Abstract
Prior to the Fontan procedure, patients with single ventricle physiology with Glenn shunt are typically referred for cardiac catheterization to assess hemodynamics and potentially provide interventional measures. Currently, echocardiography provides detailed information which together with other non-invasive imaging such as CT scan and MRI may obviate the need for routine cardiac catheterization prior to the Fontan procedure. In this study, we examine the findings in cardiac catheterization in this population to determine: (a) the accuracy of echocardiography in providing adequate information prior to the Fontan procedure, particularly in identifying those in need of per-catheter intervention, and (b) the percentage of patients requiring interventional procedures during cardiac catheterization. We performed a retrospective chart review of echocardiographic and cardiac catheterization data for patients who underwent pre-Fontan cardiac catheterization at our center in the period from 02/01/2008 to 02/28/2017. We aimed to re-examine the necessity of routine cardiac catheterization in all single ventricle patients. This was performed through examining pre-catheterization echocardiography reports and comparing them to findings of the subsequent cardiac catheterization reports. Echocardiography reports were evaluated for accuracy in identifying significant anatomical or hemodynamic findings, which may impact success of Fontan procedure as well as the ability of echocardiography to predict findings important to know prior to the Fontan procedure. In this cohort of 40 children, 3 patients were found to have significant hemodynamic findings through cardiac catheterization which were not previously known by echocardiography. In addition, 28 out of 40 patients (70%) required interventional procedures to address significant abnormalities (systemic to pulmonary arterial collaterals, pulmonary artery stenosis, aortic arch stenosis, etc.). All cases of aortic arch stenosis were detected by echocardiography, however, all patients who required systemic to pulmonary arterial or left SVC embolization were not detected by echocardiography. Furthermore, echocardiography did not detect the need for branch pulmonary artery stenosis in 50% of cases. Cardiac catheterization appears to be an essential part of patient assessment prior to Fontan completion in patients with single ventricle physiology. This current practice may change in the future if a non-invasive screening tool is found to have high positive and negative predictive values in identifying the subset of patients who require potential intervention in pre-Fontan cardiac catheterization.
Similar content being viewed by others
References
Goldstein BH, Holzer RJ, Trucco SM, Porras D, Murphy J, Foerster SR, El-Said HG, Beekman RH 3rd, Bergersen L (2016) Practice variation in single-ventricle patients undergoing elective cardiac catheterization: a report from the congenital cardiac catheterization project on outcomes (C3PO). Congenit Heart Dis 11:122–135
Fogel MA (2005) Is routine cardiac catheterization necessary in the management of patients with single ventricles across staged Fontan reconstruction? No! Pediatr Cardiol 26:154–158
Banka P, McElhinney DB, Bacha EA, Mayer JE Jr, Gauvreau K, Geva T, Brown DW (2010) What is the clinical utility of routine cardiac catheterization before a Fontan operation? Pediatr Cardiol 31:977–985
Yassin H, Bhat AN, Tysarowski P, Masud F, Dilawar M (2015) Noninvasive evaluation of single-ventricle patients before Fontan operation. Asian Cardiovasc Thorac Ann 23:412–417
Ro PS, Rychik J, Cohen MS, Mahle WT, Rome JJ (2004) Diagnostic assessment before Fontan operation in patients with bidirectional cavopulmonary anastomosis: are noninvasive methods sufficient? J Am Coll Cardiol 44:184–187
Fontan F, Baudet E (1971) Surgical repair of tricuspid atresia. Thorax 26:240–248
Pundi KN, Johnson JN, Dearani JA, Pundi KN, Li Z, Hinck CA, Dahl SH, Cannon BC, O’Leary PW, Driscoll DJ, Cetta F (2015) 40-year follow-up after the fontan operation: long-term outcomes of 1052 patients. J Am Coll Cardiol 66:1700–1710
Nakanishi T (2005) Cardiac catheterization is necessary before bidirectional Glenn and Fontan procedures in single ventricle physiology. Pediatr Cardiol 26:159–161
Brown DW, Gauvreau K, Moran AM, Jenkins KJ, Perry SB, del Nido PJ, Colan SD (2003) Clinical outcomes and utility of cardiac catheterization prior to superior cavopulmonary anastomosis. J Thorac Cardiovasc Surg 126:272–281
Giglia TM, Humpl T (2010) Preoperative pulmonary hemodynamics and assessment of operability: is there a pulmonary vascular resistance that precludes cardiac operation? Pediatr Crit Care Med 11:S57-69
Driscoll DJ, Offord KP, Feldt RH, Schaff HV, Puga FJ, Danielson GK (1992) Five- to fifteen-year follow-up after Fontan operation. Circulation 85:469–496
Cazzaniga M, Fernandez Pineda L, Villagra F, Perez De Leon J, Gomez R, Sanchez P, Diez Balda J (2002) Single-stage Fontan procedure: early and late outcome in 124 patients. Rev Esp Cardiol 55:391–412
Kaulitz R, Ziemer G, Luhmer I, Kallfelz HC (1996) Modified Fontan operation in functionally univentricular hearts: preoperative risk factors and intermediate results. J Thorac Cardiovasc Surg 112:658–664
Bartmus DA, Driscoll DJ, Offord KP, Humes RA, Mair DD, Schaff HV, Puga FJ, Danielson GK (1990) The modified Fontan operation for children less than 4 years old. J Am Coll Cardiol 15:429–435
Spicer RL, Uzark KC, Moore JW, Mainwaring RD, Lamberti JJ (1996) Aortopulmonary collateral vessels and prolonged pleural effusions after modified Fontan procedures. Am Heart J 131:1164–1168
Ascuitto RJ, Ross-Ascuitto NT (2004) Systematic-to-pulmonary collaterals: a source of flow energy loss in Fontan physiology. Pediatr Cardiol 25:472–481
Grosse-Wortmann L, Drolet C, Dragulescu A, Kotani Y, Chaturvedi R, Lee KJ, Mertens L, Taylor K, La Rotta G, van Arsdell G, Redington A, Yoo SJ (2012) Aortopulmonary collateral flow volume affects early postoperative outcome after Fontan completion: a multimodality study. J Thorac Cardiovasc Surg 144:1329–1336
Mohammad Nijres B, Abdulla RI, Awad S, Murphy J (2017) Can the pulmonary artery wedge pressure be used reliably as a surrogate for the left atrial mean pressure in pre-Fontan evaluation? Pediatr Cardiol 38(7):1434–1440
Bradley SM, McCall MM, Sistino JJ, Radtke WA (2001) Aortopulmonary collateral flow in the Fontan patient: does it matter? Ann Thorac Surg 72:408–415
Gupta A, Daggett C, Behera S, Ferraro M, Wells W, Starnes V (2004) Risk factors for persistent pleural effusions after the extracardiac Fontan procedure. J Thorac Cardiovasc Surg 127:1664–1669
McElhinney DB, Reddy VM, Tworetzky W, Petrossian E, Hanley FL, Moore P (2000) Incidence and implications of systemic to pulmonary collaterals after bidirectional cavopulmonary anastomosis. Ann Thorac Surg 69:1222–1228
Banka P, Sleeper LA, Atz AM, Cowley CG, Gallagher D, Gillespie MJ, Graham EM, Margossian R, McCrindle BW, Sang CJ, Williams IA, Newburger JW (2011) Practice variability and outcomes of coil embolization of aortopulmonary collaterals before Fontan completion: a report from the Pediatric Heart Network Fontan Cross-Sectional Study. Am Heart J 162:125–130
Stern HJ (2010) Aggressive coiling of aortopulmonary collaterals in single-ventricle patients is warranted. Pediatr Cardiol 31:449–453
Wang RP, Liang CH, Huang MP, Liu H, Deng QP, Yang MF (2012) Assessment of aortopulmonary collateral flow and pulmonary vascular growth using a 3.0 T magnetic resonance imaging system in patients who underwent bidirectional Glenn shunting. Eur J Cardiothorac Surg 41:e146-53
Grosse-Wortmann L, Al-Otay A, Yoo SJ (2009) Aortopulmonary collaterals after bidirectional cavopulmonary connection or Fontan completion: quantification with MRI. Circ Cardiovasc Imaging 2:219–225
Whitehead KK, Gillespie MJ, Harris MA, Fogel MA, Rome JJ (2009) Noninvasive quantification of systemic-to-pulmonary collateral flow: a major source of inefficiency in patients with superior cavopulmonary connections. Circ Cardiovasc Imaging 2:405–411
Dori Y, Glatz AC, Hanna BD, Gillespie MJ, Harris MA, Keller MS, Fogel MA, Rome JJ, Whitehead KK (2013) Acute effects of embolizing systemic-to-pulmonary arterial collaterals on blood flow in patients with superior cavopulmonary connections: a pilot study. Circ Cardiovasc Interv 6:101–106
Kleinerman RA (2006) Cancer risks following diagnostic and therapeutic radiation exposure in children. Pediatr Radiol 36(Suppl 2):121–125
Prakash A, Khan MA, Hardy R, Torres AJ, Chen JM, Gersony WM (2009) A new diagnostic algorithm for assessment of patients with single ventricle before a Fontan operation. J Thorac Cardiovasc Surg 138:917–923
Brown DW, Gauvreau K, Powell AJ, Lang P, Colan SD, Del Nido PJ, Odegard KC, Geva T (2007) Cardiac magnetic resonance versus routine cardiac catheterization before bidirectional glenn anastomosis in infants with functional single ventricle: a prospective randomized trial. Circulation 116:2718–2725
Downing TE, Whitehead KK, Dori Y, Gillespie MJ, Harris MA, Fogel MA, Rome JJ, Glatz AC (2013) Accuracy of conventional oximetry for flow estimation in patients with superior cavopulmonary connection: a comparison with phase-contrast cardiac MRI. Circ Cardiovasc Imaging 6:943–949
Geva T, Greil GF, Marshall AC, Landzberg M, Powell AJ (2002) Gadolinium-enhanced 3-dimensional magnetic resonance angiography of pulmonary blood supply in patients with complex pulmonary stenosis or atresia: comparison with X-ray angiography. Circulation 106:473–478
Goo HW, Yang DH, Park IS, Ko JK, Kim YH, Seo DM, Yun TJ, Park JJ (2007) Time-resolved three-dimensional contrast-enhanced magnetic resonance angiography in patients who have undergone a Fontan operation or bidirectional cavopulmonary connection: initial experience. J Magn Reson Imaging 25:727–736
Author information
Authors and Affiliations
Corresponding author
Ethics declarations
Conflict of interest
The authors declare that they have no conflicts of interest related to this study.
Ethical Approval
This study was agreed to be conducted by our Institutional Review Board.
Informed Consent
Informed Consent was waived as this study was a retrospective chart review study.
Rights and permissions
About this article
Cite this article
Mohammad Nijres, B., Murphy, J.J., Diab, K. et al. Routine Cardiac Catheterization Prior to Fontan Operation: Is It a Necessity?. Pediatr Cardiol 39, 818–823 (2018). https://doi.org/10.1007/s00246-018-1825-8
Received:
Accepted:
Published:
Issue Date:
DOI: https://doi.org/10.1007/s00246-018-1825-8