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CLINICAL RESEARCH: PULMONARY VASCULAR DISORDERS

Prevalence of "silent" pulmonary emboli in adults after the Fontan operation

^a Toronto General Hospital, University of Toronto, Toronto, Canada.

Manuscript received August 28, 2002; revised manuscript received December 16, 2002, accepted January 16, 2003.

^* Reprint request and correspondence: Dr. Judith Therrien, Toronto Congenital Cardiac Center for Adults, Toronto General Hospital, University of Toronto, Eaton Building, 200 Elizabeth St., Toronto, 12-215EN, ON M5G 2C4, Canada.
judith.therrien{at}uhn.on.ca

OBJECTIVES: The study was done to determine the prevalence of pulmonary emboli (PE) in asymptomatic adult Fontan patients and to identify the risk factors associated with PE.

BACKGROUND: Right atrial thrombi and systemic thromboembolic complications have been reported after the Fontan procedure. However, the frequency of silent PE in this patient population is not known.

METHODS: All consecutive adult Fontan patients attending the adult congenital clinic over a six-month period underwent ventilation-perfusion (VQ) scanning and blood testing for thrombophilia tendency. If the VQ scan showed an intermediate or high probability for PE, a computerized tomography (CT) pulmonary angiogram was performed to confirm the presence of PE.

RESULTS: Thirty patients (mean age 26 ± 7 years, 57% men) were included in this study. Five (17%) adult Fontan patients had an intermediate or high probability for PE on VQ scan, all of which were confirmed on CT pulmonary angiography. No patient had a thrombophilia tendency. Pulmonary emboli were not present in any patients (30%) taking warfarin. Late age at time of Fontan operation (19 ± 6 years vs. 11 ± 6 years, p = 0.012) and type of Fontan anatomy (p = 0.001) were associated with increased risk of silent PE.

CONCLUSIONS: Seventeen percent of adult patients with Fontan procedure have clinically silent PE. The long-term hemodynamic implications of this with respect to Fontan attrition over time are unknown. Large randomized prospective studies looking at anticoagulation therapy in all Fontan patients are urgently needed.

Abbreviations and Acronyms   CT = computerized tomography   PA = pulmonary artery   PE = pulmonary embolus/emboli   RA = right atrium   RV = right ventricle   TTE = transthoracic echocardiography   VQ = ventilation perfusion

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