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Original research article
Histopathological abnormalities in the central arteries and veins of Fontan subjects
  1. Brandon S Hays1,2,
  2. Michael Baker2,3,
  3. Annie Laib2,3,
  4. Wei Tan4,
  5. Sebastian Udholm1,
  6. Bryan H Goldstein1,2,
  7. Stephen P Sanders5,
  8. Alexander R Opotowsky5,
  9. Gruschen R Veldtman6
  1. 1 Heart Institute, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio, USA
  2. 2 Cardiology, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio, USA
  3. 3 Division of Pathology, Cincinnati Children’s Hospital Medical Centre, Cincinnati, Ohio, USA
  4. 4 University of Colorado at Boulder, Boulder, Colorado, USA
  5. 5 Pediatrics, Children’s Hospital, Boston, Massachusetts, USA
  6. 6 Adolescent and Adult Congenital Heart Disease Program, Cincinnati Children’s Hospital Medical Centre, Ohio, Cincinnati, USA
  1. Correspondence to Dr Gruschen R Veldtman, Adolescent and Adult Congenital Heart Disease Program, Cincinnati Children’s Hospital Medical Centre, Cincinnat, OH 45229, USA; Gruschen.veldtman{at}


Objective Fontan circulations have obligatory venous hypertension, depressed cardiac output and abnormal arterial elastance. Ventriculovascular coupling is known to be abnormal, but the underlying mechanisms are poorly defined. We aim to describe the histopathological features of vascular remodelling encountered in the central arteries and veins in the Fontan circulation as a possible underlying pathological representation of abnormal ventriculovascular coupling.

Methods Postmortemvasculature (inferior vena cava (IVC), superior vena cava (SVC), pulmonary artery (PA), pulmonary vein (PV) and aorta) of 13 patients with a Fontan circulation (mean age 29.9 years, range 9.0–59.8 years) and 2 biventricular controls (ages 17.9 and 30.2 years) was examined.

Results IVC and SVC: Eccentric and variable intimal fibromuscular proliferation occurred in 11 Fontan subjects. There was variable loss of medial smooth muscle bundles with reciprocal replacement with dense collagenous tissue.

PA: Similar intimal fibromuscular proliferation was seen; however, these intimal changes were accompanied by medial thinning rather than expansion, medial myxoid degeneration and elastic alteration.

PV: The PVs demonstrated intimal fibroproliferation and disorganisation of the muscular media.

Aorta: The aortic lamina intima was thickened, with associated fibromuscular proliferation and elasticisation. There was also moderate lymphocytic inflammation in the aortic wall.

Conclusions Vascular architectural remodelling is common in Fontan patients. The central veins demonstrate profound changes of eccentric intimal expansion and smooth muscle replacement with collagen. The pulmonary demonstrated abnormal intimal proliferation, and aortic remodelling was characterised by intima lamina thickening and a moderate degree of aortic wall inflammation.

  • Fontan Physiology
  • Vascular Biology
  • Congenital Heart Disease

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  • Contributors ARP, GRV, BHG, BSH: Construction of idea, planning of research, conduct research, manuscript writing and revision. SPS, MB, AL: Planning and advice on the obtainment of the sections, planning of the histological aspects of the study as well as interpretation of the histology. SU: Intellectual and research review, manuscript writing and revision. WT: Idea inception and formulation, design of the trial, data interpretation and writing of the manuscript.

  • Competing interests None declared.

  • Ethics approval Institutional Review Board EXEMPT.

  • Provenance and peer review Not commissioned; externally peer reviewed.