Prevalence of reoperation for pathway obstruction after Fontan operation

Fernandez, Guy; Costa, Francisco de Assis; Fontán, F; Naftel, David C.; Blackstone, Eugene H.; Kirklin, John W.

doi:10.1016/0003-4975(89)90783-2

Cited by 35 publications

(7 citation statements)

References 7 publications

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“…Prosthetic vascular grafts are widely used in these reconstructive operations, but revisions are often necessary because of their inability to grow or effectively remodel within a growing child (1)(2)(3). A strategy to address this issue is the use of living tissue-engineered vascular grafts (TEVGs).…”

mentioning

confidence: 99%

Tissue-engineered vascular grafts transform into mature blood vessels via an inflammation-mediated process of vascular remodeling

Roh

Sawh-Martinez

Brennan

et al. 2010

Proc. Natl. Acad. Sci. U.S.A.

507

499

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Biodegradable scaffolds seeded with bone marrow mononuclear cells (BMCs) are the earliest tissue-engineered vascular grafts (TEVGs) to be used clinically. These TEVGs transform into living blood vessels in vivo, with an endothelial cell (EC) lining invested by smooth muscle cells (SMCs); however, the process by which this occurs is unclear. To test if the seeded BMCs differentiate into the mature vascular cells of the neovessel, we implanted an immunodeficient mouse recipient with human BMC (hBMC)-seeded scaffolds. As in humans, TEVGs implanted in a mouse host as venous interposition grafts gradually transformed into living blood vessels over a 6-month time course. Seeded hBMCs, however, were no longer detectable within a few days of implantation. Instead, scaffolds were initially repopulated by mouse monocytes and subsequently repopulated by mouse SMCs and ECs. Seeded BMCs secreted significant amounts of monocyte chemoattractant protein-1 and increased early monocyte recruitment. These findings suggest TEVGs transform into functional neovessels via an inflammatory process of vascular remodeling.bone marrow | monocyte chemoattractant protein-1 | tissue engineering | neovascularization C ongenital heart disease is a leading cause of infant mortality, often requiring early surgical intervention to correct fatal cardiovascular malformations. Prosthetic vascular grafts are widely used in these reconstructive operations, but revisions are often necessary because of their inability to grow or effectively remodel within a growing child (1-3). A strategy to address this issue is the use of living tissue-engineered vascular grafts (TEVGs). Constructed from biodegradable polyester tubes seeded with autologous bone marrow mononuclear cells (BMCs), these grafts undergo extensive remodeling in animal recipients and appear to transform into living blood vessels, similar in morphology and function to the native veins into which they are interposed (4, 5). Ongoing clinical studies evaluating BMC-seeded grafts as venous conduits for congenital heart surgery report excellent safety profiles and 100% patency rates at 1-3 years of follow-up (6-8). Additionally, these grafts demonstrate growth potential, suggesting they may be more effective for the pediatric patient population than currently available vascular grafts (8,9).Although the functional efficacy and clinical utility of TEVGs are promising, little is known about how these BMC-seeded polyester tubes transform into living blood vessels in host recipients. It has been proposed that stem cells within the seeded BMC population differentiate into the endothelial cells (ECs) and smooth muscle cells (SMCs) of the developing neovessel, ultimately replacing the degrading polyester tube (10). This hypothesis, however, has not been directly examined.We recently developed a method for constructing small-diameter biodegradable synthetic scaffolds suitable for use as vascular grafts in mice (11). These tubular scaffolds are composed of the same materials and design used in clinical TEVGs...

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mentioning

confidence: 99%

Tissue-engineered vascular grafts transform into mature blood vessels via an inflammation-mediated process of vascular remodeling

Roh

Sawh-Martinez

Brennan

et al. 2010

Proc. Natl. Acad. Sci. U.S.A.

507

499

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“…(Circulation 1991;83:822-826) T he dynamics of right heart blood flow have been studied in patients after undergoing a Fontan procedure, in which the right ventricle is completely excluded from the circulation. 12 Bjork's modification, which includes the rudimentary right ventricle,3 is the other surgical choice for tricuspid atresia. The rationale for the modification is that the right ventricle should augment forward flow to the pulmonary circulation.…”

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confidence: 99%

A quantitative analysis of hemodynamic effects of the right ventricle included in the circulation of the Fontan procedure.

et al. 1991

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BACKGROUND Right heart hemodynamics were analyzed with a catheter-mounted velocity meter in seven patients after direct atrioventricular anastomosis for Fontan procedure (RV group) and were compared with those obtained in eight patients after direct atriopulmonary anastomosis (RA group). METHODS AND RESULTS In the RV group, cardiac output was 2.7 +/- 0.6 l/min/m2; mean right atrial and pulmonary artery pressures were both 13 +/- 3 mm Hg; mean pulmonary artery wedge pressure was 7 +/- 5 mm Hg; left ventricular end-diastolic volume, determined angiographically, was 129 +/- 40% of normal; and its ejection fraction was 0.50 +/- 0.09. In the RA group, data were similar to those of the RV group except that right heart pressure were lower in the RV group, which was related to the preoperative condition of the pulmonary circulation. In the RV group, the fraction of ventricular forward flow of the total forward flow in the main pulmonary artery ranged from 0.21 to 0.46 and was not correlated with cardiac output or with any other parameter. The backward flow into the inferior vena cava at ventricular systole was greater than the atrial flow in two patients in whom cardiac output was less than 2.2 l/min/m2, whereas caval backward flow at atrial contraction was greater than ventricular flow in the other five patients, of whom four had a cardiac output greater than 3.1 l/min/m2. CONCLUSIONS We conclude that the inclusion of right ventricle in the circulation of the Fontan procedure does not necessarily improve overall hemodynamics in most patients.

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“…Although several studies from the 1980s suggest that there are benefits to incorporation of the RV in patients with tricuspid atresia, it is unclear if and in which patients this circulatory arrangement conferred a long‐term survival or functional advantage . The RA–RV connection in a modified Björk procedure can vary in size, type, and configuration, but studies found that reintervention on the conduit/anastomosis was among the most common sources of late morbidity regardless of conduit type . This is reflected in the current study cohort, two‐thirds of whom had undergone surgical revision of the RA–RV connection prior to Melody valve implant.…”

Section: Discussionmentioning

confidence: 99%

“…This is reflected in the current study cohort, two‐thirds of whom had undergone surgical revision of the RA–RV connection prior to Melody valve implant. Although, studies have demonstrated that a direct RA appendage‐RV connection is associated with significantly less need for reintervention than pathways incorporating an extra‐anatomic RA–RV conduit, patients with a valveless direct connection are more prone to complications of a failing Fontan circulation . Although the Björk procedure is rarely employed in the current era, there remain numerous patients with this circulation who present with the various complicating factors of a Fontan circulation and require management.…”

Section: Discussionmentioning

confidence: 99%

“…Related modifications utilize a graft (either a valved xenograft conduit, a nonvalved synthetic tube, or a valved or nonvalved homograft) to connect the RA to the RV. Over time, RA–RV graft/conduit dysfunction is a common reason for symptoms after a modified Björk procedure, and revision or replacement of the RA–RV pathway is among the most common reinterventions in these patients . Although there are potential advantages to inclusion of the RV between the systemic venous and the pulmonary arterial compartments, obstruction of the RA–RV conduit and/or regurgitation of flow from the RV to the RA during ventricular contraction can impose an important hemodynamic burden.…”

Section: Introductionmentioning

confidence: 99%

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Transcatheter valve implantation for right atrium‐to‐right ventricle conduit obstruction or regurgitation after modified Björk–fontan procedure

Shah

Horlick

Eicken

et al. 2016

Cathet Cardio Intervent

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Prevalence of reoperation for pathway obstruction after Fontan operation

Cited by 35 publications

References 7 publications

Tissue-engineered vascular grafts transform into mature blood vessels via an inflammation-mediated process of vascular remodeling

Tissue-engineered vascular grafts transform into mature blood vessels via an inflammation-mediated process of vascular remodeling

A quantitative analysis of hemodynamic effects of the right ventricle included in the circulation of the Fontan procedure.

Transcatheter valve implantation for right atrium‐to‐right ventricle conduit obstruction or regurgitation after modified Björk–fontan procedure

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