Discordant 2D shear wave elastography values in post-Fontan patients with ascites: a potential interpretive pitfall

Fontan-associated liver disease (FALD) may progress to portal hypertension, ascites, and nodular liver remodelling. Two-dimensional shear wave elastography (2D-SWE) can be performed in patients with ascites, but its reliability in this setting remains uncertain. We report two post-Fontan patients with ascites and nodular liver morphology on B-mode ultrasound who showed markedly discordant liver stiffness values. The pediatric patient had high stiffness (median 24.25 kPa; IQR/median 3.4%), whereas the adult patient with clinical decompensation, large-volume ascites, and pleural effusion had unexpectedly low stiffness (median 9.55 kPa; IQR/median 23.6%). These cases suggest that substantial ascites may contribute to misleading 2D-SWE measurements. In post-Fontan patients, elastography should be interpreted alongside acquisition quality metrics, morphology, and clinical findings.