Liver Stiffness in Patients After the Fontan Procedure is Correlated with Age at Time of Surgery and Time since Surgery

Transcription

1 Liver Stiffness in Patients After the Fontan Procedure is Correlated with Age at Time of Surgery and Time since Surgery Yuki Cho 1), Daisuke Tokuhara 1), Yuki Kawasaki 2), Eiji Ehara 2), Yosuke Murakami 2), Haruo Shintaku 1) 1) 2) Department of Pediatric Cardiology, Osaka City General Hospital, Japan

2 Background The Fontan procedure is a palliative thrapy for patients with congenital heart disease especially univentricullar heart. Over 400 cases/year in Japan. Thousands of patients who had undergone Fontan procedure. Fontan procedure led to an early mortality reduction.

3 Fontan Circulation Systemic Circulation Fontan Procedure Systemic Circulation Normal Circulation Liver RA RV LV LA Single Ventricule Lung Systemic Circulation Lung Univentricular Heart Liver Single Ventricule Liver Lung

4 Complications Plastic bronchitis Protein-losing enteropathy Poor somatic growth and development Liver dysfunction Normal Liver Delayed pubertal maturation Peripheral venous insufficiency Increased risk of thromboembolism Liver cirrhosis HCC * *:Hepatocellular carcinoma

5 Evaluation of liver fibrosis Liver Biopsy Laboratory Test Abdominal Ultrasonography GOLD STANDARD! Liver enzyme Fibrosis marker Invasiveness

6 Transient Elastography; FibroScan LSM (kpa) 30 Fibrosis Stage CAP (db/m) 400 Steatosis Grade ρ=0.920* 100 ρ=0.792* *:Spearman s rank correlation coefficient Cho.Y, et al. PLOS ONE, in press

7 Objectives To elucidate liver stiffness and hepatic fat deposition in patients who had undergone the Fontan procedure.

8 Patients Children were devided into 2 groups as following; Fontan group: Patients who had undergone the Fontan procedure Control group: Children without congenital heart malformation Patients with known liver disease and obesity(bmi percentile 90 ) were excluded from the control group

9 Methods (1) Abdominal ultrasonography, FibroScan, blood examination, anthropometry. (2) Comparison of LSM *1 and CAP *2 between 2 groups. (3) Correlation of LSM and CAP with AST, ALT, and age in both group. (4) Correlation of LSM and CAP with age at surgery, and time since surgery in Fontan group. *1 LSM, liver stiffness measurement *2 CAP, controlled attenuation parameter

10 Patient Profiles Control Fontan P value* N Male:Female 81:76 22: Age (year) 11.2 ± ± AST(IU/L) 23.2 ± ± 9.1 < ALT(IU/L) 17.4 ± ± 8.6 < Type 4 collagen (ng/ml) Hyaluronic Acid (ng/ml) 3.8 ± ± 1.8 < ± ± 38.3 = APRI ** 0.28 ± ± 0.23 < *:Mann-Whitney U-test **:APRI= AST/33 PLT[10 9 /L] 100

11 LSM (kpa) 50 Result :Control Age y.o

12 LSM (kpa) 50 Result p< * :Control :Fontan Age y.o *:Mann-Whitney U-test

13 CAP (db/m) 400 Result :Control Age y.o

14 CAP (db/m) 400 Result p= * :Control :Fontan Age y.o *:Mann-Whitney U-test

15 LSM (kpa) 50 Result ρ= * ρ= * ρ= * Age (y.o) Age at Surgery (y.o) Time after Surgery (y) *:Spearman s rank correlation coefficient

16 LSM (kpa) 50 Result ρ= * ρ= * (IU/L) (IU/L) AST ALT *:Spearman s rank correlation coefficient

17 LSM (kpa) 50 Result ρ= * ρ= * ρ= * Type 4 Collagen (ng/ml) Hyaluronic Acid (ng/ml) APRI *:Spearman s rank correlation coefficient

18 Discussion Fontan group showed higher LSM value than the Control group, and LSM was correlated with time after surgery whereas was not correlated with laboratory markers. Thus blood examination is insufficient to estimate severity of liver fibrosis in patients after Fontan operation. Most of patients after Fontan procedure receive anticoagulation therapy, so it is difficult to perform the liver biopsy because of risk of bleeding. Non-invasive evaluation method for liver fibrosis is necessary for the Fontan patients.

19 Conclusion Liver stiffness increases according to the time after Fontan surgery. FibroScan, the non-invasive elastography, is useful for measureing liver stiffness in patients after Fontan procedure.