Ordonez Maria Victoria, Biglino Giovanni, Bedair Radwa
Bristol Medical School, University of Bristol, Bristol, UK.
Adult Congenital Heart Disease Service, University Hospitals Bristol, NHS Foundation Trust, Bristol, UK.
J Congenit Cardiol. 2021 Mar 24;5:3. doi: 10.1186/s40949-021-00057-z.
There is no consensus on the clinical utility of 'routine' diagnostic cardiac catheterisation in patients with Fontan palliation in the absence of symptoms or haemodynamic lesions.
We sought to evaluate whether diagnostic cardiac catheterisation for a variety of indications led to a change in the clinical management of patients with a Fontan circulation.
All adult patients (≥16 years) with Fontan palliation undergoing diagnostic cardiac catheterisation at our institution from 2016 to 2019 were included retrospectively. Patients undergoing electrophysiological studies were excluded as haemodynamic measurements were not taken. Routine cardiac catheterisation at our institution is considered in adult patients who have not had a diagnostic cardiac catheter for more than 5 years.
Thirty-eight patients, mean age 27 ± 7 years, 60% NYHA I, 31% NYHA II, 8% NYHA III, at mean duration post Fontan of 20 ± 6 years, lateral tunnel (LT) = 20, extracardiac (EC) = 14 and atriopulmonary (AP) = 4, underwent 41 diagnostic cardiac catheterisation procedures. Indication for cardiac catheterisation was as follows: haemodynamic lesion identified on cross-sectional imaging in 12; routine catheterisation in 9; cyanosis in 8; dyspnoea in 8; significant liver stiffness on ultrasound hepatic elastography in 2; and arrhythmia in 2. Of the 9 patients undergoing routine diagnostic catheterisation, 3 had not had any diagnostic catheterisation since their Fontan completion and, in the remaining six, the mean time lapsed since the last diagnostic catheter was 8 ± 3 years. The diagnostic catheterisation led to a recommended change in clinical management on 24 occasions (59%): catheter intervention in 17 (40%); surgery in 4 (10%); medication change in 3 (17%); and transplant referral in 2 (5%). The clinical indications that led to changes in clinical management were: cyanosis (8/8), dyspnoea (7/8), haemodynamic lesions on cross-sectional imaging (8/11) and arrhythmia (1/2). None of the 9 patients listed for routine diagnostic catheterisation or as a result of findings on ultrasound hepatic elastography had a recommended change in clinical management.
Diagnostic cardiac catheterisation frequently leads to changes in the clinical management of patients with Fontan palliation presenting with dyspnoea, cyanosis, and for further evaluation of potential haemodynamic lesions identified on cross-sectional imaging. Routine cardiac catheterisation in the absence of the above indications had limited impact on clinical management in our cohort.
对于无症状或无血流动力学病变的Fontan姑息治疗患者，“常规”诊断性心导管检查的临床效用尚无共识。
我们试图评估针对各种适应证进行的诊断性心导管检查是否会导致Fontan循环患者的临床管理发生改变。
回顾性纳入2016年至2019年在我院接受诊断性心导管检查的所有成年（≥16岁）Fontan姑息治疗患者。排除接受电生理研究的患者，因为未进行血流动力学测量。我院对成年患者进行常规心导管检查的标准是其距离上次诊断性心导管检查超过5年。
38例患者，平均年龄27±7岁，60%为纽约心脏协会（NYHA）心功能I级，31%为NYHA II级，8%为NYHA III级，Fontan手术后平均病程20±6年，其中侧隧道（LT）Fontan术20例，心外（EC）Fontan术14例，心房肺（AP）Fontan术4例，共接受了41次诊断性心导管检查。心导管检查的适应证如下：横断面成像发现血流动力学病变12例；常规导管检查9例；发绀8例；呼吸困难8例；超声肝脏弹性成像显示显著肝硬度2例；心律失常2例。在9例接受常规诊断性导管检查的患者中，3例自Fontan手术完成后未进行过任何诊断性导管检查，其余6例自上次诊断性导管检查后的平均间隔时间为8±3年。诊断性心导管检查导致临床管理建议改变24次（59%）：导管介入17次（40%）；手术4次（10%）；药物改变3次（17%）；转诊进行移植评估2次（5%）。导致临床管理改变的临床适应证为：发绀（8/8）、呼吸困难（7/8）、横断面成像发现血流动力学病变（8/11）和心律失常（1/2）。9例因常规诊断性导管检查或超声肝脏弹性成像结果而接受检查的患者中，均无临床管理建议改变。
诊断性心导管检查常常会使出现呼吸困难、发绀的Fontan姑息治疗患者以及为进一步评估横断面成像发现的潜在血流动力学病变的患者的临床管理发生改变。在无上述适应证的情况下进行常规心导管检查对我们队列中的临床管理影响有限。
