Significantly elevated hepatic extracellular volume in adult patients with a Fontan circulation and its correlation with impaired functional capacity

Fontan-associated liver disease is a major concern in patients who have undergone the procedure. Regular imaging of the liver is currently recommended for Fontan patients, but not other congenital heart diseases. The extracellular volume (ECV) of the liver obtained during CMR scanning and studies can show the high liver ECV in Fontan patients. However, the correlation between the liver ECV and the functional capacity of Fontan patients has not yet been reported. This study aimed to compare the liver ECV between Fontan patients and other congenital heart diseases with significant pulmonic regurgitation (PR) or tricuspid regurgitation (TR), and to evaluate the correlation between the liver ECV in adult Fontan patients and their functional capacity as well as clinical characteristics. Retrospective analysis of cardiovascular magnetic resonance imaging from patients with history of Fontan surgery between 2017 and 2021 were conducted. The clinical characteristics and liver ECV were evaluated and compared between patients and control group. Functional capacity was evaluated using a 6-min walk distance (6MWD). The correlation between the liver ECV and functional capacity was analyzed. 35 patients were enrolled in the study, including 13 Fontan patients, 12 Ebstein’s anomaly or repaired tetralogy of Fallot (rTOF) patients with significant PR or TR, and 10 patients for the control group. The liver ECV were significantly higher in Fontan patients compared with Ebstein’s anomaly/rTOF and the control group (41.% in Fontan group, 33.9% in Ebstein’s anomaly/rTOF, and 31.7% in control group with p = 0.01 and 0.0008 in Fontan vs. Ebstein’s anomaly/rTOF and Fontan vs. control group, respectively). In Fontan patients, there was a significant correlation between the liver ECV and the liver blood biochemistry with r = 0.879, p = 0.01 for AST/ALT ratio and r = 0.65, p = 0.005 for AST. The liver ECV was inversely correlated with the six-minute walk distance (r = -0.55, p = 0.02). The liver ECV in patients who had undergone Fontan operation showed a significantly elevated and has significantly inversed correlation with their functional capacity. These findings indicated that the liver ECV may be a potentialmarker for adverse clinical outcomes. However, due to small size population, further prospective study with larger number of patients may validate this findings.