Ventricular energetics after the Fontan operation: Contractility-afterload mismatch

Szabó, Gábor; Buhmann, Volker; Graf, Andy; Melnitschuk, Sergei; Bährle, Susanne; Vahl, Christian F.; Hagl, S.

doi:10.1067/mtc.2003.405

Cited by 70 publications

(63 citation statements)

References 31 publications

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“…These results indicate that SV dysfunction seems relatively unrelated to volume overload but is probably more affected by afterload conditions, as previously described [17][18][19]. Based on our results and current studies that investigated the effect of additional volume overload through aortopulmonary shunt implantation in BCPC-patients [20,21], it is unlikely that a mild or moderate amount of APC flow leads to myocardial dysfunction.…”

Section: Discussionsupporting

confidence: 46%

“…Based on our results and current studies that investigated the effect of additional volume overload through aortopulmonary shunt implantation in BCPC-patients [20,21], it is unlikely that a mild or moderate amount of APC flow leads to myocardial dysfunction. However, a cut-off value for volume overload needs to be determined, that allows an optimal ventriculararterial coupling by matching pre-and afterload to maintain efficient myocardial performance in these patients [19].…”

Section: Discussionmentioning

confidence: 99%

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Aortopulmonary Collateral Flow is Related to Pulmonary Artery Size and Affects Ventricular Dimensions in Patients After the Fontan Procedure

Latus¹,

Gummel²,

Diederichs³

et al. 2013

Thorac cardiovasc Surg

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Background: Aortopulmonary collaterals (APCs) are frequently found in patients with a single-ventricle (SV) circulation. However, knowledge about the clinical significance of the systemic-to-pulmonary shunt flow in patients after the modified Fontan procedure and its potential causes is limited. Accordingly, the aim of our study was to detect and quantify APC flow using cardiovascular magnetic resonance (CMR) and assess its impact on SV volume and function as well as to evaluate the role of the size of the pulmonary arteries in regard to the development of APCs.

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Section: Discussionsupporting

confidence: 46%

Section: Discussionmentioning

confidence: 99%

Aortopulmonary Collateral Flow is Related to Pulmonary Artery Size and Affects Ventricular Dimensions in Patients After the Fontan Procedure

Latus¹,

Gummel²,

Diederichs³

et al. 2013

Thorac cardiovasc Surg

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“…The other coupling studies in Fontan patients used similar methods as ours or even much simplified, less‐rigorous methods, but did not include similarly studied non‐Fontan patients to determine whether VA parameters were abnormal relative to persons without Fontan circulation 30, 31. A mathematical simulation study and an animal study of acute Fontan physiology indicated that immediately after creation of a Fontan circulation, Ees is mildly reduced whereas Ea is increased 24, 32. In contrast, chronically, in adult Fontan patients, we found that contractility was significantly decreased as assessed by multiple load‐insensitive measures of ventricular contractility (Ees, PRSW, and PPI) whereas Ea was similar to age, sex, and body size matched controls without CHD.…”

Section: Discussionmentioning

confidence: 99%

Ventricular‐Arterial Function and Coupling in the Adult Fontan Circulation

Saiki

Eidem

Ohtani

et al. 2016

JAHA

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BackgroundIn adult Fontan patients, ventricular or arterial dysfunction may impact homeostasis of the Fontan circulation and predispose to heart failure. We sought to characterize ventricular‐arterial (VA) properties in adult Fontan patients.Methods and ResultsAdult Fontan patients (n=170), including those with right (SRV, n=57) and left (SLV, n=113) dominant ventricular morphology, were compared to age, sex, and body size matched controls (n=170). Arterial function, load‐insensitive measures of contractility, VA coupling, diastolic function, and ventricular efficiency were assessed. Compared to controls, Fontan patients had similar arterial (Ea), but lower end‐systolic ventricular (Ees), elastance, preload recruitable stroke work and peak power index, impaired VA coupling, eccentric remodeling, reduced ventricular efficiency and increased diastolic stiffness (P<0.05 for all). Ventricular efficiency declined steeply with higher heart rate in Fontan, but not control, patients. Among Fontan patients (n=123) and controls (n=162) with preserved cardiac index (CI; ≥2.5 L/min per m2), Fontan patients had worse contractility than controls, but CI was preserved owing to relative tachycardia, lower afterload, and eccentric remodeling. However, 25% of Fontan patients had reduced CI and were distinguished from those with preserved CI by less‐eccentric remodeling and worse diastolic function, rather than more‐impaired contractility.ConclusionsAdult Fontan patients have contractile and diastolic dysfunction with normal afterload, impaired VA coupling, and reduced ventricular efficiency with heightened sensitivity to heart rate. Maintenance of CI is dependent on lower afterload, eccentric remodeling, and relative preservation of diastolic function. These data contribute to our understanding of circulatory physiology in adult Fontan patients.

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“…This criterion, although arbitrary by itself, has been even more inappropriately applied to univentricular hearts, despite the fact that studies have shown that peak systolic gradients \20 mm Hg can cause significant diastolic dysfunction [23,41] [37]. Is it reasonable, therefore, to accept any arch gradient in a univentricular heart, which is already exposed to increased afterload [32,38]?…”

mentioning

confidence: 99%

Fontan “Ten Commandments” Revisited and Revised

Stern

2010

Pediatr Cardiol

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Choussat's ''Ten Commandments,'' which describes the components of an ideal Fontan candidate, was first published in 1977. Despite the wisdom in these commandments, it is clear from a historic perspective that total compliance with all criteria does not necessarily portend excellent long-term survival. I believe the end point of the original commandments should be modified to include improvement in long-term survival. I suggest the following single commandment: ''Thou Shalt Be Perfect.''

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Ventricular energetics after the Fontan operation: Contractility-afterload mismatch

Cited by 70 publications

References 31 publications

Aortopulmonary Collateral Flow is Related to Pulmonary Artery Size and Affects Ventricular Dimensions in Patients After the Fontan Procedure

Aortopulmonary Collateral Flow is Related to Pulmonary Artery Size and Affects Ventricular Dimensions in Patients After the Fontan Procedure

Ventricular‐Arterial Function and Coupling in the Adult Fontan Circulation

Fontan “Ten Commandments” Revisited and Revised

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