Pediatric Cardiology

, Volume 35, Issue 4, pp 569–579 | Cite as

Beyond a Broken Heart: Circulatory Dysfunction in the Failing Fontan

  • Makoto Mori
  • Alfredo J. Aguirre
  • Robert W. Elder
  • Ali Kashkouli
  • Alton Brad Farris
  • Ryan M. Ford
  • Wendy M. BookEmail author
Review Article


The role of ventricular dysfunction in late morbidity and mortality of univentricular hearts has been described previously. However, a significant proportion of adult Fontan patients who die or require heart transplantation do so with preserved ventricular function. The clinical deterioration in patients who have undergone Fontan palliation requires a broader view of circulatory dysfunction, one that takes into account the complex interaction of regulatory systems affecting hepatic, renal, and pulmonary blood flow, in addition to cardiac function. This review focuses primarily on the pathophysiology of multiple organ involvement in this circulatory dysfunction, with particular focus on the consequences of hepatic dysfunction and portal hypertension. The authors discuss hepatic perfusion, both in health and disease, and review the current understanding of liver histopathology and liver disease in adult Fontan patients and similar clinicopathologic states. They compare and contrast features of postsinusoidal portal hypertension with more typical adult cirrhotic disease. Finally, they delineate the related effects of portal hypertensive physiology on the systemic and pulmonary vasculature, the kidney, and the heart itself and discuss how these changes affect the care of the adult Fontan patient.


Fontan Adult congenital heart disease Fontan failure Hepatic disease Portal hypertension 



We thank Matthew Certain, MD, and Nicholas Wozmak, MD, for their contributions to the artwork.


  1. 1.
    Alessandria C, Ozdogan O, Guevara M, Restuccia T, Jimenez W, Arroyo V, Rodes J, Gines P (2005) MELD score and clinical type predict prognosis in hepatorenal syndrome: relevance to liver transplantation. Hepatology 41:1282–1289CrossRefPubMedGoogle Scholar
  2. 2.
    Anderson PA, Sleeper LA, Mahony L, Colan SD, Atz AM, Breitbart RE, Gersony WM, Gallagher D, Geva T, Margossian R, McCrindle BW, Paridon S, Schwartz M, Stylianou M, Williams RV, Clark BJ 3rd, Pediatric Heart Network I (2008) Contemporary outcomes after the Fontan procedure: a Pediatric Heart Network multicenter study. J Am Coll Cardiol 52:85–98PubMedCentralCrossRefPubMedGoogle Scholar
  3. 3.
    Aoki T, Imamura H, Kaneko J, Sakamoto Y, Matsuyama Y, Kokudo N, Sugawara Y, Makuuchi M (2005) Intraoperative direct measurement of hepatic arterial buffer response in patients with or without cirrhosis. Liver Transpl 11:684–691CrossRefPubMedGoogle Scholar
  4. 4.
    Asrani SK, Warnes CA, Kamath PS (2013) Hepatocellular carcinoma after the Fontan procedure. N Engl J Med 368:1756–1757CrossRefPubMedGoogle Scholar
  5. 5.
    Assenza GE, Graham DA, Landzberg MJ, Valente AM, Singh MN, Bashir A, Fernandes S, Mortele KJ, Ukomadu C, Volpe M, Wu F (2013) MELD-XI score and cardiac mortality or transplantation in patients after Fontan surgery. Heart 99:491–496CrossRefPubMedGoogle Scholar
  6. 6.
    Baek JS, Bae EJ, Ko JS, Kim GB, Kwon BS, Lee SY, Noh CI, Park EA, Lee W (2010) Late hepatic complications after Fontan operation: noninvasive markers of hepatic fibrosis and risk factors. Heart 96:1750–1755CrossRefPubMedGoogle Scholar
  7. 7.
    Bendall JK, Cave AC, Heymes C, Gall N, Shah AM (2002) Pivotal role of a gp91(phox)-containing NADPH oxidase in angiotensin II-induced cardiac hypertrophy in mice. Circulation 105:293–296CrossRefPubMedGoogle Scholar
  8. 8.
    Bishop JM, Donald KW, Wade OL (1955) Changes in the oxygen content of hepatic venous blood during exercise in patients with rheumatic heart disease. J Clin Invest 34:1114–1125PubMedCentralCrossRefPubMedGoogle Scholar
  9. 9.
    Bryant T, Ahmad Z, Millward-Sadler H, Burney K, Stedman B, Kendall T, Vettukattil J, Haw M, Salmon AP, Cope R, Hacking N, Breen D, Sheron N, Veldtman GR (2011) Arterialised hepatic nodules in the Fontan circulation: hepaticocardiac interactions. Int J Cardiol 151:268–272CrossRefPubMedGoogle Scholar
  10. 10.
    Bulut OP, Romero R, Mahle WT, McConnell M, Braithwaite K, Shehata BM, Gupta NA, Vos M, Alazraki A (2013) Magnetic resonance imaging identifies unsuspected liver abnormalities in patients after the Fontan procedure. J Pediatr 63(1):201–206CrossRefGoogle Scholar
  11. 11.
    Busse R, Fleming I (1998) Pulsatile stretch and shear stress: physical stimuli determining the production of endothelium-derived relaxing factors. J Vasc Res 35:73–84CrossRefPubMedGoogle Scholar
  12. 12.
    Cazzaniga M, Salerno F, Visentin S, Cirello I, Donarini C, Cugno M (2008) Increased flow-mediated vasodilation in cirrhotic patients with ascites: relationship with renal resistive index. Liver Int 28:1396–1401CrossRefPubMedGoogle Scholar
  13. 13.
    Chokshi A, Cheema FH, Schaefle KJ, Jiang JF, Collado E, Shahzad K, Khawaja T, Farr M, Takayama H, Naka Y, Mancini DM, Schulze PC (2012) Hepatic dysfunction and survival after orthotopic heart transplantation: application of the MELD scoring system for outcome prediction. J Heart Lung Transplant 31:591–600PubMedCentralCrossRefPubMedGoogle Scholar
  14. 14.
    Copple BL, Bai S, Burgoon LD, Moon JO (2011) Hypoxia-inducible factor-1 alpha regulates the expression of genes in hypoxic hepatic stellate cells important for collagen deposition and angiogenesis. Liver Int 31:230–244PubMedCentralCrossRefPubMedGoogle Scholar
  15. 15.
    d’Udekem Y, Iyengar AJ, Cochrane AD, Grigg LE, Ramsay JM, Wheaton GR, Penny DJ, Brizard CP (2007) The Fontan procedure: contemporary techniques have improved long-term outcomes. Circulation 116:I157–I164PubMedGoogle Scholar
  16. 16.
    Duncan BW, Desai S (2003) Pulmonary arteriovenous malformations after cavopulmonary anastomosis. Ann Thorac Surg 76(5):1759–1766CrossRefPubMedGoogle Scholar
  17. 17.
    Elder RW, McCabe NM, Hebson C, Veledar E, Romero R, Ford RM, Mahle WT, Kogon BE, Sahu A, Jokhadar M, McConnell ME, Book WM (2013) Features of portal hypertension are associated with major adverse events in Fontan patients: the VAST study. Int J Cardiol 168(4):3764–3769PubMedCentralCrossRefPubMedGoogle Scholar
  18. 18.
    Fontan F, Baudet E (1971) Surgical repair of tricuspid atresia. Thorax 26:240PubMedCentralCrossRefPubMedGoogle Scholar
  19. 19.
    Fratz S, Fineman JR, Gorlach A, Sharma S, Oishi P, Schreiber C, Kietzmann T, Adatia I, Hess J, Black SM (2011) Early determinants of pulmonary vascular remodeling in animal models of complex congenital heart disease. Circulation 123:916–923CrossRefPubMedGoogle Scholar
  20. 20.
    Garcia-Tsao G, Friedman S, Iredale J, Pinzani M (2010) Now there are many (stages) where before there was one: in search of a pathophysiological classification of cirrhosis. Hepatology 51:1445–1449PubMedCentralCrossRefPubMedGoogle Scholar
  21. 21.
    Gelow JM, Desai AS, Hochberg CP, Glickman JN, Givertz MM, Fang JC (2010) Clinical predictors of hepatic fibrosis in chronic advanced heart failure. Circ Heart Fail 3:59–64CrossRefPubMedGoogle Scholar
  22. 22.
    Gentles TL, Mayer JE, Gauvreau K, Newburger JW, Lock JE, Kupferschmid JP, Burnett J, Jonas RA, Castaneda AR, Wernovsky G (1997) Fontan operation in five hundred consecutive patients: factors influencing early and late outcome. J Thorac Cardiovasc Surg 114:376–391CrossRefPubMedGoogle Scholar
  23. 23.
    Gerbes AL, Jungst D, Remien J, Sauerbruch T, Paumgartner G (1986) Evidence for downregulation of beta-2-adrenoceptors in cirrhotic-patients with severe ascites. Lancet 1:1409–1411CrossRefPubMedGoogle Scholar
  24. 24.
    Ghaferi AA, Hutchins GM (2005) Progression of liver pathology in patients undergoing the Fontan procedure: chronic passive congestion, cardiac cirrhosis, hepatic adenoma, and hepatocellular carcinoma. J Thorac Cardiovasc Surg 129:1348–1352CrossRefPubMedGoogle Scholar
  25. 25.
    Guha IN, Bokhandi S, Ahmad Z, Sheron N, Cope R, Marshall C, Veldtman G (2011) Structural and functional uncoupling of liver performance in the Fontan circulation. Int J Cardiol 164(1):77–81CrossRefPubMedGoogle Scholar
  26. 26.
    Gupta D, Vijaya DR, Gupta R, Dhiman RK, Bhargava M, Verma DMJ, Chawla YK (2001) Prevalence of hepatopulmonary syndrome in cirrhosis and extrahepatic portal venous obstruction. Am J Gastroenterol 96:3395–3399CrossRefPubMedGoogle Scholar
  27. 27.
    Higashiyama H, Yamaguchi M, Kumada K, Sasaki H, Yamaguchi T, Ozawa K (1994) Functional deterioration of the liver by elevated inferior vena cava pressure: a proposed upper safety limit of pressure for maintaining liver viability in dogs. Intensive Care Med 20:124–129CrossRefPubMedGoogle Scholar
  28. 28.
    Hillege HL, Nitsch D, Pfeffer MA, Swedberg K, McMurray JJ, Yusuf S, Granger CB, Michelson EL, Ostergren J, Cornel JH, de Zeeuw D, Pocock S, van Veldhuisen DJ, Candesartan MI (2006) Heart failure: assessment of reduction in morbidity: renal function as a predictor of outcome in a broad spectrum of patients with heart failure. Circulation 113:671–678CrossRefPubMedGoogle Scholar
  29. 29.
    Hsia TY, Khambadkone S, Redington AN, Migliavacca F, Deanfield JE, de Leval MR (2000) Effects of respiration and gravity on infradiaphragmatic venous flow in normal and Fontan patients. Circulation 102:148–153Google Scholar
  30. 30.
    Inai K, Nakanishi T, Nakazawa M (2005) Clinical correlation and prognostic predictive value of neurohumoral factors in patients late after the Fontan operation. Am Heart J 150:588–594CrossRefPubMedGoogle Scholar
  31. 31.
    Ishida H, Kogaki S, Ichimori H, Narita J, Nawa N, Ueno T, Takahashi K, Kayatani F, Kishimoto H, Nakayama M, Sawa Y, Beghetti M, Ozono K (2012) Overexpression of endothelin-1 and endothelin receptors in the pulmonary arteries of failed Fontan patients. Int J Cardiol 159:34–39CrossRefPubMedGoogle Scholar
  32. 32.
    Iwakiri Y, Groszmann RJ (2006) The hyperdynamic circulation of chronic liver diseases: from the patient to the molecule. Hepatology 43:S121–S131CrossRefPubMedGoogle Scholar
  33. 33.
    Jonas RA, Castaneda AR (1988) Modified Fontan procedure: atrial baffle and systemic venous to pulmonary artery anastomotic techniques. J Card Surg 3:91–96CrossRefPubMedGoogle Scholar
  34. 34.
    Kelbaek H, Rabol A, Brynjolf I, Eriksen J, Bonnevie O, Godtfredsen J, Munck O, Lund JO (1987) Hemodynamic-response to exercise in patients with alcoholic liver-cirrhosis. Clin Physiol 7:35–41CrossRefPubMedGoogle Scholar
  35. 35.
    Kendall TJ, Stedman B, Hacking N, Haw M, Vettukattill JJ, Salmon AP, Cope R, Sheron N, Millward-Sadler H, Veldtman GR, Iredale JP (2008) Hepatic fibrosis and cirrhosis in the Fontan circulation: a detailed morphological study. J Clin Pathol 61:504–508CrossRefPubMedGoogle Scholar
  36. 36.
    Khairy P, Poirier N, Mercier LA (2007) Univentricular heart. Circulation 115:800–812CrossRefPubMedGoogle Scholar
  37. 37.
    Khairy P, Fernandes SM, Mayer JE, Triedman JK, Walsh EP, Lock JE, Landzberg MJ (2008) Long-term survival, modes of death, and predictors of mortality in patients with Fontan surgery. Circulation 117:85–92CrossRefPubMedGoogle Scholar
  38. 38.
    Kiesewetter CH, Sheron N, Vettukattill JJ, Hacking N, Stedman B, Millward-Sadler H, Haw M, Cope R, Salmon AP, Sivaprakasam MC, Kendall T, Keeton BR, Iredale JP, Veldtman GR (2007) Hepatic changes in the failing Fontan circulation. Heart 93:579–584PubMedCentralCrossRefPubMedGoogle Scholar
  39. 39.
    Kirshbom PM, Mahle WT, Joyner RW, Leong T, Wilson M, Kogon BE, Kanter KR, Bouzyk MM (2008) The endothelin-1 G5665T polymorphism impacts transplant-free survival for single-ventricle patients. J Thorac Cardiovasc Surg 136:117–122CrossRefPubMedGoogle Scholar
  40. 40.
    Kleber G, Steudel N, Behrmann C, Zipprich A, Hubner G, Lotterer E, Fleig WE (1999) Hepatic arterial flow volume and reserve in patients with cirrhosis: use of intraarterial Doppler and adenosine infusion. Gastroenterology 116:906–914CrossRefPubMedGoogle Scholar
  41. 41.
    Lautt WW (1985) Mechanism and role of intrinsic regulation of hepatic arterial blood flow: hepatic arterial buffer response. Am J Physiol 249:G549–G556PubMedGoogle Scholar
  42. 42.
    McCabe NM, Veledar E, Romero R, Hebson C, Jokhadar M, Sahu A, McConnell ME, Kogon BE, Book WM (2012) Abstract 10056: clinical portal hypertension is related to major adverse outcomes in adolescents and adults with congenital heart disease after Fontan palliation. Circulation 126:A10056CrossRefGoogle Scholar
  43. 43.
    Menon KVN, Shah V, Kamath PS (2004) Current concepts: the Budd–Chiari syndrome. N Engl J Med 350:578–585CrossRefPubMedGoogle Scholar
  44. 44.
    Mitchell MB, Campbell DN, Ivy D, Boucek MM, Sondheimer HM, Pietra B, Das BB, Coll JR (2004) Evidence of pulmonary vascular disease after heart transplantation for Fontan circulation failure. J Thorac Cardiovasc Surg 128:693–702CrossRefPubMedGoogle Scholar
  45. 45.
    Mullens W, Abrahams Z, Francis GS, Sokos G, Taylor DO, Starling RC, Young JB, Tang WHW (2009) Importance of venous congestion for worsening of renal function in advanced decompensated heart failure. J Am Coll Cardiol 53:589–596PubMedCentralCrossRefPubMedGoogle Scholar
  46. 46.
    Myers RP, Cerini R, Sayegh R, Moreau R, Degott C, Lebrec D, Lee SS (2003) Cardiac hepatopathy: clinical, hemodynamic, and histologic characteristics and correlations. Hepatology 37:393–400CrossRefPubMedGoogle Scholar
  47. 47.
    Navar LG, Inscho EW, Majid DSA, Imig JD, HarrisonBernard LM, Mitchell KD (1996) Paracrine regulation of the renal microcirculation. Physiol Rev 76:425–536PubMedGoogle Scholar
  48. 48.
    Ohuchi H, Takasugi H, Ohashi H, Yamada O, Watanabe K, Yagihara T, Echigo S (2004) Abnormalities of neurohormonal and cardiac autonomic nervous activities relate poorly to functional status in Fontan patients. Circulation 110:2601–2608CrossRefPubMedGoogle Scholar
  49. 49.
    Panos RJ, Baker SK (1996) Mediators, cytokines, and growth factors in liver–lung interactions. Clin Chest Med 17:151CrossRefPubMedGoogle Scholar
  50. 50.
    Piran S, Veldtman G, Siu S, Webb GD, Liu PP (2002) Heart failure and ventricular dysfunction in patients with single or systemic right ventricles. Circulation 105:1189–1194CrossRefPubMedGoogle Scholar
  51. 51.
    Presson RG, Baumgartner WA, Peterson AJ, Glenny RW, Wagner WW (2002) Pulmonary capillaries are recruited during pulsatile flow. J Appl Physiol 92:1183–1190CrossRefPubMedGoogle Scholar
  52. 52.
    Rabie RN, Cazzaniga M, Salerno F, Wong F (2009) The use of E/A ratio as a predictor of outcome in cirrhotic patients treated with transjugular intrahepatic portosystemic shunt. Am J Gastroenterol 104:2458–2466CrossRefPubMedGoogle Scholar
  53. 53.
    Rodriguez-Roisin R, Krowka MJ (2008) Current concepts: hepatopulmonary syndrome: a liver-induced lung vascular disorder. N Engl J Med 358:2378–2387CrossRefPubMedGoogle Scholar
  54. 54.
    Rychik J (2010) Forty years of the Fontan operation: a failed strategy. Semin Thorac Cardiovasc Surg Pediatr Card Surg Annu 13(1):96–100CrossRefPubMedGoogle Scholar
  55. 55.
    Rychik J, Veldtman G, Rand E, Russo P, Rome JJ, Krok K, Goldberg DJ, Cahill AM, Wells RG (2012) The precarious state of the liver after a Fontan operation: summary of a multidisciplinary symposium. Pediatr Cardiol 3(7):1001–1012CrossRefGoogle Scholar
  56. 56.
    Sakata R, Ueno T, Nakamura T, Ueno H, Sata M (2004) Mechanical stretch induces TGF-beta synthesis in hepatic stellate cells. Eur J Clin Invest 34:129–136CrossRefPubMedGoogle Scholar
  57. 57.
    Schouten JNL, Garcia-Pagan JC, Valla DC, Janssen HLA (2011) Idiopathic noncirrhotic portal hypertension. Hepatology 54:1071–1081CrossRefPubMedGoogle Scholar
  58. 58.
    Schrier RW (1974) Effects of adrenergic nervous system and catecholamines on systemic and renal hemodynamics, sodium and water excretion, and renin secretion. Kidney Int 6:291–306CrossRefPubMedGoogle Scholar
  59. 59.
    Schwartz MC, Sullivan L, Cohen MS, Russo P, John AS, Guo R, Guttenberg M, Rand EB (2012) Hepatic pathology may develop before the Fontan operation in children with functional single ventricle: an autopsy study. J Thorac Cardiovasc Surg 143:904–909CrossRefPubMedGoogle Scholar
  60. 60.
    Schwartz MC, Sullivan LM, Glatz AC, Rand E, Russo P, Goldberg DJ, Rome JJ, Cohen MS (2013) Portal and sinusoidal fibrosis are common on liver biopsy after Fontan surgery. Pediatr Cardiol 34:135–142CrossRefPubMedGoogle Scholar
  61. 61.
    Sethasine S, Jain D, Groszmann RJ, Garcia-Tsao G (2012) Quantitative histological-hemodynamic correlations in cirrhosis. Hepatology 55:1146–1153PubMedCentralCrossRefPubMedGoogle Scholar
  62. 62.
    Sherlock S (1951) The liver in heart failure: relation of anatomical, functional, and circulatory changes. Br Heart J 13:273–293PubMedCentralCrossRefPubMedGoogle Scholar
  63. 63.
    Sola E, Gines P (2010) Renal and circulatory dysfunction in cirrhosis: current management and future perspectives. J Hepatol 53:1135–1145CrossRefPubMedGoogle Scholar
  64. 64.
    Tanaka M, Wanless IR (1998) Pathology of the liver in Budd–Chiari syndrome: portal vein thrombosis and the histogenesis of veno-centric cirrhosis, veno-portal cirrhosis, and large regenerative nodules. Hepatology 27:488–496CrossRefPubMedGoogle Scholar
  65. 65.
    Teltschik Z, Wiest R, Beisner J, Nuding S, Hofmann C, Schoelmerich J, Bevins CL, Stange EF, Wehkamp J (2012) Intestinal bacterial translocation in rats with cirrhosis is related to compromised Paneth cell antimicrobial host defense. Hepatology 55:1154–1163CrossRefPubMedGoogle Scholar
  66. 66.
    Toyoda Y, Okada M, Sugimoto T, Yoshida M, Ataka K, Yamashita C (1996) Successful surgical treatment of cardiac cirrhosis: tricuspid surgery and plasma exchange. J Cardiovasc Surg 37:305–307Google Scholar
  67. 67.
    Trevisani F, Sica G, Mainqua P, Santese G, de Notariis S, Caraceni P, Domenicali M, Zaca F, Grazi GL, Mazziotti A, Cavallari A, Bernardi M (1999) Autonomic dysfunction and hyperdynamic circulation in cirrhosis with ascites. Hepatology 30:1387–1392CrossRefPubMedGoogle Scholar
  68. 68.
    Valeriano V, Funaro S, Lionetti R, Riggio O, Pulcinelli G, Fiore P, Masini A, De Castro S, Merli M (2000) Modification of cardiac function in cirrhotic patients with and without ascites. Am J Gastroenterol 95:3200–3205CrossRefPubMedGoogle Scholar
  69. 69.
    Velpula M, Sheron N, Guha N, Salmon T, Hacking N, Veldtman GR (2011) Direct measurement of portosystemic gradient in a failing Fontan circulation. Congenit Heart Dis 6:175–178CrossRefPubMedGoogle Scholar
  70. 70.
    Wang A, Book WM, McConnell M, Lyle T, Rodby K, Mahle WT (2007) Prevalence of hepatitis C infection in adult patients who underwent congenital heart surgery prior to screening in 1992. Am J Cardiol 100:1307–1309CrossRefPubMedGoogle Scholar
  71. 71.
    Warnes CA, Williams RG, Bashore TM, Child JS, Connolly HM, Dearani JA, Del Nido P, Fasules JW, Graham TP Jr, Hijazi ZM, Hunt SA, King ME, Landzberg MJ, Miner PD, Radford MJ, Walsh EP, Webb GD (2008) ACC/AHA 2008 Guidelines for the Management of Adults with Congenital Heart Disease: Executive Summary: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (writing committee to develop guidelines for the management of adults with congenital heart disease). Circulation 118:2395–2451CrossRefPubMedGoogle Scholar
  72. 72.
    Wiest R, Groszmann RJ (2002) The paradox of nitric oxide in cirrhosis and portal hypertension: too much, not enough. Hepatology 35:478–491CrossRefPubMedGoogle Scholar
  73. 73.
    Wu FM, Ukomadu C, Odze RD, Valente AM, Mayer JE, Earing MG (2011) Liver disease in the patient with Fontan circulation. Congenit Heart Dis 6:190–201CrossRefPubMedGoogle Scholar
  74. 74.
    Yamazaki T, Komuro I, Kudoh S, Zou YZ, Shiojima I, Hiroi Y, Mizuno T, Maemura K, Kurihara H, Aikawa R, Takano H, Yazaki Y (1996) Endothelin-1 is involved in mechanical stress-induced cardiomyocyte hypertrophy. J Biol Chem 271:3221–3228CrossRefPubMedGoogle Scholar
  75. 75.
    Zambruni A, Trevisani F, Caraceni P, Bernardi M (2006) Cardiac electrophysiological abnormalities in patients with cirrhosis. J Hepatol 44:994–1002CrossRefPubMedGoogle Scholar
  76. 76.
    Zardi EM, Abbate A, Zardi DM, Dobrina A, Margiotta D, Van Tassel BW, Afeltra A, Sanyal AJ (2010) Cirrhotic cardiomyopathy. J Am Coll Cardiol 56:539–549CrossRefPubMedGoogle Scholar
  77. 77.
    Zipprich A, Steudel N, Behrmann C, Meiss F, Sziegoleit U, Fleig WE, Kleber G (2003) Functional significance of hepatic arterial flow reserve in patients with cirrhosis. Hepatology 37:385–392CrossRefPubMedGoogle Scholar

Copyright information

© Springer Science+Business Media New York 2014

Authors and Affiliations

  • Makoto Mori
    • 1
  • Alfredo J. Aguirre
    • 1
  • Robert W. Elder
    • 2
  • Ali Kashkouli
    • 3
  • Alton Brad Farris
    • 4
  • Ryan M. Ford
    • 5
  • Wendy M. Book
    • 1
    Email author
  1. 1.Division of CardiologyEmory University School of MedicineAtlantaUSA
  2. 2.Section of CardiologyYale University School of MedicineNew HavenUSA
  3. 3.Division of NephrologyEmory University School of MedicineAtlantaUSA
  4. 4.Department of PathologyEmory University School of MedicineAtlantaUSA
  5. 5.Transplant HepatologyEmory University School of MedicineAtlantaUSA

Personalised recommendations