# Single Ventricle / HLHS — GCMD Library living collection

Also covered as: cloaca · anorectal malformation · tethered cord · pulmonary hypoplasia · scoliosis · hypoplastic left heart syndrome · urogenital sinus · pulmonary hypertension

Experts: Dr. Todd Ponsky, Dr. Ian Glenn, Dr. Marc Levitt, Dr. Dr. Veldman

Updated: n/a · 12 episodes · 312 cited statements

## Episodes
### Fundamentals
- [How Does the Blood Go Round in Single Ventricles and Fontans? New Horizons in...](https://team.globalcastmd.com/watch/how-does-the-blood-go-round-in-single-ventricles-and-fontans-new-horizons-in-896) — video · 24:58 · [machine version](https://team.globalcastmd.com/watch/how-does-the-blood-go-round-in-single-ventricles-and-fontans-new-horizons-in-896.md)

### Diagnosis & Workup
- [Advanced Imaging of the Fontan, What is Driving Fontan Failure: New Horizons...](https://team.globalcastmd.com/watch/advanced-imaging-of-the-fontan-what-is-driving-fontan-failure-new-horizons-892) — video · 24:44 · [machine version](https://team.globalcastmd.com/watch/advanced-imaging-of-the-fontan-what-is-driving-fontan-failure-new-horizons-892.md)
- [Case Review Dynamic Assessment of the Fontan Part II: New Horizons in Medical...](https://team.globalcastmd.com/watch/case-review-dynamic-assessment-of-the-fontan-part-ii-new-horizons-in-medical-894) — video · 14:38 · [machine version](https://team.globalcastmd.com/watch/case-review-dynamic-assessment-of-the-fontan-part-ii-new-horizons-in-medical-894.md)
- [Case Review Dynamic Assessment of the Fontan Part I: New Horizons in Medical...](https://team.globalcastmd.com/watch/case-review-dynamic-assessment-of-the-fontan-part-i-new-horizons-in-medical-895) — video · 22:46 · [machine version](https://team.globalcastmd.com/watch/case-review-dynamic-assessment-of-the-fontan-part-i-new-horizons-in-medical-895.md)

### Medical Management
- [How do we manage thrombogenicity and thrombosis in the Fontan? New Horizons...](https://team.globalcastmd.com/watch/how-do-we-manage-thrombogenicity-and-thrombosis-in-the-fontan-new-horizons-886) — video · 16:51 · [machine version](https://team.globalcastmd.com/watch/how-do-we-manage-thrombogenicity-and-thrombosis-in-the-fontan-new-horizons-886.md)
- [The Role of Trans-Catheter Arrhythmia Management - Patient Based Decision...](https://team.globalcastmd.com/watch/the-role-of-trans-catheter-arrhythmia-management-patient-based-decision-890) — video · 20:55 · [machine version](https://team.globalcastmd.com/watch/the-role-of-trans-catheter-arrhythmia-management-patient-based-decision-890.md)

### Surgical Management
- [Update on Surgical Practice and Current State on Fontan Conversion Surgery:...](https://team.globalcastmd.com/watch/update-on-surgical-practice-and-current-state-on-fontan-conversion-surgery-889) — video · 25:00 · [machine version](https://team.globalcastmd.com/watch/update-on-surgical-practice-and-current-state-on-fontan-conversion-surgery-889.md)
- [Transplantation and Ventricular Assist Devices: New Horizons in Medical and...](https://team.globalcastmd.com/watch/transplantation-and-ventricular-assist-devices-new-horizons-in-medical-and-891) — video · 23:13 · [machine version](https://team.globalcastmd.com/watch/transplantation-and-ventricular-assist-devices-new-horizons-in-medical-and-891.md)
- [Trans-Catheter Interventions: New Horizons in Medical and Surgical Fontan...](https://team.globalcastmd.com/watch/trans-catheter-interventions-new-horizons-in-medical-and-surgical-fontan-893) — video · 17:26 · [machine version](https://team.globalcastmd.com/watch/trans-catheter-interventions-new-horizons-in-medical-and-surgical-fontan-893.md)

### Evidence & Research
- [Outcomes of Fontan Patients Undergoing Combined Heart - Liver Transplantation in Pediatric Hospitals Across the U.S.](https://team.globalcastmd.com/watch/outcomes-of-fontan-patients-undergoing-combined-heart-liver-transplantation-in-pediatric-hospitals-across-the-u-s-11307) — video · 0:59 · [machine version](https://team.globalcastmd.com/watch/outcomes-of-fontan-patients-undergoing-combined-heart-liver-transplantation-in-pediatric-hospitals-across-the-u-s-11307.md)

### Case-Based Learning
- [Pregnancy in a Fontan Patient:  New Horizons in Medical and Surgical Fontan...](https://team.globalcastmd.com/watch/pregnancy-in-a-fontan-patient-new-horizons-in-medical-and-surgical-fontan-887) — video · 18:27 · [machine version](https://team.globalcastmd.com/watch/pregnancy-in-a-fontan-patient-new-horizons-in-medical-and-surgical-fontan-887.md)

### Long-Term Care
- [Psychosocial Outcomes: New Horizons in Medical and Surgical Fontan Management...](https://team.globalcastmd.com/watch/psychosocial-outcomes-new-horizons-in-medical-and-surgical-fontan-management-888) — video · 22:39 · [machine version](https://team.globalcastmd.com/watch/psychosocial-outcomes-new-horizons-in-medical-and-surgical-fontan-management-888.md)

## Chapters
- [0:00](https://team.globalcastmd.com/watch/how-do-we-manage-thrombogenicity-and-thrombosis-in-the-fontan-new-horizons-886?t=0) Introduction and thrombotic burden in Fontan circulation (Ep 1)
- [3:19](https://team.globalcastmd.com/watch/how-do-we-manage-thrombogenicity-and-thrombosis-in-the-fontan-new-horizons-886?t=199) Case 1: Young adult with superficial thrombophlebitis and abnormal labs (Ep 1)
- [4:40](https://team.globalcastmd.com/watch/how-do-we-manage-thrombogenicity-and-thrombosis-in-the-fontan-new-horizons-886?t=280) Pathophysiology: Virchow's triad in Fontan circulation (Ep 1)
- [5:48](https://team.globalcastmd.com/watch/how-do-we-manage-thrombogenicity-and-thrombosis-in-the-fontan-new-horizons-886?t=348) Aspirin versus warfarin and time-in-therapeutic-range data (Ep 1)
- [7:41](https://team.globalcastmd.com/watch/how-do-we-manage-thrombogenicity-and-thrombosis-in-the-fontan-new-horizons-886?t=461) Case 2: Active 10-year-old with factor V Leiden and challenges of universal anticoagulation (Ep 1)
- [9:16](https://team.globalcastmd.com/watch/how-do-we-manage-thrombogenicity-and-thrombosis-in-the-fontan-new-horizons-886?t=556) Biomarkers for risk stratification and the honeymoon phase (Ep 1)
- [12:13](https://team.globalcastmd.com/watch/how-do-we-manage-thrombogenicity-and-thrombosis-in-the-fontan-new-horizons-886?t=733) Proposed personalized monitoring approach and case management (Ep 1)
- [15:20](https://team.globalcastmd.com/watch/how-do-we-manage-thrombogenicity-and-thrombosis-in-the-fontan-new-horizons-886?t=920) Direct oral anticoagulants: need for data and monitoring (Ep 1)
- [0:00](https://team.globalcastmd.com/watch/pregnancy-in-a-fontan-patient-new-horizons-in-medical-and-surgical-fontan-887?t=0) Case Presentation: 21-Year-Old Pregnant Fontan Patient (Ep 2)
- [5:58](https://team.globalcastmd.com/watch/pregnancy-in-a-fontan-patient-new-horizons-in-medical-and-surgical-fontan-887?t=358) General Principles of Pregnancy in Fontan Patients (Ep 2)
- [12:37](https://team.globalcastmd.com/watch/pregnancy-in-a-fontan-patient-new-horizons-in-medical-and-surgical-fontan-887?t=757) Antepartum Care, Delivery Planning, and Contraception (Ep 2)
- [17:15](https://team.globalcastmd.com/watch/pregnancy-in-a-fontan-patient-new-horizons-in-medical-and-surgical-fontan-887?t=1035) Closing Discussion on Anticoagulation Strategy (Ep 2)
- [0:00](https://team.globalcastmd.com/watch/psychosocial-outcomes-new-horizons-in-medical-and-surgical-fontan-management-888?t=0) Introduction and Psychosocial Framework for Fontan Patients (Ep 3)
- [4:32](https://team.globalcastmd.com/watch/psychosocial-outcomes-new-horizons-in-medical-and-surgical-fontan-management-888?t=272) Neurodevelopmental Issues and Mental Health Prevalence (Ep 3)
- [8:21](https://team.globalcastmd.com/watch/psychosocial-outcomes-new-horizons-in-medical-and-surgical-fontan-management-888?t=501) Case Presentation: 15-Year-Old Fontan Patient Background (Ep 3)
- [14:12](https://team.globalcastmd.com/watch/psychosocial-outcomes-new-horizons-in-medical-and-surgical-fontan-management-888?t=852) Case Presentation: Evaluation Results and Diagnoses (Ep 3)
- [18:31](https://team.globalcastmd.com/watch/psychosocial-outcomes-new-horizons-in-medical-and-surgical-fontan-management-888?t=1111) Care Plan, Discussion, and Clinical Recommendations (Ep 3)
- [0:00](https://team.globalcastmd.com/watch/update-on-surgical-practice-and-current-state-on-fontan-conversion-surgery-889?t=0) Introduction and Speaker Handoff (Ep 4)
- [1:23](https://team.globalcastmd.com/watch/update-on-surgical-practice-and-current-state-on-fontan-conversion-surgery-889?t=83) Fontan Takedown: Indications and Outcomes (Ep 4)
- [5:10](https://team.globalcastmd.com/watch/update-on-surgical-practice-and-current-state-on-fontan-conversion-surgery-889?t=310) Fontan Conversion: Technique and Arrhythmia Management (Ep 4)
- [10:39](https://team.globalcastmd.com/watch/update-on-surgical-practice-and-current-state-on-fontan-conversion-surgery-889?t=639) Patient Selection and Future of Fontan Conversion (Ep 4)
- [13:46](https://team.globalcastmd.com/watch/update-on-surgical-practice-and-current-state-on-fontan-conversion-surgery-889?t=826) Heart Transplantation: Surgical Technique for Fontan Anatomy (Ep 4)
- [16:48](https://team.globalcastmd.com/watch/update-on-surgical-practice-and-current-state-on-fontan-conversion-surgery-889?t=1008) Lymphatic Decompression and Conclusions (Ep 4)
- [19:32](https://team.globalcastmd.com/watch/update-on-surgical-practice-and-current-state-on-fontan-conversion-surgery-889?t=1172) Audience Poll Results and Discussion (Ep 4)
- [22:45](https://team.globalcastmd.com/watch/update-on-surgical-practice-and-current-state-on-fontan-conversion-surgery-889?t=1365) Late Fontan Takedown Feasibility Discussion (Ep 4)
- [0:00](https://team.globalcastmd.com/watch/the-role-of-trans-catheter-arrhythmia-management-patient-based-decision-890?t=0) Introduction and case presentations (Ep 5)
- [1:44](https://team.globalcastmd.com/watch/the-role-of-trans-catheter-arrhythmia-management-patient-based-decision-890?t=104) Natural history and treatment limitations (Ep 5)
- [3:31](https://team.globalcastmd.com/watch/the-role-of-trans-catheter-arrhythmia-management-patient-based-decision-890?t=211) Fontan type and ablation access challenges (Ep 5)
- [7:00](https://team.globalcastmd.com/watch/the-role-of-trans-catheter-arrhythmia-management-patient-based-decision-890?t=420) Tachycardia mechanisms and ablation targets (Ep 5)
- [9:56](https://team.globalcastmd.com/watch/the-role-of-trans-catheter-arrhythmia-management-patient-based-decision-890?t=596) Ablation outcomes and realistic goals (Ep 5)
- [13:12](https://team.globalcastmd.com/watch/the-role-of-trans-catheter-arrhythmia-management-patient-based-decision-890?t=792) Management approach and conclusions (Ep 5)
- [15:09](https://team.globalcastmd.com/watch/the-role-of-trans-catheter-arrhythmia-management-patient-based-decision-890?t=909) Panel discussion and audience poll (Ep 5)
- [0:00](https://team.globalcastmd.com/watch/transplantation-and-ventricular-assist-devices-new-horizons-in-medical-and-891?t=0) Introduction and Early Fontan Failure (Ep 6)
- [2:55](https://team.globalcastmd.com/watch/transplantation-and-ventricular-assist-devices-new-horizons-in-medical-and-891?t=175) Risk Factors and Late Fontan Failure Outcomes (Ep 6)
- [5:14](https://team.globalcastmd.com/watch/transplantation-and-ventricular-assist-devices-new-horizons-in-medical-and-891?t=314) Protein-Losing Enteropathy and Plastic Bronchitis (Ep 6)
- [8:46](https://team.globalcastmd.com/watch/transplantation-and-ventricular-assist-devices-new-horizons-in-medical-and-891?t=526) Transplant Outcomes and Allocation System Challenges (Ep 6)
- [11:46](https://team.globalcastmd.com/watch/transplantation-and-ventricular-assist-devices-new-horizons-in-medical-and-891?t=706) Mechanical Support Device Selection (Ep 6)
- [18:19](https://team.globalcastmd.com/watch/transplantation-and-ventricular-assist-devices-new-horizons-in-medical-and-891?t=1099) Goals of Mechanical Support and Future Directions (Ep 6)
- [20:02](https://team.globalcastmd.com/watch/transplantation-and-ventricular-assist-devices-new-horizons-in-medical-and-891?t=1202) Destination Therapy and Atrial Cannulation Discussion (Ep 6)
- [0:00](https://team.globalcastmd.com/watch/advanced-imaging-of-the-fontan-what-is-driving-fontan-failure-new-horizons-892?t=0) Introduction and ventricular assessment in Fontan failure (Ep 7)

## Statements
Every statement is attributed, typed, and timestamped; the link is the citation.
- The patient underwent coarctation repair and PA banding at 2 days of life via end-to-end anastomotic repair after resection of coarc segment, plus left carotid to left subclavian artery side-to-side anastomosis — Anisa Chowdhury (clinical) [Ep 2 · 0:46](https://team.globalcastmd.com/watch/pregnancy-in-a-fontan-patient-new-horizons-in-medical-and-surgical-fontan-887?t=46)
- The patient underwent right modified Blalock-Thomas-Taussig shunt at 6 weeks of age, bidirectional Glenn at 6 months, and 20mm extracardiac Fontan at 4 years of age — Anisa Chowdhury (clinical) [Ep 2 · 1:00](https://team.globalcastmd.com/watch/pregnancy-in-a-fontan-patient-new-horizons-in-medical-and-surgical-fontan-887?t=60)
- The Fontan fenestration spontaneously closed and patient had transcatheter coil and vascular plugging of veno-venous collaterals at approximately 10 years of age — Anisa Chowdhury (clinical) [Ep 2 · 1:12](https://team.globalcastmd.com/watch/pregnancy-in-a-fontan-patient-new-horizons-in-medical-and-surgical-fontan-887?t=72)
- On 2006 catheterization, Fontan pressures were 12 mmHg and left ventricular end-diastolic pressure was 5 mmHg, both normal — Anisa Chowdhury (clinical) [Ep 2 · 1:22](https://team.globalcastmd.com/watch/pregnancy-in-a-fontan-patient-new-horizons-in-medical-and-surgical-fontan-887?t=82)
- Patient was lost to follow-up from age 16 to 21 years until presenting pregnant in first trimester — Anisa Chowdhury (clinical) [Ep 2 · 1:41](https://team.globalcastmd.com/watch/pregnancy-in-a-fontan-patient-new-horizons-in-medical-and-surgical-fontan-887?t=101)
- Lisinopril is teratogenic and should be stopped in pregnancy — Anisa Chowdhury (guideline) [Ep 2 · 1:49](https://team.globalcastmd.com/watch/pregnancy-in-a-fontan-patient-new-horizons-in-medical-and-surgical-fontan-887?t=109)
- Patient had 3 prior miscarriages and was told to use Depo-Provera contraception but only had 1 injection in past 3-4 years — Anisa Chowdhury (clinical) [Ep 2 · 1:58](https://team.globalcastmd.com/watch/pregnancy-in-a-fontan-patient-new-horizons-in-medical-and-surgical-fontan-887?t=118)
- Patient had baseline NYHA class 2-3 dyspneic symptoms (short of breath climbing one flight of stairs or walking 2 blocks) with no change during first couple trimesters of pregnancy — Anisa Chowdhury (clinical) [Ep 2 · 2:08](https://team.globalcastmd.com/watch/pregnancy-in-a-fontan-patient-new-horizons-in-medical-and-surgical-fontan-887?t=128)
- Patient's oxygen saturation was low-normal at 92% on room air — Anisa Chowdhury (clinical) [Ep 2 · 2:39](https://team.globalcastmd.com/watch/pregnancy-in-a-fontan-patient-new-horizons-in-medical-and-surgical-fontan-887?t=159)
- Echocardiogram showed mildly reduced left ventricular systolic function with estimated LVEF 45-50% — Anisa Chowdhury (clinical) [Ep 2 · 3:20](https://team.globalcastmd.com/watch/pregnancy-in-a-fontan-patient-new-horizons-in-medical-and-surgical-fontan-887?t=200)
- Patient had mild polycythemia with hemoglobin of 17, indicative of probable intermittent desaturations likely from venous collaterals — Anisa Chowdhury (clinical) [Ep 2 · 4:20](https://team.globalcastmd.com/watch/pregnancy-in-a-fontan-patient-new-horizons-in-medical-and-surgical-fontan-887?t=260)
- Patient was classified as WHO class 3 risk, indicating significantly elevated risk of both maternal morbidity and mortality during peripartum period — Anisa Chowdhury (clinical) [Ep 2 · 4:43](https://team.globalcastmd.com/watch/pregnancy-in-a-fontan-patient-new-horizons-in-medical-and-surgical-fontan-887?t=283)
- Management included aspirin 162 mg daily; stronger anticoagulation not pursued given unremarkable thrombophilia profile — Anisa Chowdhury (clinical) [Ep 2 · 5:06](https://team.globalcastmd.com/watch/pregnancy-in-a-fontan-patient-new-horizons-in-medical-and-surgical-fontan-887?t=306)
- Beta blocker was considered if LV function remained depressed on subsequent visits — Anisa Chowdhury (clinical) [Ep 2 · 5:18](https://team.globalcastmd.com/watch/pregnancy-in-a-fontan-patient-new-horizons-in-medical-and-surgical-fontan-887?t=318)
- Normal pregnancy causes decreased systemic vascular resistance, decreased PVR, increased heart rate, drop in blood pressure mid-pregnancy that rises again, and increase in cardiac output by about 50% and blood volume by 25% — Nicole Brown (clinical) [Ep 2 · 7:11](https://team.globalcastmd.com/watch/pregnancy-in-a-fontan-patient-new-horizons-in-medical-and-surgical-fontan-887?t=431)
- Risk of thrombosis is about 6 times normal during pregnancy and as high as 11 times normal in first 6 weeks postpartum — Nicole Brown (epidemiological) [Ep 2 · 7:33](https://team.globalcastmd.com/watch/pregnancy-in-a-fontan-patient-new-horizons-in-medical-and-surgical-fontan-887?t=453)
- During labor without analgesia, cardiac output may increase by about 30% during each contraction; with regional analgesia this is mitigated to some degree — Nicole Brown (clinical) [Ep 2 · 7:53](https://team.globalcastmd.com/watch/pregnancy-in-a-fontan-patient-new-horizons-in-medical-and-surgical-fontan-887?t=473)
- It takes about 6 months for cardiac output to return to non-pregnant levels postpartum — Nicole Brown (clinical) [Ep 2 · 8:26](https://team.globalcastmd.com/watch/pregnancy-in-a-fontan-patient-new-horizons-in-medical-and-surgical-fontan-887?t=506)
- Miscarriage rate among Fontan single ventricle patients is about 46% — Nicole Brown (epidemiological) [Ep 2 · 8:45](https://team.globalcastmd.com/watch/pregnancy-in-a-fontan-patient-new-horizons-in-medical-and-surgical-fontan-887?t=525)
- In a systematic review of about 198 pregnancies in 110 Fontan women, there were no maternal deaths — Nicole Brown (epidemiological) [Ep 2 · 9:05](https://team.globalcastmd.com/watch/pregnancy-in-a-fontan-patient-new-horizons-in-medical-and-surgical-fontan-887?t=545)
- In Fontan pregnancies, SVT occurs in about 8.9% and heart failure in about 5% — Nicole Brown (epidemiological) [Ep 2 · 9:22](https://team.globalcastmd.com/watch/pregnancy-in-a-fontan-patient-new-horizons-in-medical-and-surgical-fontan-887?t=562)
- Most Fontan women deliver between 26 and 36 weeks gestation, not making it to term (37 weeks) — Nicole Brown (epidemiological) [Ep 2 · 9:40](https://team.globalcastmd.com/watch/pregnancy-in-a-fontan-patient-new-horizons-in-medical-and-surgical-fontan-887?t=580)
- Risk of congenital heart disease in fetus of Fontan mother is probably between 3-10% — Nicole Brown (epidemiological) [Ep 2 · 9:56](https://team.globalcastmd.com/watch/pregnancy-in-a-fontan-patient-new-horizons-in-medical-and-surgical-fontan-887?t=596)
- WHO class 3 indicates significantly increased risk of maternal mortality or severe morbidity; in Fontan pregnancy it is more the morbidity that is concerning, not the mortality — Nicole Brown (clinical) [Ep 2 · 10:23](https://team.globalcastmd.com/watch/pregnancy-in-a-fontan-patient-new-horizons-in-medical-and-surgical-fontan-887?t=623)
- Fontan women should be followed in a multidisciplinary care unit with serial echocardiograms — Nicole Brown (guideline) [Ep 2 · 10:52](https://team.globalcastmd.com/watch/pregnancy-in-a-fontan-patient-new-horizons-in-medical-and-surgical-fontan-887?t=652)
- Higher-risk Fontan patients include those with significant NYHA functional class deterioration, residual cyanosis, pulmonary hypertension, arrhythmias, multi-organ failure, or protein-losing enteropathy; these should be classified as class 4 and advised against pregnancy — Nicole Brown (guideline) [Ep 2 · 11:20](https://team.globalcastmd.com/watch/pregnancy-in-a-fontan-patient-new-horizons-in-medical-and-surgical-fontan-887?t=680)
- Warfarin is concerning from aspect of teratogenicity, especially in first trimester — Nicole Brown (clinical) [Ep 2 · 13:35](https://team.globalcastmd.com/watch/pregnancy-in-a-fontan-patient-new-horizons-in-medical-and-surgical-fontan-887?t=815)
- Aspirin seems reasonable for most Fontan pregnant patients — Nicole Brown (opinion) [Ep 2 · 13:46](https://team.globalcastmd.com/watch/pregnancy-in-a-fontan-patient-new-horizons-in-medical-and-surgical-fontan-887?t=826)
- For Fontan patients at higher thrombotic risk (arrhythmias, prior clot, low cardiac output), therapeutic anticoagulation should be considered — Nicole Brown (guideline) [Ep 2 · 13:51](https://team.globalcastmd.com/watch/pregnancy-in-a-fontan-patient-new-horizons-in-medical-and-surgical-fontan-887?t=831)
- Delivery should be at tertiary care center where highest level of cardiac, OB, anesthesia, and neonatal care is available — Nicole Brown (guideline) [Ep 2 · 14:27](https://team.globalcastmd.com/watch/pregnancy-in-a-fontan-patient-new-horizons-in-medical-and-surgical-fontan-887?t=867)
- Left lateral decubitus position improves systemic venous return in pregnant Fontan patients — Nicole Brown (clinical) [Ep 2 · 14:50](https://team.globalcastmd.com/watch/pregnancy-in-a-fontan-patient-new-horizons-in-medical-and-surgical-fontan-887?t=890)
- Fontan patients should be kept adequately hydrated but avoid fluid overload — Nicole Brown (guideline) [Ep 2 · 14:56](https://team.globalcastmd.com/watch/pregnancy-in-a-fontan-patient-new-horizons-in-medical-and-surgical-fontan-887?t=896)
- Vaginal delivery with epidural is the preferred method for most Fontan women from cardiovascular perspective — Nicole Brown (guideline) [Ep 2 · 15:10](https://team.globalcastmd.com/watch/pregnancy-in-a-fontan-patient-new-horizons-in-medical-and-surgical-fontan-887?t=910)
- Oxytocin should be used at lowest effective dose to avoid significant hemodynamic fluctuations — Nicole Brown (guideline) [Ep 2 · 15:24](https://team.globalcastmd.com/watch/pregnancy-in-a-fontan-patient-new-horizons-in-medical-and-surgical-fontan-887?t=924)
- Fontan women should stay in hospital for up to about a week postpartum because that is how long it takes for hemodynamics to settle back out — Nicole Brown (guideline) [Ep 2 · 15:32](https://team.globalcastmd.com/watch/pregnancy-in-a-fontan-patient-new-horizons-in-medical-and-surgical-fontan-887?t=932)
- Estrogen-containing contraceptives should be avoided in Fontan women because of increased thrombogenicity — Nicole Brown (guideline) [Ep 2 · 15:58](https://team.globalcastmd.com/watch/pregnancy-in-a-fontan-patient-new-horizons-in-medical-and-surgical-fontan-887?t=958)
- Pneumoperitoneum required for laparoscopic tubal ligation may be detrimental for Fontan patients — Nicole Brown (clinical) [Ep 2 · 16:10](https://team.globalcastmd.com/watch/pregnancy-in-a-fontan-patient-new-horizons-in-medical-and-surgical-fontan-887?t=970)
- Subdermal contraceptive implants are lowest risk, requiring only local anesthesia — Nicole Brown (opinion) [Ep 2 · 16:23](https://team.globalcastmd.com/watch/pregnancy-in-a-fontan-patient-new-horizons-in-medical-and-surgical-fontan-887?t=983)
- The aspirin dose of 162 mg in this patient was based on aspirin resistance testing — Veldman (clinical) [Ep 2 · 18:06](https://team.globalcastmd.com/watch/pregnancy-in-a-fontan-patient-new-horizons-in-medical-and-surgical-fontan-887?t=1086)
- Many centers use full anticoagulation in pregnant Fontan patients by definition, but this carries risk of antepartum and postpartum hemorrhage — Veldman (clinical) [Ep 2 · 18:14](https://team.globalcastmd.com/watch/pregnancy-in-a-fontan-patient-new-horizons-in-medical-and-surgical-fontan-887?t=1094)
- Psychosocial functioning is the interplay between psychological factors (internal processes including neurocognitive functioning, cognitive and intellectual functioning, executive functioning, mood, anxiety, temperament, and personality factors) and social factors (levels of social support including family supports, school supports for children, employment, social interactions with peers, community involvement, and areas where they may feel productive in their social roles). — Stacey Morrison (clinical) [Ep 3 · 1:42](https://team.globalcastmd.com/watch/psychosocial-outcomes-new-horizons-in-medical-and-surgical-fontan-management-888?t=102)
- The presence of a congenital heart defect, especially a Fontan, often results in enormous emotional and financial strain on families, with continual effects from ongoing medical care and routine disruptions. — Stacey Morrison (clinical) [Ep 3 · 2:40](https://team.globalcastmd.com/watch/psychosocial-outcomes-new-horizons-in-medical-and-surgical-fontan-management-888?t=160)
- Early life experiences of families with Fontan patients have profound impact and these experiences resonate across a lifetime. — Stacey Morrison (clinical) [Ep 3 · 3:11](https://team.globalcastmd.com/watch/psychosocial-outcomes-new-horizons-in-medical-and-surgical-fontan-management-888?t=191)
- Children with complex CHD are at risk of neurological and cognitive impairment, and Fontan patients may be especially vulnerable. — Stacey Morrison (clinical) [Ep 3 · 3:24](https://team.globalcastmd.com/watch/psychosocial-outcomes-new-horizons-in-medical-and-surgical-fontan-management-888?t=204)
- A multidisciplinary clinic at Children's includes psychology, developmental pediatricians, cardiologists, social work, education consultant, OT, nutrition, and speech and language professionals, focusing on evaluation, consultation, and coordination of care for especially vulnerable children followed into adulthood. — Stacey Morrison (clinical) [Ep 3 · 3:34](https://team.globalcastmd.com/watch/psychosocial-outcomes-new-horizons-in-medical-and-surgical-fontan-management-888?t=214)
- As adults, Fontan patients remain at risk for significant sequelae and face significant and very unique life stressors that place them at increased risk for ongoing distress. — Stacey Morrison (clinical) [Ep 3 · 4:13](https://team.globalcastmd.com/watch/psychosocial-outcomes-new-horizons-in-medical-and-surgical-fontan-management-888?t=253)
- Typical neurodevelopmental issues in Fontan patients include lower IQ, difficulty with math and language-based academic achievement, impairments in expressive and receptive language skills and written expression skills (including organization and planning of expression), executive functioning deficits (behavioral and metacognitive), flexible attention shifting problems (distractibility and hyperfocus), poor planning and organization problems, difficulty with time management, diminished fine and gross motor skills, working memory issues, and slowed processing speed. — Stacey Morrison (clinical) [Ep 3 · 4:32](https://team.globalcastmd.com/watch/psychosocial-outcomes-new-horizons-in-medical-and-surgical-fontan-management-888?t=272)
- A very high number of Fontan patients are left-handed (anecdotal observation). — Stacey Morrison (clinical) [Ep 3 · 5:44](https://team.globalcastmd.com/watch/psychosocial-outcomes-new-horizons-in-medical-and-surgical-fontan-management-888?t=344)
- Approximately 1 in 3 adults with CHD in North America experience difficulty with depression and/or anxiety. — Stacey Morrison (epidemiological) [Ep 3 · 6:02](https://team.globalcastmd.com/watch/psychosocial-outcomes-new-horizons-in-medical-and-surgical-fontan-management-888?t=362)
- Adolescents with single ventricle congenital heart disease have a 5-fold increase in rates of anxiety disorders as well as ADHD compared with their healthy control peers. — Stacey Morrison (epidemiological) [Ep 3 · 6:13](https://team.globalcastmd.com/watch/psychosocial-outcomes-new-horizons-in-medical-and-surgical-fontan-management-888?t=373)
- Adults with CHD may have significantly higher risk of PTSD than in the general population. — Stacey Morrison (epidemiological) [Ep 3 · 6:29](https://team.globalcastmd.com/watch/psychosocial-outcomes-new-horizons-in-medical-and-surgical-fontan-management-888?t=389)
- The chronic impact over time of disruption contributes to PTSD risk, and parents early on also show signs of PTSD. — Stacey Morrison (clinical) [Ep 3 · 6:50](https://team.globalcastmd.com/watch/psychosocial-outcomes-new-horizons-in-medical-and-surgical-fontan-management-888?t=410)
- Mitigating psychosocial factors for adults with Fontan include differences in body image or perceptions of scarring, perceived health status or severity of disease, poor social support or social anxiety, performance anxiety, tendency to compare themselves and feel different than others with difficulties in social situations, communication skill deficits extending into adulthood, lack of awareness of how these factors impact self-adjustment and ability to interact with others and coping skills, perceived or real lack of independence, impulsivity or poor problem solving, ongoing difficulty maintaining employment for physical or psychological reasons, and contributing financial strain. — Stacey Morrison (clinical) [Ep 3 · 7:07](https://team.globalcastmd.com/watch/psychosocial-outcomes-new-horizons-in-medical-and-surgical-fontan-management-888?t=427)
- The case patient is a 15-year-old female with complex medical history resulting in a Fontan, who had feeding difficulties early on requiring a G-tube in early childhood. — Stacey Morrison (clinical) [Ep 3 · 8:43](https://team.globalcastmd.com/watch/psychosocial-outcomes-new-horizons-in-medical-and-surgical-fontan-management-888?t=523)
- Extra medical requirements such as G-tubes can contribute to changes in parent-child interactions and family dynamics. — Stacey Morrison (clinical) [Ep 3 · 9:06](https://team.globalcastmd.com/watch/psychosocial-outcomes-new-horizons-in-medical-and-surgical-fontan-management-888?t=546)
- The case patient has an extensive medication regimen, could verbalize her medication list, was very aware of all medications, and was reported to take them consistently; on adaptive scales, self-care and health management was really high. — Stacey Morrison (clinical) [Ep 3 · 9:16](https://team.globalcastmd.com/watch/psychosocial-outcomes-new-horizons-in-medical-and-surgical-fontan-management-888?t=556)
- Children and young adults who tend to be anxious do a really nice job of taking care of their healthcare regimen and are very hypervigilant about that area. — Stacey Morrison (clinical) [Ep 3 · 9:39](https://team.globalcastmd.com/watch/psychosocial-outcomes-new-horizons-in-medical-and-surgical-fontan-management-888?t=579)
- The case patient lives in a rural area with her mother and 16-year-old brother; parents are divorced (contentious early on), and she does not have consistent contact with her father. — Stacey Morrison (clinical) [Ep 3 · 10:05](https://team.globalcastmd.com/watch/psychosocial-outcomes-new-horizons-in-medical-and-surgical-fontan-management-888?t=605)
- The case patient had friends in school but recently moved, lost established friends, and her closest friend had moved away with no contact; the family as a whole is pretty isolated and mother is under quite a bit of stress. — Stacey Morrison (clinical) [Ep 3 · 10:21](https://team.globalcastmd.com/watch/psychosocial-outcomes-new-horizons-in-medical-and-surgical-fontan-management-888?t=621)
- The case patient just transitioned into high school with academic concerns surrounding reading comprehension, math reasoning, retention of complex academic information (especially abstract reasoning), and applied skills including written expression. — Stacey Morrison (clinical) [Ep 3 · 11:00](https://team.globalcastmd.com/watch/psychosocial-outcomes-new-horizons-in-medical-and-surgical-fontan-management-888?t=660)
- The case patient missed quite a bit of school for medical reasons (appointments and procedures), and over time there were increased days staying home because she didn't feel good, probably could have gone to school at least part of the day, which played into anxiety and comfort of being home. — Stacey Morrison (clinical) [Ep 3 · 11:09](https://team.globalcastmd.com/watch/psychosocial-outcomes-new-horizons-in-medical-and-surgical-fontan-management-888?t=669)
- Loss of school days results in losing instruction time, piled-up assignments, and missing social interaction and positive social experiences that contribute to sense of satisfaction and competency. — Stacey Morrison (clinical) [Ep 3 · 11:45](https://team.globalcastmd.com/watch/psychosocial-outcomes-new-horizons-in-medical-and-surgical-fontan-management-888?t=705)
- At presentation, the case patient was complaining of fluttering heart and a lot of somatic body pain; she denied anxiety when asked directly, but her mother reported she reported feeling panicky and was panting (significant signs of anxiety). — Stacey Morrison (clinical) [Ep 3 · 12:05](https://team.globalcastmd.com/watch/psychosocial-outcomes-new-horizons-in-medical-and-surgical-fontan-management-888?t=725)
- The case patient is described as very meek, very self-conscious, and often very keyed up or on edge; at school she would not ask for help and wanted to be under the radar if at all possible. — Stacey Morrison (clinical) [Ep 3 · 12:31](https://team.globalcastmd.com/watch/psychosocial-outcomes-new-horizons-in-medical-and-surgical-fontan-management-888?t=751)
- The case patient worried about missing assignments, which could lead to more procrastination and avoidance of school; she did not view herself as being as capable as peers, and any talk about differences led her to report feeling stupid or not smart. — Stacey Morrison (clinical) [Ep 3 · 12:44](https://team.globalcastmd.com/watch/psychosocial-outcomes-new-horizons-in-medical-and-surgical-fontan-management-888?t=764)
- During evaluation, the case patient presented as extremely polite, arrived a bit late, very cooperative, very soft-spoken, difficult to get her to engage, does not initiate; on verbal components there was a lot of query and exploring needed to get information; if not sure of an answer she was hesitant to take a guess; on nonverbal tasks her approach was disorganized; she seemed anxious and when things became more challenging she tended to shut down and become tearful, appeared embarrassed. — Stacey Morrison (clinical) [Ep 3 · 13:07](https://team.globalcastmd.com/watch/psychosocial-outcomes-new-horizons-in-medical-and-surgical-fontan-management-888?t=787)
- On the WISC-5 (standardized cognitive measure), the case patient's full-scale IQ is 82, which falls in the low average range when compared to other children her age. — Stacey Morrison (clinical) [Ep 3 · 14:18](https://team.globalcastmd.com/watch/psychosocial-outcomes-new-horizons-in-medical-and-surgical-fontan-management-888?t=858)
- The case patient's verbal index was in the average range, nonverbal in the low average range, and her weakest areas of performance were working memory and processing speed. — Stacey Morrison (clinical) [Ep 3 · 14:35](https://team.globalcastmd.com/watch/psychosocial-outcomes-new-horizons-in-medical-and-surgical-fontan-management-888?t=875)
- Academically, the case patient's stronger areas are basic phonetic decoding, reading accuracy, sentence completion, spelling, and numerical sequencing (basic rote skills). — Stacey Morrison (clinical) [Ep 3 · 14:57](https://team.globalcastmd.com/watch/psychosocial-outcomes-new-horizons-in-medical-and-surgical-fontan-management-888?t=897)
- The case patient has difficulty with higher-level reading comprehension, reading fluency (reads slowly, has to reread for accuracy of understanding), math calculation and reasoning, and listening recall. — Stacey Morrison (clinical) [Ep 3 · 15:10](https://team.globalcastmd.com/watch/psychosocial-outcomes-new-horizons-in-medical-and-surgical-fontan-management-888?t=910)
- In the classroom, the case patient often feels overwhelmed and very anxious, feels like she's behind the eight ball at all times, has difficult time processing what's being instructed (feels it's going too fast), doesn't ask questions, often does not bring home materials needed or actual assignment requirements because she has hard time copying from the board and keeping up with her planner. — Stacey Morrison (clinical) [Ep 3 · 15:27](https://team.globalcastmd.com/watch/psychosocial-outcomes-new-horizons-in-medical-and-surgical-fontan-management-888?t=927)
- Low-level organizational and processing issues contribute to further withdrawal and feeling of inadequacy in the case patient. — Stacey Morrison (clinical) [Ep 3 · 16:00](https://team.globalcastmd.com/watch/psychosocial-outcomes-new-horizons-in-medical-and-surgical-fontan-management-888?t=960)
- The case patient reports a high level of test anxiety, with her mind going blank and difficulty recalling any information. — Stacey Morrison (clinical) [Ep 3 · 16:11](https://team.globalcastmd.com/watch/psychosocial-outcomes-new-horizons-in-medical-and-surgical-fontan-management-888?t=971)
- Diagnostic rating scales (BRIEF - Behavior Rating Inventory of Executive Function) distributed to school personnel, mother, and patient showed significant executive dysfunction in areas of organization, planning, initiating, task persistence, and attention dysregulation. — Stacey Morrison (clinical) [Ep 3 · 16:33](https://team.globalcastmd.com/watch/psychosocial-outcomes-new-horizons-in-medical-and-surgical-fontan-management-888?t=993)
- The case patient met criteria for ADHD, predominantly inattentive presentation (not the hyperactive or impulsive components). — Stacey Morrison (clinical) [Ep 3 · 17:08](https://team.globalcastmd.com/watch/psychosocial-outcomes-new-horizons-in-medical-and-surgical-fontan-management-888?t=1028)
- Additional ratings indicated significant levels of anxiety and somatic or health-related complaints, a lot of dysphoria, and sense of inadequacy, best represented with a diagnosis of generalized anxiety disorder. — Stacey Morrison (clinical) [Ep 3 · 17:17](https://team.globalcastmd.com/watch/psychosocial-outcomes-new-horizons-in-medical-and-surgical-fontan-management-888?t=1037)
- The initial care plan included encouragement to pursue ongoing counseling (with the psychologist or options close to home); the family was very closed in and other than medically presenting were not really likely to come in, and despite voicing interest they did not come back for psychotherapy. — Stacey Morrison (clinical) [Ep 3 · 17:46](https://team.globalcastmd.com/watch/psychosocial-outcomes-new-horizons-in-medical-and-surgical-fontan-management-888?t=1066)
- The school was willing to accommodate with a shortened school week (3 partial days per week) to allow time for medical planning and appointments while condensing core instruction time, with assistance in core instruction areas so the patient could demonstrate mastery without excessive assignments compiling. — Stacey Morrison (clinical) [Ep 3 · 18:38](https://team.globalcastmd.com/watch/psychosocial-outcomes-new-horizons-in-medical-and-surgical-fontan-management-888?t=1118)
- All listed psychosocial factors (limited social support, low self-confidence and performance anxiety, isolation) are contributing factors to patient outcomes, with the relative importance dependent on where the family is at; isolation is a significant part because it plays into low sense of competency and further social withdrawal, not integrating back into the community. — Stacey Morrison (opinion) [Ep 3 · 19:48](https://team.globalcastmd.com/watch/psychosocial-outcomes-new-horizons-in-medical-and-surgical-fontan-management-888?t=1188)
- Clinicians should assume that Fontan patients are going to have adjustment issues, which normalizes the challenges and gives credence to them, starting the conversation very early that emotional and mental support is a basic part of the care plan (equal opportunity, not selective for those not doing well). — Stacey Morrison (opinion) [Ep 3 · 21:08](https://team.globalcastmd.com/watch/psychosocial-outcomes-new-horizons-in-medical-and-surgical-fontan-management-888?t=1268)
- Having conversations about mental health very early is important because there is still a lot of misconception about what that represents; conversations should start early with parents as well to normalize that they are juggling a lot and this disrupts work and the entire family. — Stacey Morrison (opinion) [Ep 3 · 21:48](https://team.globalcastmd.com/watch/psychosocial-outcomes-new-horizons-in-medical-and-surgical-fontan-management-888?t=1308)
- A solution-focused approach asking 'what is working' taps into patient and family strengths. — Stacey Morrison (opinion) [Ep 3 · 22:12](https://team.globalcastmd.com/watch/psychosocial-outcomes-new-horizons-in-medical-and-surgical-fontan-management-888?t=1332)
- In adult Fontan patients, ventricular function is either moderately or severely dysfunctional but often does not change very much over the years. — Andrew Crean (clinical) [Ep 7 · 2:37](https://team.globalcastmd.com/watch/advanced-imaging-of-the-fontan-what-is-driving-fontan-failure-new-horizons-892?t=157)
- A change in ventricular function in a Fontan patient is an indicator to look at the ventricle more carefully, as this is not frequently seen. — Andrew Crean (clinical) [Ep 7 · 2:50](https://team.globalcastmd.com/watch/advanced-imaging-of-the-fontan-what-is-driving-fontan-failure-new-horizons-892?t=170)
- Embolic ventricular dysfunction is not a common feature of Fontans, but embolic complications are seen roughly once a year in the Toronto center. — Andrew Crean (epidemiological) [Ep 7 · 3:57](https://team.globalcastmd.com/watch/advanced-imaging-of-the-fontan-what-is-driving-fontan-failure-new-horizons-892?t=237)
- Thrombus imaging in Fontan circuits is generally not done very well, particularly in adult Fontan circulations. — Andrew Crean (opinion) [Ep 7 · 4:11](https://team.globalcastmd.com/watch/advanced-imaging-of-the-fontan-what-is-driving-fontan-failure-new-horizons-892?t=251)
- Timing is everything in imaging of the Fontan circulation, and usually imaging is performed too quickly, leading to false-positive thrombus diagnoses. — Andrew Crean (clinical) [Ep 7 · 6:07](https://team.globalcastmd.com/watch/advanced-imaging-of-the-fontan-what-is-driving-fontan-failure-new-horizons-892?t=367)
- Premature contrast timing is a particular problem with on-call PE studies done in the middle of the night. — Andrew Crean (clinical) [Ep 7 · 6:13](https://team.globalcastmd.com/watch/advanced-imaging-of-the-fontan-what-is-driving-fontan-failure-new-horizons-892?t=373)
- Radiologists imaging the chest typically want to image in the pulmonary arterial phase, which is too early to adequately opacify the IVC portion of Fontan circuits. — Andrew Crean (clinical) [Ep 7 · 7:07](https://team.globalcastmd.com/watch/advanced-imaging-of-the-fontan-what-is-driving-fontan-failure-new-horizons-892?t=427)
- In large atriopulmonary Fontans, it can take up to 7 minutes for contrast to fully opacify the circuit and confidently exclude thrombus. — Andrew Crean (clinical) [Ep 7 · 8:02](https://team.globalcastmd.com/watch/advanced-imaging-of-the-fontan-what-is-driving-fontan-failure-new-horizons-892?t=482)
- Late gadolinium enhancement imaging performed 10 minutes after contrast administration is effective for detecting thrombus in Fontan circuits. — Andrew Crean (clinical) [Ep 7 · 10:23](https://team.globalcastmd.com/watch/advanced-imaging-of-the-fontan-what-is-driving-fontan-failure-new-horizons-892?t=623)
- Both CT and MRI are exquisitely good at looking at the presence of thrombus in Fontan circuits, and CT allows easy volumetric measurement of thrombus over time. — Andrew Crean (clinical) [Ep 7 · 10:40](https://team.globalcastmd.com/watch/advanced-imaging-of-the-fontan-what-is-driving-fontan-failure-new-horizons-892?t=640)
- The tried and tested approach to managing large atrial thrombus in Fontan patients involves anticoagulation with heparin. — Andrew Crean (clinical) [Ep 7 · 11:16](https://team.globalcastmd.com/watch/advanced-imaging-of-the-fontan-what-is-driving-fontan-failure-new-horizons-892?t=676)
- Resolution of Glenn shunt thrombus with TPA was associated with normalization of albumin levels, suggesting a link between venous obstruction and protein-losing enteropathy. — Andrew Crean (clinical) [Ep 7 · 12:36](https://team.globalcastmd.com/watch/advanced-imaging-of-the-fontan-what-is-driving-fontan-failure-new-horizons-892?t=756)
- Fontan patients in their mid-80s oxygen saturation without open fenestrations are unusual and warrant investigation for causes of desaturation. — Andrew Crean (clinical) [Ep 7 · 13:21](https://team.globalcastmd.com/watch/advanced-imaging-of-the-fontan-what-is-driving-fontan-failure-new-horizons-892?t=801)
- Veno-venous collaterals and arteriovenous malformations are easily seen by CT or MRI angiography but very difficult to detect in any other way. — Andrew Crean (clinical) [Ep 7 · 14:06](https://team.globalcastmd.com/watch/advanced-imaging-of-the-fontan-what-is-driving-fontan-failure-new-horizons-892?t=846)
- The spatial resolution of cross-sectional imaging, particularly CT, allows detection of very subtle features such as highly stenotic coronary sinus drainage to the left atrium. — Andrew Crean (clinical) [Ep 7 · 14:39](https://team.globalcastmd.com/watch/advanced-imaging-of-the-fontan-what-is-driving-fontan-failure-new-horizons-892?t=879)
- A Fontan patient presenting with a heart failure phenotype, particularly edema, does not necessarily have pump failure; conduit stenosis can present with anasarca. — Andrew Crean (clinical) [Ep 7 · 16:05](https://team.globalcastmd.com/watch/advanced-imaging-of-the-fontan-what-is-driving-fontan-failure-new-horizons-892?t=965)
- Plastic bronchitis has not been seen in adult Fontan patients in 10 years at the Toronto center, though it is easy to detect by CT. — Andrew Crean (clinical) [Ep 7 · 17:21](https://team.globalcastmd.com/watch/advanced-imaging-of-the-fontan-what-is-driving-fontan-failure-new-horizons-892?t=1041)
- In adult patients, echocardiography is not adequate for thrombus detection in a Fontan circuit. — Andrew Crean (opinion) [Ep 7 · 18:13](https://team.globalcastmd.com/watch/advanced-imaging-of-the-fontan-what-is-driving-fontan-failure-new-horizons-892?t=1093)
- Transesophageal echo for detecting thrombus in an atriopulmonary Fontan is a waste of time and should not be done prior to cardioversion. — Andrew Crean (opinion) [Ep 7 · 19:47](https://team.globalcastmd.com/watch/advanced-imaging-of-the-fontan-what-is-driving-fontan-failure-new-horizons-892?t=1187)
- It took roughly 10 years and many cases where CT or MR were right and echo was wrong to convert colleagues in Toronto away from routine TEE for Fontan thrombus assessment. — Andrew Crean (clinical) [Ep 7 · 20:03](https://team.globalcastmd.com/watch/advanced-imaging-of-the-fontan-what-is-driving-fontan-failure-new-horizons-892?t=1203)
- Cardiac CT can be obtained within about 1 hour, which is more practical than organizing space on the CCU for a TEE in a sick Fontan patient. — Andrew Crean (clinical) [Ep 7 · 20:13](https://team.globalcastmd.com/watch/advanced-imaging-of-the-fontan-what-is-driving-fontan-failure-new-horizons-892?t=1213)
- The spatial resolution of cardiac CT is at worst 0.5 millimeters isotropic, which is sufficient to detect small thrombi. — Andrew Crean (clinical) [Ep 7 · 20:53](https://team.globalcastmd.com/watch/advanced-imaging-of-the-fontan-what-is-driving-fontan-failure-new-horizons-892?t=1253)
- In 10 years of practice, there have been no cases requiring escalation from CT to echo based on doubt about thrombus detection. — Andrew Crean (clinical) [Ep 7 · 21:25](https://team.globalcastmd.com/watch/advanced-imaging-of-the-fontan-what-is-driving-fontan-failure-new-horizons-892?t=1285)
- Fontan-associated plastic bronchitis occurs in less than 2% of patients with Fontan circulation — Brian (epidemiological) [Ep 8 · 1:56](https://team.globalcastmd.com/watch/trans-catheter-interventions-new-horizons-in-medical-and-surgical-fontan-893?t=116)
- Plastic bronchitis is characterized by proteinaceous lymphatic effluent into the tracheobronchial tree where there are connections between the lymphatic circulation and the airway — Brian (clinical) [Ep 8 · 2:01](https://team.globalcastmd.com/watch/trans-catheter-interventions-new-horizons-in-medical-and-surgical-fontan-893?t=121)
- With evaporation of water content through breathing, characteristic fibrinous airway casts remain and may be expectorated in whole or in part — Brian (clinical) [Ep 8 · 2:09](https://team.globalcastmd.com/watch/trans-catheter-interventions-new-horizons-in-medical-and-surgical-fontan-893?t=129)
- The incidence of fenestration thrombosis or stenosis early after the procedure and in short and mid-term follow-up is very high with bare metal stents, presumably from tissue invagination through the cells of the stent and tissue factor exposure to blood — Brian (clinical) [Ep 8 · 5:16](https://team.globalcastmd.com/watch/trans-catheter-interventions-new-horizons-in-medical-and-surgical-fontan-893?t=316)
- Even on anticoagulation, thrombosis is pretty common with bare metal stents used for fenestration creation — Brian (clinical) [Ep 8 · 5:34](https://team.globalcastmd.com/watch/trans-catheter-interventions-new-horizons-in-medical-and-surgical-fontan-893?t=334)
- Good procedures don't always mean much - one can do a good intervention in a complex population but it doesn't always mean you're going to change the ultimate clinical outcome — Brian (opinion) [Ep 8 · 5:46](https://team.globalcastmd.com/watch/trans-catheter-interventions-new-horizons-in-medical-and-surgical-fontan-893?t=346)
- The Fontan population has a very high incidence of liver-related pathologies — Brian (epidemiological) [Ep 8 · 6:51](https://team.globalcastmd.com/watch/trans-catheter-interventions-new-horizons-in-medical-and-surgical-fontan-893?t=411)
- Having obstruction in the inferior limb of the Fontan can be a real problem as it only serves to augment venous hypertension — Brian (clinical) [Ep 8 · 7:09](https://team.globalcastmd.com/watch/trans-catheter-interventions-new-horizons-in-medical-and-surgical-fontan-893?t=429)
- A resting absence of gradient does not rule out the presence of hemodynamically meaningful obstruction — Brian (clinical) [Ep 8 · 7:13](https://team.globalcastmd.com/watch/trans-catheter-interventions-new-horizons-in-medical-and-surgical-fontan-893?t=433)
- Left innominate vein obstruction can create opportunity for patients to present with either plastic bronchitis or protein-losing enteropathy, two diagnoses associated with very adverse clinical outcomes that have been shown increasingly to be associated with lymphatic pathology, especially by the group from Philadelphia — Brian (clinical) [Ep 8 · 8:37](https://team.globalcastmd.com/watch/trans-catheter-interventions-new-horizons-in-medical-and-surgical-fontan-893?t=517)
- Secondary palliations (palliation of a palliation, the Fontan circuit) have limitations - they may not offer cure, may not even offer substantial benefits — Brian (opinion) [Ep 8 · 9:47](https://team.globalcastmd.com/watch/trans-catheter-interventions-new-horizons-in-medical-and-surgical-fontan-893?t=587)
- Sometimes we're not able to test the hypothesis until we actually perform the intervention — Brian (opinion) [Ep 8 · 9:57](https://team.globalcastmd.com/watch/trans-catheter-interventions-new-horizons-in-medical-and-surgical-fontan-893?t=597)
- The approach to transcatheter interventions must be taken from a multidisciplinary perspective - therapies have both medical and surgical considerations to future therapies, to the need for anticoagulation — Brian (opinion) [Ep 8 · 10:03](https://team.globalcastmd.com/watch/trans-catheter-interventions-new-horizons-in-medical-and-surgical-fontan-893?t=603)
- Everything we do can have sequelae - it's really important to make sure that the multiple disciplines we use to care for these patients all understand and appreciate the implications of decision making and therapies — Brian (opinion) [Ep 8 · 10:38](https://team.globalcastmd.com/watch/trans-catheter-interventions-new-horizons-in-medical-and-surgical-fontan-893?t=638)
- Stent in conduit equals thrombogenic behavior substrate — Brian (clinical) [Ep 8 · 12:59](https://team.globalcastmd.com/watch/trans-catheter-interventions-new-horizons-in-medical-and-surgical-fontan-893?t=779)
- A 12-year-old young man being on Coumadin is not free (not without consequences) — Brian (opinion) [Ep 8 · 13:05](https://team.globalcastmd.com/watch/trans-catheter-interventions-new-horizons-in-medical-and-surgical-fontan-893?t=785)
- Having seen many of these patients grow up and face symptoms increasing through their teenage years, it's worth being aggressive when there's anatomic deficiencies within the circuit — Brian (opinion) [Ep 8 · 13:18](https://team.globalcastmd.com/watch/trans-catheter-interventions-new-horizons-in-medical-and-surgical-fontan-893?t=798)
- The fluid challenge protocol involves giving 15 cc per kilo with no limit of fluid volume rapidly via central access in about 2 minutes, then starting a timer with 5 minutes from the end of fluid challenge until repeat hemodynamic runs are measured — Brian (clinical) [Ep 8 · 13:59](https://team.globalcastmd.com/watch/trans-catheter-interventions-new-horizons-in-medical-and-surgical-fontan-893?t=839)
- Fluid challenge is not performed if patients have overt diastolic dysfunction, defined as baseline EDP at resting EDP of greater than 15 — Brian (clinical) [Ep 8 · 14:19](https://team.globalcastmd.com/watch/trans-catheter-interventions-new-horizons-in-medical-and-surgical-fontan-893?t=859)
- Fluid challenge is not performed if patients have baseline Fontan pressure greater than 18 and/or repeated hospitalizations with heart failure to get volume off — Brian (clinical) [Ep 8 · 14:30](https://team.globalcastmd.com/watch/trans-catheter-interventions-new-horizons-in-medical-and-surgical-fontan-893?t=870)
- We can safely take Gore-Tex tubes to at least 110% of their nominal diameter — Brian (clinical) [Ep 8 · 15:23](https://team.globalcastmd.com/watch/trans-catheter-interventions-new-horizons-in-medical-and-surgical-fontan-893?t=923)
- Beyond 110% of nominal diameter, there is a bit of risk, but the risk is probably pretty subtle for moderate dilation (e.g., 18mm tube to 22mm) — Brian (opinion) [Ep 8 · 15:31](https://team.globalcastmd.com/watch/trans-catheter-interventions-new-horizons-in-medical-and-surgical-fontan-893?t=931)
- There is always risk at the anastomosis where it's hard to necessarily cover that should a problem arise because hepatic vein enters very close — Brian (clinical) [Ep 8 · 15:44](https://team.globalcastmd.com/watch/trans-catheter-interventions-new-horizons-in-medical-and-surgical-fontan-893?t=944)
- Gore-Tex tubes can be taken up to about 110% - the stiffness constant is very high and you cannot generate enough pressure in the balloon to stretch the Gore-Tex much more than about 110% (clinical) [Ep 8 · 16:06](https://team.globalcastmd.com/watch/trans-catheter-interventions-new-horizons-in-medical-and-surgical-fontan-893?t=966)
- The risk of rupture is actually very low when dilating Gore-Tex conduits (opinion) [Ep 8 · 16:17](https://team.globalcastmd.com/watch/trans-catheter-interventions-new-horizons-in-medical-and-surgical-fontan-893?t=977)
- There are few patients who have an undersized tube at placement and really require augmentation of the nominal diameter — Brian (epidemiological) [Ep 8 · 16:32](https://team.globalcastmd.com/watch/trans-catheter-interventions-new-horizons-in-medical-and-surgical-fontan-893?t=992)
- Extracardiac conduits are three-dimensional structures that are not circular - if a 22mm tube measures 17mm in the frontal plane, it often measures 25mm in the lateral plane, and the cross-sectional area is just fine — Brian (clinical) [Ep 8 · 17:01](https://team.globalcastmd.com/watch/trans-catheter-interventions-new-horizons-in-medical-and-surgical-fontan-893?t=1021)
- It's important that there's a true stenosis, not just a non-circular shape, for us to want to treat conduit narrowing — Brian (opinion) [Ep 8 · 17:19](https://team.globalcastmd.com/watch/trans-catheter-interventions-new-horizons-in-medical-and-surgical-fontan-893?t=1039)
- 40-50% of cardiac output at baseline in Fontan patients is driven directly by the work of breathing — Andrew Reddington (clinical) [Ep 11 · 2:43](https://team.globalcastmd.com/watch/how-does-the-blood-go-round-in-single-ventricles-and-fontans-new-horizons-in-896?t=163)
- Negative mean airway pressure during normal ventilation draws blood into the Fontan circuit — Andrew Reddington (clinical) [Ep 11 · 3:14](https://team.globalcastmd.com/watch/how-does-the-blood-go-round-in-single-ventricles-and-fontans-new-horizons-in-896?t=194)
- Valsalva maneuver with mean airway pressure elevated to 20 cm H2O cuts off spontaneous respiratory flow, leaving only tiny flow with ventricular systole — Andrew Reddington (clinical) [Ep 11 · 3:25](https://team.globalcastmd.com/watch/how-does-the-blood-go-round-in-single-ventricles-and-fontans-new-horizons-in-896?t=205)
- Low pulmonary vascular resistance is a prerequisite for good Fontan outcome — Andrew Reddington (clinical) [Ep 11 · 4:01](https://team.globalcastmd.com/watch/how-does-the-blood-go-round-in-single-ventricles-and-fontans-new-horizons-in-896?t=241)
- In normal individuals, nitric oxide does not reduce pulmonary vascular resistance because the pulmonary vascular bed is maximally vasodilated — Andrew Reddington (clinical) [Ep 11 · 4:52](https://team.globalcastmd.com/watch/how-does-the-blood-go-round-in-single-ventricles-and-fontans-new-horizons-in-896?t=292)
- Nitric oxide produced a statistically and physiologically significant fall in pulmonary vascular resistance of about 1 index wood unit in teenage Fontan patients — Andrew Reddington (clinical) [Ep 11 · 5:01](https://team.globalcastmd.com/watch/how-does-the-blood-go-round-in-single-ventricles-and-fontans-new-horizons-in-896?t=301)
- Only half of teenage Fontan patients showed benefit from nitric oxide — Andrew Reddington (clinical) [Ep 11 · 5:39](https://team.globalcastmd.com/watch/how-does-the-blood-go-round-in-single-ventricles-and-fontans-new-horizons-in-896?t=339)
- If only half of Fontan patients benefit from nitric oxide, they are unlikely to further benefit from PDE5 inhibitors — Andrew Reddington (opinion) [Ep 11 · 6:00](https://team.globalcastmd.com/watch/how-does-the-blood-go-round-in-single-ventricles-and-fontans-new-horizons-in-896?t=360)
- The systemic ventricle in Fontan circulation is hypercontractile to match its increased afterload — Andrew Reddington (clinical) [Ep 11 · 8:22](https://team.globalcastmd.com/watch/how-does-the-blood-go-round-in-single-ventricles-and-fontans-new-horizons-in-896?t=502)
- Arterial elastance is high in Fontan patients but relatively well coupled to ventricular elastance — Andrew Reddington (clinical) [Ep 11 · 9:29](https://team.globalcastmd.com/watch/how-does-the-blood-go-round-in-single-ventricles-and-fontans-new-horizons-in-896?t=569)
- The primary problem in Fontan ventricles is in diastole, not systole — Andrew Reddington (clinical) [Ep 11 · 9:29](https://team.globalcastmd.com/watch/how-does-the-blood-go-round-in-single-ventricles-and-fontans-new-horizons-in-896?t=569)
- In early post-Fontan course, it is early diastole (E wave) that is affected, not late diastole (A wave), with virtual abolishment of early rapid filling — Andrew Reddington (clinical) [Ep 11 · 10:14](https://team.globalcastmd.com/watch/how-does-the-blood-go-round-in-single-ventricles-and-fontans-new-horizons-in-896?t=614)
- Time constant of relaxation and isovolumic relaxation time are prolonged in early post-Fontan patients, indicative of impaired relaxation — Andrew Reddington (clinical) [Ep 11 · 10:43](https://team.globalcastmd.com/watch/how-does-the-blood-go-round-in-single-ventricles-and-fontans-new-horizons-in-896?t=643)
- Impaired early relaxation is due to incoordinate wall motion during isovolumic relaxation, with post-systolic shortening of one part of the ventricle causing another part to move outward — Andrew Reddington (clinical) [Ep 11 · 10:56](https://team.globalcastmd.com/watch/how-does-the-blood-go-round-in-single-ventricles-and-fontans-new-horizons-in-896?t=656)
- Longer isovolumic relaxation time correlates with longer hospital stay immediately after Fontan operation — Andrew Reddington (clinical) [Ep 11 · 12:23](https://team.globalcastmd.com/watch/how-does-the-blood-go-round-in-single-ventricles-and-fontans-new-horizons-in-896?t=743)
- Late post-Fontan patients can develop pseudonormalized filling pattern (E > A) due to rising left atrial pressure despite persistent incoordinate relaxation — Andrew Reddington (clinical) [Ep 11 · 13:03](https://team.globalcastmd.com/watch/how-does-the-blood-go-round-in-single-ventricles-and-fontans-new-horizons-in-896?t=783)
- In normal individuals, left ventricular end-diastolic pressure rises by about 2 mmHg per decade after age 30 — Andrew Reddington (clinical) [Ep 11 · 13:36](https://team.globalcastmd.com/watch/how-does-the-blood-go-round-in-single-ventricles-and-fontans-new-horizons-in-896?t=816)
- Fontan patients with high diastolic stiffness may have low end-diastolic pressure because reduced preload causes the ventricle to become smaller and pressure to fall down the pressure-volume curve — Andrew Reddington (clinical) [Ep 11 · 15:33](https://team.globalcastmd.com/watch/how-does-the-blood-go-round-in-single-ventricles-and-fontans-new-horizons-in-896?t=933)
- Bench pressing 500 pounds essentially cuts off pulmonary blood flow in Fontan patients — Andrew Reddington (clinical) [Ep 11 · 17:37](https://team.globalcastmd.com/watch/how-does-the-blood-go-round-in-single-ventricles-and-fontans-new-horizons-in-896?t=1057)
- Sustained Valsalva maneuvers may be particularly disadvantageous in old atrio-pulmonary Fontans due to direct effects on atrial stretch and potential for chronic atrial arrhythmias — Andrew Reddington (opinion) [Ep 11 · 18:13](https://team.globalcastmd.com/watch/how-does-the-blood-go-round-in-single-ventricles-and-fontans-new-horizons-in-896?t=1093)
- Mayo Clinic series with longer follow-up suggests right ventricular morphology does appear to be a risk factor late after Fontan (epidemiological) [Ep 11 · 19:32](https://team.globalcastmd.com/watch/how-does-the-blood-go-round-in-single-ventricles-and-fontans-new-horizons-in-896?t=1172)
- Rise in end-diastolic pressure in normal individuals is more rapid with hypertension, diabetes, other risk factors, and ventricular volume load such as AV valve or aortic regurgitation — Andrew Reddington (clinical) [Ep 11 · 21:58](https://team.globalcastmd.com/watch/how-does-the-blood-go-round-in-single-ventricles-and-fontans-new-horizons-in-896?t=1318)
- Fontan patients frequently have some degree of volume load and have had volume load for the first few years of life — Andrew Reddington (clinical) [Ep 11 · 22:33](https://team.globalcastmd.com/watch/how-does-the-blood-go-round-in-single-ventricles-and-fontans-new-horizons-in-896?t=1353)
- All Fontan patients have very raised arterial impedance and systemic vascular resistance — Andrew Reddington (clinical) [Ep 11 · 22:44](https://team.globalcastmd.com/watch/how-does-the-blood-go-round-in-single-ventricles-and-fontans-new-horizons-in-896?t=1364)
- There is no evidence-based role for ACE inhibition or arterial vasodilators in short-term Fontan management, as systemic vasodilation drops cardiac output — Andrew Reddington (opinion) [Ep 11 · 23:18](https://team.globalcastmd.com/watch/how-does-the-blood-go-round-in-single-ventricles-and-fontans-new-horizons-in-896?t=1398)
- Management of left ventricular end-diastolic pressure, fibrosis, and vascular biology have real potential as therapeutic targets in long-term Fontan management — Andrew Reddington (opinion) [Ep 11 · 23:38](https://team.globalcastmd.com/watch/how-does-the-blood-go-round-in-single-ventricles-and-fontans-new-horizons-in-896?t=1418)
- Understanding the impact of long-term therapies for diastolic dysfunction will require 10-20 years of follow-up — Andrew Reddington (opinion) [Ep 11 · 23:58](https://team.globalcastmd.com/watch/how-does-the-blood-go-round-in-single-ventricles-and-fontans-new-horizons-in-896?t=1438)
- The difference between 10-15 year outcomes and 20-30 year outcomes is important; abnormalities in diastolic relaxation will likely become clinically manifest later, and 30-year RV vs LV data are not yet available (opinion) [Ep 11 · 24:38](https://team.globalcastmd.com/watch/how-does-the-blood-go-round-in-single-ventricles-and-fontans-new-horizons-in-896?t=1478)
- Fontan circulation is a profoundly prothrombotic state and thrombosis is a major cause of death in patients with Fontan circulation. — Joe (clinical) [Ep 1 · 1:01](https://team.globalcastmd.com/watch/how-do-we-manage-thrombogenicity-and-thrombosis-in-the-fontan-new-horizons-886?t=61)
- Many thrombotic events in Fontan patients are subclinical but clinically significant. — Joe (clinical) [Ep 1 · 1:10](https://team.globalcastmd.com/watch/how-do-we-manage-thrombogenicity-and-thrombosis-in-the-fontan-new-horizons-886?t=70)
- The cumulative hazard risk of thrombotic events in Fontan patients increases over time, with Fontan circulation becoming essentially a freight train of thrombogenicity. — Joe (clinical) [Ep 1 · 2:19](https://team.globalcastmd.com/watch/how-do-we-manage-thrombogenicity-and-thrombosis-in-the-fontan-new-horizons-886?t=139)
- Fontan circulation's thrombotic risk is comparable to paroxysmal nocturnal hemoglobinuria (30-40% risk over 5 years), antiphospholipid antibody syndrome, and unprovoked venous thromboembolism (20-30% recurrence rate). — Joe (clinical) [Ep 1 · 2:41](https://team.globalcastmd.com/watch/how-do-we-manage-thrombogenicity-and-thrombosis-in-the-fontan-new-horizons-886?t=161)
- Relative hypoxia and loss of pulsatile flow in the venous system is very thrombogenic for endothelial cells. — Joe (clinical) [Ep 1 · 4:52](https://team.globalcastmd.com/watch/how-do-we-manage-thrombogenicity-and-thrombosis-in-the-fontan-new-horizons-886?t=292)
- Hypoxia and loss of pulsatile flow result in upregulation of tissue factor expression (the primary initiator of the clotting cascade), upregulation of adhesion molecules that activate inflammatory cells, and increased secretion of factor VIII and von Willebrand factor. — Joe (clinical) [Ep 1 · 5:01](https://team.globalcastmd.com/watch/how-do-we-manage-thrombogenicity-and-thrombosis-in-the-fontan-new-horizons-886?t=301)
- Protein-losing enteropathy (PLE) results in increased inflammatory system activation in Fontan patients. — Joe (clinical) [Ep 1 · 5:17](https://team.globalcastmd.com/watch/how-do-we-manage-thrombogenicity-and-thrombosis-in-the-fontan-new-horizons-886?t=317)
- Liver synthetic dysfunction can develop over time in Fontan patients and worsen hemostatic system activation. — Joe (clinical) [Ep 1 · 5:22](https://team.globalcastmd.com/watch/how-do-we-manage-thrombogenicity-and-thrombosis-in-the-fontan-new-horizons-886?t=322)
- Overall data supports that warfarin is better thromboprophylaxis than aspirin in Fontan patients. — Joe (clinical) [Ep 1 · 6:05](https://team.globalcastmd.com/watch/how-do-we-manage-thrombogenicity-and-thrombosis-in-the-fontan-new-horizons-886?t=365)
- Excellent time-in-therapeutic-range above 80% with warfarin is achievable using a paternalistic approach with aggressive monitoring and phone follow-up. — Joe (clinical) [Ep 1 · 7:05](https://team.globalcastmd.com/watch/how-do-we-manage-thrombogenicity-and-thrombosis-in-the-fontan-new-horizons-886?t=425)
- Even with well-managed anticoagulation, the bleeding risk is around 2% per year. — Joe (epidemiological) [Ep 1 · 8:33](https://team.globalcastmd.com/watch/how-do-we-manage-thrombogenicity-and-thrombosis-in-the-fontan-new-horizons-886?t=513)
- Warfarin is very problematic from a pharmacokinetic standpoint and poorly managed warfarin may actually increase thrombotic risk. — Joe (clinical) [Ep 1 · 8:43](https://team.globalcastmd.com/watch/how-do-we-manage-thrombogenicity-and-thrombosis-in-the-fontan-new-horizons-886?t=523)
- Direct oral anticoagulants (DOACs) such as rivaroxaban and apixaban seem superior to warfarin in many ways but are completely unproven in Fontan patients. — Joe (clinical) [Ep 1 · 8:52](https://team.globalcastmd.com/watch/how-do-we-manage-thrombogenicity-and-thrombosis-in-the-fontan-new-horizons-886?t=532)
- The honeymoon phase duration can vary and may be predictable using biomarkers. — Joe (opinion) [Ep 1 · 9:40](https://team.globalcastmd.com/watch/how-do-we-manage-thrombogenicity-and-thrombosis-in-the-fontan-new-horizons-886?t=580)
- Elevated factor VIII is a strong marker of increased thrombotic risk and can be elevated due to genetic factors, endothelial cell activation, or as an acute phase reactant indicating inflammation. — Joe (clinical) [Ep 1 · 10:17](https://team.globalcastmd.com/watch/how-do-we-manage-thrombogenicity-and-thrombosis-in-the-fontan-new-horizons-886?t=617)
- Fontan circulation, even in the context of liver dysfunction, shifts the hemostatic balance toward a thrombophilic state. — Joe (clinical) [Ep 1 · 12:13](https://team.globalcastmd.com/watch/how-do-we-manage-thrombogenicity-and-thrombosis-in-the-fontan-new-horizons-886?t=733)
- Monitoring D-dimer, factor VIII, liver function tests, and albumin every 6 months can predict when the honeymoon period of relatively low thrombotic risk is ending. — Joe (opinion) [Ep 1 · 13:00](https://team.globalcastmd.com/watch/how-do-we-manage-thrombogenicity-and-thrombosis-in-the-fontan-new-horizons-886?t=780)
- Aspirin VerifyNow is an extremely reliable and reproducible test that confirms patients are taking aspirin and having an antiplatelet response. — Joe (clinical) [Ep 1 · 14:40](https://team.globalcastmd.com/watch/how-do-we-manage-thrombogenicity-and-thrombosis-in-the-fontan-new-horizons-886?t=880)
- DOACs need to be studied in the Fontan population before determining how good or bad they are. — Joe (opinion) [Ep 1 · 15:26](https://team.globalcastmd.com/watch/how-do-we-manage-thrombogenicity-and-thrombosis-in-the-fontan-new-horizons-886?t=926)
- To use DOACs routinely in Fontan patients, reliable monitoring methods are needed because organ function can change rapidly in these patients. — Joe (clinical) [Ep 1 · 15:36](https://team.globalcastmd.com/watch/how-do-we-manage-thrombogenicity-and-thrombosis-in-the-fontan-new-horizons-886?t=936)
- DOACs are most likely better than poorly controlled warfarin, but high time-in-therapeutic-range is achievable with warfarin in most patients. — Joe (opinion) [Ep 1 · 16:21](https://team.globalcastmd.com/watch/how-do-we-manage-thrombogenicity-and-thrombosis-in-the-fontan-new-horizons-886?t=981)
- The Fontan is a surgically created condition of severe chronic right heart failure with sequelae including venous hypertension, hepatic congestion, lymphatic congestion, restrictive lung disease, altered pulmonary vasculature, and single ventricle dysfunction. — Twaddle (clinical) [Ep 4 · 1:41](https://team.globalcastmd.com/watch/update-on-surgical-practice-and-current-state-on-fontan-conversion-surgery-889?t=101)
- Fontan takedown indications include low cardiac output and elevated CVP, frequently resulting in a progressive downward spiral. — Twaddle (clinical) [Ep 4 · 2:50](https://team.globalcastmd.com/watch/update-on-surgical-practice-and-current-state-on-fontan-conversion-surgery-889?t=170)
- Early revision is reasonable for Fontan failure if the anatomic problem is clearly established and the patient is not too debilitated. — Twaddle (clinical) [Ep 4 · 3:00](https://team.globalcastmd.com/watch/update-on-surgical-practice-and-current-state-on-fontan-conversion-surgery-889?t=180)
- Temporary mechanical support may be considered if the problem is primarily arrhythmias or predictably temporary ventricular dysfunction. — Twaddle (clinical) [Ep 4 · 3:13](https://team.globalcastmd.com/watch/update-on-surgical-practice-and-current-state-on-fontan-conversion-surgery-889?t=193)
- Late Fontan takedown might help hepatic congestion problems, but there are not many large series and outcomes are generally poor. — Twaddle (clinical) [Ep 4 · 3:38](https://team.globalcastmd.com/watch/update-on-surgical-practice-and-current-state-on-fontan-conversion-surgery-889?t=218)
- Bambino Gesù in Rome reported 18 Fontan takedowns over 25 years (1990-2015), with 2 in immediate postoperative period and 16 within 2 months of completion Fontan. — Twaddle (epidemiological) [Ep 4 · 4:03](https://team.globalcastmd.com/watch/update-on-surgical-practice-and-current-state-on-fontan-conversion-surgery-889?t=243)
- In the Bambino Gesù series, there were 17 early survivors, 3 underwent subsequent successful Fontan palliation, 4 underwent transplantation with 2 late survivors, and 10 remained with bidirectional Glenn physiology with reasonable saturations at median 7-year follow-up. — Twaddle (epidemiological) [Ep 4 · 4:33](https://team.globalcastmd.com/watch/update-on-surgical-practice-and-current-state-on-fontan-conversion-surgery-889?t=273)
- A European multi-institutional registry study (1971-2012) reported 38 Fontan takedowns with average time from Fontan to takedown of 0.6 years, early mortality of approximately 25%, five late deaths, and 44% reaching final endpoint by study conclusion. — Twaddle (epidemiological) [Ep 4 · 5:10](https://team.globalcastmd.com/watch/update-on-surgical-practice-and-current-state-on-fontan-conversion-surgery-889?t=310)
- Fontan conversion is primarily used for patients after atrial-pulmonary Fontan with atrial arrhythmias. — Twaddle (clinical) [Ep 4 · 6:30](https://team.globalcastmd.com/watch/update-on-surgical-practice-and-current-state-on-fontan-conversion-surgery-889?t=390)
- Fontan conversion always involves large atrial reduction combined with a maze operation or lesion set to prevent propagation of macro-reentrant circuits, which are the mechanism for most arrhythmias encountered. — Twaddle (clinical) [Ep 4 · 6:55](https://team.globalcastmd.com/watch/update-on-surgical-practice-and-current-state-on-fontan-conversion-surgery-889?t=415)
- The maze lesion set is accomplished by incision and use of a cryo catheter using frozen argon to achieve cryo lesions. — Twaddle (clinical) [Ep 4 · 7:21](https://team.globalcastmd.com/watch/update-on-surgical-practice-and-current-state-on-fontan-conversion-surgery-889?t=441)
- The lesion set for maze procedure must be altered to accommodate specific anatomy when patients lack typical tricuspid and mitral valves or have atypical coronary sinus position as in heterotaxy syndrome. — Twaddle (clinical) [Ep 4 · 8:32](https://team.globalcastmd.com/watch/update-on-surgical-practice-and-current-state-on-fontan-conversion-surgery-889?t=512)
- Data from Chicago shows that the more complete the arrhythmia procedure (biattrial maze vs. right atrial maze vs. isthmal ablation), the lower the risk of arrhythmia recurrence. — Twaddle (epidemiological) [Ep 4 · 9:15](https://team.globalcastmd.com/watch/update-on-surgical-practice-and-current-state-on-fontan-conversion-surgery-889?t=555)
- A more complete lesion set is indicated if performing the operation for arrhythmias. — Twaddle (opinion) [Ep 4 · 9:43](https://team.globalcastmd.com/watch/update-on-surgical-practice-and-current-state-on-fontan-conversion-surgery-889?t=583)
- The Chicago group reported low Fontan conversion mortality of 1.4%, while multi-center trials show early mortality around 10%. — Twaddle (epidemiological) [Ep 4 · 9:53](https://team.globalcastmd.com/watch/update-on-surgical-practice-and-current-state-on-fontan-conversion-surgery-889?t=593)
- Conditional survival after Fontan conversion appears similar between European experience and Chicago, suggesting mortality differences are primarily due to patient selection and execution of the operation. — Twaddle (epidemiological) [Ep 4 · 10:19](https://team.globalcastmd.com/watch/update-on-surgical-practice-and-current-state-on-fontan-conversion-surgery-889?t=619)
- A Japanese study examined prophylactic Fontan conversion in 7 arrhythmia-free atrial-pulmonary Fontan patients versus 25 with tachyarrhythmias, finding the prophylactic group had no late deaths and complete freedom from arrhythmias and protein-losing enteropathy. — Twaddle (epidemiological) [Ep 4 · 10:39](https://team.globalcastmd.com/watch/update-on-surgical-practice-and-current-state-on-fontan-conversion-surgery-889?t=639)
- It is uncertain whether the Japanese study justifies prophylactic Fontan conversion because it is unclear how those patients would have done if left alone. — Twaddle (opinion) [Ep 4 · 11:32](https://team.globalcastmd.com/watch/update-on-surgical-practice-and-current-state-on-fontan-conversion-surgery-889?t=692)
- The number of patients with atrial-pulmonary Fontan is decreasing, making Fontan conversion potentially a short-lived concern. — Twaddle (epidemiological) [Ep 4 · 11:47](https://team.globalcastmd.com/watch/update-on-surgical-practice-and-current-state-on-fontan-conversion-surgery-889?t=707)
- Candidates for Fontan conversion require preserved ventricular function and preserved end-organ function, as this is primarily an arrhythmia procedure. — Twaddle (clinical) [Ep 4 · 12:04](https://team.globalcastmd.com/watch/update-on-surgical-practice-and-current-state-on-fontan-conversion-surgery-889?t=724)
- Contraindications to Fontan conversion include protein-losing enteropathy, older age (related to elevation of end-diastolic pressure), ascites, and right or indeterminate ventricular morphology. — Twaddle (clinical) [Ep 4 · 12:15](https://team.globalcastmd.com/watch/update-on-surgical-practice-and-current-state-on-fontan-conversion-surgery-889?t=735)
- Biattrial arrhythmia operation has been identified as a risk factor for mortality in Fontan conversion. — Twaddle (epidemiological) [Ep 4 · 12:38](https://team.globalcastmd.com/watch/update-on-surgical-practice-and-current-state-on-fontan-conversion-surgery-889?t=758)
- In Australia and New Zealand, the number of atrial-pulmonary Fontans peaked in early 1990s and is now decreasing, with only extracardiac conduit Fontans performed since 2007. — Twaddle (epidemiological) [Ep 4 · 13:04](https://team.globalcastmd.com/watch/update-on-surgical-practice-and-current-state-on-fontan-conversion-surgery-889?t=784)
- The classic atrial-pulmonary Fontan conversion operation is anticipated to decrease in the next few years. — Twaddle (opinion) [Ep 4 · 13:32](https://team.globalcastmd.com/watch/update-on-surgical-practice-and-current-state-on-fontan-conversion-surgery-889?t=812)
- All Fontan patients being considered for transplant will have concerning pulmonary artery anatomy. — Twaddle (clinical) [Ep 4 · 14:13](https://team.globalcastmd.com/watch/update-on-surgical-practice-and-current-state-on-fontan-conversion-surgery-889?t=853)
- Pulmonary arteries in Fontan patients have been at low pressure throughout life and can be very delicate and thin-walled, with many aortopulmonary collaterals creating surgical challenges. — Twaddle (clinical) [Ep 4 · 14:48](https://team.globalcastmd.com/watch/update-on-surgical-practice-and-current-state-on-fontan-conversion-surgery-889?t=888)
- After Fontan heart excision and Glenn takedown, defects from the Glenn and extracardiac conduit commonly require repair, along with management of stented areas that are frequently not adequately dilated. — Twaddle (clinical) [Ep 4 · 15:11](https://team.globalcastmd.com/watch/update-on-surgical-practice-and-current-state-on-fontan-conversion-surgery-889?t=911)
- Hilar pulmonary arteries in Fontan patients are very thin, frequently manipulated at previous surgery, may be deserosalized or have adventitia removed, are prone to injury, and posterior injuries can be very challenging to repair. — Twaddle (clinical) [Ep 4 · 15:37](https://team.globalcastmd.com/watch/update-on-surgical-practice-and-current-state-on-fontan-conversion-surgery-889?t=937)
- The preferred strategy for pulmonary artery reconstruction in Fontan transplant is to perform this part of the operation with circulatory arrest, manipulating only central pulmonary arteries rather than hilar vessels. — Twaddle (opinion) [Ep 4 · 16:00](https://team.globalcastmd.com/watch/update-on-surgical-practice-and-current-state-on-fontan-conversion-surgery-889?t=960)
- Lymphatic circulation drains into central venous circulation, so venous hypertension results in lymphatic hypertension, which leads to protein-losing enteropathy and plastic bronchitis. — Twaddle (clinical) [Ep 4 · 16:59](https://team.globalcastmd.com/watch/update-on-surgical-practice-and-current-state-on-fontan-conversion-surgery-889?t=1019)
- Most lymphatic drainage from the lower half of the body and left half of the trunk drains to the junction of the left internal jugular vein and innominate vein. — Twaddle (clinical) [Ep 4 · 17:17](https://team.globalcastmd.com/watch/update-on-surgical-practice-and-current-state-on-fontan-conversion-surgery-889?t=1037)
- Doctor Hiroska published two case reports of innominate vein detachment from superior vena cava and anastomosis to low-pressure atrium, with improvement in protein-losing enteropathy. — Twaddle (epidemiological) [Ep 4 · 17:36](https://team.globalcastmd.com/watch/update-on-surgical-practice-and-current-state-on-fontan-conversion-surgery-889?t=1056)
- Christian Kreutzer from Argentina has suggested creating a second detachment of proximal innominate vein from left internal jugular and left subclavian vein, then reconstructing innominate vein using Gore-Tex tube graft to avoid right-to-left shunting and cyanosis. — Twaddle (clinical) [Ep 4 · 18:04](https://team.globalcastmd.com/watch/update-on-surgical-practice-and-current-state-on-fontan-conversion-surgery-889?t=1084)
- Fontan takedown is a life-saving operation for some patients with early failure. — Twaddle (opinion) [Ep 4 · 18:42](https://team.globalcastmd.com/watch/update-on-surgical-practice-and-current-state-on-fontan-conversion-surgery-889?t=1122)
- Fontan conversion is an option for individuals with atrial-pulmonary Fontan, arrhythmias, and preserved function. — Twaddle (opinion) [Ep 4 · 18:52](https://team.globalcastmd.com/watch/update-on-surgical-practice-and-current-state-on-fontan-conversion-surgery-889?t=1132)
- The future role of Fontan conversion is unclear as the number of individuals with atrial-pulmonary connections decreases over time. — Twaddle (opinion) [Ep 4 · 18:58](https://team.globalcastmd.com/watch/update-on-surgical-practice-and-current-state-on-fontan-conversion-surgery-889?t=1138)
- Lymphatic decompression may provide palliation, but experience is very early. — Twaddle (opinion) [Ep 4 · 19:06](https://team.globalcastmd.com/watch/update-on-surgical-practice-and-current-state-on-fontan-conversion-surgery-889?t=1146)
- The best hope for long-term survival probably rests with mechanical support and transplantation, requiring better understanding of support, sensitization, and immunosuppression. — Twaddle (opinion) [Ep 4 · 19:11](https://team.globalcastmd.com/watch/update-on-surgical-practice-and-current-state-on-fontan-conversion-surgery-889?t=1151)
- In the case scenario of an 8-year-old with heterotaxy, post-op day 2 from fenestrated Fontan with low output, elevated CVP, oliguria, ascites, worsening acidosis, good ventricular function, mild AV valve regurgitation, sinus rhythm, and no pathway obstruction, the patient likely has elevation of end-diastolic pressure or increased pulmonary vascular resistance as cause of failure. — Twaddle (clinical) [Ep 4 · 20:48](https://team.globalcastmd.com/watch/update-on-surgical-practice-and-current-state-on-fontan-conversion-surgery-889?t=1248)
- ECMO (either VA or VV) is unlikely to fix elevated end-diastolic pressure or increased pulmonary vascular resistance and may make them worse. — Twaddle (clinical) [Ep 4 · 21:16](https://team.globalcastmd.com/watch/update-on-surgical-practice-and-current-state-on-fontan-conversion-surgery-889?t=1276)
- VV ECMO would not have much role in the face of low cardiac output. — Twaddle (clinical) [Ep 4 · 21:25](https://team.globalcastmd.com/watch/update-on-surgical-practice-and-current-state-on-fontan-conversion-surgery-889?t=1285)
- While dialysis might be required at some point in acute Fontan failure, it is unlikely to reverse the process. — Twaddle (clinical) [Ep 4 · 21:30](https://team.globalcastmd.com/watch/update-on-surgical-practice-and-current-state-on-fontan-conversion-surgery-889?t=1290)
- Poor ventricular function is a contraindication to Fontan conversion, while severe mitral regurgitation and left pulmonary artery stenosis are problems that can potentially be rectified. — Twaddle (clinical) [Ep 4 · 22:28](https://team.globalcastmd.com/watch/update-on-surgical-practice-and-current-state-on-fontan-conversion-surgery-889?t=1348)
- Either people are not doing late Fontan takedown in adults, or if they are doing it, the results were not worthy of publication. — Twaddle (opinion) [Ep 4 · 24:14](https://team.globalcastmd.com/watch/update-on-surgical-practice-and-current-state-on-fontan-conversion-surgery-889?t=1454)
- The degree of cyanosis after late Fontan takedown would be dramatic, even with an additional source of pulmonary blood flow or shunt. — Twaddle (opinion) [Ep 4 · 24:23](https://team.globalcastmd.com/watch/update-on-surgical-practice-and-current-state-on-fontan-conversion-surgery-889?t=1463)
- Older patients who have been acyanotic will not do well with significant cyanosis, even if cardiac output is improved, despite such cyanosis being well tolerated in small children. — Twaddle (clinical) [Ep 4 · 24:36](https://team.globalcastmd.com/watch/update-on-surgical-practice-and-current-state-on-fontan-conversion-surgery-889?t=1476)
- Atrial fibrillation as an isolated phenomenon in Fontan patients is relatively rare — Rick Choi (clinical) [Ep 5 · 8:30](https://team.globalcastmd.com/watch/the-role-of-trans-catheter-arrhythmia-management-patient-based-decision-890?t=510)
- It is unknown whether ablating arrhythmia substrates in Fontan patients will change their overall risk of death or transplant — Rick Choi (opinion) [Ep 5 · 11:00](https://team.globalcastmd.com/watch/the-role-of-trans-catheter-arrhythmia-management-patient-based-decision-890?t=660)
- Fontan conversion with arrhythmia surgery achieves freedom from arrhythmia around 50 to 60%, probably not all that different than catheter ablation alone — Rick Choi (clinical) [Ep 5 · 13:23](https://team.globalcastmd.com/watch/the-role-of-trans-catheter-arrhythmia-management-patient-based-decision-890?t=803)
- Fontan patients with SVT are likely to have recurrence of SVT — Rick Choi (clinical) [Ep 5 · 14:16](https://team.globalcastmd.com/watch/the-role-of-trans-catheter-arrhythmia-management-patient-based-decision-890?t=856)
- Anti-arrhythmic medications are reasonable but unlikely to keep Fontan patients completely tachycardia-free — Rick Choi (clinical) [Ep 5 · 14:23](https://team.globalcastmd.com/watch/the-role-of-trans-catheter-arrhythmia-management-patient-based-decision-890?t=863)
- New onset atrial tachycardia or increased tachycardia burden is often an early indicator of other issues in Fontan patients — Rick Choi (clinical) [Ep 5 · 14:30](https://team.globalcastmd.com/watch/the-role-of-trans-catheter-arrhythmia-management-patient-based-decision-890?t=870)
- Catheter ablation plays a major role in management of SVT in Fontan patients and is reasonable as either first or second line management — Rick Choi (opinion) [Ep 5 · 14:37](https://team.globalcastmd.com/watch/the-role-of-trans-catheter-arrhythmia-management-patient-based-decision-890?t=877)
- In older Fontan patients undergoing ablation, sometimes 2/3 of the atrial tissue is essentially scar with no electrical activity — Rick Choi (clinical) [Ep 5 · 16:50](https://team.globalcastmd.com/watch/the-role-of-trans-catheter-arrhythmia-management-patient-based-decision-890?t=1010)
- Extracardiac Fontan patients will have reduced early arrhythmia incidence due to less surgical scarring, but may face same late risk from atrial stretch and fibrosis unless there is true hemodynamic benefit at 20-30 years — Rick Choi (opinion) [Ep 5 · 17:02](https://team.globalcastmd.com/watch/the-role-of-trans-catheter-arrhythmia-management-patient-based-decision-890?t=1022)
- Mayo Clinic Fontan arrhythmia data was largely from atrial-pulmonary Fontan patients — Grushin (clinical) [Ep 5 · 17:22](https://team.globalcastmd.com/watch/the-role-of-trans-catheter-arrhythmia-management-patient-based-decision-890?t=1042)
- Rick's typical approach is to give Fontan patients one arrhythmia episode and monitor them going forward, either off or on medications, then consider ablation after recurrent atrial arrhythmia — Rick Choi (opinion) [Ep 5 · 13:35](https://team.globalcastmd.com/watch/the-role-of-trans-catheter-arrhythmia-management-patient-based-decision-890?t=815)
- If Fontan patient's goal is to be completely off Coumadin after atrial arrhythmia, the only way to probably do that safely is to go ahead with catheter ablation — Rick Choi (opinion) [Ep 5 · 18:43](https://team.globalcastmd.com/watch/the-role-of-trans-catheter-arrhythmia-management-patient-based-decision-890?t=1123)
- Early ablation procedures in Fontan patients are easier, probably involving one or two circuits, whereas waiting 5-6 years results in more complex cases with 5 or 6 circuits — Rick Choi (clinical) [Ep 5 · 19:01](https://team.globalcastmd.com/watch/the-role-of-trans-catheter-arrhythmia-management-patient-based-decision-890?t=1141)
- Rick's center has not seen many young patients with atrial arrhythmias, having done lateral tunnels or extracardiac Fontans primarily for a long time — Rick Choi (clinical) [Ep 5 · 19:46](https://team.globalcastmd.com/watch/the-role-of-trans-catheter-arrhythmia-management-patient-based-decision-890?t=1186)
- Protein-losing enteropathy causes accumulating risk factors including edema, low albumin, poor nutrition, electrolyte disturbances, low IgG with increased infections, malnutrition, and prothrombotic state. — Andrew Lotz (clinical) [Ep 6 · 5:55](https://team.globalcastmd.com/watch/transplantation-and-ventricular-assist-devices-new-horizons-in-medical-and-891?t=355)
- A patient with PLE for 5 years becomes very prothrombotic, which is important for VAD outcomes, and becomes malnourished, making them a poor transplant or VAD candidate. — Andrew Lotz (clinical) [Ep 6 · 6:33](https://team.globalcastmd.com/watch/transplantation-and-ventricular-assist-devices-new-horizons-in-medical-and-891?t=393)
- Plastic bronchitis patients who go through to transplant do very well post-transplant. — Andrew Lotz (clinical) [Ep 6 · 8:17](https://team.globalcastmd.com/watch/transplantation-and-ventricular-assist-devices-new-horizons-in-medical-and-891?t=497)
- Under recent pediatric allocation system changes, congenital patients on one inotrope can be status 1A only if they are in the hospital; Fontan patients with PLE or plastic bronchitis who are not on inotropes will be status 2. — Andrew Lotz (guideline) [Ep 6 · 10:56](https://team.globalcastmd.com/watch/transplantation-and-ventricular-assist-devices-new-horizons-in-medical-and-891?t=656)
- Approximately one year ago, patients could be sent home on low-dose dopamine or milrinone and remain status 1A; this is no longer the case under current allocation rules. — Andrew Lotz (guideline) [Ep 6 · 11:20](https://team.globalcastmd.com/watch/transplantation-and-ventricular-assist-devices-new-horizons-in-medical-and-891?t=680)
- For urgent VAD placement at Cincinnati Children's, continuous-flow short-term devices (CentriMag in particular, some institutions use Rotaflow) are used to support patients for weeks to months to transplantation. — Andrew Lotz (clinical) [Ep 6 · 13:04](https://team.globalcastmd.com/watch/transplantation-and-ventricular-assist-devices-new-horizons-in-medical-and-891?t=784)
- The Berlin Heart is still available for small children, but most Fontans are bigger, so HVAD is increasingly used. — Andrew Lotz (clinical) [Ep 6 · 13:42](https://team.globalcastmd.com/watch/transplantation-and-ventricular-assist-devices-new-horizons-in-medical-and-891?t=822)
- HVAD can be safely placed in 25 kg single-ventricle patients, and many institutions (including Cincinnati) may push down to 15 kg. — Andrew Lotz (clinical) [Ep 6 · 13:52](https://team.globalcastmd.com/watch/transplantation-and-ventricular-assist-devices-new-horizons-in-medical-and-891?t=832)
- Continuous-flow devices for single-ventricle physiology seem to be working very well compared to Berlin Heart data. — Andrew Lotz (opinion) [Ep 6 · 13:58](https://team.globalcastmd.com/watch/transplantation-and-ventricular-assist-devices-new-horizons-in-medical-and-891?t=838)
- For patients over approximately 35 kg, SynCardia total artificial heart is an option, removing all ventricular mass and supporting the patient. — Andrew Lotz (clinical) [Ep 6 · 14:15](https://team.globalcastmd.com/watch/transplantation-and-ventricular-assist-devices-new-horizons-in-medical-and-891?t=855)
- If a patient does not need respiratory support, supporting an organ that doesn't need support should probably be avoided, which is why ECMO is not the preferred option when lungs are functioning well. — Andrew Lotz (opinion) [Ep 6 · 16:03](https://team.globalcastmd.com/watch/transplantation-and-ventricular-assist-devices-new-horizons-in-medical-and-891?t=963)
- Only 2 SynCardia devices have been placed in single-ventricle patients in the US. — Andrew Lotz (epidemiological) [Ep 6 · 17:44](https://team.globalcastmd.com/watch/transplantation-and-ventricular-assist-devices-new-horizons-in-medical-and-891?t=1064)
- For SynCardia placement in single-ventricle patients, a capacitant chamber must be built because two AV valves are needed or the anatomy must be addressed in some fashion. — Andrew Lotz (clinical) [Ep 6 · 17:52](https://team.globalcastmd.com/watch/transplantation-and-ventricular-assist-devices-new-horizons-in-medical-and-891?t=1072)
- A smaller 50 cc SynCardia device is now available, making it an option for smaller Fontan patients. — Andrew Lotz (clinical) [Ep 6 · 18:07](https://team.globalcastmd.com/watch/transplantation-and-ventricular-assist-devices-new-horizons-in-medical-and-891?t=1087)
- The advanced cardiomyopathy learning network is now operational and working to share experiences with Fontan and VAD to understand which patients benefit from VAD and what the best support strategy is. — Andrew Lotz (clinical) [Ep 6 · 19:10](https://team.globalcastmd.com/watch/transplantation-and-ventricular-assist-devices-new-horizons-in-medical-and-891?t=1150)
- The upcoming adult allocation system changes will be more favorable for Fontan patients, but the recent pediatric allocation changes were not favorable for Fontan PLE or plastic bronchitis patients. — Andrew Lotz (guideline) [Ep 6 · 19:34](https://team.globalcastmd.com/watch/transplantation-and-ventricular-assist-devices-new-horizons-in-medical-and-891?t=1174)
- In pediatric VAD practice, 'destination therapy' has been reframed as 'chronic therapy,' with the concept that patients can transition in and out of transplant candidacy status. — Andrew Lotz (clinical) [Ep 6 · 20:48](https://team.globalcastmd.com/watch/transplantation-and-ventricular-assist-devices-new-horizons-in-medical-and-891?t=1248)
- If a patient is not labeled as destination therapy, the goal remains getting them to transplant candidacy, which may result in longer life and probably better quality of life, although that is yet to be determined. — Andrew Lotz (opinion) [Ep 6 · 21:06](https://team.globalcastmd.com/watch/transplantation-and-ventricular-assist-devices-new-horizons-in-medical-and-891?t=1266)
- There are only about 20 Fontans in all of Intermacs and Pedimacs (the two VAD registries) available to study. — Andrew Lotz (epidemiological) [Ep 6 · 21:40](https://team.globalcastmd.com/watch/transplantation-and-ventricular-assist-devices-new-horizons-in-medical-and-891?t=1300)
- A handful of Fontan patients have been successfully supported with atrial cannulation. — Andrew Lotz (clinical) [Ep 6 · 22:22](https://team.globalcastmd.com/watch/transplantation-and-ventricular-assist-devices-new-horizons-in-medical-and-891?t=1342)
- Atrial cannulation allows flow into the VAD where a restrictive or small-cavity ventricle sometimes clamps around the cannula and does not allow flow; this phenomenon has been observed. — Andrew Lotz (clinical) [Ep 6 · 22:54](https://team.globalcastmd.com/watch/transplantation-and-ventricular-assist-devices-new-horizons-in-medical-and-891?t=1374)
- Mean capillary filling pressure is a measure of intravascular volume status and venous wall tension and compliance, which is very often abnormal in Fontan circulation patients with reduced compliance. (clinical) [Ep 9 · 3:41](https://team.globalcastmd.com/watch/case-review-dynamic-assessment-of-the-fontan-part-ii-new-horizons-in-medical-894?t=221)
- Fontan patients who respond with rapid venous pressure increases during exercise tend to have diminished exercise capacity, while those with minimal pressure changes tend to exercise longer. (clinical) [Ep 9 · 4:30](https://team.globalcastmd.com/watch/case-review-dynamic-assessment-of-the-fontan-part-ii-new-horizons-in-medical-894?t=270)
- Fontan patients drop their renal near-infrared spectroscopy values very precipitously and early during exercise compared to normal controls, and these values do not return to normal even after 5-6 minutes of recovery. (clinical) [Ep 9 · 5:02](https://team.globalcastmd.com/watch/case-review-dynamic-assessment-of-the-fontan-part-ii-new-horizons-in-medical-894?t=302)
- Cerebral near-infrared spectroscopy shows an early drop in Fontan patients during exercise but returns to normal by the second minute of exercise, in contrast to renal NIRS. (clinical) [Ep 9 · 5:24](https://team.globalcastmd.com/watch/case-review-dynamic-assessment-of-the-fontan-part-ii-new-horizons-in-medical-894?t=324)
- Dynamic assessment of the Fontan patient is essential, and this technique gives good insight to pick up occult abnormal physiology in well-functioning Fontans that would not be appreciated until much later when the patient becomes ill. (opinion) [Ep 9 · 7:31](https://team.globalcastmd.com/watch/case-review-dynamic-assessment-of-the-fontan-part-ii-new-horizons-in-medical-894?t=451)
- With exercise comes central venous hypertension in Fontan patients, which begets liver disease amongst other things. (clinical) [Ep 9 · 8:38](https://team.globalcastmd.com/watch/case-review-dynamic-assessment-of-the-fontan-part-ii-new-horizons-in-medical-894?t=518)
- With any form of exercise, if you take the extremes, the detrimental effects may well outweigh the beneficial effects. (opinion) [Ep 9 · 9:04](https://team.globalcastmd.com/watch/case-review-dynamic-assessment-of-the-fontan-part-ii-new-horizons-in-medical-894?t=544)
- Submaximal exercise protocols already incorporate most of the venous pressure rise seen during maximal testing. (clinical) [Ep 9 · 10:06](https://team.globalcastmd.com/watch/case-review-dynamic-assessment-of-the-fontan-part-ii-new-horizons-in-medical-894?t=606)
- Patients on transplant lists get better with exercise largely because of skeletal muscle function and oxygen extraction improvements, but the hemodynamics may or may not change. (clinical) [Ep 9 · 10:36](https://team.globalcastmd.com/watch/case-review-dynamic-assessment-of-the-fontan-part-ii-new-horizons-in-medical-894?t=636)
- Vessels in Fontan patients change in their histopathology to accommodate higher pressures, with perivenular changes in the liver being quite striking, and vascular adaptive responses seen in the SVC and IVC. (clinical) [Ep 9 · 11:04](https://team.globalcastmd.com/watch/case-review-dynamic-assessment-of-the-fontan-part-ii-new-horizons-in-medical-894?t=664)
- There is virtually no data in any condition suggesting that if you change vascular biology acutely, you change exercise function. (clinical) [Ep 9 · 11:38](https://team.globalcastmd.com/watch/case-review-dynamic-assessment-of-the-fontan-part-ii-new-horizons-in-medical-894?t=698)
- In biventricular patients, supine exercise is limited compared to upright exercise. (clinical) [Ep 9 · 13:15](https://team.globalcastmd.com/watch/case-review-dynamic-assessment-of-the-fontan-part-ii-new-horizons-in-medical-894?t=795)
- In Fontan patients, exercise limitation during supine exercise looks the same as in biventricular patients, with no particular advantage to swimming or other flat exercises in terms of ultimate performance. (clinical) [Ep 9 · 13:38](https://team.globalcastmd.com/watch/case-review-dynamic-assessment-of-the-fontan-part-ii-new-horizons-in-medical-894?t=818)
- This testing increasingly picks up occult problems including obstructions in the Fontan circuit that may not be known about with just echo and clinical assessment. (clinical) [Ep 9 · 14:10](https://team.globalcastmd.com/watch/case-review-dynamic-assessment-of-the-fontan-part-ii-new-horizons-in-medical-894?t=850)
- In any circulation, blood flow per unit time is dependent upon the drop in pressure across the vascular bed and the vascular resistance (Ohm's law). — Brian Goldstein (clinical) [Ep 10 · 1:26](https://team.globalcastmd.com/watch/case-review-dynamic-assessment-of-the-fontan-part-i-new-horizons-in-medical-895?t=86)
- Biventricular circulation is characterized by low right ventricular pressure, low pulmonary arterial pressure, and low pulmonary vascular resistance. — Brian Goldstein (clinical) [Ep 10 · 2:07](https://team.globalcastmd.com/watch/case-review-dynamic-assessment-of-the-fontan-part-i-new-horizons-in-medical-895?t=127)
- During exercise in biventricular circulation, cardiac output can increase to approximately 5 times baseline cardiac output. — Brian Goldstein (clinical) [Ep 10 · 2:31](https://team.globalcastmd.com/watch/case-review-dynamic-assessment-of-the-fontan-part-i-new-horizons-in-medical-895?t=151)
- The pulmonary vascular resistance falls characteristically during exercise in biventricular circulation, allowing for substantial augmentation of pulmonary blood flow. — Brian Goldstein (clinical) [Ep 10 · 2:41](https://team.globalcastmd.com/watch/case-review-dynamic-assessment-of-the-fontan-part-i-new-horizons-in-medical-895?t=161)
- In the Fontan circuit, the pulmonary vascular resistance is typically both fixed and elevated. — Brian Goldstein (clinical) [Ep 10 · 3:01](https://team.globalcastmd.com/watch/case-review-dynamic-assessment-of-the-fontan-part-i-new-horizons-in-medical-895?t=181)
- In Fontan circulation, baseline cardiac output is typically near normal but a bit reduced, 70 to 80%. — Brian Goldstein (clinical) [Ep 10 · 3:28](https://team.globalcastmd.com/watch/case-review-dynamic-assessment-of-the-fontan-part-i-new-horizons-in-medical-895?t=208)
- Central venous pressure in Fontan patients is chronically elevated because there is no ventricle to do the work of the subpulmonary blood flow. — Brian Goldstein (clinical) [Ep 10 · 3:39](https://team.globalcastmd.com/watch/case-review-dynamic-assessment-of-the-fontan-part-i-new-horizons-in-medical-895?t=219)
- With exercise in Fontan patients, cardiac output increases quite a bit more limited than in the two ventricle population, characterized by increased central venous pressure and increased pulmonary vascular resistance. — Brian Goldstein (clinical) [Ep 10 · 3:49](https://team.globalcastmd.com/watch/case-review-dynamic-assessment-of-the-fontan-part-i-new-horizons-in-medical-895?t=229)
- At rest with zero exercise, cardiac output in typical or good Fontan patients is 70 to 80% of a normal biventricular patient, and identifying differences between these two populations may be subtle. — Brian Goldstein (clinical) [Ep 10 · 4:30](https://team.globalcastmd.com/watch/case-review-dynamic-assessment-of-the-fontan-part-i-new-horizons-in-medical-895?t=270)
- With augmentation of cardiac output or with stress or exercise, the difference between the Fontan patient and the biventricular patient becomes substantially increased. — Brian Goldstein (clinical) [Ep 10 · 4:49](https://team.globalcastmd.com/watch/case-review-dynamic-assessment-of-the-fontan-part-i-new-horizons-in-medical-895?t=289)
- The limitations of cardiac output in the Fontan circulation can be distilled down to pulmonary vascular resistance, diastolic function of the ventricle, and systolic function of the ventricle. — Brian Goldstein (clinical) [Ep 10 · 5:16](https://team.globalcastmd.com/watch/case-review-dynamic-assessment-of-the-fontan-part-i-new-horizons-in-medical-895?t=316)
- Systolic function is typically preserved in Fontan patients, at least preserved until very late in the clinical presentation with difficulties. — Brian Goldstein (clinical) [Ep 10 · 5:28](https://team.globalcastmd.com/watch/case-review-dynamic-assessment-of-the-fontan-part-i-new-horizons-in-medical-895?t=328)
- Most or all variables in Fontan circulation may be pretty typical or near normal at rest, thus to understand limitations, one must evaluate these variables in a dynamic or stressed state. — Brian Goldstein (clinical) [Ep 10 · 5:50](https://team.globalcastmd.com/watch/case-review-dynamic-assessment-of-the-fontan-part-i-new-horizons-in-medical-895?t=350)
- In a series of Fontan patients who underwent supine exercise with invasive hemodynamics, pulmonary vascular resistance was elevated at rest and with exercise, the pulmonary vascular resistance was quite static and did not decrease as expected with maximal exercise. — Brian Goldstein (clinical) [Ep 10 · 6:56](https://team.globalcastmd.com/watch/case-review-dynamic-assessment-of-the-fontan-part-i-new-horizons-in-medical-895?t=416)
- In patients with biventricular circulation, pulmonary vascular resistance begins lower and falls with exercise. — Brian Goldstein (clinical) [Ep 10 · 7:21](https://team.globalcastmd.com/watch/case-review-dynamic-assessment-of-the-fontan-part-i-new-horizons-in-medical-895?t=441)
- The Pediatric Heart Network Fuel trial is a randomized trial of 400 Fontan patients, with 200 receiving udenafil (a PDE5 inhibitor) and 200 receiving placebo, evaluating exercise capacity after 6 months of therapy. — Brian Goldstein (clinical) [Ep 10 · 8:05](https://team.globalcastmd.com/watch/case-review-dynamic-assessment-of-the-fontan-part-i-new-horizons-in-medical-895?t=485)
- In a study comparing Fontan patients with normal diastolic function versus those with diastolic dysfunction by echocardiography, patients with diastolic dysfunction had reduced peak VO2 and peak work with both supine and upright exercise. — Brian Goldstein (clinical) [Ep 10 · 9:27](https://team.globalcastmd.com/watch/case-review-dynamic-assessment-of-the-fontan-part-i-new-horizons-in-medical-895?t=567)
- Echocardiographic measures of diastolic function have not been validated in a Fontan population. — Brian Goldstein (clinical) [Ep 10 · 10:16](https://team.globalcastmd.com/watch/case-review-dynamic-assessment-of-the-fontan-part-i-new-horizons-in-medical-895?t=616)
- Invasive assessment of end-diastolic pressure in symptomatic Fontan patients is frequently unrevealing in the resting state because patients are often preload starved from being NPO, lying supine, and not undergoing stress. — Brian Goldstein (clinical) [Ep 10 · 10:27](https://team.globalcastmd.com/watch/case-review-dynamic-assessment-of-the-fontan-part-i-new-horizons-in-medical-895?t=627)
- In a protocol of rapid volume expansion (ventricular stress testing) in 46 Fontan patients, ventricular filling pressure (end-diastolic pressure) was significantly increased after exposure to volume, while transpulmonary gradient, pulmonary vascular resistance, and cardiac index were not significantly affected. — Brian Goldstein (clinical) [Ep 10 · 11:05](https://team.globalcastmd.com/watch/case-review-dynamic-assessment-of-the-fontan-part-i-new-horizons-in-medical-895?t=665)
- About 35% of Fontan patients demonstrated occult diastolic dysfunction, defined as a post volume challenge end-diastolic pressure of greater than or equal to 15 millimeters of mercury. — Brian Goldstein (clinical) [Ep 10 · 12:09](https://team.globalcastmd.com/watch/case-review-dynamic-assessment-of-the-fontan-part-i-new-horizons-in-medical-895?t=729)
- In univariate analysis, higher baseline end-diastolic pressure, longer duration of Fontan circulation, and lower baseline cardiac index were associated with higher fluid challenge end-diastolic pressure. — Brian Goldstein (clinical) [Ep 10 · 12:22](https://team.globalcastmd.com/watch/case-review-dynamic-assessment-of-the-fontan-part-i-new-horizons-in-medical-895?t=742)
- Longer duration of Fontan circulation was associated with a greater change in filling pressure during volume challenge. — Brian Goldstein (clinical) [Ep 10 · 12:53](https://team.globalcastmd.com/watch/case-review-dynamic-assessment-of-the-fontan-part-i-new-horizons-in-medical-895?t=773)
- In multivariable analysis, baseline end-diastolic pressure was the only finding associated with the final end-diastolic pressure after volume challenge. — Brian Goldstein (clinical) [Ep 10 · 12:58](https://team.globalcastmd.com/watch/case-review-dynamic-assessment-of-the-fontan-part-i-new-horizons-in-medical-895?t=778)
- The volume challenge protocol has been shared with a number of other large congenital heart centers and has now been performed in over 100 patients. — Brian Goldstein (clinical) [Ep 10 · 13:06](https://team.globalcastmd.com/watch/case-review-dynamic-assessment-of-the-fontan-part-i-new-horizons-in-medical-895?t=786)
- Fontan patients can have the presence of mechanical dyssynchrony without electrical dyssynchrony, which contributes to overall ventricular dysfunction, both systolic and diastolic. — Brian Goldstein (clinical) [Ep 10 · 14:24](https://team.globalcastmd.com/watch/case-review-dynamic-assessment-of-the-fontan-part-i-new-horizons-in-medical-895?t=864)
- Acute improvements in ventricular mechanics from pacing could translate to long-term clinical benefits, though this is an unproven assertion. — Brian Goldstein (opinion) [Ep 10 · 15:02](https://team.globalcastmd.com/watch/case-review-dynamic-assessment-of-the-fontan-part-i-new-horizons-in-medical-895?t=902)
- In the catheterization laboratory, a multimodality setup with conductance catheter feeds, electrical anatomic mapping, fluoro, ECG, and voltage mapping can identify ideal pacing sites and demonstrate ventricular mechanic changes at each site. — Brian Goldstein (clinical) [Ep 10 · 15:37](https://team.globalcastmd.com/watch/case-review-dynamic-assessment-of-the-fontan-part-i-new-horizons-in-medical-895?t=937)
- Dynamic assessment of the Fontan circulation might provide substantial insight beyond what can be obtained in the resting state. — Brian Goldstein (opinion) [Ep 10 · 16:09](https://team.globalcastmd.com/watch/case-review-dynamic-assessment-of-the-fontan-part-i-new-horizons-in-medical-895?t=969)
- Pathologies in pulmonary vascular resistance and diastolic function are likely to play critical roles in the limitations of Fontan patients. — Brian Goldstein (opinion) [Ep 10 · 16:38](https://team.globalcastmd.com/watch/case-review-dynamic-assessment-of-the-fontan-part-i-new-horizons-in-medical-895?t=998)
- In the Fuel trial with 400 patients, efforts have not been made to identify those patients who specifically have problems with pulmonary vascular resistance before inclusion in the trial. — Brian Goldstein (clinical) [Ep 10 · 18:07](https://team.globalcastmd.com/watch/case-review-dynamic-assessment-of-the-fontan-part-i-new-horizons-in-medical-895?t=1087)
- Patients with relatively low pulmonary vascular resistance but substantial ventricular noncompliance may not respond to PDE5 inhibitor therapy if the drug does not have lusotropic effects to overcome ventricular fibrosis and noncompliance. — Brian Goldstein (opinion) [Ep 10 · 18:24](https://team.globalcastmd.com/watch/case-review-dynamic-assessment-of-the-fontan-part-i-new-horizons-in-medical-895?t=1104)
- BNP was measured after exercise in the invasive exercise cohort, and almost universally it was a meaningless measure, with every patient's number between 15 and 40. — Brian Goldstein (clinical) [Ep 10 · 21:09](https://team.globalcastmd.com/watch/case-review-dynamic-assessment-of-the-fontan-part-i-new-horizons-in-medical-895?t=1269)
- The easy biomarker has proved difficult to identify in Fontan patients because their end-diastolic pressure is probably quite low and not straining their atrium. — Brian Goldstein (opinion) [Ep 10 · 21:27](https://team.globalcastmd.com/watch/case-review-dynamic-assessment-of-the-fontan-part-i-new-horizons-in-medical-895?t=1287)
- Hideki Senzaki's group has looked at profibrotic markers in the blood in the Fontan circulation, with some patients having very high levels of circulating effectors of fibrosis. — Reddington (clinical) [Ep 10 · 21:56](https://team.globalcastmd.com/watch/case-review-dynamic-assessment-of-the-fontan-part-i-new-horizons-in-medical-895?t=1316)

## Host summaries
Recaps by a host of what the experts said — not the host's own clinical position.
- Stacey Morrison is a clinical psychologist working in adult congenital heart disease and the Fontan Clinic. — The host summarizes what Dr. Stacey Morrison said [Ep 3 · 0:03](https://team.globalcastmd.com/watch/psychosocial-outcomes-new-horizons-in-medical-and-surgical-fontan-management-888?t=3)
- T1 mapping in adolescent Fontan patients shows fibrosis content is higher than in normal controls and significantly higher in those with systemic right ventricles compared to systemic left ventricles. — Andrew Crean summarizes what Dr. Mike Takahashi said [Ep 7 · 1:51](https://team.globalcastmd.com/watch/advanced-imaging-of-the-fontan-what-is-driving-fontan-failure-new-horizons-892?t=111)
- There are large series in the adult AF population with outcomes up to about a year suggesting no increased stroke risk when CT is used instead of TEE for pre-cardioversion thrombus assessment. — Andrew Crean summarizes what Dr. Mike Takahashi said [Ep 7 · 24:05](https://team.globalcastmd.com/watch/advanced-imaging-of-the-fontan-what-is-driving-fontan-failure-new-horizons-892?t=1445)
- CHOP data showed no difference in outcomes in the first 10 years after Fontan between hypoplastic left heart syndrome and systemic left ventricle patients — Andrew Reddington summarizing the discussion [Ep 11 · 6:54](https://team.globalcastmd.com/watch/how-does-the-blood-go-round-in-single-ventricles-and-fontans-new-horizons-in-896?t=414)
- Boston data showed patients born with systemic left ventricle with normally related great vessels or single right ventricle do better than all other diagnoses — Andrew Reddington summarizing the discussion [Ep 11 · 7:21](https://team.globalcastmd.com/watch/how-does-the-blood-go-round-in-single-ventricles-and-fontans-new-horizons-in-896?t=441)
- Melbourne group data showed right ventricular dominance is a risk factor if present at birth, but after surviving the first couple of years post-Fontan, survival curves are essentially identical regardless of ventricular morphology — Andrew Reddington summarizing the discussion [Ep 11 · 7:40](https://team.globalcastmd.com/watch/how-does-the-blood-go-round-in-single-ventricles-and-fontans-new-horizons-in-896?t=460)
- Force-frequency relationships in systemic right and left ventricles in univentricular circulation outperformed normal ventricles — Andrew Reddington summarizing the discussion [Ep 11 · 8:37](https://team.globalcastmd.com/watch/how-does-the-blood-go-round-in-single-ventricles-and-fontans-new-horizons-in-896?t=517)
- End-systolic elastance in Fontan patients is orders of magnitude higher than normals and even greater than in systemic right ventricle of Mustard patients — Andrew Reddington summarizing the discussion [Ep 11 · 9:03](https://team.globalcastmd.com/watch/how-does-the-blood-go-round-in-single-ventricles-and-fontans-new-horizons-in-896?t=543)
- MRI tagging showed some segments of Fontan ventricular wall were 180 degrees out of phase with other parts, in systole when rest of ventricle was in diastole — Andrew Reddington summarizing the discussion [Ep 11 · 11:58](https://team.globalcastmd.com/watch/how-does-the-blood-go-round-in-single-ventricles-and-fontans-new-horizons-in-896?t=718)
- Eight-year follow-up of Fontan patients showed maintained incoordinate relaxation, shortened IVRT suggesting rising left atrial pressure, and faster E wave deceleration suggesting falling compliance — Andrew Reddington summarizing the discussion [Ep 11 · 14:18](https://team.globalcastmd.com/watch/how-does-the-blood-go-round-in-single-ventricles-and-fontans-new-horizons-in-896?t=858)
- Diastolic compliance of Fontan ventricles (predominantly left ventricles) is highly abnormal, unlike Mustard systemic right ventricles where diastolic compliance is not a problem — Andrew Reddington summarizing the discussion [Ep 11 · 14:47](https://team.globalcastmd.com/watch/how-does-the-blood-go-round-in-single-ventricles-and-fontans-new-horizons-in-896?t=887)
- PHN data at 10-12 years post-Fontan showed systemic right ventricles had far more patients with increased E/E' ratio (indicating increased stiffness) compared to systemic left ventricles — Andrew Reddington summarizing the discussion [Ep 11 · 20:04](https://team.globalcastmd.com/watch/how-does-the-blood-go-round-in-single-ventricles-and-fontans-new-horizons-in-896?t=1204)
- Recent conductance catheter work from the Netherlands shows a tight relationship between arterial elastance and ventricular end-diastolic pressure — Andrew Reddington summarizing the discussion [Ep 11 · 23:01](https://team.globalcastmd.com/watch/how-does-the-blood-go-round-in-single-ventricles-and-fontans-new-horizons-in-896?t=1381)
- More Fontan patients are surviving into adolescence and adulthood — Lizzie Lee summarizing a resource [Ep 12 · 0:11](https://team.globalcastmd.com/watch/outcomes-of-fontan-patients-undergoing-combined-heart-liver-transplantation-in-pediatric-hospitals-across-the-u-s-11307?t=11)
- Liver disease is becoming a rising issue in Fontan patients — Lizzie Lee summarizing a resource [Ep 12 · 0:11](https://team.globalcastmd.com/watch/outcomes-of-fontan-patients-undergoing-combined-heart-liver-transplantation-in-pediatric-hospitals-across-the-u-s-11307?t=11)
- Combined heart-liver transplantation is happening more often in Fontan patients — Lizzie Lee summarizing a resource [Ep 12 · 0:11](https://team.globalcastmd.com/watch/outcomes-of-fontan-patients-undergoing-combined-heart-liver-transplantation-in-pediatric-hospitals-across-the-u-s-11307?t=11)
- The study examined children and young adults undergoing combined heart-liver transplant at hospitals across the US in the last few years — Lizzie Lee summarizing a resource [Ep 12 · 0:21](https://team.globalcastmd.com/watch/outcomes-of-fontan-patients-undergoing-combined-heart-liver-transplantation-in-pediatric-hospitals-across-the-u-s-11307?t=21)
- Many of the patients in the study had hypoplastic left heart syndrome — Lizzie Lee summarizing a resource [Ep 12 · 0:28](https://team.globalcastmd.com/watch/outcomes-of-fontan-patients-undergoing-combined-heart-liver-transplantation-in-pediatric-hospitals-across-the-u-s-11307?t=28)
- About 85% of patients survived at 1 year after combined heart-liver transplant — Lizzie Lee summarizing a resource [Ep 12 · 0:36](https://team.globalcastmd.com/watch/outcomes-of-fontan-patients-undergoing-combined-heart-liver-transplantation-in-pediatric-hospitals-across-the-u-s-11307?t=36)
- Long-term outcomes after combined heart-liver transplant were excellent — Lizzie Lee summarizing a resource [Ep 12 · 0:36](https://team.globalcastmd.com/watch/outcomes-of-fontan-patients-undergoing-combined-heart-liver-transplantation-in-pediatric-hospitals-across-the-u-s-11307?t=36)
- Three-year survival after combined heart-liver transplant was basically identical to patients who received heart transplant alone — Lizzie Lee summarizing a resource [Ep 12 · 0:41](https://team.globalcastmd.com/watch/outcomes-of-fontan-patients-undergoing-combined-heart-liver-transplantation-in-pediatric-hospitals-across-the-u-s-11307?t=41)
- Combined heart-liver transplant is effective for Fontan patients with advanced liver disease — Lizzie Lee summarizing a resource [Ep 12 · 0:48](https://team.globalcastmd.com/watch/outcomes-of-fontan-patients-undergoing-combined-heart-liver-transplantation-in-pediatric-hospitals-across-the-u-s-11307?t=48)
- Combined heart-liver transplant is increasingly common for Fontan patients with advanced liver disease — Lizzie Lee summarizing a resource [Ep 12 · 0:48](https://team.globalcastmd.com/watch/outcomes-of-fontan-patients-undergoing-combined-heart-liver-transplantation-in-pediatric-hospitals-across-the-u-s-11307?t=48)
- The prevalence of silent pulmonary embolism in adults with Fontan circulation may be as high as 1 in 5 (20%). — Joe summarizing the discussion [Ep 1 · 1:23](https://team.globalcastmd.com/watch/how-do-we-manage-thrombogenicity-and-thrombosis-in-the-fontan-new-horizons-886?t=83)
- In Paul Monagle's study comparing aspirin and warfarin in newer style Fontans, patients had an overall cumulative risk of 22% for thrombotic events. — Joe summarizing the discussion [Ep 1 · 1:39](https://team.globalcastmd.com/watch/how-do-we-manage-thrombogenicity-and-thrombosis-in-the-fontan-new-horizons-886?t=99)
- Reanalysis of Monagle's data showed that warfarin with time-in-therapeutic-range of 60% or better edged out aspirin over time. — Joe summarizing the discussion [Ep 1 · 6:14](https://team.globalcastmd.com/watch/how-do-we-manage-thrombogenicity-and-thrombosis-in-the-fontan-new-horizons-886?t=374)
- Retrospective data from Cedric Manliot's group showed warfarin was clearly better than aspirin, though both were significantly better than no thromboprophylaxis. — Joe summarizing the discussion [Ep 1 · 6:39](https://team.globalcastmd.com/watch/how-do-we-manage-thrombogenicity-and-thrombosis-in-the-fontan-new-horizons-886?t=399)
- In patients with excellent time-in-therapeutic-range (>80%), Grushin's group observed only one thrombotic event over 53 patient-years. — Joe summarizing the discussion [Ep 1 · 7:14](https://team.globalcastmd.com/watch/how-do-we-manage-thrombogenicity-and-thrombosis-in-the-fontan-new-horizons-886?t=434)
- Thrombotic risk in Fontan patients follows a bimodal incidence: initial post-surgical risk, then a honeymoon phase of variable duration, followed by inexorable increase in thrombotic risk. — Joe summarizing the discussion [Ep 1 · 9:16](https://team.globalcastmd.com/watch/how-do-we-manage-thrombogenicity-and-thrombosis-in-the-fontan-new-horizons-886?t=556)
- Elevated D-dimer is a strong marker of increased thrombotic risk in adults with unprovoked venous thromboembolism. — Joe summarizing the discussion [Ep 1 · 10:08](https://team.globalcastmd.com/watch/how-do-we-manage-thrombogenicity-and-thrombosis-in-the-fontan-new-horizons-886?t=608)
- Factor VIII activity increases significantly post-Fontan, and in one study the four patients with the highest factor VIII levels were the ones who developed thrombotic complications. — Joe summarizing the discussion [Ep 1 · 10:49](https://team.globalcastmd.com/watch/how-do-we-manage-thrombogenicity-and-thrombosis-in-the-fontan-new-horizons-886?t=649)
- In Fontan patients, natural anticoagulants (antithrombin, protein C) are often lower, consistent with liver synthetic dysfunction developing over time. — Joe summarizing the discussion [Ep 1 · 11:10](https://team.globalcastmd.com/watch/how-do-we-manage-thrombogenicity-and-thrombosis-in-the-fontan-new-horizons-886?t=670)
- Despite lower procoagulants from liver dysfunction, Fontan patients have elevated prothrombin fragment 1.2, indicating they are at thrombotic risk rather than bleeding risk. — Joe summarizing the discussion [Ep 1 · 11:46](https://team.globalcastmd.com/watch/how-do-we-manage-thrombogenicity-and-thrombosis-in-the-fontan-new-horizons-886?t=706)
- Some have recommended replacing central pulmonary arteries with a Gore-Tex graft in Fontan transplant patients. — Twaddle summarizing a resource [Ep 4 · 15:26](https://team.globalcastmd.com/watch/update-on-surgical-practice-and-current-state-on-fontan-conversion-surgery-889?t=926)
- In early Boston Fontan data, macro-reentrant atrial tachycardia was ubiquitous out to 20 years — Rick Choi summarizing the discussion [Ep 5 · 1:45](https://team.globalcastmd.com/watch/the-role-of-trans-catheter-arrhythmia-management-patient-based-decision-890?t=105)
- After first atrial tachycardia and cardioversion in Fontan patients, risk of future tachycardia is upwards of 80 or 90% — Rick Choi summarizing the discussion [Ep 5 · 2:13](https://team.globalcastmd.com/watch/the-role-of-trans-catheter-arrhythmia-management-patient-based-decision-890?t=133)
- While incidence of tachycardia is heavily related to Fontan type, risk of recurrent tachycardia is the same for all Fontan types — Rick Choi summarizing the discussion [Ep 5 · 2:29](https://team.globalcastmd.com/watch/the-role-of-trans-catheter-arrhythmia-management-patient-based-decision-890?t=149)
- Anti-arrhythmic medications do not achieve complete suppression of atrial tachycardia in Fontan patients — Rick Choi summarizing the discussion [Ep 5 · 2:40](https://team.globalcastmd.com/watch/the-role-of-trans-catheter-arrhythmia-management-patient-based-decision-890?t=160)
- In multiple studies, essentially 100% of Fontan patients on anti-arrhythmics alone have recurrence of tachycardia over 5 to 6 years — Rick Choi summarizing the discussion [Ep 5 · 2:52](https://team.globalcastmd.com/watch/the-role-of-trans-catheter-arrhythmia-management-patient-based-decision-890?t=172)
- Lateral tunnel Fontans have had significantly less incidence of atrial arrhythmias compared to atrial-pulmonary Fontans — Rick Choi summarizing the discussion [Ep 5 · 4:37](https://team.globalcastmd.com/watch/the-role-of-trans-catheter-arrhythmia-management-patient-based-decision-890?t=277)
- Data on whether extracardiac conduit has significantly lower arrhythmia incidence than intracardiac conduit is discrepant, with some studies showing significant improvement and others showing less difference — Rick Choi summarizing the discussion [Ep 5 · 4:45](https://team.globalcastmd.com/watch/the-role-of-trans-catheter-arrhythmia-management-patient-based-decision-890?t=285)
- In Boston study of ~90 Fontan ablation patients, over half required trans-baffle procedure, with moderate or severe complication rate of about 10% — Rick Choi summarizing the discussion [Ep 5 · 6:11](https://team.globalcastmd.com/watch/the-role-of-trans-catheter-arrhythmia-management-patient-based-decision-890?t=371)
- In trans-baffle ablation cases, catastrophic complications included death and major shunts with cyanosis, whereas non-trans-baffle complications were primarily kidney injury — Rick Choi summarizing the discussion [Ep 5 · 6:30](https://team.globalcastmd.com/watch/the-role-of-trans-catheter-arrhythmia-management-patient-based-decision-890?t=390)
- In study of 52 Fontan ablation patients, 80 different arrhythmia mechanisms were identified, meaning majority of patients had more than one mechanism — Rick Choi summarizing the discussion [Ep 5 · 7:52](https://team.globalcastmd.com/watch/the-role-of-trans-catheter-arrhythmia-management-patient-based-decision-890?t=472)
- In Fontan ablations, macro-reentrant tachycardia was most common type but represented less than half of ablations, with focal atrial tachycardia and AVNRT being important mechanisms — Rick Choi summarizing the discussion [Ep 5 · 8:05](https://team.globalcastmd.com/watch/the-role-of-trans-catheter-arrhythmia-management-patient-based-decision-890?t=485)
- Ed Walsh felt that atrial tachycardia was a risk factor for sudden death in Fontan patients — Rick Choi summarizing the discussion [Ep 5 · 10:18](https://team.globalcastmd.com/watch/the-role-of-trans-catheter-arrhythmia-management-patient-based-decision-890?t=618)
- In several studies, Fontans with arrhythmias do worse than Fontans without arrhythmias in terms of freedom from death or transplant — Rick Choi summarizing the discussion [Ep 5 · 10:38](https://team.globalcastmd.com/watch/the-role-of-trans-catheter-arrhythmia-management-patient-based-decision-890?t=638)
- Arrhythmia is a significant predictor of outcome in Fontan risk stratification models — Rick Choi summarizing the discussion [Ep 5 · 10:52](https://team.globalcastmd.com/watch/the-role-of-trans-catheter-arrhythmia-management-patient-based-decision-890?t=652)
- In Mayo study of 260 Fontan patients with arrhythmia, almost all patients had recurrence of atrial tachycardia regardless of management strategy — Rick Choi summarizing the discussion [Ep 5 · 11:47](https://team.globalcastmd.com/watch/the-role-of-trans-catheter-arrhythmia-management-patient-based-decision-890?t=707)
- High recurrence rate in Mayo study was heavily driven by high prevalence of patients on anti-arrhythmic medications alone — Rick Choi summarizing the discussion [Ep 5 · 11:56](https://team.globalcastmd.com/watch/the-role-of-trans-catheter-arrhythmia-management-patient-based-decision-890?t=716)
- Catheter ablation in Fontan patients achieved freedom from recurrence in the range of 40 to 50%, not the 95-97% typical of other ablation types — Rick Choi summarizing the discussion [Ep 5 · 12:05](https://team.globalcastmd.com/watch/the-role-of-trans-catheter-arrhythmia-management-patient-based-decision-890?t=725)
- In study using clinical arrhythmia severity scores, Fontan patients who underwent ablation had significant improvement in scores following ablation — Rick Choi summarizing the discussion [Ep 5 · 12:31](https://team.globalcastmd.com/watch/the-role-of-trans-catheter-arrhythmia-management-patient-based-decision-890?t=751)
- Even in Fontan patients who had recurrence of tachycardia after ablation, there was still some improvement in overall arrhythmia burden, though not as robust as in patients without recurrence — Rick Choi summarizing the discussion [Ep 5 · 12:52](https://team.globalcastmd.com/watch/the-role-of-trans-catheter-arrhythmia-management-patient-based-decision-890?t=772)
- In surgical ablation data from Chicago, isthmus ablation-only strategy had much worse outcomes than more aggressive strategies, but aggressive strategies bring sinus node dysfunction into the equation — Rick Choi summarizing the discussion [Ep 5 · 16:06](https://team.globalcastmd.com/watch/the-role-of-trans-catheter-arrhythmia-management-patient-based-decision-890?t=966)
- In the Bernstein 2006 pediatric heart transplant study group multi-center analysis, risk factors for poor Fontan transplant outcomes included mechanical ventilation at listing, younger age (0-4 years), status 1 listing, and shorter time interval from Fontan (less than 6 months). — Andrew Lotz summarizing a resource [Ep 6 · 2:55](https://team.globalcastmd.com/watch/transplantation-and-ventricular-assist-devices-new-horizons-in-medical-and-891?t=175)
- If Fontan patients are selected appropriately, they do just as well as dilated cardiomyopathy patients post-heart transplant. — Andrew Lotz summarizing a resource [Ep 6 · 4:57](https://team.globalcastmd.com/watch/transplantation-and-ventricular-assist-devices-new-horizons-in-medical-and-891?t=297)
- The 1998 Mertens study showed approximately 50% survival at 5 years after PLE diagnosis. — Andrew Lotz summarizing a resource [Ep 6 · 7:06](https://team.globalcastmd.com/watch/transplantation-and-ventricular-assist-devices-new-horizons-in-medical-and-891?t=426)
- A 2014 paper showed 85% survival five years after PLE diagnosis. — Andrew Lotz summarizing a resource [Ep 6 · 7:26](https://team.globalcastmd.com/watch/transplantation-and-ventricular-assist-devices-new-horizons-in-medical-and-891?t=446)
- Schumacher from Michigan showed 50% freedom from death or transplant at 5 years in patients diagnosed with plastic bronchitis. — Andrew Lotz summarizing a resource [Ep 6 · 8:01](https://team.globalcastmd.com/watch/transplantation-and-ventricular-assist-devices-new-horizons-in-medical-and-891?t=481)
- Current pediatric transplant survival across all centers is 92% at 1 year and 86% at 5 years. — Andrew Lotz summarizing a resource [Ep 6 · 9:19](https://team.globalcastmd.com/watch/transplantation-and-ventricular-assist-devices-new-horizons-in-medical-and-891?t=559)
- Fontan transplant survival, aggregating available data, is approximately 80% at 1 year and 75% at 5 years. — Andrew Lotz summarizing a resource [Ep 6 · 9:28](https://team.globalcastmd.com/watch/transplantation-and-ventricular-assist-devices-new-horizons-in-medical-and-891?t=568)
- Multi-center Fontan post-transplant studies show higher waitlist time and mortality compared to dilated cardiomyopathy. — Andrew Lotz summarizing a resource [Ep 6 · 9:53](https://team.globalcastmd.com/watch/transplantation-and-ventricular-assist-devices-new-horizons-in-medical-and-891?t=593)
- Standard listing criteria underestimate the degree of illness in Fontan patients. — Andrew Lotz summarizing a resource [Ep 6 · 10:07](https://team.globalcastmd.com/watch/transplantation-and-ventricular-assist-devices-new-horizons-in-medical-and-891?t=607)
- Fontan transplant patients have increased risk for early graft failure post-transplant. — Andrew Lotz summarizing a resource [Ep 6 · 10:11](https://team.globalcastmd.com/watch/transplantation-and-ventricular-assist-devices-new-horizons-in-medical-and-891?t=611)
- Death from sepsis is more common in Fontan transplant patients. — Andrew Lotz summarizing a resource [Ep 6 · 10:17](https://team.globalcastmd.com/watch/transplantation-and-ventricular-assist-devices-new-horizons-in-medical-and-891?t=617)
- Bleeding is more common in Fontan transplant patients since they are multiple-time redo surgeries. — Andrew Lotz summarizing a resource [Ep 6 · 10:20](https://team.globalcastmd.com/watch/transplantation-and-ventricular-assist-devices-new-horizons-in-medical-and-891?t=620)
- PLE resolves in Fontan transplant survivors. — Andrew Lotz summarizing a resource [Ep 6 · 10:28](https://team.globalcastmd.com/watch/transplantation-and-ventricular-assist-devices-new-horizons-in-medical-and-891?t=628)
- In the Excor (Berlin Heart) registry, there were only 5 stage 3 (Fontan) patients, with 3 survivors; days on support were 1, 3, and 229 days, representing a very limited dataset. — Andrew Lotz summarizing a resource [Ep 6 · 14:51](https://team.globalcastmd.com/watch/transplantation-and-ventricular-assist-devices-new-horizons-in-medical-and-891?t=891)
- The Intermacs adult registry shows only 17 single-ventricle patients, and the device type used is not clear in the registry. — Andrew Lotz summarizing a resource [Ep 6 · 15:16](https://team.globalcastmd.com/watch/transplantation-and-ventricular-assist-devices-new-horizons-in-medical-and-891?t=916)
- Among all adults listed as status 2 (where PLE adult Fontan patients would be), only 30-40% get transplanted within one year. — Andrew Lotz summarizing a resource [Ep 6 · 18:25](https://team.globalcastmd.com/watch/transplantation-and-ventricular-assist-devices-new-horizons-in-medical-and-891?t=1105)
- Among congenital heart disease patients on medical therapy (not all Fontans), one-third would be transplanted at 1 year. — Andrew Lotz summarizing a resource [Ep 6 · 18:37](https://team.globalcastmd.com/watch/transplantation-and-ventricular-assist-devices-new-horizons-in-medical-and-891?t=1117)
- In restrictive cardiomyopathy, Berlin Heart data shows that atrial cannulation does not perform as well as ventricular cannulation. — Andrew Lotz summarizing a resource [Ep 6 · 22:31](https://team.globalcastmd.com/watch/transplantation-and-ventricular-assist-devices-new-horizons-in-medical-and-891?t=1351)
- Peripheral venous pressure measured in the antecubital vein during exercise is highly correlated with central venous pressure in Fontan patients, based on data from Hideki Senzaki's group. — The host summarizing the discussion [Ep 9 · 3:11](https://team.globalcastmd.com/watch/case-review-dynamic-assessment-of-the-fontan-part-ii-new-horizons-in-medical-894?t=191)
- Mean capillary filling pressure measured using arm cuff occlusion technique correlates highly with values obtained in the catheterization laboratory. — The host summarizing the discussion [Ep 9 · 3:26](https://team.globalcastmd.com/watch/case-review-dynamic-assessment-of-the-fontan-part-ii-new-horizons-in-medical-894?t=206)
- Data suggests that when venous pressures transduced to hepatic veins exceed 25 mmHg for any length of time, subclinical evidence of hepatocellular damage occurs due to perfusion problems. — The host summarizing the discussion [Ep 9 · 5:57](https://team.globalcastmd.com/watch/case-review-dynamic-assessment-of-the-fontan-part-ii-new-horizons-in-medical-894?t=357)
- Exercise participation, whether formal or informal, begets improved exercise capacity, and exercise should be seen as a good thing for Fontan patients who may have been inappropriately restricted. — The host summarizing the discussion [Ep 9 · 8:16](https://team.globalcastmd.com/watch/case-review-dynamic-assessment-of-the-fontan-part-ii-new-horizons-in-medical-894?t=496)
- Gravity affects flow patterns in Fontan patients, with very different patterns of hepatic venous flow depending on whether lying flat or standing up, as shown by Ty Shah at Great Ormond Street. — The host summarizing the discussion [Ep 9 · 13:55](https://team.globalcastmd.com/watch/case-review-dynamic-assessment-of-the-fontan-part-ii-new-horizons-in-medical-894?t=835)
- With echocardiographic assessment of diastolic function, nearly 3/4 of Fontan patients demonstrate abnormalities of early relaxation or elevated atrial filling pressure, suggesting problems with diastolic function are quite prevalent. — Brian Goldstein summarizing a resource [Ep 10 · 9:03](https://team.globalcastmd.com/watch/case-review-dynamic-assessment-of-the-fontan-part-i-new-horizons-in-medical-895?t=543)

## Changelog
- Sep 24: 23 off-topic items removed (matched a keyword, not the subject)
- Sep 9: Summaries and takeaways published for 4 audiences
- Sep 7: Audit reverted — short clips unhidden
- Sep 7: 2 items hidden — never mention Single Ventricle / HLHS; unhide from the owner view
- Aug 31: 23 doctors auto-found from episode dossiers
- Aug 30: 23 doctors auto-found from episode dossiers
- Aug 30: 23 doctors auto-found from episode dossiers
- Aug 29: 23 doctors auto-found from episode dossiers
- Aug 29: 23 doctors auto-found from episode dossiers
- Aug 29: Collection generated from campaign corpus: 37 items, 34 dossiers, summaries for 4 audience(s)
- Aug 29: Collection reviewed and published
- Aug 29: Collection generated from campaign corpus: 35 items, 34 dossiers, summaries for 1 audience(s)
- Aug 29: Collection generated from campaign corpus: 35 items, 34 dossiers, summaries for 3 audience(s)

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Educational content from recorded physician discussions — not medical advice. Cite the canonical URL or the ?t= deep link. Policy: https://team.globalcastmd.com/ai