Objective: Risk factors for major adverse events late after Fontan palliation are unknown. Prior studies have suggested ventricular function and morphology as important risk factors. The aim of this study is to (1) characterize the late major adverse event profile in adult Fontan patients and (2) identify additional risk factors that may contribute to adverse outcomes. Design and Setting: A retrospective review of all adult patients >15 years post-Fontan seen at a tertiary academic center was conducted. Clinical, laboratory, cardiac data, and abdominal imaging were collected via chart review. Major adverse events (death, cardiac transplantation, or listing) were identified, and timing of events was plotted using Kaplan-Meier methods. Univariate and multivariate logistic regression was used to determine independent predictors of late-term events. Results: A total of 123 adult Fontan patients were identified (mean time post-Fontan 22.4 years [±4.4]). Major adverse events occurred in 19/123 patients (15%). In this 15-year survivor cohort, transplant-free survival rates were 94.6%, 82.9%, and 59.8% at 20, 25, and 30 years postoperation, respectively. Modes of death were Fontan failure with preserved function (4), congestive heart failure with decreased function (2), sudden death (2), thromboembolic event (1), post-Fontan conversion (2), and posttransplant (2). No differences in adverse outcomes were found based on morphology of the systemic ventricle, Fontan type, or systolic ventricular function. On the other hand, features of portal hypertension (OR 19.0, CI 4.7-77.3, P < .0001), presence of a pacemaker (OR 13.4, CI 2.6-69.8, P=.002), and systemic oxygen desaturation (OR 0.86, CI 0.75-0.98, P=.02) were risk factors for major adverse events in the multivariate analysis. Conclusions: In adult Fontan patients surviving >15 years post-Fontan, portal hypertension, oxygen desaturation, and need for pacemaker were predictive of adverse events. Traditional measures may not predict late-term outcomes in adult survivors; further study of the liver's role in late outcomes is warranted.

Background. Mid-term survivors of the Fontan procedure are at risk for progressive heart failure, and endothelial dysfunction is thought to contribute to this process. Aldosterone antagonism has been shown to improve survival in adults with heart failure and the effects are mediated in part by changes in endothelial function. In the present study, we sought to determine if a short course of spironolactone improves endothelial function and alters serum cytokine profiles in adolescents and adults with single ventricle heart. Methods. Subjects had baseline assessment of flow-mediated dilation and cytokine profiles (C-reactive protein, interleukin-6, interleukin-1b, interleukin-10, tumor necrosis factor-alpha). They were started on spironolactone 25 mg once a day and uptitrated to 50mg once daily. After 4 weeks, flow-mediated dilation and cytokine profiles were re-evaluated. Results. Ten subjects (median age 28 years) were enrolled and completedthe protocol. The median flow-mediated dilation at baseline was 9.1% and did not change significantly after 4 weeks of spironolactone 7.6%, P =.46. There was mild elevation in serum cytokine profiles and only interleukin-1b decreased significantly with therapy, 0.39 to 0.23 pg/mL, P =.04. Conclusions. In this small study, a short course of spironolactone did not improve endothelial function or alter the majority of serum cytokine levels. Whether single ventricle patients might realize other potential benefits of aldosterone antagonism such as reduced cardiac fibrosis remains to be determined.

Fontan failure can occur even with normal systolic ventricular function and often in the context of significant liver disease. We hypothesized that Fontan failure is hemodynamically distinct from traditional heart failure and characterized by low systemic vascular resistance (SVR) index and preserved cardiac index. Twenty-seven symptomatic adult Fontan (SAF) patients who underwent catheterization from 2001 to 2011 constituted our study group. Fifty-four predominantly asymptomatic pediatric Fontan (PF) patients who underwent catheterization during the same period were randomly selected to perform a control:case cohort analysis. Clinical comparisons were made between the 2 groups. The adults were more symptomatic than the PF cohort (New York Heart Association classes I and II or III and IV: 48% or 52% [SAF] vs 94% or 6% [PF], respectively, p <0.01). SAF versus PF mean catheterization findings were central venous pressure 18 ± 6 versus 14 ± 3 mm Hg (p <0.01), SVR index 1,680 ± 368 versus 1,960 ± 550 dyn s/cm 5/m2 (p = 0.02), and cardiac index 2.7 ± 0.8 versus 2.8 ± 0.7 L/min/m2 (p = 0.25). By imaging, the SAF cohort demonstrated a greater incidence of abnormal liver texture changes (96% vs 75%, p = 0.04) and nodularity (77% vs 42%, p = 0.02). In conclusion, adult patients with failing Fontan circulation had a lower SVR index and similar cardiac index compared with the pediatric cohort. Liver disease in the adults was more advanced. Our data suggest that Fontan failure is a distinct circulatory derangement with hemodynamic features similar to portal hypertension, albeit with limited ability to augment cardiac output.

Congenital heart defects (CHDs) are the most common type of birth defect, affecting ≈1% of births per year.1 Although survival has been improving over time, there remain numerous gaps in the understanding of the public health impact of CHDs across the lifespan. Recognizing that there was “a lack of rigorous epidemiological and longitudinal data on individuals of all ages with congenital heart disease,” the US Congress provided funding through the Appropriations Act of 2012 to the US Centers for Disease Control and Prevention (CDC) to investigate the gaps in understanding of the public health impact of CHDs.2 Given the broad array of possible topics to address with limited resources, the CDC invited experts to a meeting on September 10–11, 2012, to seek individual input on the major gaps in the understanding of CHDs and to suggest public health strategies to address those gaps. Fifty experts attended the meeting representing diverse specialties and perspectives including medical content (CHDs), methods (public health strategies), and personal experience. The group included persons and stakeholders from varied disciplines (physicians, surgeons, epidemiologists, public health officials, advocates, and patients) with a broad representation of public health, professional, and CHD advocacy organizations (the full list of experts is included in the section). Prior to the meeting, participants received background information to lay the foundation for the meeting. Participants were asked to attend 1 of 2 live webinars hosted by the CDC to outline the public health framework for congenital heart defects. Participants also received articles covering key topics in public health and congenital heart defects for review on their own prior to the meeting.3–6 Finally, at the initiation of the meeting, background presentations were delivered on the current state of knowledge for each of the 4 key areas: epidemiology, health services, long-term morbidity/mortality, and long-term psychosocial and neurodevelopmental outcomes. For the major activity of the conference, invitees participated in 1 of 4 focus groups centered on 1 of those key areas. Each group was charged with 3 tasks: (1) identifying the key gaps in public health for CHDs, (2) brainstorming potential strategies to address those gaps, and (3) suggesting a prioritization of the identified gaps and strategies based on their potential impact and feasibility. The results of each group, with notable overlaps, were discussed by the full panel of participants to help guide an overall list of suggested major focus areas. After a large group discussion of the 32 gaps identified, the gaps identified as prioritized, in no particular order, included prevalence of CHDs across the lifespan, risk factors for development of CHDs, long-term outcomes for persons with CHDs, health services delivery for persons with CHDs, and public awareness of the burden and impact of CHDs. As outlined in Table 1, we have synthesized the prioritized gaps and their accompanying strategies into a public health science agenda for CHDs.