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. 2025 Mar;4(3):101591.
doi: 10.1016/j.jacadv.2025.101591. Epub 2025 Feb 21.

Acute Effects of Enhanced External Counterpulsation in Adults With Fontan Circulation

Fred M Wu  1 , Amrit Misra  2 , Christopher W Valle  2 , Madeline E Duncan  3 , Sunil J Ghelani  3 , Marie D Gerhard-Herman  4 , Stuart R Lipsitz  2 , Rahul H Rathod  3 , Michelle Z Gurvitz  2 , Michael N Singh  2 , Anne Marie Valente  2
Affiliations

Acute Effects of Enhanced External Counterpulsation in Adults With Fontan Circulation

Fred M Wu et al. JACC Adv. 2025 Mar.

Abstract

Background: Patients with Fontan circulation exhibit reduced cardiac output.

Objectives: The purpose of this study was to study the safety and acute hemodynamic effects of enhanced external counterpulsation (EECP) in a cohort of Fontan patients.

Methods: This was a pilot study of ambulatory adults with Fontan circulation at a single, large-volume adult congenital heart disease center. Patients underwent 1 hour of EECP divided into 20-minute stages (80 mm Hg, 160 mm Hg, and 240 mm Hg). Transthoracic echocardiography and pulmonary blood flow (PBF) measurement were performed at baseline, during each stage of EECP, and after EECP completion. Patients were monitored for symptoms throughout. For the primary endpoint, PBF was compared between baseline and EECP at target pressure of 240 mm Hg.

Results: There were 23 patients enrolled (52% male). The median age was 30.9 years (27.8, 37.8). Twenty-two patients (96%) completed a full hour of EECP. EECP pressure was reduced in the final stage for 3 patients due to discomfort. No patients reported adverse symptoms during EECP. PBF increased from 4.5 L/min at baseline to 5.2 L/min during the final stage of EECP (P = 0.001) and returned to baseline post-EECP (4.2 L/min [P = 0.05 vs baseline]). Oxygen saturation remained increased compared to baseline throughout EECP treatment (baseline: 93.0%, 80 mm Hg: 94.3% [P = 0.008], 160 mm Hg: 94.6% [P ≤ 0.001], 240 mm Hg: 94.6% [P = 0.007]). There was no change in mean arterial pressure, heart rate, ventricular function, or valvar regurgitation.

Conclusions: Our results suggest that EECP is well-tolerated in adult Fontan patients and acutely improves PBF. Further study is warranted to explore its longer-term therapeutic effects.

Keywords: adult congenital heart disease; enhanced external counterpulsation; fontan; single ventricle.

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Conflict of interest statement

Funding support and author disclosures This study was supported by the Additional Ventures Single Ventricle Research Fund, the Boston Adult Congenital Heart Disease Program Dunlevie Fund, and the Sarah Marie Liamos Fund for Adult Congenital Heart Disease Research (Boston, MA, USA). No sponsors had any involvement in study design; in the collection, analysis, and interpretation of data; in the writing of the report; or in the decision to submit the article for publication. The authors have reported that they have no relationships relevant to the contents of this paper to disclose.

Figures

None
Graphical abstract
Central Illustration
Central Illustration
Acute Effects of Enhanced External Counterpulsation in Adults with Fontan Circulation Enhanced external counterpulsation (EECP), which sequentially compresses the lower extremity blood vessels in diastole and the rapidly decompresses them at the onset of systole, is associated with an increase in pulmonary blood flow during active treatment. EECP = enhanced external counterpulsation.
Figure 1
Figure 1
Subject Recruitment Consolidated Standards of Reporting Trials flow diagram of study recruitment.
Figure 2
Figure 2
ECG and Finger Plethysmography Waveforms During EECP Typical finger plethysmographic tracings during counterpulsation showing progressive decrease in the systolic peak, S, accompanied by progressive increase in the diastolic peak, d, at cuff pressures of 80 mm Hg (A), 160 mm Hg (B), and 240 mm Hg (C). ECG = electrocardiogram; EECP = enhanced external counterpulsation; HR = heart rate; SpO2 = oxygen saturation.
Figure 3
Figure 3
Pulmonary Blood Flow Measurements Before and During EECP Spaghetti plot showing individual and mean (thick black line) pulmonary blood flow measurements at baseline and during each phase of EECP EECP = enhanced external counterpulsation.
See this image and copyright information in PMC

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