A Path FORWARD: Development of a Comprehensive Multidisciplinary Clinic to Create Health and Wellness for the Child and Adolescent with a Fontan Circulation

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.

Recommendations for Centers Performing Pediatric Heart Surgery in the United States

“…Multidisciplinary Fontan follow-up programs have also been developed by several centers in recent years to support longitudinal, coordinated, and specialized care for this patient population. 134 These programs typically include congenital cardiac surgeons, pediatric cardiologists, and other specialists such as gastroenterology, hematology, and others as well as support for mental health needs and social work and dedicated staff to facilitate care coordination. It is recommended that Comprehensive Care Centers either offer such a program or establish a collaboration with other centers who have a program (similar to Essential Care Centers), as patient volumes may not support a dedicated program at all centers.…”

Current diagnostic and therapeutic strategies for the management of lymphatic insufficiency in patients with hypoplastic left heart syndrome

“…Modern management of lymphatic insufficiency involves medical, interventional and surgical strategies and is multidisciplinary (1,4,63). Treatment algorithms have recently been proposed for most lymphatic flow disorders and may help to establish a more uniform diagnostic and therapeutic approach throughout centers (Figures 7-10) (25,46).…”

Unique clinical challenges for the teenager with congenital heart disease

“…A number of strategies may be of benefit to the cardiologist and teenager with CHD. Some programs have incorporated screening surveys or even a mental health professional into a comprehensive clinic to help assess mental and neuropsychiatric needs of the patient [28]. This may be ‘ideal state’ but may not be practical in most outpatient cardiology office visits.…”