Arterial stiffness in adult patients after Fontan procedure
Cardiovascular Ultrasound
Arterial stiffness in adult patients after Fontan procedure
Lidia Tomkiewicz-Pajak 0
Hanna Dziedzic-Oleksy 0
Jacek Pajak
Maria Olszowska 0
Jacek Kolcz
Monika Komar 0
Piotr Podolec 0
0 Institute of Cardiology, Jagiellonian University Medical College and John Paul II Hospital , 80 Pradnicka St., 31-202 Krakow , Poland
Objectives: Increased arterial stiffness is a risk factor of atherosclerosis and cardio-vascular complications. The aim of the study was to determine whether peripheral vascular function might be an early marker of impaired health status in patients with a single ventricle after Fontan procedure. Methods and results: Twenty five consecutive adults (11 women and 14 men) aged 24.7 ± 6.2 years after the Fontan procedure and 25 sex, age and BMI match healthy volunteers underwent physical examination, blood analysis, transthoracic echocardiography and noninvasive assessment of aortic stiffness. Augmented pressure and Augmentation Index (AIx) were both significantly elevated in Fontan when compared to the controls (6,08 ± 0,7 vs. 2,0 ± 3,7; p = 0.002 and 17,01 ± 3,3 vs. 6,05 ± 11; p < 0.001, respectively). There were no differences in pulse wave velocity (PWV), mean blood pressure (BP), brachial pulse pressure (PP), central: systolic BP, diastolic BP and PP. In Fontan group we find negative correlation between PWV and SatO2 (r = −0.68; p = 0.04) and positive correlation with WBC (0.72; p = 0.72; p = 0.013), INR (0.81; p = 0.008), TNFα (r = 0.45; p = 0.04), and postoperative time (r = 0.77; p = 0.02). AIx correlates positively only with age at surgery (r = 0.45; p = 0.04). Bilirubin level correlates positively with brachial PP (r = 0.71; p = 0.02) and central PP (r = 0.68; p = 0.03). The multivariate model showed that SatO2 (β = −0.44, p = 0.04) was the only independent predictor of PWV (R2 = 0.32, p = 0.03). Conclusion: Adult Fontan patients have an increased arterial stiffness assessed by a noninvasive technique. Low arterial oxygen saturation postoperative time, age at surgery, white blood cells, TNFα and bilirubin level are associated with arterial stiffening in these patients. The combination of blood parameters of the hepatic function and noninvasive measurements of arterial stiffness could be helpful in comprehensive care of patients with Fontan circulation.
Adult; Fontan patients; Arterial stiffness
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Introduction
Non-invasive measurement of vascular parameters is
increasingly used to assess the risk of cardiovascular disease.
It is considered that the loss of elasticity of the walls of the
arteries, especially the aorta is a marker of the early changes
that may lead to the development of atherosclerosis and its
following complications (eg, hypertension, stroke,
myocardial infarction) in healthy individuals [1]. Increase in arterial
stiffness was proven to be caused by several factors such
as age, hypertension, hypercholesterolemia, diabetes, and
smoking [2-5]. In the detection of early growth of the aortic
wall stiffness pulse wave velocity (PWV) and/or
augmentation index (AIx) are commonly used [6].
Fontan operation is a widely used method of treatment
of patients with single ventricle. The main goal of this
procedure is the separation of the pulmonary and
systemic circulation. The treatment is multistage and it
results in the absence of subpulmonary ventricle. The
blood flow through the lungs is effected due to the
pressure gradient between the systemic veins and the left
atrium and has non-pulsatile character [7,8].
A vast majority of the patients born with a functional
single ventricle, who underwent Fontan surgery in early
childhood, survive over 20 years [9]. The longer the time
since the surgery, the more frequent remote
complications are noted [8,9]. Thus patients are at high risk of
mortality and morbidity. The development of impaired
functional health status is caused by reduced cardiac
output, increased systemic vascular resistance,
ventricular dysfunction, arrhythmia, and heart failure [7-10].
The present study was designed to evaluate the
usefulness of the noninvasive measurement of arterial stiffness
to determine whether peripheral vascular function might
be an early marker of impaired health status in patients
with a single ventricle after Fontan procedure. We also
evaluated the impact of endothelial dysfunction and
inflammation on parameters of arterial stiffness.
Material and methods
Study population
The patients were recruited consecutively at the John
Paul II Hospital in Krakow and enrolled into the study if
they had had the Fontan operation, were ≥18 years old,
and were clinically stable for at least 3 months before
the study.
The patients underwent physical examination, blood
analysis, transthoracic echocardiography and
noninvasive assessment of aortic stiffness. Medical histories were
taken and they included demographic, anatomic data,
previous interventions and medical therapy. The
exclusion criteria were: arrhythmia, any acute illness, (...truncated)