Key result
Super-Fontan strategy linked to ~2 mm Hg lower resting CVP and increased cardiac index.
Why the study?
Fontan circulation relies on reduced venous capacitance and elevated central venous pressure, resulting in congestive end-organ damage that impairs prognosis. Whether adding aggressive arterial and venous dilation to pulmonary dilation (the super-Fontan strategy) can improve Fontan hemodynamics and ameliorate organ congestion was unknown.
Does aggressive arterial and venous dilation therapy in addition to pulmonary dilation therapy (super-Fontan strategy) improve resting and exercise hemodynamics and reduce central venous pressure in patients late after Fontan surgery?
Cohort (n=30)
No
Does aggressive arterial and venous dilation therapy in addition to pulmonary dilation therapy (super-Fontan strategy) improve resting and exercise hemodynamics and reduce central venous pressure in patients late after Fontan surgery?
Adding aggressive systemic venodilation (isosorbide dinitrate) and arterial dilation (ACEI/ARB) to pulmonary vasodilators significantly increases venous capacitance and lowers central venous pressure both at rest and during exercise in school-aged Fontan patients, potentially mitigating congestive hepatopathy.
Answers are grounded in this paper and cite their sources.
May lower CVP at rest and exercise in Fontan patients; hypothesis-generating pending randomized trials.
Objective Fontan circulation maintains preload and cardiac output by reducing venous capacitance and increasing central venous pressure (CVP). The resultant congestive end-organ damage affects patient prognosis. Therefore, a better circulatory management strategy to ameliorate organ congestion is required in patients with Fontan circulation. We sought to verify whether aggressive arterial and venous dilation therapy in addition to pulmonary dilation (super-Fontan strategy) can improve Fontan circulation and reduce congestion. Methods Patients after Fontan surgery who received the super-Fontan strategy in a single center were recruited. Participants were examined using medical records between 2010 and 2018. We retrospectively analyzed the changes in hemodynamics at rest and during treadmill exercise before and after the introduction of this therapy. Results The therapy significantly increased venous capacitance (3.21 ± 1.27 mL/kg/mm Hg to 3.79 ± 1.30 mL/kg/mm Hg, P = .017) and decreased total pulmonary resistance, leading to significantly reduced CVP (11.7 ± 2.4 mm Hg to 9.7 ± 2.2 mm Hg, P < .001) and increased cardiac index (CI) (3.09 ± 1.01 L/min/m 2 to 3.54 ± 1.19 L/min/m 2 , P = .047). Furthermore, this strategy significantly reduced the elevations in CVP (19.6 ± 5.3 mm Hg to 15.4 ± 2.7 mm Hg, P = .002) with preserved CI in response to exercise. CVP at rest and during exercise was significantly positively correlated with serum markers of hepatic congestion and fibrosis, respectively. Conclusions The super-Fontan strategy is a therapy that turns the heart failure condition of Fontan circulation into a more physiological condition. However, whether the strategy improves long-term prognosis warrants further studies.
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Ishikawa et al. (2022) conducted a cohort in Fontan circulation (n=30). Super-Fontan strategy (aggressive arterial and venous dilation therapy with isosorbide dinitrate and enalapril/candesartan in addition to pulmonary vasodilators) vs. Baseline pre-treatment status (and 28 age-matched biventricular controls with isolated paroxysmal ventricular contraction for exercise comparison) was evaluated on Resting central venous pressure (CVP, mm Hg) (p=<0.001). The super-Fontan strategy reduced resting CVP from 11.7 to 9.7 mm Hg and peak exercise CVP from 19.6 to 15.4 mm Hg while increasing resting cardiac index.
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