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Background: The true incidence of cardiac thrombi,
intra-tunnel thrombi and pulmonary thromboembolic events is unknown in patients
undergoing total cavopulmonary connection (TCPC) for a functionally
univentricular heart. No consensus is found in the literature regarding the
tools for diagnosis of cardiac thrombi, intra-tunnel thrombi and pulmonary
thromboembolism. This study used 16 slice-multi-slice Computerized Tomographic
(MSCT) angiography in evaluating the diagnostic accuracy and incidence of these
thromboembolic events.
Methods: Thirty-two patients with total cavopulmonary
connections were evaluated with echocardiography and 16 slice-multi-slice CT
angiography for thromboembolic events.
Results: A total number of 4 (12.5%) patients were
detected to have thromboembolic complications through MSCT angiography. Out of
which, only one (3.1%) patient was detected to have thrombus through
echocardiography. Two (6.3%) out of 4 patients had asymptomatic segmental
pulmonary embolism which was detected by MSCT angiography.
Conclusion: 16 slice-multi-slice CT angiography is an
effective screening method to accurately diagnose the presence or absence of
intra-and extra cardiac thrombus and asymptomatic silent pulmonary embolism
after Fontan operation in order to optimize diagnostic and therapeutic
strategies.
Keywords: Univentricular repair, Cavopulmonary
connection, Multi-slice computed tomographic angiography, Intra-tunnel Thromboembolic
events
INTRODUCTION
Despite improved survival and functional status of patients undergoing
total cavopulmonary connection (TCPC), the pulmonary circulation remains
anatomically abnormal and systemic ventricular function remains depressed,
accounting for the current residual mortality and morbidity after this
procedure [1,2]. Systemic venous hypertension, systemic and pulmonary venous
obstruction, residual intracardiac right-to-left shunts, supraventricular
arrhythmias, persistent ventricular dysfunction and thromboembolic events are
the various causes of morbidity and mortality following Fontan operation [1,2].
Thrombosis of the Fontan pathway is often silent and may remain undetected
until pathway obstruction results in significant elevation of venous pressures
[3-6].
The true incidence of cardiac and intra-tunnel thrombi, pulmonary thromboembolism and systemic thromboembolic events is unknown [1-11]. Moreover, no consensus is found in the literature regarding the tools for diagnosis of cardiac and intra-tunnel thrombi and pulmonary thromboembolism [7-11]. Although echocardiography and angiography are the traditionally dominant imaging modalities, magnetic resonance imaging and computerized tomography are valuable non-invasive adjuncts.
Doppler
echocardiography is limited by a small field of view, a variable acoustic
window, inability to penetrate air and bone, and difficulty in delineating
extra cardiac vascular structures in their entirety. The interpretation of
echocardiographic results is expertise dependent.
Cardiac
catheterization and angiography is a traditional invasive imaging modality that
yields important hemodynamic data and defines the vascular anatomy. But it is
expensive. Patient is exposed to high doses of ionizing radiation and is
limited by the risks inherent to iodinated contrast material wherein high doses
of radio opaque dye is used as compared to CT angiography.
Magnetic resonance
angiography plays a valuable role in this study especially the hemodynamic
aspect. Although it is superior, limitations being expensive, not easily
available in all centers, longer scanning times and it cannot be used in
patients who have undergone preoperative/postoperative coil embolisation,
artifacts, shunt take downs with metallic clips and patients with pacemaker
device implanted [11,12]. Hence, CT angiography play a valuable role in
bridging the gaps created by echocardiography, angiography and MR angiography
in evaluation of patients who have previously undergone univentricular repair
[5,13]. CT angiography has the advantage of easy availability and very short
scanning time. It is less expensive and less invasive. Lower doses of ionizing
radiations and radio-opaque dye are used as compared to conventional
angiography and cardiac catheterization. With the advantage of direct
multi-planar image reformation, multi-slice CT (MSCT) angiography has the
benefits of improved diagnostic accuracy by detecting even peripheral pulmonary
embolism at the sub-segmental arterial level even in patients with impaired
respiratory function. To our knowledge however, there has been no systemic
evaluation of usefulness of multi-slice computerized tomography angiography is
demonstrating Fontan pathway. This prospective, non-randomized study was
performed: i) To evaluate the occurrence of thrombotic obstruction of the Fontan
pathway; ii) To diagnose silent thromboembolic events within both central and
segmental pulmonary arterial pathways; iii) To determine the role of 16-slice
multi-slice CT angiography in evaluating Fontan pathway obstruction; iv) To
evaluate the sensitivity, specificity and predictive accuracy of CT findings;
and, v) To identify the predisposing risk factors to optimize diagnostic and
therapeutic strategies for patients after Fontan operation.
METHODS
Between January
1988 and June 2017, 660 patients underwent univentricular repair at All India
Institute of Medical Sciences, New Delhi, India. This prospective study
included 32 consecutive patients with univentricular repair who were seen for
routine follow-up between April 2004 and June 2017 at our institution, who are
either asymptomatic or in patients with suspected Fontan failure in the
immediate postoperative period who were randomly selected. Informed consent was
obtained from all participants.
Two basic
modifications of univentricular repair were utilized and varied according to
the preoperative anatomy. Modifications include an intra-atrial lateral tunnel
fenestrated total cavopulmonary connection (LT-TCPC) and an extra cardiac
polytetrafluoroethylene conduit TCPC (EC-TCPC).
Patient age,
gender, operative details of the TCPC, NYHA functional class, current
prescription medications, ECG, prothrombin time and complete two-dimensional
transthoracic echocardiography and Doppler study (Hewlett-Packard Model 5500)
performed in all patients. Systemic ventricular function was assessed
qualitatively and graded 1 (Ejection fraction >0.60: Normal), 2 (Ejection
fraction 0.40-0.60: Mild dysfunction) 3 (Ejection fraction 0.20-0.40: Moderate
dysfunction) and 4 (Ejection fraction <0.20: Severe dysfunction) and the presence
of cardiac; intra tunnel thrombi and pulmonary thromboembolism was recorded. A
CT pulmonary angiogram was performed on a 16 slice-multi-slice CT scanner
(Sensation 16, Siemens, Germany). The patient was placed in supine position
with an 18 g cannula inserted into antecubital vein. A bolus tracking was
performed keeping the region of interest over right and left pulmonary artery.
A non-ionic contrast, Iohexol 65% (2 mg/kg) was injected at 2-2.5 cc/s. During
breath hold, image acquisition was started automatically by the scanner once
the peak of contrast in pulmonary artery reached 110 HU. This was then
commenced from base of the neck to diaphragm.
The parameter for
scanning include; slice thickness of 1 mm, rotation time of 0.42 s in a 11-12 s
breath hold from base of neck to diaphragm with a table speed of 7.5 to 15
mm/s. Axial images were reconstructed to produce multi-planar reconstructions
and oblique images as required. The volume of injected contrast agent, table
speed and exposure factors varied with the patient body habitus. Soft copy
images were interrogated using scroll mode on a dedicated computer by an experienced
chest radiologist. The diagnosis of intra-tunnel thrombi, cardiac thrombi and
pulmonary thromboembolism was made in accordance with published criteria.
STATISTICAL ANALYSIS
Statistical
analysis was carried out using Stata 11.0 (College Station, Texas, USA).
Continuous data were presented as mean ± standard deviation, whereas
categorical variables were presented as frequency distribution and percentage.
The p value of <0.05 was considered as statistically significant.
RESULTS
A total of 32 patients undergoing modified Fontan procedures were studied. The baseline characteristics of patients are shown in Table 1. The age group of the study ranged from 4 to 30 years (mean 14.2 ± 6.4 years), 26 (81.3%) were males and 6 (18.7%) were females. The age at Fontan operation ranged from 2 to 28 years (mean 9.1 ± 5.7 years). The number of years since Fontan operation ranged from 1 month to 13 years (mean 5 ± 3.7 years). The underlying cardiac morphology was tricuspid atresia in 10 (31.3%) patients and non-tricuspid atresia type in 22 (68.7%) patients. The summary of cardiac morphology is shown in Table 2. Twenty-seven (84.4%) patients had undergone lateral tunnel fenestrated TCPC and 5 (15.6%) patients had undergone extra cardiac conduit TCPC. The individual patient characteristics are summarized in Tables 2 and 3. Twenty-eight (87.5%) patients were in NYHA functional class I, 2 (6.3%) were in class II, 1 (3.1%) in class III and 1 (3.1%) in class IV.
Echocardiographically
estimated ventricular function was normal in 28 (87.5%) patients, mild
dysfunction in 2 (6.3%), moderate dysfunction in 1 (3.1%) and severe
dysfunction in 1 (3.1%) patients. Thirty-one (96.9%) patients were in normal
sinus rhythm. One (3.1%) patient had intermittent complete heart block, for
which a permanent pacemaker implantation was done. All 32 (100%) patients were
on low dose warfarin and aspirin according to our institute protocol.
There were 4 (12.5%) patients with thromboembolic complications. The characteristics of those patients with presence of thromboemboli are shown in Table 4. Out of 4 patients detected thromboembolism through MSCT angiography, one patient was detected of having thrombus by echocardiography (p=0.59). Two (6.3%) patients, who underwent operation at the age of 22 and 28 years (mean 25 years) had asymptomatic segmental pulmonary thromboembolism (PE) with mild ventricular dysfunction and 2 (6.3%) patients who had undergone operation at the age of 7 years had symptomatic right atrial intra-tunnel and pulmonary arterial thromboembolism with moderate to severe ventricular dysfunction.
DISCUSSION
Physiologic
correction accomplished with various modifications of the original Fontan
procedure has improved survival and functional status of patients with a
functionally univentricular heart. However, the pulmonary circulation remains
anatomically abnormal and systemic ventricular function remains depressed,
accounting for the current residual mortality and morbidity after this
procedure [1,2,6]. Systemic venous hypertension, systemic and pulmonary venous
obstruction, residual intra-cardiac-right-to-left shunts, supraventricular
arrhythmias, intra-tunnel and intra cardiac thromboembolic occurrences and
persistent systemic ventricular dysfunction are the various causes of
continuing morbidity and mortality following the Fontan procedure [1,2,6].
Central venous and
intracardiac thrombosis is the major causes of morbidity and mortality after
Fontan procedure. Shirai et al. [12] described a retrospective series of 16
patients undergoing extra cardiac Fontan procedures. The median follow-up was
13 months, and the incidence of intracardiac thrombosis was 19%. On the basis
of these findings, the authors have begun routine antithrombotic prophylaxis
with aspirin for 6 months after all Fontan procedures. The usefulness of such a
protocol, as the authors point out, remains to be proven [12].
Prophylactic
anticoagulation with warfarin or antiplatelet agents after Fontan procedures is
frequently recommended [3,4,7]. However, no consensus is found in the
literature or in routine clinical practice as to the optimal type or duration
of anticoagulation. Consequently, a wide variety of prophylactic anticoagulant
regimens are currently used.
The incidence of
thromboembolism after Fontan procedures is the determining factor for
appropriateness of prophylactic anticoagulation. Point prevalence for
intracardiac thrombosis ranged from 17% to 20% in the cross-sectional survey.
Reported incidences of venous thromboembolism and stroke ranged from 3% to 16%
and 3% to 19%, respectively [3,4,7,10]. A number of authors have analyzed a
variety of possible predisposing factors, including demographic and surgical
factors (patient age at operation; type of Fontan procedure performed,
including the presence or absence of fenestration; type of material used for
the conduit; use of valved or non-valved conduits) and hemodynamic factors
(arrhythmias, right-to-left shunts, polycythemia and low cardiac output).
Although some studies claimed statistically significant relationships,
predisposing risk factors were not identified with consistency or certainty.
Consequently, no conclusions can be made about the relative contribution of
patient demographic, surgical or hemodynamic factors in causing thromboembolism
after Fontan procedures [7].
Coon et al. [3]
investigated the frequency and location of thrombus in their population of
children based on the type of Fontan operation performed. Between January 1987
and January 1999, 592 patients underwent echocardiography after Fontan
operation and 52 (8.8%) had intracardiac thrombus. Median age at Fontan
operation was 1.9 years (range 0.8 to 35.1). Thrombus was detected in the
systemic venous atrium in 26 (48%) in the pulmonary venous atrium in 22 (44%),
in both atria 1 (2%), in the hypoplastic left ventricular cavity in 2 (8%) and
in the ligated pulmonary artery stump in 1 (2%).
In conclusion,
thrombus formation occurs with equal frequency after atriopulmonary or lateral
tunnel type Fontan modification, as well as in patients with or without
fenestration. Thrombi are as commonly seen on the pulmonary venous side as they
are on the systemic venous side and are usually adherent the baffle/patch
separating the venous circulations. Their study lends support to the suggestion
that thrombus formation after Fontan operation may be inherent to the
physiology of cavopulmonary flow and not specifically related to the type of
Fontan connection created or in patients on aspirin or warfarin [3].
Balling and
colleagues reported that intracardiac thrombus is difficult to determine by
means of routine transthoracic echocardiography. They evaluated in 52 patients
the occurrence of intracardiac thrombi in different types of Fontan
modifications as determined by transesophageal echocardiography. In 17 (33%)
patients, thrombus formation could be found without clinical evidence of
thromboembolic complications. Neither underlying morphologic disease nor age at
operation, type of Fontan operation, sex, follow-up interval, arrhythmias or
laboratory or hemodynamic findings could be identified as predisposing risk
factors. They recommended routine transesophageal echocardiography to exclude
eventual thrombi. Because of the high incidence of thrombi, they suggested oral
anticoagulation therapy in all patients [4].
Verma et al. [8]
studied the prevalence of pulmonary emboli (PE) in asymptomatic adult Fontan
patients. Right atrial thrombi and systemic thromboembolic complications have
been reported after the Fontan procedure. However, the frequency of silent
pulmonary embolism (PE) in this patient population is not known. Thirty
consecutive adult Fontan patients attending the adult congenital clinic over a
six-month period underwent ventilation-perfusion (VQ) scanning and blood
testing for thrombophilia tendency. If the VQ scan showed an intermediate or
high probability for pulmonary embolism, a computerized tomography (CT)
pulmonary angiogram was performed to confirm the presence of pulmonary
embolism. Seventeen percent of adult patients with Fontan procedure have
clinically silent pulmonary embolism. Pulmonary embolism were not present in
any patients (30%) taking warfarin. Late age at the time of Fontan operation
and type of Fontan anatomy were associated with increased risk of silent
pulmonary embolism [8].
Helical and
electron beam CT technology have made it possible to image the thorax in a
short period of time, often during a single breath-hold. With these rapid
scanning techniques, one can image a volume of tissue during peak contrast
enhancement using only a moderate amount of intravenous contrast material. With
good opacification of the pulmonary arteries, emboli within the vessels can be
visualized in a relatively non-invasive manner [11-13]. In 1992 Remy-Jardin et
al. [13] published the first prospective study comparing angiography with a
helical CT examination tailored to visualize the pulmonary vessels. This and
subsequent studies have confirmed that helical and electron beam CT are
approximately 90% sensitive and 90% specific for the evaluation of suspected
pulmonary embolism to the level of the segmental or larger vessels. Many
hospitals are using CT as a routine clinical tool for pulmonary emboli
evaluation and Kuzo et al. [9] believe that CT has the potential to replace the
ventilation perfusion scan for the diagnosis of pulmonary embolism in many
clinical situations.
Bergin et al. [11]
evaluated the accuracy of identification of central and segmental chronic
pulmonary thromboembolic disease on helical computerized tomographic (CT) scans
and on magnetic resonance (MR) images on 55 patients suspected of having
chronic pulmonary thromboembolism. Central vessel disease was determined more
accurately with helical CT scans (accuracy of 0.79 for each of the two readers)
than with angiograms (accuracy of 0.74) or with MR images (accuracy of 0.39 and
0.46 for two readers). Segmental vessel disease was also more accurately
determined with CT scans (accuracy of 0.75 and 0.76 for two readers) than with
MR images (accuracy of 0.61 and 0.57 for two readers). They concluded that
helical CT is a useful alternative to conventional angiography for diagnosis of
chronic thromboembolism but may not be sufficient for selecting candidates for
surgery in all cases [11]. In 2002 Remy-Jardin et al. [13] compared the impact of
multi-slice CT (MSCT) angiogram with conventional helical single slice CT
(SSCT) on image quality and diagnostic value in patients with pulmonary
embolism with underlying respiratory disease and concluded that the benefits of
MSCT were more marked for patients with underlying respiratory disease to
detect even peripheral pulmonary embolism at sub-segmental arterial level and
improvement in image quality on MSCT scans accounts for the improved diagnostic
accuracy of CT angiography, in particular for patients with impaired
respiratory function [13]. However, the utility of this technique in the
patients operated with univentricular repair for assessment of thrombus and
embolism has not been reported to the best of our knowledge.
In the present
study, 16 slice multi-slice CT angiography showed presence of thrombus
including at the segmental pulmonary arterial level in 4 (12.5%) patients as
against echocardiography, which showed only one patient (3.1%) with right
atrial and intra tunnel thrombus. MSCT angiography also showed 2 (6.3%)
patients with asymptomatic segmental pulmonary embolism. A subset of patients
undergoing various modifications of Fontan procedure will have failure of the
previously functional Fontan circuit. Occult pulmonary embolism will cause
increased pulmonary vascular resistance and silent Fontan pathway obstruction
leading to disturbed flow dynamics and ventricular dysfunction. Hence there is
a need to know the incidence of silent pulmonary thromboembolism. The only
reported prevalence of silent pulmonary thromboembolism in the Fontan
population was 17% and all these patients were not on anticoagulants.[8] In our
study the prevalence of silent PE was 6.3% and all these patients were on
anticogulant medication. In the previous study, the type of Fontan operations
were more of atriopulmonary, Right atrial to right ventricle non-valved conduit
and other complex conduit repairs of initial modifications.[8] Our study
included only recent modifications of lateral tunnel fenestrated TCPC and extra
cardiac conduit TCPC. Hence, the incidence of silent pulmonary embolism may be
less in our study as compared to the previous study. But the overall incidence
of thromboembolic complications was 12.5% which is comparable to other studies.
CONCLUSION
A 16 slice-multi-slice computerized tomographic angiography is an effective screening method to accurately diagnose the thromboembolic complications and silent pulmonary emboli after Fontan operation in order to optimize diagnostic and therapeutic strategies. However, these findings may form the basis for further study with larger study samples.
1. Airan B,
Sharrna R, Choudhary SK, Mohanty SR, Chowdhury UK, et al. (2000) Univentricular
repair: Is routine fenestration justified? Ann Thorac Surg 69: 1900-1906.
2. Chowdhury
UK, Airan B, Subramaniam G, Kothari SS, Saxena A, et al. (2005) Specific issues
after extra cardiac Fontan operation at mid-term follow up. Systemic
ventricular function, growth potential, arrhythmia and thromboembolism. Ann
Thorac Surg 80: 665-672
3. Coon PD,
Rychik J, Novello RT, Ro PS, Gaynor JW, et al. (2001) Thrombus formation after
the Fontan operation. Ann Thorac Surg 71: 1990-1994.
4. Balling
G, Vogt M, Kaemmerer H, Eicken A, Meisner H, et al. (2000) Intracardiac
thrombus formation after Fontan operation. J Thoracic Cardiovasc Surg 119:
745-752.
5. Haramati
LB, Glickstein JS, Issenberg HR, Haramati N, Croooke GA (2002) MR imaging and
CT of vascular anomalies and connection in patients with congenital heart
disease: Significance in surgical planning. Radiographics 22: 337-349.
6. Chowdhury
UK, Mishra PK, Airan B, Sharma R, Subramaniam GK, et al. (2004) Postoperative
assessment of the univentricular repair by dynamic radionuclide studies. Ann
Thorac Surg 78: 658-665.
7. Monagle
P, Cochrane A, McCrindle B, Benson L, Williams W, et al. (1998) Thromboembolic
complications after Fontan procedure the role of prophylactic anticoagulation.
J Thorac Cardiovasc Surg 115: 493-498.
8. Verma C,
Warr MR, Hendler AL, Paul MS, Webb GD, et al. (2003) Prevalence of silent
pulmonary emboli in adults after the Fontan operation. J Am Coll Cardiol 41:
2252-2258.
9. Kuzo RS,
Goodman LR (1997) CT evaluation of pulmonary emboli: Technique and
interpretation. Am J Roentgenol 169: 959-965.
10. Greaves
SM, Hart EM, Brown K, Young DA, Batra P, et al. (1995) Pulmonary
thromboembolism: Spectrum of clinical findings on CT. AJR Am J Roentgenal 165:
1359-1363.
11. Bergin
CJ, Sirlin CB, Hauschildt JP, Huynh TV, Auger WR, et al. (1997) Chronic
thromboembolism: Diagnosis with helical CT and MR imaging with angiographic and
surgical correlation. Radiology 204: 695-702.
12. Shirai
LK, Rosenthal DN, Reitz BA, Robbins RC, Dubin AM (1998) Arrhythmias and
thromboembolic complications after the extra cardiac Fontan operation. J Thorac
Cardiovasc Surg 115: 499-505.
13. Remy-Jardin
M, Tillie-Leblond I, Szapiro D, Ghaye B, Cotte L, et al. (2002) CT angiography
of pulmonary embolism in patients with underlying respiratory disease: impact
of multi-slice CT on image quality and negative predictive value. Eur Radiol
12: 1971-1978.
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