on liver biopsy. AST-to-platelet ratio index (APRI), Fibrosis-4 (FIB-4) and Liver Stiffness Measurement (LSM) from FibroScan were used as non-invasive fibrosis scores.

RESULTS

Sixty-six patients (26/47; 55.3% adults and 13/19 children; 68.4%) had ALD on biopsy. ALD was associated with lower platelet count (151 vs. 198 K/uL, p = 0.003), higher APRI (0.64 vs. 0.32, p = 0.01), higher FIB-4 (0.64 vs. 0.32, p = 0.02). Liver fibrosis score correlated with APRI (0.34, p = 0.02) and FIB-4 (0.47, p = 0.001) in adults. LSM had a high sensitivity at 81.3% with 45.5% specificity at a cut-off 18.5 kPa.

CONCLUSIONS

APRI and FIB-4 had modest discrimination to identify adults with advanced liver disease, but not children, indicating that these values may be followed as a marker of FALD progression in older patients.

Conduit Size, Branch Pulmonary Artery Size, and Reoperation in Patients With Truncus Arteriosus

BACKGROUND

Optimal right ventricle-to-pulmonary artery (RV-PA) conduit size for patients with truncus arteriosus is controversial. We aimed to determine the relationship between branch PA size and the need for conduit reoperation following repair of truncus arteriosus.

METHODS

We performed a single-center chart review of patients who underwent truncus arteriosus repair from January 2009 to December 2023. Branch PAs were measured in systole, at the narrowest point if focal stenosis was present. For branch PA diameter analyses, the smaller diameter PA was used. Univariate Cox proportional hazards regression analysis was performed to determine hazard ratios (HRs) with 95% confidence intervals (CIs) for echocardiographic measures and conduit reoperation.

RESULTS

We included 33 patients. Median age at surgery was 23 days (range: 3--34). Thirty-two patients received a bovine jugular vein graft, one patient received an aortic homograft. Mean RV-PA conduit Z-score was 2.7 ± 0.5 and mean preoperative conduit-to-PA ratio 2.6 ± 0.6. Postoperative diameter of at least one branch PA was decreased in 31 patients (93.9%); mean change was -19% ± 17%. Mean postoperative conduit-to-PA ratio was 3.3 ± 0.9. Conduit reoperation occurred in 19 patients (58%); median time to reoperation was 1.6 years (range: 0.4-10.4). Conduit reoperation was not associated with conduit diameter or Z-score. Conduit reoperation was significantly associated with truncus type A2 or A3 PA anatomy (HR: 3.53; 95%CI: 1.14-10.94) and conduit-to-PA ratio ≥ 4 (HR: 4.94; 95%CI: 1.63-14.97).

CONCLUSION

In a single-center cohort of children who underwent repair of truncus arteriosus, RV-PA conduit diameter was not associated with increased conduit longevity. Rather, larger postoperative RV-PA conduit to branch PA diameter ratio was significantly associated with greater hazard for conduit reoperation.

Deep Sedation in Pediatric Patients With Single Ventricle Physiology Outside of the Operating Room

Background: Advancements in palliative surgery of patients with single ventricle physiology have led to an increase in the need for deep sedation protocols for painful procedures. However, positive pressure ventilation during anesthesia can result in unfavorable cardiopulmonary interactions. This patient population may benefit from sedation from these painful procedures. Methods: This study aims to demonstrate the safety and efficacy of deep sedation by pediatric intensivists outside the operating room for children with single ventricle physiology. This is a single-center, retrospective chart review on consecutive pediatric patients with single ventricle physiology who received deep sedation performed by pediatric intensivists between 2013 and 2020. Results: Thirty-three sedations were performed on 27 unique patients. The median age was 3.7 years (25th%-75th%: 2.1-15.6). The majority of the sedations, 88% (29/33), were done on children with Fontan physiology and 12% (4/33) were status-post superior cavopulmonary anastomosis. The primary cardiac defect was hypoplastic left heart in 63% (17/27) of all sedation procedures. There were 24 chest tube placements and 9 cardioversions. Ketamine alone [median dose 1.5 mg/kg (range 0.8-3.7)], ketamine [median dose 1 mg/kg (range 0.1-2.1)] with propofol [median dose 2.3 mg/kg (range 0.7-3.8)], and ketamine [median dose 1.5 mg/kg (range 0.4-3.0)] with morphine [median dose 0.06 mg/kg (range 0.03-0.20)] were the most common sedation regimens used. Adverse events (AEs) occurred in 4 patients (15%), three of which were transient AEs. All sedation encounters were successfully completed. Conclusion: Procedural deep sedation can be safely and effectively administered to single ventricle patients by intensivist-led sedation teams in selective case.

Platelet slope and long-term clinical outcomes in children and adults with Fontan-associated liver disease

BACKGROUND AND OBJECTIVES

There is a lack of robust literature describing a relationship between platelet count as a reflection of liver fibrosis and Fontan-associated liver disease (FALD). The present study investigated the serial longitudinal relationship of laboratory tests to cirrhosis and clinical outcomes in patients following Fontan procedure.

METHODS

This was a retrospective study of patients with Fontan procedure who underwent laboratory evaluation at least 1 year after surgery. Clinical data, including death, failing Fontan physiology, and heart transplantation, were investigated. Cirrhosis was defined as stage 4 fibrosis on liver biopsy and/or evidence of cirrhosis from imaging. Portal hypertension (PHTN) was calculated using the VAST score (one point each for Varices, Ascites, Splenomegaly, and Thrombocytopenia); VAST score ≥ 2 indicating PHTN features.

RESULTS

Among 376 patients (184 children and 192 adults), cirrhosis was recorded in 52/376 (13.8%). Platelet counts in those with FALD-associated cirrhosis decreased significantly starting 25, 30 and 35 years after Fontan, compared to the non-cirrhosis group (151 vs. 188; p = 0.01, 134 vs. 174; p = 0.02, and 127 vs. 202 × 103/uL; p = 0.04, respectively). Patients with cirrhosis and PHTN features had significantly worse heart transplant-free survival, overall survival, and failing Fontan physiology compared to patients without cirrhosis.

CONCLUSIONS

FALD patients with cirrhosis develop decreasing platelet counts 25 years after Fontan procedure. Lower platelets, even if near normal range, can be a marker of cirrhosis in FALD. Cirrhosis with PHTN is an associated with worse heart transplant-free survival, overall survival, and failing Fontan.