Early Experience and Lessons Learned Using Implanted Hemodynamic Monitoring in Patients With Fontan Circulation
William H Marshall1,2, Saurabh Rajpal1,2, May Ling Mah2
1Division of Cardiovascular Medicine, Department of Internal Medicine The Ohio State University Wexner Medical Center Columbus OH.
Insights
Implanted hemodynamic monitoring (IHM) in Fontan circulation patients did not reduce heart failure hospitalizations, but IHM pressures correlated with mortality and liver disease scores, unlike catheterization pressures.
Area of Science:
- Cardiology
- Congenital Heart Disease
- Hemodynamic Monitoring
Background:
- Limited data exist on implanted hemodynamic monitoring (IHM) in patients with Fontan circulation.
- This study reports the experience of using the CardioMEMS HF system in adults with Fontan circulation.
Purpose of the Study:
- To evaluate the effectiveness of IHM in reducing heart failure hospitalizations in Fontan patients.
- To assess procedural and device-related complications of IHM in this population.
- To explore the association of IHM-derived pressures with mortality and liver disease severity.
Main Methods:
- A single-center, retrospective study of 18 adult Fontan patients who underwent IHM placement (2015-2022).
- Evaluation of heart failure hospitalizations, procedural complications, and device-related complications.
- Analysis of the association between pulmonary artery pressure (via catheterization and IHM) and mortality/MELD-XI scores.
Main Results:
- IHM placement was successful in 17 of 18 patients; low procedural and device-related complication rates were observed.
- Heart failure hospitalizations remained similar before and after IHM, with low patient adherence to data transmission.
- IHM pressures, not catheterization pressures, were significantly associated with Model for End-Stage Liver Disease Excluding International Normalized Ratio (MELD-XI) scores and mortality.
Conclusions:
- Implanted hemodynamic monitoring did not reduce heart failure hospitalizations in this Fontan circulation cohort, partly due to low patient adherence.
- Device-related complications were infrequent.
- IHM pressures appear to better reflect real-world hemodynamic conditions and prognosis in Fontan patients compared to traditional catheterization pressures.
Background:
Data on the use of implanted hemodynamic monitoring (IHM) in patients with Fontan circulation are limited. This study reports our experience using the CardioMEMS HF system in adults with Fontan circulation.
Methods And Results:
This single-center, retrospective study evaluated heart failure hospitalizations, procedural complications, and device-related complications in patients with Fontan circulation referred for IHM placement (2015-2022). The association of pulmonary artery pressure (by most recent catheterization and median IHM pressure within 30 days of placement) with both death and follow-up Model for End-Stage Liver Disease Excluding International Normalized Ratio score were evaluated. Of 18 patients referred for IHM placement, 17 were successful (median age, 30 [range 21-48] years, 6 women). Procedural complications (access site hematomas, pulmonary artery staining) occurred in 3 patients, without device-related procedural complications. In follow-up (median, 35 [range, 6-83] months), 1 patient developed a pulmonary embolism (possibly device-related). Heart failure hospitalizations/year were similar before and after IHM (median, 1 [interquartile range, 0-1.0] versus 0.6 [0-2.3]; P=0.268), though only 46% of heart failure hospitalizations had associated IHM transmissions. IHM pressures were associated with Model for End-Stage Liver Disease Excluding International Normalized Ratio scores (R2=0.588, P<0.001), though catheterization pressures were not (R2=0.140, P=0.139). The long-term mortality rate was 53% in this cohort. On unadjusted survival analysis, IHM pressures ≥18 mm Hg were associated with mortality (log rank P=0.041), which was not reproduced with catheterization pressures (log rank P=0.764).
Conclusions:
In patients with Fontan circulation, IHM did not reduce heart failure hospitalizations, though patient adherence to transmission was low. Device-related complications were low. IHM pressures may better represent real-life conditions compared with catheterization given associations with mortality and Model for End-Stage Liver Disease Excluding International Normalized Ratio score.
