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Agarwal D, Hunt ML, Sridharan A, Larson AC, Rychik J, Licht DJ, Davey MG, Flake AW, Gaynor JW, Didier RA. Unique model of chronic hypoxia in fetal lambs demonstrates abnormal contrast-enhanced ultrasound brain perfusion. Pediatr Res 2024:10.1038/s41390-024-03206-3. [PMID: 38849480 DOI: 10.1038/s41390-024-03206-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/21/2023] [Revised: 03/28/2024] [Accepted: 03/31/2024] [Indexed: 06/09/2024]
Abstract
BACKGROUND Children with congenital heart disease (CHD) demonstrate long-term neurodevelopmental impairments. We investigated contrast-enhanced ultrasound (CEUS) cerebral perfusion in a fetal animal model exposed to sub-physiologic oxygen at equivalent levels observed in human fetuses with CHD. METHODS Fifteen fetal lambs [hypoxic animals (n = 9) and normoxic controls (n = 6)] maintained in an extrauterine environment underwent periodic brain CEUS. Perfusion parameters including microvascular flow velocity (MFV), transit time, and microvascular blood flow (MBF) were extrapolated from a standardized plane; regions of interest (ROI) included whole brain, central/thalami, and peripheral parenchymal analyses. Daily echocardiographic parameters and middle cerebral artery (MCA) pulsatility indices (PIs) were obtained. RESULTS Hypoxic lambs demonstrated decreased MFV, increased transit time, and decreased MBF (p = 0.026, p = 0.016, and p < 0.001, respectively) by whole brain analyses. MFV and transit time were relatively preserved in the central/thalami (p = 0.11, p = 0.08, p = 0.012, respectively) with differences in the peripheral parenchyma (all p < 0.001). In general, cardiac variables did not correlate with cerebral CEUS perfusion parameters. Hypoxic animals demonstrated decreased MCA PI compared to controls (0.65 vs. 0.78, respectively; p = 0.027). CONCLUSION Aberrations in CEUS perfusion parameters suggest that in environments of prolonged hypoxia, there are regional microvascular differences incompletely characterized by MCA interrogation offering insights into fetal conditions which may contribute to patient outcomes. IMPACT This work utilizes CEUS to study cerebral microvascular perfusion in a unique fetal animal model subjected to chronic hypoxic conditions equal to fetuses with congenital heart disease. CEUS demonstrates altered parameters with regional differences that are incompletely characterized by MCA Doppler values. These findings show that routine MCA Doppler interrogation may be inadequate in assessing microvascular perfusion differences. To our knowledge, this study is the first to utilize CEUS to assess microvascular perfusion in this model. The results offer insight into underlying conditions and physiological changes which may contribute to known neurodevelopmental impairments in those with congenital heart disease.
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Affiliation(s)
- Divyansh Agarwal
- Perelman School of Medicine, University of Philadelphia, Philadelphia, PA, USA
- Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Mallory L Hunt
- Department of Surgery, Children's Hospital of Philadelphia, Philadelphia, PA, USA
- Center for Fetal Research, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Anush Sridharan
- Department of Radiology, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Abby C Larson
- Department of Surgery, Children's Hospital of Philadelphia, Philadelphia, PA, USA
- Center for Fetal Research, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Jack Rychik
- Perelman School of Medicine, University of Philadelphia, Philadelphia, PA, USA
- Department of Cardiology, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Daniel J Licht
- Perelman School of Medicine, University of Philadelphia, Philadelphia, PA, USA
- Department of Neurology, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Marcus G Davey
- Center for Fetal Research, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Alan W Flake
- Perelman School of Medicine, University of Philadelphia, Philadelphia, PA, USA
- Department of Surgery, Children's Hospital of Philadelphia, Philadelphia, PA, USA
- Center for Fetal Research, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - J William Gaynor
- Perelman School of Medicine, University of Philadelphia, Philadelphia, PA, USA
- Department of Surgery, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Ryne A Didier
- Perelman School of Medicine, University of Philadelphia, Philadelphia, PA, USA.
- Department of Radiology, Children's Hospital of Philadelphia, Philadelphia, PA, USA.
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Maleyeff L, Park HJ, Khazal ZSH, Wypij D, Rollins CK, Yun HJ, Bellinger DC, Watson CG, Roberts AE, Newburger JW, Grant PE, Im K, Morton SU. Meta-regression of sulcal patterns, clinical and environmental factors on neurodevelopmental outcomes in participants with multiple CHD types. Cereb Cortex 2024; 34:bhae224. [PMID: 38836834 DOI: 10.1093/cercor/bhae224] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2024] [Revised: 05/07/2024] [Accepted: 05/13/2024] [Indexed: 06/06/2024] Open
Abstract
Congenital heart disease affects 1% of infants and is associated with impaired neurodevelopment. Right- or left-sided sulcal features correlate with executive function among people with Tetralogy of Fallot or single ventricle congenital heart disease. Studies of multiple congenital heart disease types are needed to understand regional differences. Further, sulcal pattern has not been studied in people with d-transposition of the great arteries. Therefore, we assessed the relationship between sulcal pattern and executive function, general memory, and processing speed in a meta-regression of 247 participants with three congenital heart disease types (114 single ventricle, 92 d-transposition of the great arteries, and 41 Tetralogy of Fallot) and 94 participants without congenital heart disease. Higher right hemisphere sulcal pattern similarity was associated with improved executive function (Pearson r = 0.19, false discovery rate-adjusted P = 0.005), general memory (r = 0.15, false discovery rate P = 0.02), and processing speed (r = 0.17, false discovery rate P = 0.01) scores. These positive associations remained significant in for the d-transposition of the great arteries and Tetralogy of Fallot cohorts only in multivariable linear regression (estimated change β = 0.7, false discovery rate P = 0.004; β = 4.1, false discovery rate P = 0.03; and β = 5.4, false discovery rate P = 0.003, respectively). Duration of deep hypothermic circulatory arrest was also associated with outcomes in the multivariate model and regression tree analysis. This suggests that sulcal pattern may provide an early biomarker for prediction of later neurocognitive challenges among people with congenital heart disease.
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Affiliation(s)
- Lara Maleyeff
- Department of Biostatistics, Epidemiology, and Occupational Health, McGill University, Montreal, QC, Canada
| | - Hannah J Park
- Division of Newborn Medicine, Boston Children's Hospital, Boston 02115, MA, United States
| | - Zahra S H Khazal
- Division of Newborn Medicine, Boston Children's Hospital, Boston 02115, MA, United States
| | - David Wypij
- Department of Pediatrics, Harvard Medical School, Boston MA, United States
- Department of Cardiology, Boston Children's Hospital, Boston 02115, MA, United States
- Department of Biostatistics, Harvard T.H. Chan School of Public Health, Boston MA, United States
| | - Caitlin K Rollins
- Department of Neurology, Boston Children's Hospital 02115 Boston, MA, United States
- Department of Neurology, Harvard Medical School, Boston MA, United States
| | - Hyuk Jin Yun
- Division of Newborn Medicine, Boston Children's Hospital, Boston 02115, MA, United States
- Fetal Neonatal Neuroimaging and Developmental Science Center, Division of Newborn Medicine, Department of Pediatrics, Boston Children's Hospital, Boston 02115, MA, United States
| | - David C Bellinger
- Department of Neurology, Boston Children's Hospital 02115 Boston, MA, United States
- Department of Psychiatry, Boston Children's Hospital, Boston 02115, MA, United States
- Department of Psychiatry, Harvard Medical School, Boston MA, United States
| | - Christopher G Watson
- Department of Neurology, Boston Children's Hospital 02115 Boston, MA, United States
| | - Amy E Roberts
- Department of Pediatrics, Harvard Medical School, Boston MA, United States
- Department of Cardiology, Boston Children's Hospital, Boston 02115, MA, United States
| | - Jane W Newburger
- Department of Pediatrics, Harvard Medical School, Boston MA, United States
- Department of Cardiology, Boston Children's Hospital, Boston 02115, MA, United States
| | - P Ellen Grant
- Department of Biostatistics, Epidemiology, and Occupational Health, McGill University, Montreal, QC, Canada
- Fetal Neonatal Neuroimaging and Developmental Science Center, Division of Newborn Medicine, Department of Pediatrics, Boston Children's Hospital, Boston 02115, MA, United States
- Department of Radiology, Boston Children's Hospital, Boston 02115, MA, United States
| | - Kiho Im
- Division of Newborn Medicine, Boston Children's Hospital, Boston 02115, MA, United States
- Department of Pediatrics, Harvard Medical School, Boston MA, United States
- Fetal Neonatal Neuroimaging and Developmental Science Center, Division of Newborn Medicine, Department of Pediatrics, Boston Children's Hospital, Boston 02115, MA, United States
| | - Sarah U Morton
- Division of Newborn Medicine, Boston Children's Hospital, Boston 02115, MA, United States
- Department of Pediatrics, Harvard Medical School, Boston MA, United States
- Fetal Neonatal Neuroimaging and Developmental Science Center, Division of Newborn Medicine, Department of Pediatrics, Boston Children's Hospital, Boston 02115, MA, United States
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3
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Hofer J, Blum M, Wiltsche R, Deluggi N, Holzinger D, Fellinger J, Tulzer G, Blum G, Oberhuber R. Research gaps in the neurodevelopmental assessment of children with complex congenital heart defects: a scoping review. Front Pediatr 2024; 12:1340495. [PMID: 38846331 PMCID: PMC11155449 DOI: 10.3389/fped.2024.1340495] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/21/2023] [Accepted: 04/15/2024] [Indexed: 06/09/2024] Open
Abstract
Background Children with congenital heart defects (CHD) are at risk for a range of developmental disabilities that challenge cognition, executive functioning, self-regulation, communication, social-emotional functioning, and motor skills. Ongoing developmental surveillance is therefore key to maximizing neurodevelopmental outcome opportunities. It is crucial that the measures used cover the spectrum of neurodevelopmental domains relevant to capturing possible predictors and malleable factors of child development. Objectives This work aimed to synthesize the literature on neurodevelopmental measures and the corresponding developmental domains assessed in children aged 1-8 years with complex CHD. Methods PubMed was searched for terms relating to psycho-social, cognitive and linguistic-communicative outcomes in children with CHD. 1,380 papers with a focus on complex CHD that reported neurodevelopmental assessments were identified; ultimately, data from 78 articles that used standardized neurodevelopmental assessment tools were extracted. Results Thirty-nine (50%) of these excluded children with syndromes, and 9 (12%) excluded children with disorders of intellectual development. 10% of the studies were longitudinal. The neurodevelopmental domains addressed by the methods used were: 53% cognition, 16% psychosocial functioning, 18% language/communication/speech production, and 13% motor development-associated constructs. Conclusions Data on social communication, expressive and receptive language, speech motor, and motor function are underrepresented. There is a lack of research into everyday use of language and into measures assessing language and communication early in life. Overall, longitudinal studies are required that include communication measures and their interrelations with other developmental domains.
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Affiliation(s)
- Johannes Hofer
- Research Institute for Developmental Medicine, Johannes Kepler University of Linz, Linz, Austria
- Institute of Neurology of Senses and Language, Hospital of St. John of God, Linz, Austria
| | - Marina Blum
- Research Institute for Developmental Medicine, Johannes Kepler University of Linz, Linz, Austria
| | - Regina Wiltsche
- Research Institute for Developmental Medicine, Johannes Kepler University of Linz, Linz, Austria
| | - Nikoletta Deluggi
- Research Institute for Developmental Medicine, Johannes Kepler University of Linz, Linz, Austria
| | - Daniel Holzinger
- Research Institute for Developmental Medicine, Johannes Kepler University of Linz, Linz, Austria
- Institute of Neurology of Senses and Language, Hospital of St. John of God, Linz, Austria
- Institute of Linguistics, University of Graz, Graz, Austria
| | - Johannes Fellinger
- Research Institute for Developmental Medicine, Johannes Kepler University of Linz, Linz, Austria
- Institute of Neurology of Senses and Language, Hospital of St. John of God, Linz, Austria
- Division of Social Psychiatry, University Clinic for Psychiatry and Psychotherapy, Medical University of Vienna, Vienna, Austria
| | - Gerald Tulzer
- Department of Pediatric Cardiology, Children’s Heart Center Linz, Kepler University Hospital, Linz, Austria
| | - Gina Blum
- Research Institute for Developmental Medicine, Johannes Kepler University of Linz, Linz, Austria
| | - Raphael Oberhuber
- Research Institute for Developmental Medicine, Johannes Kepler University of Linz, Linz, Austria
- Department of Pediatric Cardiology, Children’s Heart Center Linz, Kepler University Hospital, Linz, Austria
- Department of Inclusive Education, University of Education Upper Austria, Linz, Austria
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4
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Mercer-Rosa L, Favilla E. Neurodevelopment in patients with repaired tetralogy of Fallot. Front Pediatr 2024; 12:1137131. [PMID: 38737635 PMCID: PMC11082288 DOI: 10.3389/fped.2024.1137131] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/09/2023] [Accepted: 03/14/2024] [Indexed: 05/14/2024] Open
Abstract
Neurodevelopmental sequelae are prevalent and debilitating for patients with congenital heart defects. Patients born with tetralogy of Fallot (TOF) are susceptible for abnormal neurodevelopment as they have several risk factors surrounding the perinatal and perioperative period. Some risk factors have been well described in other forms of congenital heart defects, including transposition of the great arteries and single ventricle heart disease, but they have been less studied in the growing population of survivors of TOF surgery, particularly in infancy and childhood. Adolescents with TOF, even without a genetic syndrome, exhibit neuro-cognitive deficits in executive function, visual-spatial skills, memory, attention, academic achievement, social cognition, and problem-solving, to mention a few. They also have greater prevalence of anxiety disorder, disruptive behavior and attention-deficit hyperactivity disorder. These deficits impact their academic performance, social adjustment, and quality of life, thus resulting in significant stress for patients and their families. Further, they can impact their social adjustment, employment and career development as an adult. Infants and younger children can also have significant deficits in gross and fine motor skills, cognitive deficits and abnormal receptive language. Many of the risk factors associated with abnormal neurodevelopment in these patients are not readily modifiable. Therefore, patients should be referred for evaluation and early intervention to help maximize their neurodevelopment and improve overall outcomes. More study is needed to identify potentially modifiable risk factors and/or mediators of neurodevelopment, such as environmental and socio-economic factors.
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Affiliation(s)
- Laura Mercer-Rosa
- Division of Cardiology, Department of Pediatrics, University of Pennsylvania Perelman School of Medicine, Children’s Hospital of Philadelphia, Philadelphia, PA, United States
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Sood E, Newburger JW, Anixt JS, Cassidy AR, Jackson JL, Jonas RA, Lisanti AJ, Lopez KN, Peyvandi S, Marino BS. Neurodevelopmental Outcomes for Individuals With Congenital Heart Disease: Updates in Neuroprotection, Risk-Stratification, Evaluation, and Management: A Scientific Statement From the American Heart Association. Circulation 2024; 149:e997-e1022. [PMID: 38385268 DOI: 10.1161/cir.0000000000001211] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/23/2024]
Abstract
Over the past decade, new research has advanced scientific knowledge of neurodevelopmental trajectories, factors that increase neurodevelopmental risk, and neuroprotective strategies for individuals with congenital heart disease. In addition, best practices for evaluation and management of developmental delays and disorders in this high-risk patient population have been formulated based on literature review and expert consensus. This American Heart Association scientific statement serves as an update to the 2012 statement on the evaluation and management of neurodevelopmental outcomes in children with congenital heart disease. It includes revised risk categories for developmental delay or disorder and an updated list of factors that increase neurodevelopmental risk in individuals with congenital heart disease according to current evidence, including genetic predisposition, fetal and perinatal factors, surgical and perioperative factors, socioeconomic disadvantage, and parental psychological distress. It also includes an updated algorithm for referral, evaluation, and management of individuals at high risk. Risk stratification of individuals with congenital heart disease with the updated categories and risk factors will identify a large and growing population of survivors at high risk for developmental delay or disorder and associated impacts across the life span. Critical next steps must include efforts to prevent and mitigate developmental delays and disorders. The goal of this scientific statement is to inform health care professionals caring for patients with congenital heart disease and other key stakeholders about the current state of knowledge of neurodevelopmental outcomes for individuals with congenital heart disease and best practices for neuroprotection, risk stratification, evaluation, and management.
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Kim AY, Woo W, Saxena A, Tanidir IC, Yao A, Kurniawati Y, Thakur V, Shin YR, Shin JI, Jung JW, Barron DJ. Treatment of hypoplastic left heart syndrome: a systematic review and meta-analysis of randomised controlled trials. Cardiol Young 2024; 34:659-666. [PMID: 37724575 DOI: 10.1017/s1047951123002986] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 09/21/2023]
Abstract
BACKGROUND This meta-analysis aimed to consolidate existing data from randomised controlled trials on hypoplastic left heart syndrome. METHODS Hypoplastic left heart syndrome specific randomised controlled trials published between January 2005 and September 2021 in MEDLINE, EMBASE, and Cochrane databases were included. Regardless of clinical outcomes, we included all randomised controlled trials about hypoplastic left heart syndrome and categorised them according to their results. Two reviewers independently assessed for eligibility, relevance, and data extraction. The primary outcome was mortality after Norwood surgery. Study quality and heterogeneity were assessed. A random-effects model was used for analysis. RESULTS Of the 33 included randomised controlled trials, 21 compared right ventricle-to-pulmonary artery shunt and modified Blalock-Taussig-Thomas shunt during the Norwood procedure, and 12 regarded medication, surgical strategy, cardiopulmonary bypass tactics, and ICU management. Survival rates up to 1 year were superior in the right ventricle-to-pulmonary artery shunt group; this difference began to disappear at 3 years and remained unchanged until 6 years. The right ventricle-to-pulmonary artery shunt group had a significantly higher reintervention rate from the interstage to the 6-year follow-up period. Right ventricular function was better in the modified Blalock-Taussig-Thomas shunt group 1-3 years after the Norwood procedure, but its superiority diminished in the 6-year follow-up. Randomised controlled trials regarding medical treatment, surgical strategy during cardiopulmonary bypass, and ICU management yielded insignificant results. CONCLUSIONS Although right ventricle-to-pulmonary artery shunt appeared to be superior in the early period, the two shunts applied during the Norwood procedure demonstrated comparable long-term prognosis despite high reintervention rates in right ventricle-to-pulmonary artery shunt due to pulmonary artery stenosis. For medical/perioperative management of hypoplastic left heart syndrome, further randomised controlled trials are needed to deliver specific evidence-based recommendations.
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Affiliation(s)
- A Y Kim
- Division of Pediatric Cardiology, Department of Pediatrics, Severance Cardiovascular Hospital, Yonsei University College of Medicine, Seoul, Korea
- Department of Pediatrics, Yonsei University College of Medicine, Seoul, Korea
| | - W Woo
- Department of Thoracic and Cardiovascular Surgery, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - A Saxena
- Department of Cardiology, All India Institute of Medical Sciences, New Delhi, India
| | - I C Tanidir
- Department of Pediatric Cardiology, Basaksehir Cam and Sakura City Hospital, Istanbul, Turkey
| | - A Yao
- Department of Health Service Promotion, University of Tokyo, Japan
| | - Y Kurniawati
- Department of Pediatric Cardiology, National Cardiovascular Center Harapan Kita, Jakarta, Indonesia
| | - V Thakur
- Department of Pediatrics, Labatt Family Heart Center, The Hospital for Sick Children, University of Toronto, Toronto, ON, Canada
| | - Y R Shin
- Department of Cardiovascular Surgery, Yonsei University College of Medicine, Seoul, Korea
| | - J I Shin
- Department of Pediatrics, Labatt Family Heart Center, The Hospital for Sick Children, University of Toronto, Toronto, ON, Canada
- Severance Underwood Meta-research Center, Institute of Convergence Science, Yonsei University, Seoul, South Korea
| | - J W Jung
- Division of Pediatric Cardiology, Department of Pediatrics, Severance Cardiovascular Hospital, Yonsei University College of Medicine, Seoul, Korea
- Department of Pediatrics, Yonsei University College of Medicine, Seoul, Korea
| | - D J Barron
- Division of Cardiovascular Surgery, Department of Surgery, The Hospital for Sick Children, University of Toronto, Toronto, ON, Canada
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Zaidi AH, Saleeb SF, Gurvitz M, Bucholz E, Gauvreau K, Jenkins KJ, de Ferranti SD. Social Determinants of Health Including Child Opportunity Index Leading to Gaps in Care for Patients With Significant Congenital Heart Disease. J Am Heart Assoc 2024; 13:e028883. [PMID: 38353239 PMCID: PMC11010070 DOI: 10.1161/jaha.122.028883] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/23/2022] [Accepted: 10/11/2023] [Indexed: 02/21/2024]
Abstract
BACKGROUND Gaps in care (GIC) are common for patients with congenital heart disease (CHD) and can lead to worsening clinical status, unplanned hospitalization, and mortality. Understanding of how social determinants of health (SDOH) contribute to GIC in CHD is incomplete. We hypothesize that SDOH, including Child Opportunity Index (COI), are associated with GIC in patients with significant CHD. METHODS AND RESULTS A total of 8554 patients followed at a regional specialty pediatric hospital with moderate to severe CHD seen in cardiology clinic between January 2013 and December 2015 were retrospectively reviewed. SDOH factors including race, ethnicity, language, and COI calculated based on home address and zip code were analyzed. GIC of >3.25 years were identified in 32% (2709) of patients. GIC were associated with ages 14 to 29 years (P<0.001), Black race or Hispanic ethnicity (P<0.001), living ≥150 miles from the hospital (P=0.017), public health insurance (P<0.001), a maternal education level of high school or less (P<0.001), and a low COI (P<0.001). Multivariable analysis showed that GIC were associated with age ≥14 years, Black race or Hispanic ethnicity, documenting <3 caregivers as contacts, mother's education level being high school or less, a very low/low COI, and insurance status (C statistic 0.66). CONCLUSIONS One-third of patients followed in a regional referral center with significant CHD experienced a substantial GIC (>3.25 years). Several SDOH, including a low COI, were associated with GIC. Hospitals should adopt formal GIC improvement programs focusing on SDOH to improve continuity of care and ultimately overall outcomes for patients with CHD.
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Affiliation(s)
- Abbas H. Zaidi
- Department of CardiologyBoston Children’s HospitalBostonMA
- Department of PediatricsHarvard Medical SchoolBostonMA
- Present address:
Nemours Children's Hospital‐DelawareWilmingtonDE
| | - Susan F. Saleeb
- Department of CardiologyBoston Children’s HospitalBostonMA
- Department of PediatricsHarvard Medical SchoolBostonMA
| | - Michelle Gurvitz
- Department of CardiologyBoston Children’s HospitalBostonMA
- Department of PediatricsHarvard Medical SchoolBostonMA
| | - Emily Bucholz
- Department of CardiologyBoston Children’s HospitalBostonMA
- Department of PediatricsHarvard Medical SchoolBostonMA
- Present address:
University of Colorado DenverDenverCO
- Present address:
Children’s Hospital ColoradoAuroraCO
| | - Kimberlee Gauvreau
- Department of CardiologyBoston Children’s HospitalBostonMA
- Department of PediatricsHarvard Medical SchoolBostonMA
| | - Kathy J. Jenkins
- Department of CardiologyBoston Children’s HospitalBostonMA
- Department of PediatricsHarvard Medical SchoolBostonMA
| | - Sarah D. de Ferranti
- Department of CardiologyBoston Children’s HospitalBostonMA
- Department of PediatricsHarvard Medical SchoolBostonMA
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Thomson LM, Mancuso CA, Wolfe KR, Khailova L, Niemiec S, Ali E, DiMaria M, Mitchell M, Twite M, Morgan G, Frank BS, Davidson JA. The proteomic fingerprint in infants with single ventricle heart disease in the interstage period: evidence of chronic inflammation and widespread activation of biological networks. Front Pediatr 2023; 11:1308700. [PMID: 38143535 PMCID: PMC10748388 DOI: 10.3389/fped.2023.1308700] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/06/2023] [Accepted: 11/20/2023] [Indexed: 12/26/2023] Open
Abstract
Introduction Children with single ventricle heart disease (SVHD) experience significant morbidity across systems and time, with 70% of patients experiencing acute kidney injury, 33% neurodevelopmental impairment, 14% growth failure, and 5.5% of patients suffering necrotizing enterocolitis. Proteomics is a method to identify new biomarkers and mechanisms of injury in complex physiologic states. Methods Infants with SVHD in the interstage period were compared to similar-age healthy controls. Serum samples were collected, stored at -80°C, and run on a panel of 1,500 proteins in single batch analysis (Somalogic Inc., CO). Partial Least Squares-Discriminant Analysis (PLS-DA) was used to compare the proteomic profile of cases and controls and t-tests to detect differences in individual proteins (FDR <0.05). Protein network analysis with functional enrichment was performed in STRING and Cytoscape. Results PLS-DA readily discriminated between SVHD cases (n = 33) and controls (n = 24) based on their proteomic pattern alone (Accuracy = 0.96, R2 = 0.97, Q2 = 0.80). 568 proteins differed between groups (FDR <0.05). We identified 25 up-regulated functional clusters and 13 down-regulated. Active biological systems fell into six key groups: angiogenesis and cell proliferation/turnover, immune system activation and inflammation, altered metabolism, neural development, gastrointestinal system, and cardiac physiology and development. Conclusions We report a clear differentiation in the circulating proteome of patients with SVHD and healthy controls with >500 circulating proteins distinguishing the groups. These proteomic data identify widespread protein dysregulation across multiple biologic systems with promising biological plausibility as drivers of SVHD morbidity.
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Affiliation(s)
- Lindsay M. Thomson
- Department of Pediatrics, University of Colorado Anschutz Medical Campus, Aurora, CO, United States
| | - Christopher A. Mancuso
- Department of Biostatistics and Informatics, University of Colorado Anschutz Medical Campus, Aurora, CO, United States
| | - Kelly R. Wolfe
- Department of Pediatrics, University of Colorado Anschutz Medical Campus, Aurora, CO, United States
| | - Ludmila Khailova
- Department of Pediatrics, University of Colorado Anschutz Medical Campus, Aurora, CO, United States
| | - Sierra Niemiec
- Department of Biostatistics and Informatics, University of Colorado Anschutz Medical Campus, Aurora, CO, United States
| | - Eiman Ali
- Department of Pediatrics, University of Colorado Anschutz Medical Campus, Aurora, CO, United States
| | - Michael DiMaria
- Department of Pediatrics, University of Colorado Anschutz Medical Campus, Aurora, CO, United States
| | - Max Mitchell
- Department of Surgery, University of Colorado Anschutz Medical Campus, Aurora, CO, United States
| | - Mark Twite
- Department of Anesthesia, University of Colorado Anschutz Medical Campus, Aurora, CO, United States
| | - Gareth Morgan
- Department of Pediatrics, University of Colorado Anschutz Medical Campus, Aurora, CO, United States
| | - Benjamin S. Frank
- Department of Pediatrics, University of Colorado Anschutz Medical Campus, Aurora, CO, United States
| | - Jesse A. Davidson
- Department of Pediatrics, University of Colorado Anschutz Medical Campus, Aurora, CO, United States
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9
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Dijkhuizen EI, de Munck S, de Jonge RCJ, Dulfer K, van Beynum IM, Hunfeld M, Rietman AB, Joosten KFM, van Haren NEM. Early brain magnetic resonance imaging findings and neurodevelopmental outcome in children with congenital heart disease: A systematic review. Dev Med Child Neurol 2023; 65:1557-1572. [PMID: 37035939 DOI: 10.1111/dmcn.15588] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/15/2022] [Revised: 02/27/2023] [Accepted: 03/01/2023] [Indexed: 04/11/2023]
Abstract
AIM To investigate the association between early brain magnetic resonance imaging (MRI) findings and neurodevelopmental outcome (NDO) in children with congenital heart disease (CHD). METHOD A search for studies was conducted in Embase, Medline, Web of Science, Cochrane Central, PsycINFO, and Google Scholar. Observational and interventional studies were included, in which patients with CHD underwent surgery before 2 months of age, a brain MRI scan in the first year of life, and neurodevelopmental assessment beyond the age of 1 year. RESULTS Eighteen studies were included. Thirteen found an association between either quantitative or qualitative brain metrics and NDO: 5 out of 7 studies showed decreased brain volume was significantly associated with worse NDO, as did 7 out of 10 studies on brain injury. Scanning protocols and neurodevelopmental tests varied strongly. INTERPRETATION Reduced brain volume and brain injury in patients with CHD can be associated with impaired NDO, yet standardized scanning protocols and neurodevelopmental assessment are needed to further unravel trajectories of impaired brain development and its effects on outcome.
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Affiliation(s)
- Emma I Dijkhuizen
- Department of Neonatal and Pediatric Intensive Care, Division of Pediatric Intensive Care, Erasmus MC Sophia Children's Hospital, Rotterdam, the Netherlands
| | - Sophie de Munck
- Department of Pediatric Surgery, Erasmus MC Sophia Children's Hospital, Rotterdam, the Netherlands
| | - Rogier C J de Jonge
- Department of Neonatal and Pediatric Intensive Care, Division of Pediatric Intensive Care, Erasmus MC Sophia Children's Hospital, Rotterdam, the Netherlands
| | - Karolijn Dulfer
- Department of Neonatal and Pediatric Intensive Care, Division of Pediatric Intensive Care, Erasmus MC Sophia Children's Hospital, Rotterdam, the Netherlands
| | - Ingrid M van Beynum
- Department of Pediatric Surgery, Erasmus MC Sophia Children's Hospital, Rotterdam, the Netherlands
- Department of Pediatric Cardiology, Erasmus MC Sophia Children's Hospital, Rotterdam, the Netherlands
| | - Maayke Hunfeld
- Department of Neonatal and Pediatric Intensive Care, Division of Pediatric Intensive Care, Erasmus MC Sophia Children's Hospital, Rotterdam, the Netherlands
- Department of Pediatric Neurology, Erasmus MC Sophia Children's Hospital, Rotterdam, the Netherlands
| | - André B Rietman
- Department of Pediatric Surgery, Erasmus MC Sophia Children's Hospital, Rotterdam, the Netherlands
- Department of Child and Adolescent Psychiatry/Psychology, Erasmus MC Sophia Children's Hospital, Rotterdam, the Netherlands
| | - Koen F M Joosten
- Department of Neonatal and Pediatric Intensive Care, Division of Pediatric Intensive Care, Erasmus MC Sophia Children's Hospital, Rotterdam, the Netherlands
| | - Neeltje E M van Haren
- Department of Child and Adolescent Psychiatry/Psychology, Erasmus MC Sophia Children's Hospital, Rotterdam, the Netherlands
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10
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Padovani P, Singh Y, Pass RH, Vasile CM, Nield LE, Baruteau AE. E-Health: A Game Changer in Fetal and Neonatal Cardiology? J Clin Med 2023; 12:6865. [PMID: 37959330 PMCID: PMC10650296 DOI: 10.3390/jcm12216865] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2023] [Revised: 10/20/2023] [Accepted: 10/26/2023] [Indexed: 11/15/2023] Open
Abstract
Technological advancements have greatly impacted the healthcare industry, including the integration of e-health in pediatric cardiology. The use of telemedicine, mobile health applications, and electronic health records have demonstrated a significant potential to improve patient outcomes, reduce healthcare costs, and enhance the quality of care. Telemedicine provides a useful tool for remote clinics, follow-up visits, and monitoring for infants with congenital heart disease, while mobile health applications enhance patient and parents' education, medication compliance, and in some instances, remote monitoring of vital signs. Despite the benefits of e-health, there are potential limitations and challenges, such as issues related to availability, cost-effectiveness, data privacy and security, and the potential ethical, legal, and social implications of e-health interventions. In this review, we aim to highlight the current application and perspectives of e-health in the field of fetal and neonatal cardiology, including expert parents' opinions.
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Affiliation(s)
- Paul Padovani
- CHU Nantes, Department of Pediatric Cardiology and Pediatric Cardiac Surgery, FHU PRECICARE, Nantes Université, 44000 Nantes, France;
- CHU Nantes, INSERM, CIC FEA 1413, Nantes Université, 44000 Nantes, France
| | - Yogen Singh
- Division of Neonatology, Department of Pediatrics, Loma Linda University School of Medicine, Loma Linda, CA 92354, USA
- Division of Neonatal and Developmental Medicine, Department of Pediatrics, Stanford University School of Medicine, Stanford, CA 94305, USA
| | - Robert H. Pass
- Department of Pediatric Cardiology, Mount Sinai Kravis Children’s Hospital, New York, NY 10029, USA;
| | - Corina Maria Vasile
- Department of Pediatric and Adult Congenital Cardiology, University Hospital of Bordeaux, 33600 Bordeaux, France;
| | - Lynne E. Nield
- Division of Cardiology, Labatt Family Heart Centre, The Hospital for Sick Children, University of Toronto, Toronto, ON M5S 1A1, Canada
- Sunnybrook Health Sciences Centre, Toronto, ON M4N 3M5, Canada
| | - Alban-Elouen Baruteau
- CHU Nantes, Department of Pediatric Cardiology and Pediatric Cardiac Surgery, FHU PRECICARE, Nantes Université, 44000 Nantes, France;
- CHU Nantes, INSERM, CIC FEA 1413, Nantes Université, 44000 Nantes, France
- CHU Nantes, CNRS, INSERM, L’Institut du Thorax, Nantes Université, 44000 Nantes, France
- INRAE, UMR 1280, PhAN, Nantes Université, 44000 Nantes, France
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11
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Hassan A, Chegondi M, Porayette P. Five decades of Fontan palliation: What have we learned? What should we expect? J Int Med Res 2023; 51:3000605231209156. [PMID: 37910851 PMCID: PMC10621298 DOI: 10.1177/03000605231209156] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2023] [Accepted: 10/04/2023] [Indexed: 11/03/2023] Open
Abstract
The Fontan procedure is the final palliative surgery in a series of staged surgeries to reroute the systemic venous blood flow directly to the lungs, with the ventricle(s) pumping oxygenated blood to the body. Advances in medical and surgical techniques have improved patients' overall survival after the Fontan procedure. However, Fontan-associated chronic comorbidities are common. In addition to chronic cardiac dysfunction and arrhythmias, complications involving other organs such as the liver, lungs, intestine, lymphatic system, brain, and blood frequently occur. This narrative review focuses on the immediate and late consequences in children, pregnant women, and other adults with Fontan circulation. In addition, we describe the technical advancements that might change the way single-ventricle patients are managed in future.
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Affiliation(s)
- Adil Hassan
- Department of Internal Medicine, University of Iowa, Iowa City, IA 52242, USA
| | - Madhuradhar Chegondi
- Division of Pediatric Critical Care Medicine, Stead Family Children’s Hospital, University of Iowa, Iowa City, IA 52242, USA
| | - Prashob Porayette
- Division of Pediatric Cardiology, Stead Family Children’s Hospital, University of Iowa, Iowa City, IA 52242, USA
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12
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Panigrahy A, Schmithorst V, Ceschin R, Lee V, Beluk N, Wallace J, Wheaton O, Chenevert T, Qiu D, Lee JN, Nencka A, Gagoski B, Berman JI, Yuan W, Macgowan C, Coatsworth J, Fleysher L, Cannistraci C, Sleeper LA, Hoskoppal A, Silversides C, Radhakrishnan R, Markham L, Rhodes JF, Dugan LM, Brown N, Ermis P, Fuller S, Cotts TB, Rodriguez FH, Lindsay I, Beers S, Aizenstein H, Bellinger DC, Newburger JW, Umfleet LG, Cohen S, Zaidi A, Gurvitz M. Design and Harmonization Approach for the Multi-Institutional Neurocognitive Discovery Study (MINDS) of Adult Congenital Heart Disease (ACHD) Neuroimaging Ancillary Study: A Technical Note. J Cardiovasc Dev Dis 2023; 10:381. [PMID: 37754810 PMCID: PMC10532244 DOI: 10.3390/jcdd10090381] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2023] [Revised: 08/29/2023] [Accepted: 08/31/2023] [Indexed: 09/28/2023] Open
Abstract
Dramatic advances in the management of congenital heart disease (CHD) have improved survival to adulthood from less than 10% in the 1960s to over 90% in the current era, such that adult CHD (ACHD) patients now outnumber their pediatric counterparts. ACHD patients demonstrate domain-specific neurocognitive deficits associated with reduced quality of life that include deficits in educational attainment and social interaction. Our hypothesis is that ACHD patients exhibit vascular brain injury and structural/physiological brain alterations that are predictive of specific neurocognitive deficits modified by behavioral and environmental enrichment proxies of cognitive reserve (e.g., level of education and lifestyle/social habits). This technical note describes an ancillary study to the National Heart, Lung, and Blood Institute (NHLBI)-funded Pediatric Heart Network (PHN) "Multi-Institutional Neurocognitive Discovery Study (MINDS) in Adult Congenital Heart Disease (ACHD)". Leveraging clinical, neuropsychological, and biospecimen data from the parent study, our study will provide structural-physiological correlates of neurocognitive outcomes, representing the first multi-center neuroimaging initiative to be performed in ACHD patients. Limitations of the study include recruitment challenges inherent to an ancillary study, implantable cardiac devices, and harmonization of neuroimaging biomarkers. Results from this research will help shape the care of ACHD patients and further our understanding of the interplay between brain injury and cognitive reserve.
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Affiliation(s)
- Ashok Panigrahy
- Department of Radiology, UPMC Children’s Hospital of Pittsburgh, 4401 Penn Ave. Floor 2, Pittsburgh, PA 15224, USA; (V.S.); (R.C.); (V.L.); (N.B.); (J.W.); (A.H.)
- Department of Pediatric Radiology, Children’s Hospital of Pittsburgh of UPMC, 45th Str., Penn Ave., Pittsburgh, PA 15201, USA
| | - Vanessa Schmithorst
- Department of Radiology, UPMC Children’s Hospital of Pittsburgh, 4401 Penn Ave. Floor 2, Pittsburgh, PA 15224, USA; (V.S.); (R.C.); (V.L.); (N.B.); (J.W.); (A.H.)
| | - Rafael Ceschin
- Department of Radiology, UPMC Children’s Hospital of Pittsburgh, 4401 Penn Ave. Floor 2, Pittsburgh, PA 15224, USA; (V.S.); (R.C.); (V.L.); (N.B.); (J.W.); (A.H.)
| | - Vince Lee
- Department of Radiology, UPMC Children’s Hospital of Pittsburgh, 4401 Penn Ave. Floor 2, Pittsburgh, PA 15224, USA; (V.S.); (R.C.); (V.L.); (N.B.); (J.W.); (A.H.)
| | - Nancy Beluk
- Department of Radiology, UPMC Children’s Hospital of Pittsburgh, 4401 Penn Ave. Floor 2, Pittsburgh, PA 15224, USA; (V.S.); (R.C.); (V.L.); (N.B.); (J.W.); (A.H.)
| | - Julia Wallace
- Department of Radiology, UPMC Children’s Hospital of Pittsburgh, 4401 Penn Ave. Floor 2, Pittsburgh, PA 15224, USA; (V.S.); (R.C.); (V.L.); (N.B.); (J.W.); (A.H.)
| | - Olivia Wheaton
- HealthCore Inc., 480 Pleasant Str., Watertown, MA 02472, USA;
| | - Thomas Chenevert
- Department of Radiology, Michigan Medicine University of Michigan, 1500 E Medical Center Dr., Ann Arbor, MI 48109, USA;
- Congenital Heart Center, C. S. Mott Children’s Hospital, 1540 E Hospital Dr., Ann Arbor, MI 48109, USA
| | - Deqiang Qiu
- Department of Radiology and Imaging Sciences, Emory School of Medicine, 1364 Clifton Rd., Atlanta, GA 30322, USA;
| | - James N Lee
- Department of Radiology, The University of Utah, 50 2030 E, Salt Lake City, UT 84112, USA;
| | - Andrew Nencka
- Department of Radiology, Medical College of Wisconsin, 9200 W Wisconsin Ave., Milwaukee, WI 53226, USA;
| | - Borjan Gagoski
- Department of Radiology, Boston Children’s Hospital, 300 Longwood Ave., Boston, MA 02115, USA;
| | - Jeffrey I. Berman
- Department of Radiology, Children’s Hospital of Philadelphia, 3401 Civic Center Blvd., Philadelphia, PA 19104, USA;
| | - Weihong Yuan
- Department of Radiology, Cincinnati Children’s Hospital Medical Center, 3333 Burnet Ave., Cincinnati, OH 45229, USA;
- Department of Radiology, University of Cincinnati College of Medicine, 3230 Eden Ave., Cincinnati, OH 45267, USA
| | - Christopher Macgowan
- Department of Medical Biophysics, University of Toronto, 101 College Str. Suite 15-701, Toronto, ON M5G 1L7, Canada;
- The Hospital for Sick Children Division of Translational Medicine, 555 University Ave., Toronto, ON M5G 1X8, Canada
| | - James Coatsworth
- Department of Radiology, Medical University of South Carolina, 171 Ashley Ave., Room 372, Charleston, SC 29425, USA;
| | - Lazar Fleysher
- BioMedical Engineering and Imaging Institute, Icahn School of Medicine at Mount Sinai, 1470 Madison Ave., New York, NY 10029, USA; (L.F.); (C.C.); (A.Z.)
| | - Christopher Cannistraci
- BioMedical Engineering and Imaging Institute, Icahn School of Medicine at Mount Sinai, 1470 Madison Ave., New York, NY 10029, USA; (L.F.); (C.C.); (A.Z.)
| | - Lynn A. Sleeper
- Department of Cardiology, Boston Children’s Hospital, 300 Longwood Ave., Boston, MA 02115, USA; (L.A.S.); (J.W.N.); (M.G.)
| | - Arvind Hoskoppal
- Department of Radiology, UPMC Children’s Hospital of Pittsburgh, 4401 Penn Ave. Floor 2, Pittsburgh, PA 15224, USA; (V.S.); (R.C.); (V.L.); (N.B.); (J.W.); (A.H.)
| | - Candice Silversides
- Department of Cardiology, University of Toronto, C. David Naylor Building, 6 Queen’s Park Crescent West, Third Floor, Toronto, ON M5S 3H2, Canada;
| | - Rupa Radhakrishnan
- Department of Radiology and Imaging Sciences, Indiana University School of Medicine, 550 University Blvd., Indianapolis, IN 46202, USA;
| | - Larry Markham
- Department of Cardiology, University of Indiana School of Medicine, 545 Barnhill Dr., Indianapolis, IN 46202, USA;
| | - John F. Rhodes
- Department of Cardiology, Medical University of South Carolina, 96 Jonathan Lucas Str. Ste. 601, MSC 617, Charleston, SC 29425, USA;
| | - Lauryn M. Dugan
- Department of Cardiology, Cincinnati Children’s Hospital Medical Center, 3333 Burnet Ave., Cincinnati, OH 45229, USA; (L.M.D.); (N.B.)
| | - Nicole Brown
- Department of Cardiology, Cincinnati Children’s Hospital Medical Center, 3333 Burnet Ave., Cincinnati, OH 45229, USA; (L.M.D.); (N.B.)
| | - Peter Ermis
- Department of Radiology, Texas Children’s Hospital, Houston, TX 77030, USA; (P.E.); (S.F.)
| | - Stephanie Fuller
- Department of Radiology, Texas Children’s Hospital, Houston, TX 77030, USA; (P.E.); (S.F.)
| | - Timothy Brett Cotts
- Departments of Internal Medicine and Pediatrics, Michigan Medicine University of Michigan, 1500 E Medical Center Dr., Ann Arbor, MI 48109, USA;
| | - Fred Henry Rodriguez
- Department of Cardiology, Emory School of Medicine, 100 Woodruff Circle, Atlanta, GA 30322, USA;
| | - Ian Lindsay
- Department of Cardiology, The University of Utah, 95 S 2000 E, Salt Lake City, UT 84112, USA;
| | - Sue Beers
- Department of Psychiatry, University of Pittsburgh School of Medicine, 3811 O’Hara Str., Pittsburgh, PA 15213, USA; (S.B.); (H.A.)
| | - Howard Aizenstein
- Department of Psychiatry, University of Pittsburgh School of Medicine, 3811 O’Hara Str., Pittsburgh, PA 15213, USA; (S.B.); (H.A.)
| | - David C. Bellinger
- Cardiac Neurodevelopmental Program, Boston Children’s Hospital, 300 Longwood Ave., Boston, MA 02115, USA;
| | - Jane W. Newburger
- Department of Cardiology, Boston Children’s Hospital, 300 Longwood Ave., Boston, MA 02115, USA; (L.A.S.); (J.W.N.); (M.G.)
| | - Laura Glass Umfleet
- Department of Neuropsychology, Medical College of Wisconsin, 9200 W Wisconsin Ave., Milwaukee, WI 53226, USA;
| | - Scott Cohen
- Heart and Vascular Center, Medical College of Wisconsin, 8701 Watertown Plank Rd., Milwaukee, WI 53226, USA;
| | - Ali Zaidi
- BioMedical Engineering and Imaging Institute, Icahn School of Medicine at Mount Sinai, 1470 Madison Ave., New York, NY 10029, USA; (L.F.); (C.C.); (A.Z.)
| | - Michelle Gurvitz
- Department of Cardiology, Boston Children’s Hospital, 300 Longwood Ave., Boston, MA 02115, USA; (L.A.S.); (J.W.N.); (M.G.)
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13
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Ramonfaur D, Zhang X, Garza AP, García-Pons JF, Britton-Robles SC. Hypoplastic Left Heart Syndrome: A Review. Cardiol Rev 2023; 31:149-154. [PMID: 35349498 DOI: 10.1097/crd.0000000000000435] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
Hypoplastic left heart syndrome is a rare and poorly understood congenital disorder featuring a univentricular myocardium, invariably resulting in early childhood death if left untreated. The process to palliate this congenital cardiomyopathy is of high complexity and may include invasive interventions in the first week of life. The preferred treatment strategy involves a staged correction with 3 surgical procedures at different points in time. The Norwood procedure is usually performed within the first weeks of life and aims to increase systemic circulation and relieve pulmonary vascular pressure. This procedure is followed by the bidirectional Glenn and the Fontan procedures in later life, which offer to decrease stress in the ventricular chamber. The prognosis of children with this disease has greatly improved in the past decades; however, it is still largely driven by multiple modifiable and nonmodifiable variables. Novel and clever alternatives have been proposed to improve the survival and neurodevelopment of these patients, although they are not used as standard of care in all centers. The neurodevelopmental outcomes among these patients have received particular attention in the last decade in light to improve this very limiting associated comorbidity that compromises quality of life.
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Affiliation(s)
- Diego Ramonfaur
- From the Division of Postgraduate Medical Education, Harvard Medical School, Boston, MA
| | - Xiaoya Zhang
- From the Division of Postgraduate Medical Education, Harvard Medical School, Boston, MA
| | - Abraham P Garza
- Departamento de Medicina, Tecnológico de Monterrey, Escuela de Medicina y Ciencias de la Salud, Monterrey, México
| | - José Fernando García-Pons
- División de Ciencias de la Salud, Departamento de Medicina y Nutrición, Universidad de Guanajuato, Guanajuato, México
| | - Sylvia C Britton-Robles
- Departamento de Medicina, Tecnológico de Monterrey, Escuela de Medicina y Ciencias de la Salud, Monterrey, México
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14
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Schmithorst V, Ceschin R, Lee V, Wallace J, Sahel A, Chenevert TL, Parmar H, Berman JI, Vossough A, Qiu D, Kadom N, Grant PE, Gagoski B, LaViolette PS, Maheshwari M, Sleeper LA, Bellinger DC, Ilardi D, O’Neil S, Miller TA, Detterich J, Hill KD, Atz AM, Richmond ME, Cnota J, Mahle WT, Ghanayem NS, Gaynor JW, Goldberg CS, Newburger JW, Panigrahy A. Single Ventricle Reconstruction III: Brain Connectome and Neurodevelopmental Outcomes: Design, Recruitment, and Technical Challenges of a Multicenter, Observational Neuroimaging Study. Diagnostics (Basel) 2023; 13:1604. [PMID: 37174995 PMCID: PMC10178603 DOI: 10.3390/diagnostics13091604] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2023] [Revised: 04/25/2023] [Accepted: 04/27/2023] [Indexed: 05/15/2023] Open
Abstract
Patients with hypoplastic left heart syndrome who have been palliated with the Fontan procedure are at risk for adverse neurodevelopmental outcomes, lower quality of life, and reduced employability. We describe the methods (including quality assurance and quality control protocols) and challenges of a multi-center observational ancillary study, SVRIII (Single Ventricle Reconstruction Trial) Brain Connectome. Our original goal was to obtain advanced neuroimaging (Diffusion Tensor Imaging and Resting-BOLD) in 140 SVR III participants and 100 healthy controls for brain connectome analyses. Linear regression and mediation statistical methods will be used to analyze associations of brain connectome measures with neurocognitive measures and clinical risk factors. Initial recruitment challenges occurred that were related to difficulties with: (1) coordinating brain MRI for participants already undergoing extensive testing in the parent study, and (2) recruiting healthy control subjects. The COVID-19 pandemic negatively affected enrollment late in the study. Enrollment challenges were addressed by: (1) adding additional study sites, (2) increasing the frequency of meetings with site coordinators, and (3) developing additional healthy control recruitment strategies, including using research registries and advertising the study to community-based groups. Technical challenges that emerged early in the study were related to the acquisition, harmonization, and transfer of neuroimages. These hurdles were successfully overcome with protocol modifications and frequent site visits that involved human and synthetic phantoms.
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Affiliation(s)
- Vanessa Schmithorst
- Department of Radiology, UPMC Children’s Hospital of Pittsburgh, 4401 Penn Avenue, Floor 2, Pittsburgh, PA 15224, USA
| | - Rafael Ceschin
- Department of Radiology, UPMC Children’s Hospital of Pittsburgh, 4401 Penn Avenue, Floor 2, Pittsburgh, PA 15224, USA
- Department of Biomedical Informatics, University of Pittsburgh School, 5607 Baum Blvd., Pittsburgh, PA 15206, USA
| | - Vincent Lee
- Department of Radiology, UPMC Children’s Hospital of Pittsburgh, 4401 Penn Avenue, Floor 2, Pittsburgh, PA 15224, USA
| | - Julia Wallace
- Department of Radiology, UPMC Children’s Hospital of Pittsburgh, 4401 Penn Avenue, Floor 2, Pittsburgh, PA 15224, USA
| | - Aurelia Sahel
- Department of Radiology, UPMC Children’s Hospital of Pittsburgh, 4401 Penn Avenue, Floor 2, Pittsburgh, PA 15224, USA
| | - Thomas L. Chenevert
- Michigan Medicine Department of Radiology, University of Michigan, 1500 E Medical Center Dr., Ann Arbor, MI 48109, USA
| | - Hemant Parmar
- Michigan Medicine Department of Radiology, University of Michigan, 1500 E Medical Center Dr., Ann Arbor, MI 48109, USA
| | - Jeffrey I. Berman
- Department of Radiology, Children’s Hospital of Philadelphia, 3401 Civic Center Blvd., Philadelphia, PA 19104, USA
| | - Arastoo Vossough
- Department of Radiology, Children’s Hospital of Philadelphia, 3401 Civic Center Blvd., Philadelphia, PA 19104, USA
| | - Deqiang Qiu
- Department of Radiology and Imaging Sciences, Children’s Healthcare of Atlanta, Emory University, 1364 Clifton Rd, Atlanta, GA 30322, USA
| | - Nadja Kadom
- Department of Radiology and Imaging Sciences, Children’s Healthcare of Atlanta, Emory University, 1364 Clifton Rd, Atlanta, GA 30322, USA
| | - Patricia Ellen Grant
- Children’s Hospital Boston, Fetal-Neonatal Neuroimaging and Developmental Science Center (FNNDSC), 300 Longwood Avenue, Boston, MA 02115, USA
| | - Borjan Gagoski
- Department of Radiology, Children’s Hospital Boston, 300 Longwood Avenue, Boston, MA 02115, USA
| | - Peter S. LaViolette
- Department of Radiology, Medical College of Wisconsin, 9200 W Wisconsin Avenue, Milwaukee, WI 53226, USA
| | - Mohit Maheshwari
- Department of Radiology, Medical College of Wisconsin, 9200 W Wisconsin Avenue, Milwaukee, WI 53226, USA
| | - Lynn A. Sleeper
- Department of Cardiology, Boston Children’s Hospital, 300 Longwood Avenue, Boston, MA 02115, USA
- Department of Pediatrics, Harvard Medical School, 25 Shattuck Street, Boston, MA 02115, USA
| | - David C. Bellinger
- Cardiac Neurodevelopmental Program, Department of Neurology, Boston Children’s Hospital, 300 Longwood Avenue, Boston, MA 02115, USA
| | - Dawn Ilardi
- Department of Neuropsychology, Children’s Healthcare of Atlanta, 1400 Tullie Road NE, Atlanta, GA 30329, USA
| | - Sharon O’Neil
- Children’s Hospital Los Angeles, Neuropsychology Core of the Saban Research Institute, 4661 Sunset Blvd., Los Angeles, CA 90027, USA
| | - Thomas A. Miller
- Division of Pediatric Cardiology, Department of Pediatrics, University of Utah School of Medicine, 30 N 1900 E, Salt Lake City, UT 84132, USA
| | - Jon Detterich
- Division of Pediatric Cardiology, Children’s Hospital Los Angeles, 4650 Sunset Blvd., Los Angeles, CA 90027, USA
| | - Kevin D. Hill
- Division of Pediatric Cardiology, Department of Pediatrics, Duke University School of Medicine, 7506 Hospital North, DUMC Box 3090, Durham, NC 27710, USA
| | - Andrew M. Atz
- Division of Pediatric Cardiology, Medical University of South Carolina, 96 Jonathan Lucas St. Ste. 601, MSC 617, Charleston, SC 29425, USA
| | - Marc E. Richmond
- Program for Pediatric Cardiomyopathy, Heart Failure, and Transplantation, New York-Presbyterian Morgan Stanley Children’s Hospital, 3959 Broadway MSCH North, 2nd Floor, New York, NY 10032, USA
| | - James Cnota
- Fetal Heart Program, Cincinnati Children’s, 3333 Burnet Avenue, Cincinnati, OH 45229, USA
| | - William T. Mahle
- Division of Pediatric Cardiology, Children’s Healthcare of Atlanta, 1400 Tullie Rd NE Suite 630, Atlanta, GA 30329, USA
| | - Nancy S. Ghanayem
- Section of Pediatric Critical Care, Department of Pediatrics, Comer Children’s Hospital, University of Chicago Medicine, 5721 S. Maryland Avenue, Chicago, IL 60637, USA
- Department of Pediatrics, Medical College of Wisconsin Section of Pediatric Critical Care, 9000 W. Wisconsin Avenue MS 681, Milwaukee, WI 53226, USA
| | - J. William Gaynor
- Heart Failure and Transplant Program, Children’s Hospital of Philadelphia, 3401 Civic Center Blvd., Philadelphia, PA 19104, USA
| | - Caren S. Goldberg
- Department of Pediatrics, Division of Cardiology, C.S. Mott Children’s Hospital, 1540 E Hospital Dr #4204, Ann Arbor, MI 48109, USA
| | - Jane W. Newburger
- Department of Cardiology, Boston Children’s Hospital, 300 Longwood Avenue, Boston, MA 02115, USA
| | - Ashok Panigrahy
- Department of Radiology, UPMC Children’s Hospital of Pittsburgh, 4401 Penn Avenue, Floor 2, Pittsburgh, PA 15224, USA
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15
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Schmithorst V, Ceschin R, Lee V, Wallace J, Sahel A, Chenevert T, Parmar H, Berman JI, Vossough A, Qiu D, Kadom N, Grant PE, Gagoski B, LaViolette P, Maheshwari M, Sleeper LA, Bellinger D, Ilardi D, O’Neil S, Miller TA, Detterich J, Hill KD, Atz AM, Richmond M, Cnota J, Mahle WT, Ghanayem N, Gaynor W, Goldberg CS, Newburger JW, Panigrahy A. Single Ventricle Reconstruction III: Brain Connectome and Neurodevelopmental Outcomes: Design, Recruitment, and Technical Challenges of a Multicenter, Observational Neuroimaging Study. MEDRXIV : THE PREPRINT SERVER FOR HEALTH SCIENCES 2023:2023.04.12.23288433. [PMID: 37131744 PMCID: PMC10153324 DOI: 10.1101/2023.04.12.23288433] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/04/2023]
Abstract
Patients with hypoplastic left heart syndrome who have been palliated with the Fontan procedure are at risk for adverse neurodevelopmental outcomes, lower quality of life, and reduced employability. We describe the methods (including quality assurance and quality control protocols) and challenges of a multi-center observational ancillary study, SVRIII (Single Ventricle Reconstruction Trial) Brain Connectome. Our original goal was to obtain advanced neuroimaging (Diffusion Tensor Imaging and Resting-BOLD) in 140 SVR III participants and 100 healthy controls for brain connectome analyses. Linear regression and mediation statistical methods will be used to analyze associations of brain connectome measures with neurocognitive measures and clinical risk factors. Initial recruitment challenges occurred related to difficulties with: 1) coordinating brain MRI for participants already undergoing extensive testing in the parent study, and 2) recruiting healthy control subjects. The COVID-19 pandemic negatively affected enrollment late in the study. Enrollment challenges were addressed by 1) adding additional study sites, 2) increasing the frequency of meetings with site coordinators and 3) developing additional healthy control recruitment strategies, including using research registries and advertising the study to community-based groups. Technical challenges that emerged early in the study were related to the acquisition, harmonization, and transfer of neuroimages. These hurdles were successfully overcome with protocol modifications and frequent site visits that involved human and synthetic phantoms. Trial registration number ClinicalTrials.gov Registration Number: NCT02692443.
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Affiliation(s)
- Vanessa Schmithorst
- Department of Radiology, UPMC Children’s Hospital of Pittsburgh, 4401 Penn Ave, Floor 2, Pittsburgh, PA 15224 USA
| | - Rafael Ceschin
- Department of Radiology, UPMC Children’s Hospital of Pittsburgh, 4401 Penn Ave, Floor 2, Pittsburgh, PA 15224 USA
- Department of Biomedical Informatics, University of Pittsburgh School, 5607 Baum Blvd, Pittsburgh, PA 15206-3701 USA
| | - Vince Lee
- Department of Radiology, UPMC Children’s Hospital of Pittsburgh, 4401 Penn Ave, Floor 2, Pittsburgh, PA 15224 USA
| | - Julia Wallace
- Department of Radiology, UPMC Children’s Hospital of Pittsburgh, 4401 Penn Ave, Floor 2, Pittsburgh, PA 15224 USA
| | - Aurelia Sahel
- Department of Radiology, UPMC Children’s Hospital of Pittsburgh, 4401 Penn Ave, Floor 2, Pittsburgh, PA 15224 USA
| | - Thomas Chenevert
- Department of Radiology, Michigan Medicine, University of Michigan, University of Michigan, 1500 E Medical Center Dr, Ann Arbor, MI 48109 USA
| | - Hemant Parmar
- Department of Radiology, Michigan Medicine, University of Michigan, University of Michigan, 1500 E Medical Center Dr, Ann Arbor, MI 48109 USA
| | - Jeffrey I. Berman
- Department of Radiology, Children’s Hospital of Philadelphia, 3401 Civic Center Blvd, Philadelphia, PA 19104, USA
| | - Arastoo Vossough
- Department of Radiology, Children’s Hospital of Philadelphia, 3401 Civic Center Blvd, Philadelphia, PA 19104, USA
| | - Deqiang Qiu
- Department of Radiology and Imaging Sciences, Children’s Healthcare of Atlanta, Emory University, 1364 Clifton Rd, Atlanta, GA 30322 USA
| | - Nadja Kadom
- Department of Radiology and Imaging Sciences, Children’s Healthcare of Atlanta, Emory University, 1364 Clifton Rd, Atlanta, GA 30322 USA
| | - Patricia Ellen Grant
- Fetal-Neonatal Neuroimaging and Developmental Science Center (FNNDSC), Children’s Hospital Boston, 300 Longwood Avenue, Boston, MA 02115 USA
| | - Borjan Gagoski
- Department of Radiology, Children’s Hospital Boston, 300 Longwood Ave, Boston, MA 02115 USA
| | - Peter LaViolette
- Department of Radiology, Medical College of Wisconsin, 9200 W Wisconsin Ave, Milwaukee, WI 53226 USA
| | - Mohit Maheshwari
- Department of Radiology, Medical College of Wisconsin, 9200 W Wisconsin Ave, Milwaukee, WI 53226 USA
| | - Lynn A. Sleeper
- Department of Cardiology, Boston Children’s Hospital, 300 Longwood Avenue, Boston, MA 02115
- Department of Pediatrics, Harvard Medical School, 25 Shattuck Street, Boston, MA 02115 USA
| | - David Bellinger
- Cardiac Neurodevelopmental Program, Department of Neurology, Boston, Children’s Hospital, 300 Longwood Avenue, Boston, MA 02115 USA
| | - Dawn Ilardi
- Department of Neuropsychology, Children’s Healthcare of Atlanta, 1400 Tullie Road NE, Atlanta, GA 30329
| | - Sharon O’Neil
- Neuropsychology Core of the Saban Research Institute, Children’s Hospital Los Angeles, 4661 Sunset Blvd., Los Angeles, CA 90027 USA
| | - Thomas A. Miller
- Division of Pediatric Cardiology, Department of Pediatrics, University of Utah, School of Medicine, 30 N 1900 E, Salt Lake City, UT 84132 USA
| | - Jon Detterich
- Division of Pediatric Cardiology, Children’s Hospital Los Angeles, 4650 Sunset Blvd, Los Angeles, CA 90027 USA
| | - Kevin D. Hill
- Division of Pediatric Cardiology, Department of Pediatrics, Duke University, School of Medicine, 7506 Hospital North, DUMC Box 3090, Durham, NC 27710 USA
| | - Andrew M. Atz
- Division of Pediatric Cardiology, Medical University of South Carolina, 96 Jonathan Lucas St. Ste. 601, MSC 617, Charleston, SC 29425 USA
| | - Marc Richmond
- Program for Pediatric Cardiomyopathy, Heart Failure, and Transplantation, New York-Presbyterian Morgan Stanley Children’s Hospital, 3959 Broadway MSCH North, 2 Floor, New York, NY 10032 USA
| | - James Cnota
- Fetal Heart Program, Cincinnati Children’s, 3333 Burnet Avenue, Cincinnati, Ohio 45229-3026 USA
| | - William T. Mahle
- Division of Pediatric Cardiology, Children’s Healthcare of Atlanta, 1400 Tullie Rd NE Suite 630, Atlanta, GA 30329
| | - Nancy Ghanayem
- Section of Pediatric Critical Care, Department of Pediatrics, University of Chicago Medicine, Comer Children’s Hospital, 5721 S. Maryland Ave., Chicago, IL 60637 USA
- Section of Pediatric Critical Care, Department of Pediatrics, Medical College of Wisconsin, 9000 W. Wisconsin Ave. MS 681, Milwaukee, WI 53226 USA
| | - William Gaynor
- Heart Failure and Transplant Program, Children’s Hospital of Philadelphia, 3401 Civic Center Blvd., Philadelphia, PA 19104 USA
| | - Caren S. Goldberg
- Department of Pediatrics, Division of Cardiology, C.S. Mott Children’s Hospital, 1540 E Hospital Dr #4204, Ann Arbor, MI 48109 USA
| | - Jane W. Newburger
- Department of Cardiology, Boston Children’s Hospital, 300 Longwood Avenue, Boston, MA 02115
| | - Ashok Panigrahy
- Department of Radiology, UPMC Children’s Hospital of Pittsburgh, 4401 Penn Ave, Floor 2, Pittsburgh, PA 15224 USA
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16
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Payne E, Garden F, d'Udekem Y, Weintraub R, McCallum Z, Wightman H, Zentner D, Cordina R, Wilson TG, Ayer J. Prolonged Enteral Tube Feeding in Infants With a Functional Single Ventricle Is Associated With Adverse Outcomes After Fontan Completion. J Pediatr 2023:S0022-3476(23)00042-2. [PMID: 36708874 DOI: 10.1016/j.jpeds.2023.01.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/14/2022] [Revised: 01/13/2023] [Accepted: 01/22/2023] [Indexed: 01/26/2023]
Abstract
OBJECTIVES To define the baseline characteristics of long-term tube-fed single ventricle patients, investigate associations between long-term enteral tube feeding and growth, and determine associations with long-term outcomes after Fontan procedure. STUDY DESIGN We performed a retrospective cohort study of patients in the Australia and New Zealand Fontan Registry undergoing treatment at the Royal Children's Hospital, the Children's Hospital at Westmead, Royal Melbourne Hospital, and Royal Prince Alfred Hospital from 1981-2018. Patients were defined as tube-fed (TF) or non-tube-fed (NTF) based on enteral tube feeding at age 90 days. Feeding groups were compared regarding BMI trajectory, BMI at last follow-up, and long-term incidence of severe Fontan failure. RESULTS Of 390 patients (56(14%) TF, 334(86%) NTF), TF was associated with right ventricular dominance, hypoplastic left heart syndrome, Norwood procedure, increased procedures prior to Fontan, extracardiac conduit Fontan, Fontan fenestration, and atrioventricular valve repair/replacement. TF patients were less likely to be in the higher compared with lowest 0-6 month BMI trajectory (P<0.01,P=0.03), had lower 6month weight-for-age z-scores (P<0.01) and length-for-age z-scores (P=0.01). TF were less likely to be overweight/obese at pediatric follow-up (HR=0.31,95%CI:0.12-0.80;P=0.02) and more likely to be underweight at adult follow-up ((HR=16.51; 5%CI:2.70-101.10;P<0.01).TF compared with NTF was associated with increased risk of severe Fontan failure (HR=4.13;95%CI=1.65,10.31;P<0.01). CONCLUSIONS Prolonged infant enteral tube feeding is an independent marker of poor growth and adverse clinical outcomes extending long-term post-Fontan procedure.
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Affiliation(s)
- Emma Payne
- The University of Sydney, Sydney, AUSTRALIA; The University of Melbourne, Melbourne, AUSTRALIA
| | - Frances Garden
- The University of New South, Sydney, AUSTRALIA; The Ingham Institute of Applied Medical Research, Sydney, AUSTRALIA
| | | | - Robert Weintraub
- The University of Melbourne, Melbourne, AUSTRALIA; The Royal Children's Hospital, Melbourne, AUSTRALIA; The Murdoch Children's Research Institute, Melbourne, AUSTRALIA
| | - Zoe McCallum
- The Royal Children's Hospital, Melbourne, AUSTRALIA
| | | | - Dominica Zentner
- The University of Melbourne, Melbourne, AUSTRALIA; The Royal Melbourne Hospital, Melbourne, AUSTRALIA
| | - Rachael Cordina
- The University of Sydney, Sydney, AUSTRALIA; The Royal Prince Alfred Hospital, Sydney, AUSTRALIA
| | - Thomas G Wilson
- The University of Melbourne, Melbourne, AUSTRALIA; The Royal Children's Hospital, Melbourne, AUSTRALIA
| | - Julian Ayer
- The University of Sydney, Sydney, AUSTRALIA; The Heart Centre for Children, The Sydney Children's Hospital Network, Sydney, AUSTRALIA.
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17
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Trivedi A, Browning Carmo K, Jatana V, James-Nunez K, Gordon A. Growth and risk of adverse neuro-developmental outcome in infants with congenital heart disease: A systematic review. Acta Paediatr 2023; 112:53-62. [PMID: 36203274 PMCID: PMC10092319 DOI: 10.1111/apa.16564] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/04/2022] [Revised: 10/01/2022] [Accepted: 10/05/2022] [Indexed: 12/13/2022]
Abstract
AIM Congenital heart disease (CHD) is one of the most common birth defects affecting around 1:100 infants. In this systematic review, we aimed to determine impact of growth on neurodevelopmental outcomes of infants with CHD. METHODS Studies that reported association of growth with developmental outcomes in infants with CHD who had surgery, were included. The search strategy was prospectively registered. Relevant studies were identified by electronic searches. The Cochrane Central Register of Controlled Trials, MEDLINE and EMBASE were searched from their earliest date to February 2022. RESULTS Twenty studies met inclusion criteria. Choice of growth measures, developmental assessment tools and timing of assessment varied widely precluding conduct of a meta-analysis. Seventeen studies reported on infants who had cardio-pulmonary bypass. Birth weight was reported in thirteen studies and was associated with adverse outcome in nine. Head circumference at birth and later predicted developmental outcomes in five. Impaired postnatal growth was associated with adverse developmental outcome in seven studies. CONCLUSION Growth in infants with congenital heart disease, specifically single ventricle physiology can predict adverse neurodevelopmental outcome. Included studies showed significant clinical heterogeneity. Uniformity should be agreed by various data registries with routine prospective collection of growth and developmental data.
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Affiliation(s)
- Amit Trivedi
- Grace Centre for Newborn Intensive Care, Children's Hospital at Westmead, Westmead, New South Wales, Australia.,Faculty of Medicine and Health, The University of Sydney, Sydney, New South Wales, Australia
| | - Kathryn Browning Carmo
- Grace Centre for Newborn Intensive Care, Children's Hospital at Westmead, Westmead, New South Wales, Australia.,Faculty of Medicine and Health, The University of Sydney, Sydney, New South Wales, Australia
| | - Vishal Jatana
- Helen McMillan Paediatric Intensive Care Unit, Children's Hospital at Westmead, Westmead, New South Wales, Australia
| | - Kristen James-Nunez
- Grace Centre for Newborn Intensive Care, Children's Hospital at Westmead, Westmead, New South Wales, Australia
| | - Adrienne Gordon
- Faculty of Medicine and Health, The University of Sydney, Sydney, New South Wales, Australia.,Centre for Newborn Care, Royal Price Alfred Hospital, Camperdown, New South Wales, Australia
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18
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Lee FT, Sun L, Freud L, Seed M. A guide to prenatal counseling regarding neurodevelopment in congenital heart disease. Prenat Diagn 2022; 43:661-673. [PMID: 36575573 DOI: 10.1002/pd.6292] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2022] [Revised: 12/07/2022] [Accepted: 12/17/2022] [Indexed: 12/29/2022]
Abstract
Advances in cardiac surgical techniques taking place over the past 50 years have resulted in the vast majority of children born with congenital cardiac malformations now surviving into adulthood. As the focus shifts from survival to the functional outcomes of our patients, it is increasingly being recognized that a significant proportion of patients undergoing infant cardiac repair experience adverse neurodevelopmental (ND) outcomes. The etiology of abnormal brain development in the setting of congenital heart disease is poorly understood, complex, and likely multifactorial. Furthermore, the efficacy of therapies available for the learning disabilities, attention deficit, and hyperactivity disorders and other ND deficits complicating congenital heart disease is currently uncertain. This situation presents a challenge for prenatal counseling as current antenatal testing does not usually provide prognostic information regarding the likely ND trajectories of individual patients. However, we believe it is important for parents to be informed about potential issues with child development when a new diagnosis of congenital heart disease is disclosed. Parents deserve a comprehensive and thoughtful approach to this subject, which conveys the uncertainties involved in predicting the severity of any developmental disorders encountered, while emphasizing the improvements in outcomes that have already been achieved in infants with congenital heart disease. A balanced approach to counseling should also discuss what local arrangements are in place for ND follow-up. This review presents an up-to-date overview of ND outcomes in patients with congenital heart disease, providing possible approaches to communicating this information to parents during prenatal counseling in a sensitive and accurate manner.
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Affiliation(s)
- Fu-Tsuen Lee
- Division of Cardiology, Department of Pediatrics, The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada.,Translational Medicine Program, The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada.,Department of Physiology, Temerty Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Liqun Sun
- Division of Cardiology, Department of Pediatrics, The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada.,Translational Medicine Program, The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
| | - Lindsay Freud
- Division of Cardiology, Department of Pediatrics, The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada.,Translational Medicine Program, The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
| | - Mike Seed
- Division of Cardiology, Department of Pediatrics, The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada.,Translational Medicine Program, The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada.,Department of Physiology, Temerty Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada.,Department of Diagnostic Imaging, The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
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19
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Goldberg CS, Gaynor JW, Mahle WT, Ravishankar C, Frommelt P, Ilardi D, Bellinger D, Paridon S, Taylor M, Hill KD, Minich LL, Schwartz S, Afton K, Lamberti M, Trachtenberg FL, Gongwer R, Atz A, Burns KM, Chowdhury S, Cnota J, Detterich J, Frommelt M, Jacobs JP, Miller TA, Ohye RG, Pizarro C, Shah A, Walters P, Newburger JW. The pediatric heart network's study on long-term outcomes of children with HLHS and the impact of Norwood Shunt type in the single ventricle reconstruction trial cohort (SVRIII): Design and adaptations. Am Heart J 2022; 254:216-227. [PMID: 36115392 DOI: 10.1016/j.ahj.2022.09.005] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/10/2022] [Revised: 09/08/2022] [Accepted: 09/10/2022] [Indexed: 06/15/2023]
Abstract
BACKGROUND The Single Ventricle Reconstruction (SVR) Trial was the first randomized clinical trial of a surgical approach for treatment of congenital heart disease. Infants with hypoplastic left heart syndrome (HLHS) and other single right ventricle (RV) anomalies were randomized to a modified Blalock Taussig Thomas shunt (mBTTS) or a right-ventricular-to-pulmonary-artery shunt (RVPAS) at the time of the Norwood procedure. The aim of the Long-term Outcomes of Children with HLHS and the Impact of Norwood Shunt Type (SVR III) study is to compare early adolescent outcomes including measures of cardiac function, transplant-free survival, and neurodevelopment, between those who received a mBTTS and those who received an RVPAS. METHODS Transplant-free survivors of the SVR cohort were enrolled at 10 to 15 years of age for multifaceted in-person evaluation of cardiac function (cardiac magnetic resonance [CMR], echocardiogram and exercise test) and neurodevelopmental evaluation. Right ventricular ejection fraction measured by CMR served as the primary outcome. Development of arrhythmias, protein losing enteropathy, and other comorbidities were assessed through annual medical history interview. Through the course of SVR III, protocol modifications to engage SVR trial participants were designed to enhance recruitment and retention. CONCLUSIONS Evaluation of long-term outcomes will provide important data to inform decisions about the shunt type placed at the Norwood operation and will improve the understanding of cardiovascular and neurodevelopmental outcomes for early adolescents with HLHS.
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Affiliation(s)
- Caren S Goldberg
- Department of Pediatrics, C.S. Mott Children's Hospital, University of Michigan, Ann Arbor, MI.
| | - J William Gaynor
- Division of Cardiothoracic Surgery, Department of Surgery, Children's Hospital of Philadelphia, and the Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - William T Mahle
- Department of Pediatrics, Children's Healthcare of Atlanta, Atlanta, GE
| | - Chitra Ravishankar
- Department of Pediatrics, Children's Hospital of Philadelphia and the Perelman School of Medicine, , Philadelphia, PA
| | - Peter Frommelt
- Department of Pediatrics, Children's University of Pennsylvania Hospital of Wisconsin, Milwaukee WI
| | - Dawn Ilardi
- Department of Neuropsychology, Children's Healthcare of Atlanta, Emory University, Atlanta GE
| | - David Bellinger
- Department of Neurology, Boston Children's Hospital, Boston, MA
| | - Stephen Paridon
- Department of Pediatrics, Children's Hospital of Philadelphia and the Perelman School of Medicine, , Philadelphia, PA
| | - Michael Taylor
- Department of Pediatrics, Cincinnati Children's Hospital and Medical Center, Cincinnati OH
| | - Kevin D Hill
- Department of Pediatrics, Duke University, Durham, NC
| | - L LuAnn Minich
- Department of Pediatrics, The University of Utah and Primary Children's Hospital, Salt Lake City, UT
| | - Steven Schwartz
- Department of Critical Care Medicine, The Hospital for Sick Children, Toronto ON
| | - Katherine Afton
- Michigan Congenital Heart Center Research and Discovery, University of Michigan, Ann Arbor, MI
| | | | | | | | - Andrew Atz
- Department of Pediatrics, Medical University of South Carolina, Charleston SC
| | - Kristin M Burns
- Department of Pediatrics, Medical University of South Carolina, Charleston SC
| | - Shahryar Chowdhury
- Department of Pediatrics, Medical University of South Carolina, Charleston SC
| | - James Cnota
- Division of Pediatric Cardiology, Cincinnati Children's Hospital and Medical Center, Cincinnati OH
| | - Jon Detterich
- Department of Pediatrics, Children's Hospital of Los Angeles, Los Angeles, CA
| | - Michele Frommelt
- Department of Pediatrics, Children's University of Pennsylvania Hospital of Wisconsin, Milwaukee WI
| | | | - Thomas A Miller
- Maine Medical Center, Portland, ME; University of Utah, Salt Lake City, UT
| | - Richard G Ohye
- Department of Cardiac Surgery, University of Michigan, Ann Arbor,MI
| | | | - Amee Shah
- Department of Pediatrics, Columbia University Medical Center, New York, NY
| | | | - Jane W Newburger
- Department of Pediatric Cardiology, Boston Children's Hospital, Boston MA
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20
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Ortinau CM, Smyser CD, Arthur L, Gordon EE, Heydarian HC, Wolovits J, Nedrelow J, Marino BS, Levy VY. Optimizing Neurodevelopmental Outcomes in Neonates With Congenital Heart Disease. Pediatrics 2022; 150:e2022056415L. [PMID: 36317967 PMCID: PMC10435013 DOI: 10.1542/peds.2022-056415l] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 08/29/2022] [Indexed: 11/05/2022] Open
Abstract
Neurodevelopmental impairment is a common and important long-term morbidity among infants with congenital heart disease (CHD). More than half of those with complex CHD will demonstrate some form of neurodevelopmental, neurocognitive, and/or psychosocial dysfunction requiring specialized care and impacting long-term quality of life. Preventing brain injury and treating long-term neurologic sequelae in this high-risk clinical population is imperative for improving neurodevelopmental and psychosocial outcomes. Thus, cardiac neurodevelopmental care is now at the forefront of clinical and research efforts. Initial research primarily focused on neurocritical care and operative strategies to mitigate brain injury. As the field has evolved, investigations have shifted to understanding the prenatal, genetic, and environmental contributions to impaired neurodevelopment. This article summarizes the recent literature detailing the brain abnormalities affecting neurodevelopment in children with CHD, the impact of genetics on neurodevelopmental outcomes, and the best practices for neonatal neurocritical care, focusing on developmental care and parental support as new areas of importance. A framework is also provided for the infrastructure and resources needed to support CHD families across the continuum of care settings.
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Affiliation(s)
- Cynthia M. Ortinau
- Department of Pediatrics, Washington University in St. Louis, St. Louis, Missouri
| | - Christopher D. Smyser
- Department of Pediatrics, Washington University in St. Louis, St. Louis, Missouri
- Department of Neurology, Washington University in St. Louis, St. Louis, Missouri
- Mallinckrodt Institute of Radiology, Washington University in St. Louis, St. Louis, Missouri
| | - Lindsay Arthur
- Department of Pediatrics, University of Arkansas for Medical Sciences, Little Rock, Arkansas
| | - Erin E. Gordon
- Department of Pediatrics, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Haleh C. Heydarian
- Department of Pediatrics, University of Cincinnati College of Medicine, Division of Cardiology, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio
| | - Joshua Wolovits
- Department of Pediatrics, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Jonathan Nedrelow
- Department of Neonatology, Cook Children’s Medical Center, Fort Worth, Texas
| | - Bradley S. Marino
- Department of Pediatrics, Northwestern University Feinberg School of Medicine, Divisions of Cardiology and Critical Care Medicine, Ann & Robert H. Lurie Children’s Hospital of Chicago
| | - Victor Y. Levy
- Department of Pediatrics, Stanford University School of Medicine, Lucile Packard Children’s Hospital, Palo Alto, California
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21
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Pfitzer C, Sievers LK, Hütter A, Khaliq HA, Poryo M, Berger F, Bauer UMM, Helm PC, Schmitt KRL. Microcephaly is associated with impaired educational development in children with congenital heart disease. Front Cardiovasc Med 2022; 9:917507. [PMID: 36277771 PMCID: PMC9584804 DOI: 10.3389/fcvm.2022.917507] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2022] [Accepted: 09/02/2022] [Indexed: 11/13/2022] Open
Abstract
Objectives This study aims to evaluate the school careers of patients with congenital heart disease (CHD) and microcephaly. Methods An exploratory online survey was conducted on patients from a previous study on somatic development in children with CHD in 2018 (n = 2818). A total of 750 patients participated in the online survey (26.6%). This publication focuses on 91 patients (12.1%) diagnosed with CHD and microcephaly who participated in the new online survey. Results Microcephaly was significantly associated with CHD severity (p < 0.001). Microcephalic patients suffered from psychiatric comorbidity two times as often (67.0%) as non-microcephalic patients (29.8%). In particular, the percentage of patients with developmental delay, intellectual debility, social disability, learning disorder, or language disorder was significantly increased in microcephalic CHD patients (p < 0.001). A total of 85.7% of microcephalic patients and 47.6% of non-microcephalic patients received early interventions to foster their development. The school enrollment of both groups was similar at approximately six years of age. However, 89.9% of non-microcephalic but only 51.6% of microcephalic patients were enrolled in a regular elementary school. Regarding secondary school, only half as many microcephalic patients (14.3%) went to grammar school, while the proportion of pupils at special schools was eight times higher. Supportive interventions, e.g., for specific learning disabilities, were used by 52.7% of microcephalic patients and 21.6% of non-microcephalic patients. Conclusion Patients with CHD and microcephaly are at high risk for impaired educational development. Early identification should alert clinicians to provide targeted interventions to optimize the developmental potential.
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Affiliation(s)
- Constanze Pfitzer
- Department of Congenital Heart Disease/Pediatric Cardiology, Deutsches Herzzentrum Berlin, Berlin, Germany,Berlin Institute of Health (BIH), Berlin, Germany,DZHK (German Centre for Cardiovascular Research), Partner Site Berlin, Berlin, Germany
| | - Laura K. Sievers
- Department of Internal Medicine I., Christian-Albrechts-University and University Hospital Schleswig-Holstein, Kiel, Germany,*Correspondence: Laura K. Sievers
| | - Alina Hütter
- Department of Congenital Heart Disease/Pediatric Cardiology, Deutsches Herzzentrum Berlin, Berlin, Germany
| | - Hashim-Abdul Khaliq
- Department of Pediatric Cardiology, Saarland University Medical Center, Homburg, Germany
| | - Martin Poryo
- Department of Pediatric Cardiology, Saarland University Medical Center, Homburg, Germany
| | - Felix Berger
- Department of Congenital Heart Disease/Pediatric Cardiology, Deutsches Herzzentrum Berlin, Berlin, Germany,DZHK (German Centre for Cardiovascular Research), Partner Site Berlin, Berlin, Germany,Department of Pediatric Cardiology, Charite – Universitaetsmedizin Berlin, Berlin, Germany
| | - Ulrike M. M. Bauer
- National Register for Congenital Heart Defects, Berlin, Germany,Competence Network for Congenital Heart Defects, Berlin, Germany
| | - Paul C. Helm
- National Register for Congenital Heart Defects, Berlin, Germany,Competence Network for Congenital Heart Defects, Berlin, Germany
| | - Katharina R. L. Schmitt
- Department of Congenital Heart Disease/Pediatric Cardiology, Deutsches Herzzentrum Berlin, Berlin, Germany,DZHK (German Centre for Cardiovascular Research), Partner Site Berlin, Berlin, Germany
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22
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Baldini L, Librandi K, D’Eusebio C, Lezo A. Nutritional Management of Patients with Fontan Circulation: A Potential for Improved Outcomes from Birth to Adulthood. Nutrients 2022; 14:nu14194055. [PMID: 36235705 PMCID: PMC9572747 DOI: 10.3390/nu14194055] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2022] [Revised: 09/23/2022] [Accepted: 09/24/2022] [Indexed: 11/30/2022] Open
Abstract
Fontan circulation (FC) is a surgically achieved palliation state offered to patients affected by a wide variety of congenital heart defects (CHDs) that are grouped under the name of univentricular heart. The procedure includes three different surgical stages. Malnutrition is a matter of concern in any phase of life for these children, often leading to longer hospital stays, higher mortality rates, and a higher risk of adverse neurodevelopmental and growth outcomes. Notwithstanding the relevance of proper nutrition for this subset of patients, specific guidelines on the matter are lacking. In this review, we aim to analyze the role of an adequate form of nutritional support in patients with FC throughout the different stages of their lives, in order to provide a practical approach to appropriate nutritional management. Firstly, the burden of faltering growth in patients with univentricular heart is analyzed, focusing on the pathogenesis of malnutrition, its detection and evaluation. Secondly, we summarize the nutritional issues of each life phase of a Fontan patient from birth to adulthood. Finally, we highlight the challenges of nutritional management in patients with failing Fontan.
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Affiliation(s)
- Letizia Baldini
- Postgraduate School of Pediatrics, University of Turin, 10126 Turin, Italy
- Pediatria Specialistica, Ospedale Infantile Regina Margherita, Piazza Polonia 94, 10126 Torino, Italy
- Correspondence:
| | - Katia Librandi
- Postgraduate School of Pediatrics, University of Turin, 10126 Turin, Italy
| | - Chiara D’Eusebio
- Dietetic and Clinical Nutrition Unit, Pediatric Hospital Regina Margherita, University of Turin, 10126 Turin, Italy
| | - Antonella Lezo
- Dietetic and Clinical Nutrition Unit, Pediatric Hospital Regina Margherita, University of Turin, 10126 Turin, Italy
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23
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Ntiloudi D, Rammos S, Giannakoulas G. Growth failure in patients with hypoplastic left heart syndrome: An ongoing challenge. Int J Cardiol 2022; 364:50-51. [PMID: 35690152 DOI: 10.1016/j.ijcard.2022.06.011] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/25/2022] [Accepted: 06/07/2022] [Indexed: 11/05/2022]
Affiliation(s)
- Despoina Ntiloudi
- Department of Cardiology, Tzaneio General Hospital of Piraeus, Piraeus, Greece
| | - Spyridon Rammos
- Department of Pediatric Cardiology and Adult Congenital Heart Disease, "Onassis" Cardiac Surgery Center, Athens, Greece
| | - George Giannakoulas
- First Department of Cardiology, AHEPA University Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece.
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24
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Assessing the Association Between Pre-operative Feeding and the Development of Oral Feeding Skills in Infants with Single Ventricle Heart Disease: An Analysis of the NPC-QIC Dataset. Pediatr Cardiol 2022; 43:1141-1155. [PMID: 35157095 DOI: 10.1007/s00246-022-02837-9] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/01/2021] [Accepted: 01/28/2022] [Indexed: 01/26/2023]
Abstract
Pre-operative feeding may improve long-term feeding outcomes in single ventricle patients, including weaning from supplemental tube feedings in infancy. This study examines the association between pre-operative enteral feeding and subsequent long-term feeding outcomes while also assessing the counterbalancing risk of necrotizing enterocolitis (NEC). Secondary analysis of the National Pediatric Cardiology Quality Improvement Collaborative database was performed. The association between pre-operative feeding practice and achieving all oral feeds through the first year of life was examined using a multivariable regression model. Similarly, the association between pre-operative oral feeding and NEC was also assessed. Of 944 patients with 1-year feeding outcomes available, 58% were fed preoperatively (41.3% exclusively oral) and 12.3% were not fed per institutional approach. At hospital discharge after Stage 1 palliation, 57% required a feeding tube, while 39% required a feeding tube at their first birthday. In infants who were orally fed, the odds ratio to achieving tube-free feeding at 1 year was not significantly increased (1.3, confidence interval 0.8-2.0). Of 1740 infants with pre-operative feeding and Stage 1 there was no statistically significant difference in NEC among patients who were preoperatively fed versus those that were not fed per institutional approach (p = 0.2). Pre-operative feeding of infants with single ventricle heart disease was not associated with early achievement of tube-free feeding in the first year of life. However, pre-operative oral feeding was also not associated with increased risk of NEC, suggesting that it can be safely offered among appropriate patients.
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25
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Gardner MM, Faerber J, Glatz AC, Preminger TJ, Avitabile CM, Shankar S, Shustak RJ, Weber DR, Schachtner S, Ravishankar C, Goldberg DJ. Relationship Between Serum Brain-Type Natriuretic Peptide and Biomarkers of Growth in Infants With Shunt-Dependent Single Cardiac Ventricle. Am J Cardiol 2022; 171:146-150. [PMID: 35287945 DOI: 10.1016/j.amjcard.2022.01.052] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/19/2021] [Revised: 01/20/2022] [Accepted: 01/25/2022] [Indexed: 11/24/2022]
Abstract
For infants with shunt-dependent or ductal-dependent single ventricle heart disease, poor growth is common and associated with morbidity and impaired neurodevelopmental outcomes. Although attention has focused on nutrition to promote weight gain, little is known about the relation between heart failure and growth factors. A prospective observational pilot study was performed to assess the relation between heart failure, assessed by brain natriuretic peptide (BNP), and growth factors (insulin-like growth factor 1 [IGF-1] and insulin-like growth factor-binding protein 3) at 3 visits: (1) before discharge from neonatal intervention with the establishment of stable pulmonary blood flow, (2) immediately before superior cavopulmonary connection, and (3) before discharge after superior cavopulmonary connection operation. The relation between BNP and growth factors was analyzed using Spearman pairwise correlations at each visit and modeled over time with a linear mixed-effects model. Correlations were considered worthy of further exploration using a p <0.10, given the exploratory nature of the study. The study included 38 infants (66% male, 68% hypoplastic left heart syndrome). Median BNP was elevated at visit 1 and decreased over time (287 pg/dl [interquartile range 147 to 794], 85 pg/dl [52 to 183], and 90 pg/dl [70 to 138]). Median IGF-1 Z score was <0 at each visit but increased over time (-0.9 [interquartile range -1.1 to 0.1], -0.7 [-1.2 to 0.1], and -0.5 [-1.2 to 0]). Inverse correlations were found between BNP and IGF-1 at visit 1 (r = -0.40, p = 0.097), BNP and IGF-1 and insulin-like growth factor-binding protein 3 at visit 2 (r = -0.33, p = 0.080 and r = -0.33, p = 0.085, respectively) and BNP and IGF-1 Z score at visit 3 (r = -0.42, p = 0.049). Significant relations were likewise found between the change in BNP and the change in IGF-1 between visits 1 and 3 (p = 0.046) and between visits 2 and 3 (p = 0.048). In conclusion, this pilot study demonstrates an inverse correlation between BNP and growth factors, suggesting that the heart failure state associated with this physiology may play a mechanistic role in impaired growth.
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Selvanathan T, Smith JM, Miller SP, Field TS. Neurodevelopment and cognition across the lifespan in patients with single ventricle physiology: Abnormal brain maturation and accumulation of brain injuries. Can J Cardiol 2022; 38:977-987. [DOI: 10.1016/j.cjca.2022.02.009] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2021] [Revised: 01/19/2022] [Accepted: 02/01/2022] [Indexed: 02/08/2023] Open
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Holcomb RM, Ündar A. Are outcomes in congenital cardiac surgery better than ever? J Card Surg 2022; 37:656-663. [PMID: 35023592 DOI: 10.1111/jocs.16225] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2021] [Accepted: 12/06/2021] [Indexed: 11/27/2022]
Abstract
BACKGROUND AND AIM OF THE STUDY Congenital heart disease is the most common congenital defect among infants born in the United States. Within the first year of life, 1 in 4 of these infants will need surgery. Only one generation removed from an overall mortality of 14%, many changes have been introduced into the field. Have these changes measurably improved outcomes? METHODS The literature search was conducted through PubMed MEDLINE and Google Scholar from inception to October 31, 2021. Ultimately, 78 publications were chosen for inclusion. RESULTS The outcome of overall mortality has experienced continuous improvements in the modern era of the specialty despite the performance of more technically demanding surgeries on patients with complex comorbidities. This modality does not account for case-mix, however. In turn, clinical outcomes have not been consistent from center to center. Furthermore, variation in practice between institutions has also been documented. A recurring theme in the literature is a movement toward standardization and universalization. Examples include mortality risk-stratification that has allowed direct comparison of outcomes between programs and improved definitions of morbidities which provide an enhanced framework for diagnosis and management. CONCLUSIONS Overall mortality is now below 3%, which suggests that more patients are surviving their interventions than in any previous era in congenital cardiac surgery. Focus has transitioned from survival to improving the quality of life in the survivors by decreasing the incidence of morbidity and associated long-term effects. With the transformation toward standardization and interinstitutional collaboration, future advancements are expected.
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Affiliation(s)
- Ryan M Holcomb
- Penn State Hershey Pediatric Cardiovascular Research Center, Departments of Pediatrics, Penn State College of Medicine, Penn State Health Children's Hospital, Hershey, Pennsylvania, USA.,Surgery, Penn State College of Medicine, Penn State Health Children's Hospital, Hershey, Pennsylvania, USA
| | - Akif Ündar
- Penn State Hershey Pediatric Cardiovascular Research Center, Departments of Pediatrics, Penn State College of Medicine, Penn State Health Children's Hospital, Hershey, Pennsylvania, USA.,Biomedical Engineering, Penn State College of Medicine, Penn State Health Children's Hospital, Hershey, Pennsylvania, USA
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28
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Calderon J, Newburger JW, Rollins CK. Neurodevelopmental and Mental Health Outcomes in Patients With Fontan Circulation: A State-of-the-Art Review. Front Pediatr 2022; 10:826349. [PMID: 35356444 PMCID: PMC8959547 DOI: 10.3389/fped.2022.826349] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/30/2021] [Accepted: 02/14/2022] [Indexed: 11/13/2022] Open
Abstract
Children, adolescents and adults living with Fontan circulation face numerous neurological and developmental challenges. As the population with complex CHD increases thanks to outstanding improvement in medical and surgical care, the long-term developmental and mental health sequelae have become a public health priority in pediatric and congenital cardiology. Many patients with a Fontan circulation experience difficulty in areas of cognition related to attention and executive functioning, visual spatial reasoning and psychosocial development. They are also at high risk for mental health morbidities, particularly anxiety disorders and depression. Several hemodynamic risk factors, beginning during the fetal period, may influence outcomes and yield to abnormal brain growth and development. Brain injury such as white matter lesions, stroke or hemorrhage can occur before, during, or after surgery. Other sociodemographic and surgical risk factors such as multiple catheterizations and surgeries and prolonged hospital stay play a detrimental role in patients' neurodevelopmental prognosis. Prevention and intervention to optimize long-term outcomes are critical in the care of this vulnerable population with complex CHD.
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Affiliation(s)
- Johanna Calderon
- PhyMedExp, Université de Montpellier, National Institute of Health and Medical Research (INSERM), CNRS, Montpellier, France.,Department of Psychiatry, Harvard Medical School, Boston, MA, United States
| | - Jane W Newburger
- Department of Cardiology, Boston Children's Hospital, Boston, MA, United States.,Department of Pediatrics, Harvard Medical School, Boston, MA, United States
| | - Caitlin K Rollins
- Department of Neurology, Boston Children's Hospital, Boston, MA, United States.,Department of Neurology, Harvard Medical School, Boston, MA, United States
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29
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Ligsay A, Goldberg CS. An introduction to and review of cardiac neurodevelopment: the risks and recommended approaches. Curr Opin Pediatr 2021; 33:489-494. [PMID: 34433192 DOI: 10.1097/mop.0000000000001057] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
PURPOSE OF REVIEW To introduce the reader to the current understanding of the neurocognitive profile of congenital heart disease (CHD) survivors, the risk factors that may influence outcomes, and to the recommendations for cardiac neurodevelopmental care. RECENT FINDINGS A growing body of literature has shown that survivors of CHD are at increased risk for neurodevelopmental impairments. Multiple elements influence each patient's risk, which likely begins in utero and extends to perioperative management, surgical considerations, and long-term clinical care. Additionally, sociodemographic factors may compound these risks. Serial developmental follow-up is recommended for children with critical CHD. SUMMARY Though there are some clinical factors that increase risk, based on the high rate of developmental impairments for children with CHD, serial evaluations are recommended. Multidisciplinary and multicenter collaboration is ongoing and will facilitate moving this field forward to improve neurodevelopmental outcomes for children with CHD.
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Affiliation(s)
- Andrew Ligsay
- Division of Cardiology, Department of Pediatrics, C.S. Mott Children's Hospital, University of Michigan, Ann Arbor, Michigan, USA
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30
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Harris KC, Mackie AS, Dallaire F, Khoury M, Singer J, Mahle WT, Klassen TP, McCrindle BW. Unique Challenges of Randomised Controlled Trials in Pediatric Cardiology. Can J Cardiol 2021; 37:1394-1403. [PMID: 34186112 DOI: 10.1016/j.cjca.2021.06.013] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2021] [Revised: 06/18/2021] [Accepted: 06/20/2021] [Indexed: 02/07/2023] Open
Abstract
Pediatric cardiology has evolved over time with reductions in childhood mortality due to congenital heart disease. Surgical innovation drove early changes in care. Increasingly, the need for more robust evidence provided by randomised controlled trials (RCTs) has been recognised. Although the number of RCTs has increased, there remains a relative paucity of truly impactful trials in the field. However, those trials that have changed practice have demonstrated the potential and importance of this work. Examples include the PRIMACORP trial, which established the safety and efficacy of milrinone after cardiac surgery, and the Single Ventricle Reconstruction trial, which was the first multicentre pediatric cardiac surgical RCT. The successful conduct and important findings emanating from these trials serve as beacons as clinicians strive to improve the evidence base in this field. The establishment of national and international networks such as the Pediatric Heart Network and the Canadian Pediatric Cardiology Research Network provide a strong foundation for future collaborative work. Despite this progress, there remain important challenges to designing and executing RCTs in pediatric cardiology. These include issues of greater disease and patient heterogeneity and increased costs. The use of innovative study designs and analytic methods and the establishment of core outcome measures have the potential to overcome some of the issues related to the smaller patient numbers compared with adult disciplines. As pediatric cardiologists look to the future, it is imperative that we work together to derive the maximum benefit from the considerable efforts directed toward conducting impactful clinical trials in pediatric cardiology.
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Affiliation(s)
- Kevin C Harris
- Children's Heart Centre, British Columbia Children's Hospital &-University of British Columbia, Vancouver, British Columbia, Canada.
| | - Andrew S Mackie
- Division of Pediatric Cardiology, Department of Pediatrics Stollery Children's Hospital. University of Alberta, Edmonton, Alberta, Canada
| | - Frederic Dallaire
- Division of Pediatric Cardiology, Department of Pediatrics, Sherbrooke University, Sherbrooke, Québec, Canada
| | - Michael Khoury
- Division of Pediatric Cardiology, Department of Pediatrics Stollery Children's Hospital. University of Alberta, Edmonton, Alberta, Canada
| | - Joel Singer
- School of Population and Public Health, University of British Columbia, Vancouver, British Columbia, Canada
| | - William T Mahle
- Division of Pediatric Cardiology, Emory University, Atlanta, Georgia, USA
| | - Terry P Klassen
- Children's Hospital Research Institute of Manitoba and Department of Pediatrics, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Brian W McCrindle
- Labatt Family Heart Centre, Hospital for Sick Children and University of Toronto, Toronto, Ontario, Canada
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31
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Sanz JH, Anixt J, Bear L, Basken A, Beca J, Marino BS, Mussatto KA, Nembhard WN, Sadhwani A, Sananes R, Shekerdemian LS, Sood E, Uzark K, Willen E, Ilardi D. Characterisation of neurodevelopmental and psychological outcomes in CHD: a research agenda and recommendations from the cardiac neurodevelopmental outcome collaborative. Cardiol Young 2021; 31:876-887. [PMID: 34082845 PMCID: PMC8429101 DOI: 10.1017/s1047951121002146] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
The Neurodevelopmental and Psychological Outcomes Working Group of the Cardiac Neurodevelopmental Outcome Collaborative was formed in 2018 through support from an R13 grant from the National Heart, Lung, and Blood Institute with the goals of identifying knowledge gaps regarding the neurodevelopmental and psychological outcomes of individuals with CHD and investigations needed to advance science, policy, clinical care, and patient/family outcomes. Accurate characterisation of neurodevelopmental and psychological outcomes in children with CHD will drive improvements in patient and family outcomes through targeted intervention. Decades of research have produced a generalised perspective about neurodevelopmental and psychological outcomes in this heterogeneous population. Future investigations need to shift towards improving methods, measurement, and analyses of outcomes to better inform early identification, prevention, and intervention. Improved definition of underlying developmental, neuropsychological, and social-emotional constructs is needed, with an emphasis on symptom networks and dimensions. Identification of clinically meaningful outcomes that are most important to key stakeholders, including patients, families, schools and providers, is essential, specifically how and which neurodevelopmental differences across the developmental trajectory impact stakeholders. A better understanding of the discontinuity and patterns of neurodevelopment across the lifespan is critical as well, with some areas being more impactful at some ages than others. Finally, the field needs to account for the impact of race/ethnicity, socio-economic status, cultural and linguistic diversity on our measurement, interpretation of data, and approach to intervention and how to improve generalisability to the larger worldwide population of patients and families living with CHD.
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Affiliation(s)
- Jacqueline H. Sanz
- Division of Neuropsychology, Children’s National Hospital, Departments of Psychiatry and Behavioral Sciences & Pediatrics, George Washington University School of Medicine, Washington, DC, USA
| | - Julia Anixt
- Division of Developmental and Behavioral Pediatrics, Cincinnati Children’s Hospital Medical Center and Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
| | - Laurel Bear
- Department of Pediatrics, Medical College of Wisconsin, Herma Heart Institute, Children’s Wisconsin, Milwaukee, Wisconsin, USA
| | | | - John Beca
- Department of Intensive Care, Starship Children’s Health, Auckland, New Zealand
| | - Bradley S. Marino
- Department of Pediatric Cardiology, Cleveland Clinic Children’s Hospital, Cleveland, Ohio, USA
| | | | - Wendy N. Nembhard
- Department of Epidemiology and the Arkansas Birth Defects Center for Research and Prevention, Fay W Boozman College of Public Health, University of Arkansas for Medical Sciences, Little Rock, Arkansas, USA
| | - Anjali Sadhwani
- Department of Psychiatry, Boston Children’s Hospital & Department of Psychiatry, Harvard Medical School, Boston, Massachusetts, USA
| | - Renee Sananes
- Division of Cardiology, Department of Psychology, The Hospital for Sick Children, Department of Pediatrics, The University of Toronto, Toronto, Canada
| | - Lara S. Shekerdemian
- Department of Pediatrics, Section of Critical Care, Baylor College of Medicine, Houston, TX, USA
| | - Erica Sood
- Nemours Cardiac Center, Alfred I. duPont Hospital for Children, Wilmington, DE & Department of Pediatrics, Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Karen Uzark
- Department of Pediatrics, Section of Pediatric Cardiology, University of Michigan C.S. Mott Children’s Hospital, Ann Arbor, Michigan, USA
| | - Elizabeth Willen
- Division of Developmental and Behavioral Sciences and the Ward Family Heart Center, Children’s Mercy, Kansas City, University of Missouri-Kansas City School of Medicine, Kansas City, Missouri, USA
| | - Dawn Ilardi
- Department of Neuropsychology, Children’s Healthcare of Atlanta, Emory University, Atlanta, GA, USA
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32
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Zyblewski SC, Martin RH, Shipes VB, Hamlin-Smith K, Atz AM, Bradley SM, Kavarana MN, Mahle WT, Everett AD, Graham EM. Intraoperative methylprednisolone and neurodevelopmental outcomes in infants after cardiac surgery. Ann Thorac Surg 2021; 113:2079-2084. [PMID: 33864754 DOI: 10.1016/j.athoracsur.2021.04.006] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/18/2020] [Revised: 03/03/2021] [Accepted: 04/05/2021] [Indexed: 11/15/2022]
Abstract
BACKGROUND Neurodevelopmental impairment is a significant consequence for survivors of surgery for critical congenital heart disease. This study sought to determine if intraoperative methylprednisolone during neonatal cardiac surgery is associated with neurodevelopmental outcomes at 12 months of age and to identify early prognostic variables associated with neurodevelopmental outcomes. METHODS A planned secondary analysis of a two-center, double-blind, randomized, placebo-controlled trial of intraoperative methylprednisolone in neonates undergoing cardiac surgery was performed. A brain injury biomarker was measured perioperatively. Bayley Scales of Infant and Toddler Development-III (BSID-III) were performed at 12 months of age. Two sample t-tests and generalized linear models were used. RESULTS There were 129 participants (n=61 methylprednisolone, n=68 placebo). There were no significant differences in BSID-III scores and brain injury biomarker levels between the two treatment groups. Participants who underwent a palliative (vs. corrective) procedure had lower mean BSID-III cognitive (101+15 vs. 106+14, p=0.03) and motor scores (85+18 vs. 94+16, p<0.01). Longer ventilation time was associated with lower motor scores. Longer cardiac intensive care unit (CICU) stay was associated with lower cognitive, language, and motor scores. Cardiopulmonary bypass time, aortic cross clamp time, and deep hypothermic circulatory arrest were not associated with BSID-III scores. CONCLUSIONS Neurodevelopmental outcomes were not associated with intraoperative methylprednisolone or intraoperative variables. Participants who underwent a neonatal palliative (vs. corrective) procedure had longer CICU stays and worse neurodevelopmental outcomes at 1 year. This work suggests that interventions focused solely on the operative period may not be associated with a long-term neurodevelopmental benefit.
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Affiliation(s)
- Sinai C Zyblewski
- Department of Pediatrics, Medical University of South Carolina, Charleston, SC.
| | - Reneé H Martin
- Department of Public Health Sciences, Medical University of South Carolina, Charleston, SC
| | - Virginia B Shipes
- Department of Public Health Sciences, Medical University of South Carolina, Charleston, SC
| | - Kasey Hamlin-Smith
- Department of Pediatrics, Medical University of South Carolina, Charleston, SC
| | - Andrew M Atz
- Department of Pediatrics, Medical University of South Carolina, Charleston, SC
| | - Scott M Bradley
- Section of Pediatric Cardiac Surgery, Medical University of South Carolina, Charleston, SC
| | - Minoo N Kavarana
- Section of Pediatric Cardiac Surgery, Medical University of South Carolina, Charleston, SC
| | - William T Mahle
- Department of Pediatrics, Children's Healthcare of Atlanta and Emory University, Atlanta, GA
| | - Allen D Everett
- Department of Pediatrics, The Johns Hopkins University, Baltimore, MD
| | - Eric M Graham
- Department of Pediatrics, Medical University of South Carolina, Charleston, SC
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33
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Asschenfeldt B, Evald L, Yun HJ, Heiberg J, Østergaard L, Grant PE, Hjortdal VE, Im K, Eskildsen SF. Abnormal Left-Hemispheric Sulcal Patterns in Adults With Simple Congenital Heart Defects Repaired in Childhood. J Am Heart Assoc 2021; 10:e018580. [PMID: 33745293 PMCID: PMC8174332 DOI: 10.1161/jaha.120.018580] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
Abstract
Background Children operated on for a simple congenital heart defect (CHD) are at risk of neurodevelopmental abnormalities. Abnormal cortical development and folding have been observed in fetuses with CHD. We examined whether sulcal folding patterns in adults operated on for simple CHD in childhood differ from those of healthy controls, and whether such differences are associated with neuropsychological outcomes. Methods and Results Patients (mean age, 24.5 years) who underwent childhood surgery for isolated atrial septal defect (ASD; n=33) or ventricular septal defect (VSD; n=30) and healthy controls (n=37) were enrolled. Sulcal pattern similarity to healthy controls was determined using magnetic resonance imaging and looking at features of sulcal folds, their intersulcal relationships, and sulcal graph topology. The sulcal pattern similarity values were tested for associations with comprehensive neuropsychological scores. Patients with both ASD and VSD had decreased sulcal pattern similarity in the left hemisphere compared with controls. The differences were found in the left temporal lobe in the ASD group and in the whole left hemisphere in the VSD group (P=0.033 and P=0.039, respectively). The extent of abnormal left hemispheric sulcal pattern similarity was associated with worse neuropsychological scores (intelligence, executive function, and visuospatial abilities) in the VSD group, and special educational support in the ASD group. Conclusions Adults who underwent surgery for simple CHD in childhood display altered left hemisphere sulcal folding patterns, commensurate with neuropsychological scores for patients with VSD and special educational support for ASD. This may indicate that simple CHD affects early brain development. Registration URL: https://www.clinicaltrials.gov; Unique identifier: NCT03871881.
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Affiliation(s)
- Benjamin Asschenfeldt
- Department of Cardiothoracic and Vascular Surgery Aarhus University Hospital Aarhus N Denmark.,Department of Clinical Medicine Aarhus University Aarhus N Denmark
| | - Lars Evald
- Department of Clinical Medicine Aarhus University Aarhus N Denmark.,Hammel Neurorehabilitation Centre and University Research Clinic Hammel Denmark
| | - Hyuk Jin Yun
- Fetal Neonatal Neuroimaging and Developmental Science Center Boston Children's Hospital Boston MA.,Division of Newborn Medicine Boston Children's Hospital Boston MA.,Harvard Medical School Boston MA
| | - Johan Heiberg
- Department of Cardiothoracic and Vascular Surgery Aarhus University Hospital Aarhus N Denmark.,Department of Clinical Medicine Aarhus University Aarhus N Denmark
| | - Leif Østergaard
- Department of Clinical Medicine Aarhus University Aarhus N Denmark.,Center of Functionally Integrative Neuroscience Aarhus University Aarhus C Denmark
| | - P Ellen Grant
- Fetal Neonatal Neuroimaging and Developmental Science Center Boston Children's Hospital Boston MA.,Division of Newborn Medicine Boston Children's Hospital Boston MA.,Department of Radiology Boston Children's Hospital Boston MA.,Harvard Medical School Boston MA
| | - Vibeke Elisabeth Hjortdal
- Department of Clinical Medicine Aarhus University Aarhus N Denmark.,Department of Cardiothoracic Surgery RigshospitaletCopenhagen Denmark.,Institute of Clinical Medicine University of Copenhagen Copenhagen Denmark
| | - Kiho Im
- Fetal Neonatal Neuroimaging and Developmental Science Center Boston Children's Hospital Boston MA.,Division of Newborn Medicine Boston Children's Hospital Boston MA.,Harvard Medical School Boston MA
| | - Simon Fristed Eskildsen
- Department of Clinical Medicine Aarhus University Aarhus N Denmark.,Center of Functionally Integrative Neuroscience Aarhus University Aarhus C Denmark
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Lisanti AJ, Demianczyk AC, Vaughan K, Martino GF, Ohrenschall RS, Quinn R, Chittams JL, Medoff-Cooper B. Parental role alteration strongly influences depressive symptoms in mothers of preoperative infants with congenital heart disease. Heart Lung 2021; 50:235-241. [PMID: 33340826 PMCID: PMC7969439 DOI: 10.1016/j.hrtlng.2020.12.003] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2020] [Revised: 12/02/2020] [Accepted: 12/03/2020] [Indexed: 10/22/2022]
Abstract
BACKGROUND Mothers of infants with congenital heart disease are at risk for depression. OBJECTIVES This study explored the influence on maternal depressive symptoms of several known factors for mothers in the pediatric cardiac intensive care unit, including perceived stressors, attachment, and anxiety. METHODS This study was a secondary analysis of 30 mothers of infants awaiting cardiac surgery. Linear regressions were calculated to determine the relationships between perceived stressors, maternal attachment, anxiety, and maternal depressive symptoms. RESULTS Nearly half of mothers reported depressive symptoms above the measure cut-off score, indicating they were at risk for likely clinical depression. Subscales of perceived stress explained 61.7% of the variance in depressive symptoms (F = 11.815, p<0.0001) with parental role alteration subscale as the strongest predictor (standardized beta=0.694, p = 0.03). CONCLUSIONS Findings underscore the importance of mental health screening and instituting nursing practices to enhance parental role for mothers of infants awaiting cardiac surgery.
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Affiliation(s)
- Amy J Lisanti
- Nursing and Clinical Care Services, Children's Hospital of Philadelphia, 3401 Civic Center Blvd, Philadelphia, PA 19104, United States of America; University of Pennsylvania School of Nursing, 418 Curie Blvd, Philadelphia, PA 19104, United States of America.
| | - Abigail C Demianczyk
- Department of Child and Adolescent Psychiatry and Behavioral Sciences, Children's Hospital of Philadelphia, 3401 Civic Center Blvd, Philadelphia, PA 19104, United States of America.
| | - Kayla Vaughan
- Nursing and Clinical Care Services, Children's Hospital of Philadelphia, 3401 Civic Center Blvd, Philadelphia, PA 19104, United States of America.
| | - Giordana Fraser Martino
- Nursing and Clinical Care Services, Children's Hospital of Philadelphia, 3401 Civic Center Blvd, Philadelphia, PA 19104, United States of America.
| | - Rachel Schaake Ohrenschall
- Nursing and Clinical Care Services, Children's Hospital of Philadelphia, 3401 Civic Center Blvd, Philadelphia, PA 19104, United States of America.
| | - Ryan Quinn
- University of Pennsylvania School of Nursing, 418 Curie Blvd, Philadelphia, PA 19104, United States of America.
| | - Jesse L Chittams
- University of Pennsylvania School of Nursing, 418 Curie Blvd, Philadelphia, PA 19104, United States of America.
| | - Barbara Medoff-Cooper
- University of Pennsylvania School of Nursing, 418 Curie Blvd, Philadelphia, PA 19104, United States of America; Research Institute, Children's Hospital of Philadelphia, 3401 Civic Center Blvd, Philadelphia, PA 19104, United States of America.
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35
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Sananes R, Goldberg CS, Newburger JW, Hu C, Trachtenberg F, Gaynor JW, Mahle WT, Miller T, Uzark K, Mussatto KA, Pizarro C, Jacobs JP, Cnota J, Atz AM, Lai WW, Burns KM, Milazzo A, Votava-Smith J, Brosig CL. Six-Year Neurodevelopmental Outcomes for Children With Single-Ventricle Physiology. Pediatrics 2021; 147:peds.2020-014589. [PMID: 33441486 PMCID: PMC7849196 DOI: 10.1542/peds.2020-014589] [Citation(s) in RCA: 23] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 10/27/2020] [Indexed: 11/24/2022] Open
Abstract
OBJECTIVES To determine if neurodevelopmental deficits in children with single-ventricle physiology change with age and early developmental scores predict 6-year outcomes. METHODS In the Single Ventricle Reconstruction Trial, Bayley Scales of Infant Development, Second Edition, were administered at 14 months of age, and parents completed the Behavior Assessment System for Children, Second Edition (BASC-2) annually from the ages of 2 to 6 years. Scores were classified as average, at risk, or impaired. We calculated sensitivities, specificities, and positive and negative predictive values of earlier tests on 6-year outcomes. RESULTS Of 291 eligible participants, 244 (84%) completed the BASC-2 at 6 years; more Single Ventricle Reconstruction participants than expected on the basis of normative data scored at risk or impaired on the BASC-2 Adaptive Skills Index at that evaluation (28.7% vs 15.9%; P < .001). Children with Adaptive Skills Composite scores <2 SD below the mean at the age of 6 were more likely to have had delayed development at 14 months, particularly on the Psychomotor Development Index (sensitivity of 79%). However, the positive predictive value of the 14-month Mental Development Index and Psychomotor Development Index for 6-year BASC-2 Adaptive Scores was low (44% and 36%, respectively). Adaptive Skills Composite score impairments at the age of 6 were poorly predicted by using earlier BASC-2 assessments, with low sensitivities at the ages of 3 (37%), 4 (48%), and 5 years (55%). CONCLUSIONS Many children with hypoplastic left heart syndrome who have low adaptive skills at the age of 6 years will not be identified by screening at earlier ages. With our findings, we highlight the importance of serial evaluations for children with critical congenital heart disease throughout development.
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Affiliation(s)
- Renee Sananes
- Department of Pediatrics and Labatt Family Heart Centre, Hospital for Sick Children, University of Toronto, Toronto, Canada;
| | - Caren S. Goldberg
- Department of Pediatrics, Michigan Medicine, Medical School, University of Michigan, Ann Arbor, Michigan
| | - Jane W. Newburger
- Department of Cardiology, Boston Children’s Hospital and Department of Pediatrics, Harvard Medical School, Harvard University, Boston, Massachusetts
| | - Chenwei Hu
- New England Research Institutes, Watertown, Massachusetts
| | | | - J. William Gaynor
- Division of Pediatric Cardiothoracic Surgery, Children’s Hospital of Philadelphia, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - William T. Mahle
- Department of Pediatrics, Children’s Healthcare of Atlanta, Emory University, Atlanta, Georgia
| | - Thomas Miller
- Department of Pediatrics, Primary Children’s Hospital, University of Utah, Salt Lake City, Utah;,Division of Pediatric Cardiology, Maine Medical Center, Portland, Maine
| | - Karen Uzark
- Department of Pediatrics, Michigan Medicine, Medical School, University of Michigan, Ann Arbor, Michigan
| | | | - Christian Pizarro
- Department of Surgery, Nemours Cardiac Center, Alfred I du Pont Hospital for Children, Wilmington, Delaware
| | | | - James Cnota
- Department of Pediatrics, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio
| | - Andrew M. Atz
- Department of Pediatrics, Medical University of South Carolina, Charleston, South Carolina
| | - Wyman W. Lai
- Children’s Heart Institute, Children’s Hospital of Orange County, Orange, California
| | | | - Angelo Milazzo
- Department of Pediatrics, School of Medicine, Duke University, Durham, North Carolina;,Department of Pediatrics, East Carolina University, Greenville, North Carolina;,Department of Pediatrics, Wake Forest University, Winston-Salem, North Carolina; and
| | - Jodie Votava-Smith
- Department of Pediatrics, Children’s Hospital Los Angeles, Los Angeles, California
| | - Cheryl L. Brosig
- Pediatrics, Herma Heart Institute, Children’s Wisconsin and Medical College of Wisconsin, Milwaukee, Wisconsin
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Is Neurodevelopment Related to Exercise Capacity in Single Ventricle Patients Who Have Undergone Fontan Palliation? Pediatr Cardiol 2021; 42:408-416. [PMID: 33190162 DOI: 10.1007/s00246-020-02497-7] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/03/2020] [Accepted: 11/07/2020] [Indexed: 10/23/2022]
Abstract
Survivors of palliative surgery for single ventricle heart disease (SVHD) are at risk of poor neurodevelopmental outcomes and reduced exercise capacity. In healthy populations, reduced exercise capacity is related to decreased cognition suggesting a possible relationship between exercise capacity and neurodevelopment. Using cardiopulmonary exercise testing (CPET) and neuropsychological testing (NPT) as indicators of exercise capacity and neurodevelopment, respectively, we hypothesized that in SVHD, higher CPET measures are related to better NPT performance. Patients were retrospectively identified. CPET variables included VO2max, anaerobic threshold, peak heart rate, ventilatory efficiency, and respiratory exchange ratio. NPT instruments were divided into domains measuring attention, executive functioning, adaptive functioning, and emotional functioning. Linear regression was used to test for associations between CPET and NPT. 23 subjects with SVHD met inclusion criteria. On both CPET and NPT, the cohort scored worse than healthy, age-matched subjects. Higher VO2max and anaerobic threshold were associated with better parent-rated overall adaptive functioning (p = 0.01 and p = 0.02, respectively). Higher peak heart rate was related to better sustained visual attention (p = 0.01). In SVHD, CPET measures indicating better exercise capacity were positively associated with a subset of scores on NPT. Larger, multisite studies implementing cardiorespiratory fitness intervention and incorporating cognitive outcome measures will be needed to better characterize the relationship between neurodevelopment and functional capacity in this population. Results may assist in providing anticipatory guidance and optimizing post-Fontan developmental trajectories.
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37
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Bucholz EM, Sleeper LA, Sananes R, Brosig CL, Goldberg CS, Pasquali SK, Newburger JW. Trajectories in Neurodevelopmental, Health-Related Quality of Life, and Functional Status Outcomes by Socioeconomic Status and Maternal Education in Children with Single Ventricle Heart Disease. J Pediatr 2021; 229:289-293.e3. [PMID: 33031800 PMCID: PMC7855010 DOI: 10.1016/j.jpeds.2020.09.066] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/28/2020] [Revised: 09/22/2020] [Accepted: 09/24/2020] [Indexed: 11/18/2022]
Abstract
Trajectories of neurodevelopment and quality of life were analyzed in children with hypoplastic left heart syndrome according to socioeconomic status (SES) and maternal education. Lower SES and less maternal education were associated with greater early delays in communication and problem-solving and progressive delays in problem-solving and fine motor skills over time.
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Affiliation(s)
- Emily M Bucholz
- Department of Cardiology, Boston Children's Hospital, Boston, MA; Department of Pediatrics, Harvard Medical School, Boston, MA
| | - Lynn A Sleeper
- Department of Cardiology, Boston Children's Hospital, Boston, MA; Department of Pediatrics, Harvard Medical School, Boston, MA
| | - Renee Sananes
- Department of Psychology, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Cheryl L Brosig
- Department of Pediatrics, Medical College of Wisconsin and Herma Heart Institute, Children's Wisconsin, Milwaukee, WI
| | - Caren S Goldberg
- Department of Pediatrics, University of Michigan CS Mott Children's Hospital, Ann Arbor, MI
| | - Sara K Pasquali
- Department of Pediatrics, University of Michigan CS Mott Children's Hospital, Ann Arbor, MI
| | - Jane W Newburger
- Department of Cardiology, Boston Children's Hospital, Boston, MA; Department of Pediatrics, Harvard Medical School, Boston, MA.
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Huisenga D, La Bastide‐Van Gemert S, Van Bergen A, Sweeney J, Hadders‐Algra M. Developmental outcomes after early surgery for complex congenital heart disease: a systematic review and meta-analysis. Dev Med Child Neurol 2021; 63:29-46. [PMID: 32149404 PMCID: PMC7754445 DOI: 10.1111/dmcn.14512] [Citation(s) in RCA: 54] [Impact Index Per Article: 18.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 01/30/2020] [Indexed: 01/25/2023]
Abstract
AIM (1) To systematically review the literature on developmental outcomes from infancy to adolescence of children with complex congenital heart disease (CHD) who underwent early surgery; (2) to run a meta-regression analysis on the Bayley Scales of Infant Development, Second Edition Mental Developmental Index and Psychomotor Developmental Index (PDI) of infants up to 24 months and IQs of preschool-aged children to adolescents; (3) to assess associations between perioperative risk factors and outcomes. METHOD We searched pertinent literature (January 1990 to January 2019) in PubMed, Embase, CINAHL, and PsycINFO. Selection criteria included infants with complex CHD who had primary surgery within the first 9 weeks of life. Methodological quality, including risk of bias and internal validity, were assessed. RESULTS In total, 185 papers met the inclusion criteria; the 100 with high to moderate methodological quality were analysed in detail. Substantial heterogeneity in the group with CHD and in methodology existed. The outcome of infants with single-ventricle CHD was inferior to those with two-ventricle CHD (respectively: average scores for PDI 77 and 88; intelligence scores 92 and 98). Perioperative risk factors were inconsistently associated with developmental outcomes. INTERPRETATION The literature on children undergoing surgery in early infancy suggests that infants with a single ventricle are at highest risk of adverse developmental outcomes.
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Affiliation(s)
- Darlene Huisenga
- Department of Pediatric Rehabilitation and DevelopmentAdvocate Children’s HospitalOak LawnILUSA,University of GroningenUniversity Medical Center GroningenDepartment of PaediatricsDivision of Developmental NeurologyGroningenthe Netherlands
| | - Sacha La Bastide‐Van Gemert
- University of GroningenUniversity Medical Center GroningenDepartment of EpidemiologyGroningenthe Netherlands
| | - Andrew Van Bergen
- Department of Pediatric Rehabilitation and DevelopmentAdvocate Children’s HospitalOak LawnILUSA,Advocate Children’s Heart Institute Division of Pediatric Cardiac Critical CareAdvocate Children’s HospitalOak LawnILUSA
| | - Jane Sweeney
- Pediatric Science Doctoral ProgramRocky Mountain University of Health ProfessionsProvoUTUSA
| | - Mijna Hadders‐Algra
- University of GroningenUniversity Medical Center GroningenDepartment of PaediatricsDivision of Developmental NeurologyGroningenthe Netherlands
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Wolfe KR, Liptzin DR, Brigham D, Kelly SL, Rafferty C, Albertz M, Younoszai AK, Di Maria MV. Relationships between Physiologic and Neuropsychologic Functioning after Fontan. J Pediatr 2020; 227:239-246. [PMID: 32687915 DOI: 10.1016/j.jpeds.2020.07.043] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/27/2020] [Revised: 06/12/2020] [Accepted: 07/14/2020] [Indexed: 11/18/2022]
Abstract
OBJECTIVE To investigate potential relationships between neuropsychologic functioning and cardiac, gastroenterologic/hepatologic, and pulmonary complications in the single ventricle heart disease (SVHD) post-Fontan population. STUDY DESIGN Following the initiation of a Fontan Multidisciplinary Clinic, patients with SVHD were evaluated systematically according to a clinical care pathway, and data from multiple subspecialty evaluations were collected prospectively from 2016 to 2019. Biomarkers of cardiology, pulmonary, and hepatology/gastroenterology functioning were abstracted, along with neuropsychologic testing results. Bivariate correlations and regression analyses examined cross-sectional relationships between physiologic predictors and neuropsychologic outcomes. RESULTS The sample included a cohort of 68 youth with SVHD age 3-19 years, after Fontan palliation. Sleep-disordered breathing was related to poorer visual-motor integration skills (r = -0.33; P < .05) and marginally related to poorer executive functioning (r = -0.33; P = .05). Lower arterial blood oxygen content was related to poorer executive functioning (r = .45; P < .05). Greater atrioventricular valve regurgitation was related to lower parent-rated adaptive functioning (ρ = -0.34; P < .01). These results were maintained in regression analyses controlling for history of stroke and/or seizures. CONCLUSIONS We demonstrated associations between neuropsychologic functioning and potentially modifiable aspects of physiologic functioning in a prospectively evaluated cohort of patients with SVHD with Fontan physiology. Our findings emphasize the importance of multidisciplinary screening and care after a Fontan procedure and suggest avenues for intervention that may improve patient outcomes and quality of life.
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Affiliation(s)
- Kelly R Wolfe
- Section of Neurology, Department of Pediatrics, University of Colorado School of Medicine, Aurora, CO.
| | - Deborah R Liptzin
- Section of Pulmonology, Department of Pediatrics, University of Colorado School of Medicine, Aurora, CO
| | - Dania Brigham
- Section of Gastroenterology, Department of Pediatrics, University of Colorado School of Medicine, Aurora, CO
| | - Sarah L Kelly
- Section of Cardiology, Department of Pediatrics, University of Colorado School of Medicine, Aurora, CO
| | - Carey Rafferty
- Section of Cardiology, Department of Pediatrics, University of Colorado School of Medicine, Aurora, CO
| | - Megan Albertz
- Section of Anesthesiology, University of Colorado School of Medicine, Aurora, CO
| | - Adel K Younoszai
- Section of Cardiology, Department of Pediatrics, University of Colorado School of Medicine, Aurora, CO
| | - Michael V Di Maria
- Section of Cardiology, Department of Pediatrics, University of Colorado School of Medicine, Aurora, CO
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The origins and development of the cardiac neurodevelopment outcome collaborative: creating innovative clinical, quality improvement, and research opportunities. Cardiol Young 2020; 30:1597-1602. [PMID: 33269669 DOI: 10.1017/s1047951120003510] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Compared to the general population, individuals with complex congenital heart disease are at increased risk for deficits in cognitive, neurodevelopmental, psychosocial, and physical functioning, resulting in a diminished health-related quality of life. These deficits have been well described over the past 25 years, but significant gaps remain in our understanding of the best practices to improve neurodevelopmental and psychosocial outcomes and health-related quality of life for individuals with paediatric and congenital heart disease. Innovative clinical, quality improvement, and research opportunities with collaboration across multiple disciplines and institutions were needed to address these gaps. The Cardiac Neurodevelopmental Outcome Collaborative was founded in 2016 with a described mission to determine and implement best practices of neurodevelopmental and psychosocial services for individuals and their families with paediatric and congenital heart disease through clinical, quality improvement, and research initiatives. The vision is to be a multi-centre, multi-national, multi-disciplinary group of healthcare professionals committed to working together and partnering with families to optimise neurodevelopmental outcomes for individuals with paediatric and congenital heart disease through clinical, quality, and research initiatives, intending to maximise quality of life for every individual across the lifespan. This manuscript describes the development and organisation of the Cardiac Neurodevelopmental Outcome Collaborative.
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Abstract
Over the last two decades, heart centres have developed strategies to meet the neurodevelopmental needs of children with congenital heart disease. Since the publication of guidelines in 2012, cardiac neurodevelopmental follow-up programmes have become more widespread. Local neurodevelopmental programmes, however, have been developed independently in widely varying environments. We sought to characterise variation in structure and personnel in cardiac neurodevelopmental programmes. A 31-item survey was sent to all member institutions of the Cardiac Neurodevelopmental Outcome Collaborative. Multidisciplinary teams at each centre completed the survey. Responses were compiled in a descriptive fashion. Of the 29 invited centres, 23 responded to the survey (79%). Centres reported more anticipated neurodevelopment visits between birth and 5 years of age (median 5, range 2-8) than 5-18 years (median 2, range 0-10) with 53% of centres lacking any standard for routine neurodevelopment evaluations after 5 years of age. Estimated annual neurodevelopment clinic volume ranged from 85 to 428 visits with a median of 16% of visits involving children >5 years of age. Among responding centres, the Bayley Scales of Infant and Toddler Development and Wechsler Preschool and Primary Scale of Intelligence were the most routinely used tests. Neonatal clinical assessment was more common (64%) than routine neonatal brain imaging (23%) during hospitalisation. In response to clinical need and published guidelines, centres have established formal cardiac neurodevelopment follow-up programmes. Centres vary considerably in their approaches to routine screening and objective testing, with many centres currently focussing their resources on evaluating younger patients.
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42
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Bucholz EM, Sleeper LA, Goldberg CS, Pasquali SK, Anderson BR, Gaynor JW, Cnota JF, Newburger JW. Socioeconomic Status and Long-term Outcomes in Single Ventricle Heart Disease. Pediatrics 2020; 146:peds.2020-1240. [PMID: 32973120 PMCID: PMC7546087 DOI: 10.1542/peds.2020-1240] [Citation(s) in RCA: 40] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 07/27/2020] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND Low socioeconomic status (SES) has emerged as an important risk factor for higher short-term mortality and neurodevelopmental outcomes in children with hypoplastic left heart syndrome and related anomalies; yet little is known about how SES affects these outcomes over the long-term. METHODS We linked data from the Single Ventricle Reconstruction trial to US Census Bureau data to analyze the relationship of neighborhood SES tertiles with mortality and transplantation, neurodevelopment, quality of life, and functional status at 5 and 6 years post-Norwood procedure (N = 525). Cox proportional hazards regression and linear regression were used to assess the association of SES with mortality and neurodevelopmental outcomes, respectively. RESULTS Patients in the lowest SES tertile were more likely to be racial minorities, older at stage 2 and Fontan procedures, and to have more complications and fewer cardiac catheterizations over follow-up (all P < .05) compared with patients in higher SES tertiles. Unadjusted mortality was highest for patients in the lowest SES tertile and lowest in the highest tertile (41% vs 29%, respectively; log-rank P = .027). Adjustment for patient birth and Norwood factors attenuated these differences slightly (P = .055). Patients in the lowest SES tertile reported lower functional status and lower fine motor, problem-solving, adaptive behavior, and communication skills at 6 years (all P < .05). These differences persisted after adjustment for baseline and post-Norwood factors. Quality of life did not differ by SES. CONCLUSIONS Among patients with hypoplastic left heart syndrome, those with low SES have worse neurodevelopmental and functional status outcomes at 6 years. These differences were not explained by other patient or clinical characteristics.
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Affiliation(s)
- Emily M. Bucholz
- Department of Cardiology, Boston Children’s Hospital, Boston, Massachusetts;,Department of Pediatrics, Harvard Medical School, Harvard University, Boston, Massachusetts
| | - Lynn A. Sleeper
- Department of Cardiology, Boston Children’s Hospital, Boston, Massachusetts;,Department of Pediatrics, Harvard Medical School, Harvard University, Boston, Massachusetts
| | - Caren S. Goldberg
- Department of Pediatrics, University of Michigan and C.S. Mott Children’s Hospital, Ann Arbor, Michigan
| | - Sara K. Pasquali
- Department of Pediatrics, University of Michigan and C.S. Mott Children’s Hospital, Ann Arbor, Michigan
| | - Brett R. Anderson
- Division of Pediatric Cardiology, Department of Pediatrics, Columbia University Irving Medical Center and NewYork-Presbyterian Morgan Stanley Children’s Hospital, New York City, New York
| | - J. William Gaynor
- Division of Pediatric Cardiac Surgery, Cardiac Center, Children’s Hospital of Pennsylvania, Philadelphia, Pennsylvania; and
| | - James F. Cnota
- Department of Cardiology, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio
| | - Jane W. Newburger
- Department of Cardiology, Boston Children’s Hospital, Boston, Massachusetts;,Department of Pediatrics, Harvard Medical School, Harvard University, Boston, Massachusetts
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43
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Ortinau CM, Rollins CK, Gholipour A, Yun HJ, Marshall M, Gagoski B, Afacan O, Friedman K, Tworetzky W, Warfield SK, Newburger JW, Inder TE, Grant PE, Im K. Early-Emerging Sulcal Patterns Are Atypical in Fetuses with Congenital Heart Disease. Cereb Cortex 2020; 29:3605-3616. [PMID: 30272144 DOI: 10.1093/cercor/bhy235] [Citation(s) in RCA: 35] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2018] [Revised: 08/28/2018] [Indexed: 12/30/2022] Open
Abstract
Fetuses with congenital heart disease (CHD) have third trimester alterations in cortical development on brain magnetic resonance imaging (MRI). However, the intersulcal relationships contributing to global sulcal pattern remain unknown. This study applied a novel method for examining the geometric and topological relationships between sulci to fetal brain MRIs from 21-30 gestational weeks in CHD fetuses (n = 19) and typically developing (TD) fetuses (n = 17). Sulcal pattern similarity index (SI) to template fetal brain MRIs was determined for the position, area, and depth for corresponding sulcal basins and intersulcal relationships for each subject. CHD fetuses demonstrated altered global sulcal patterns in the left hemisphere compared with TD fetuses (TD [SI, mean ± SD]: 0.822 ± 0.023, CHD: 0.795 ± 0.030, P = 0.002). These differences were present in the earliest emerging sulci and were driven by differences in the position of corresponding sulcal basins (TD: 0.897 ± 0.024, CHD: 0.878 ± 0.019, P = 0.006) and intersulcal relationships (TD: 0.876 ± 0.031, CHD: 0.857 ± 0.018, P = 0.033). No differences in cortical gyrification index, mean curvature, or surface area were present. These data suggest our methods may be more sensitive than traditional measures for evaluating cortical developmental alterations early in gestation.
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Affiliation(s)
- Cynthia M Ortinau
- Department of Pediatrics, Washington University in St. Louis, St. Louis, MO, USA.,Department of Pediatric Newborn Medicine, Brigham and Women's Hospital, Boston, MA, USA
| | - Caitlin K Rollins
- Department of Neurology, Boston Children's Hospital, Boston, MA, USA.,Department of Neurology, Harvard Medical School, Boston, MA, USA
| | - Ali Gholipour
- Department of Radiology, Boston Children's Hospital, Boston, MA, USA.,Department of Radiology, Harvard Medical School, Boston, MA, USA
| | - Hyuk Jin Yun
- Fetal Neonatal Neuroimaging and Developmental Science Center, Boston Children's Hospital, Boston, MA, USA.,Department of Pediatrics, Harvard Medical School, Boston, MA, USA.,Division of Newborn Medicine, Boston Children's Hospital Boston, MA, USA
| | - Mackenzie Marshall
- Fetal Neonatal Neuroimaging and Developmental Science Center, Boston Children's Hospital, Boston, MA, USA
| | - Borjan Gagoski
- Department of Radiology, Boston Children's Hospital, Boston, MA, USA.,Department of Radiology, Harvard Medical School, Boston, MA, USA.,Fetal Neonatal Neuroimaging and Developmental Science Center, Boston Children's Hospital, Boston, MA, USA
| | - Onur Afacan
- Department of Radiology, Boston Children's Hospital, Boston, MA, USA.,Department of Radiology, Harvard Medical School, Boston, MA, USA
| | - Kevin Friedman
- Department of Pediatrics, Harvard Medical School, Boston, MA, USA.,Department of Cardiology, Boston Children's Hospital Boston, MA, USA
| | - Wayne Tworetzky
- Department of Pediatrics, Harvard Medical School, Boston, MA, USA.,Department of Cardiology, Boston Children's Hospital Boston, MA, USA
| | - Simon K Warfield
- Department of Radiology, Boston Children's Hospital, Boston, MA, USA.,Department of Radiology, Harvard Medical School, Boston, MA, USA
| | - Jane W Newburger
- Department of Pediatrics, Harvard Medical School, Boston, MA, USA.,Department of Cardiology, Boston Children's Hospital Boston, MA, USA
| | - Terrie E Inder
- Department of Pediatric Newborn Medicine, Brigham and Women's Hospital, Boston, MA, USA.,Department of Pediatrics, Harvard Medical School, Boston, MA, USA
| | - P Ellen Grant
- Department of Radiology, Boston Children's Hospital, Boston, MA, USA.,Department of Radiology, Harvard Medical School, Boston, MA, USA.,Fetal Neonatal Neuroimaging and Developmental Science Center, Boston Children's Hospital, Boston, MA, USA.,Division of Newborn Medicine, Boston Children's Hospital Boston, MA, USA
| | - Kiho Im
- Fetal Neonatal Neuroimaging and Developmental Science Center, Boston Children's Hospital, Boston, MA, USA.,Department of Pediatrics, Harvard Medical School, Boston, MA, USA.,Division of Newborn Medicine, Boston Children's Hospital Boston, MA, USA
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Brown KL, Pagel C, Ridout D, Wray J, Tsang VT, Anderson D, Banks V, Barron DJ, Cassidy J, Chigaru L, Davis P, Franklin R, Grieco L, Hoskote A, Hudson E, Jones A, Kakat S, Lakhani R, Lakhanpaul M, McLean A, Morris S, Rajagopal V, Rodrigues W, Sheehan K, Stoica S, Tibby S, Utley M, Witter T. Early morbidities following paediatric cardiac surgery: a mixed-methods study. HEALTH SERVICES AND DELIVERY RESEARCH 2020. [DOI: 10.3310/hsdr08300] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023] Open
Abstract
Background
Over 5000 paediatric cardiac surgeries are performed in the UK each year and early survival has improved to > 98%.
Objectives
We aimed to identify the surgical morbidities that present the greatest burden for patients and health services and to develop and pilot routine monitoring and feedback.
Design and setting
Our multidisciplinary mixed-methods study took place over 52 months across five UK paediatric cardiac surgery centres.
Participants
The participants were children aged < 17 years.
Methods
We reviewed existing literature, ran three focus groups and undertook a family online discussion forum moderated by the Children’s Heart Federation. A multidisciplinary group, with patient and carer involvement, then ranked and selected nine key morbidities informed by clinical views on definitions and feasibility of routine monitoring. We validated a new, nurse-administered early warning tool for assessing preoperative and postoperative child development, called the brief developmental assessment, by testing this among 1200 children. We measured morbidity incidence in 3090 consecutive surgical admissions over 21 months and explored risk factors for morbidity. We measured the impact of morbidities on quality of life, clinical burden and costs to the NHS and families over 6 months in 666 children, 340 (51%) of whom had at least one morbidity. We developed and piloted methods suitable for routine monitoring of morbidity by centres and co-developed new patient information about morbidities with parents and user groups.
Results
Families and clinicians prioritised overlapping but also different morbidities, leading to a final list of acute neurological event, unplanned reoperation, feeding problems, renal replacement therapy, major adverse events, extracorporeal life support, necrotising enterocolitis, surgical infection and prolonged pleural effusion. The brief developmental assessment was valid in children aged between 4 months and 5 years, but not in the youngest babies or 5- to 17-year-olds. A total of 2415 (78.2%) procedures had no measured morbidity. There was a higher risk of morbidity in neonates, complex congenital heart disease, increased preoperative severity of illness and with prolonged bypass. Patients with any morbidity had a 6-month survival of 81.5% compared with 99.1% with no morbidity. Patients with any morbidity scored 5.2 points lower on their total quality of life score at 6 weeks, but this difference had narrowed by 6 months. Morbidity led to fewer days at home by 6 months and higher costs. Extracorporeal life support patients had the lowest days at home (median: 43 days out of 183 days) and highest costs (£71,051 higher than no morbidity).
Limitations
Monitoring of morbidity is more complex than mortality, and hence this requires resources and clinician buy-in.
Conclusions
Evaluation of postoperative morbidity provides important information over and above 30-day survival and should become the focus of audit and quality improvement.
Future work
National audit of morbidities has been initiated. Further research is needed to understand the implications of feeding problems and renal failure and to evaluate the brief developmental assessment.
Funding
This project was funded by the NIHR Health Services and Delivery Research programme and will be published in full in Health Services and Delivery Research; Vol. 8, No. 30. See the NIHR Journals Library website for further project information.
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Affiliation(s)
- Katherine L Brown
- Heart and Lung Division, Great Ormond Street Hospital NHS Foundation Trust, London, UK
| | - Christina Pagel
- Clinical Operational Research Unit, University College London, London, UK
| | - Deborah Ridout
- Population, Policy and Practice Programme, UCL Great Ormond Street Institute of Child Health, London, UK
| | - Jo Wray
- Heart and Lung Division, Great Ormond Street Hospital NHS Foundation Trust, London, UK
| | - Victor T Tsang
- Heart and Lung Division, Great Ormond Street Hospital NHS Foundation Trust, London, UK
| | - David Anderson
- Departments of Paediatric Intensive Care, Cardiology and Cardiac Surgery, Evelina London Children’s Hospital, London, UK
| | - Victoria Banks
- Heart and Lung Division, Great Ormond Street Hospital NHS Foundation Trust, London, UK
| | - David J Barron
- Departments of Intensive Care and Paediatric Cardiac Surgery, Birmingham Children’s Hospital, Birmingham, UK
| | - Jane Cassidy
- Departments of Intensive Care and Paediatric Cardiac Surgery, Birmingham Children’s Hospital, Birmingham, UK
| | - Linda Chigaru
- Heart and Lung Division, Great Ormond Street Hospital NHS Foundation Trust, London, UK
| | - Peter Davis
- Departments of Intensive Care and Paediatric Cardiac Surgery, Bristol Royal Hospital for Children, Bristol, UK
| | - Rodney Franklin
- Paediatric Cardiology Department, Royal Brompton and Harefield NHS Foundation Trust, London, UK
| | - Luca Grieco
- Clinical Operational Research Unit, University College London, London, UK
| | - Aparna Hoskote
- Heart and Lung Division, Great Ormond Street Hospital NHS Foundation Trust, London, UK
| | - Emma Hudson
- Department of Applied Health Research, University College London, London, UK
| | - Alison Jones
- Departments of Intensive Care and Paediatric Cardiac Surgery, Birmingham Children’s Hospital, Birmingham, UK
| | - Suzan Kakat
- Heart and Lung Division, Great Ormond Street Hospital NHS Foundation Trust, London, UK
| | - Rhian Lakhani
- Departments of Paediatric Intensive Care, Cardiology and Cardiac Surgery, Evelina London Children’s Hospital, London, UK
| | - Monica Lakhanpaul
- Population, Policy and Practice Programme, UCL Great Ormond Street Institute of Child Health, London, UK
- Community Child Health, UCL Great Ormond Street Institute of Child Health, London, UK
| | - Andrew McLean
- Department of Intensive care, Royal Hospital for Children, Glasgow, UK
| | - Steve Morris
- Department of Applied Health Research, University College London, London, UK
| | - Veena Rajagopal
- Heart and Lung Division, Great Ormond Street Hospital NHS Foundation Trust, London, UK
| | - Warren Rodrigues
- Department of Intensive care, Royal Hospital for Children, Glasgow, UK
| | - Karen Sheehan
- Departments of Intensive Care and Paediatric Cardiac Surgery, Bristol Royal Hospital for Children, Bristol, UK
| | - Serban Stoica
- Departments of Intensive Care and Paediatric Cardiac Surgery, Bristol Royal Hospital for Children, Bristol, UK
| | - Shane Tibby
- Departments of Paediatric Intensive Care, Cardiology and Cardiac Surgery, Evelina London Children’s Hospital, London, UK
| | - Martin Utley
- Clinical Operational Research Unit, University College London, London, UK
| | - Thomas Witter
- Departments of Paediatric Intensive Care, Cardiology and Cardiac Surgery, Evelina London Children’s Hospital, London, UK
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Ortinau CM, Shimony JS. The Congenital Heart Disease Brain: Prenatal Considerations for Perioperative Neurocritical Care. Pediatr Neurol 2020; 108:23-30. [PMID: 32107137 PMCID: PMC7306416 DOI: 10.1016/j.pediatrneurol.2020.01.002] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/25/2019] [Revised: 12/21/2019] [Accepted: 01/05/2020] [Indexed: 12/17/2022]
Abstract
Altered brain development has been highlighted as an important contributor to adverse neurodevelopmental outcomes in children with congenital heart disease. Abnormalities begin prenatally and include micro- and macrostructural disturbances that lead to an altered trajectory of brain growth throughout gestation. Recent progress in fetal imaging has improved understanding of the neurobiological mechanisms and risk factors for impaired fetal brain development. The impact of the prenatal environment on postnatal neurological care has also gained increased focus. This review summarizes current data on the timing and pattern of altered prenatal brain development in congenital heart disease, the potential mechanisms of these abnormalities, and the association with perioperative neurological complications.
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Affiliation(s)
- Cynthia M Ortinau
- Department of Pediatrics, Washington University in St. Louis, St. Louis, Missouri.
| | - Joshua S Shimony
- Mallinkrodt Institute of Radiology, Washington University in St. Louis, St. Louis, Missouri
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46
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A Collaborative Learning Assessment of Developmental Care Practices for Infants in the Cardiac Intensive Care Unit. J Pediatr 2020; 220:93-100. [PMID: 32147219 PMCID: PMC7186140 DOI: 10.1016/j.jpeds.2020.01.043] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/05/2019] [Revised: 01/12/2020] [Accepted: 01/15/2020] [Indexed: 12/25/2022]
Abstract
OBJECTIVE Assess differences in approaches to and provision of developmental care for infants undergoing surgery for congenital heart disease. STUDY DESIGN A collaborative learning approach was used to stratify, assess, and compare individualized developmental care practices among multidisciplinary teams at 6 pediatric heart centers. Round robin site visits were completed with structured site visit goals and postvisit reporting. Practices of the hosting site were assessed by the visiting team and reviewed along with center self-assessments across specific domains including pain management, environment, cue-based care, and family based care coordination. RESULTS Developmental care for infants in the cardiac intensive care unit (CICU) varies at both a center and individual level. Differences in care are primarily driven by variations in infrastructure and resources, composition of multidisciplinary teams, education of team members, and use of developmental care champions. Management of pain follows a protocol in most cardiac intensive care units, but the environment varies across centers, and the provision of cue-based infant care and family-based care coordination varies widely both within and across centers. The project led to proposed changes in clinical care and center infrastructure at each participating site. CONCLUSIONS A collaborative learning design fostered rapid dissemination, comparison, and sharing of strategies to approach a complex multidisciplinary care paradigm. Our assessment of experiences revealed marked variability across and within centers. The collaborative findings were a first step toward strategies to quantify and measure developmental care practices in the cardiac intensive care unit to assess the association of complex inpatient practices with long-term neurodevelopmental outcomes.
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Marshall KH, D'Udekem Y, Sholler GF, Opotowsky AR, Costa DSJ, Sharpe L, Celermajer DS, Winlaw DS, Newburger JW, Kasparian NA. Health-Related Quality of Life in Children, Adolescents, and Adults With a Fontan Circulation: A Meta-Analysis. J Am Heart Assoc 2020; 9:e014172. [PMID: 32172648 PMCID: PMC7335513 DOI: 10.1161/jaha.119.014172] [Citation(s) in RCA: 36] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background People with a Fontan circulation experience a range of physical, psychosocial and neurodevelopmental challenges alongside, or caused by, their cardiac condition, with significant consequences for health‐related quality of life (HRQOL). We meta‐analyzed HRQOL outcomes reported by people with a Fontan circulation or their proxies and evaluated predictors of poorer HRQOL. Methods and Results Six electronic databases were searched for peer‐reviewed, English‐language articles published before March 2019. Standardized mean differences (SMD) were calculated using fixed and random‐effects models. Fifty articles reporting on 29 unique studies capturing HRQOL outcomes for 2793 people with a Fontan circulation and 1437 parent‐proxies were analyzed. HRQOL was lower in individuals with a Fontan circulation compared with healthy referents or normative samples (SMD, −0.92; 95% CI, −1.36 to −0.48; P<0.001). Lower scores were reported across all HRQOL domains, with the largest differences found for physical (SMD, −0.90; 95% CI, −1.13 to −0.67; P<0.001) and school/work functioning (SMD, −0.71; 95% CI, −0.90 to −0.52; P<0.001). Meta‐regression analyses found no significant predictors of self‐reported physical functioning, but older age at Fontan operation was associated with poorer emotional functioning (β=−0.124; P=0.004), and diagnosis of hypoplastic left heart was associated with poorer social functioning (β=−0.007; P=0.048). Sensitivity analyses showed use of the PedsQL Core Module was associated with lower HRQOL scores compared with the Short‐Form Health Survey‐36. Conclusions HRQOL outcomes for people with a Fontan circulation are lower than the general population. Optimal care acknowledges the lifelong impact of the Fontan circulation on HRQOL and offers targeted strategies to improve outcomes for this growing population.
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Affiliation(s)
- Kate H Marshall
- Heart Centre for Children The Children's Hospital at Westmead Sydney New South Wales Australia.,Discipline of Paediatrics School of Women's and Children's Health University of New South Wales Medicine The University of New South Wales Sydney New South Wales Australia
| | - Yves D'Udekem
- Heart Research Group Murdoch Children's Research Institute Melbourne Victoria Australia.,Department of Cardiac Surgery The Royal Children's Hospital Melbourne Victoria Australia
| | - Gary F Sholler
- Heart Centre for Children The Children's Hospital at Westmead Sydney New South Wales Australia.,Sydney Medical School The University of Sydney New South Wales Australia
| | - Alexander R Opotowsky
- Department of Pediatrics University of Cincinnati College of Medicine Cincinnati Ohio United States.,Cincinnati Adult Congenital Heart Disease Program Heart Institute Cincinnati Children's Hospital Cincinnati Ohio United States.,Department of Cardiology Boston Children's Hospital Boston Massachusetts United States.,Harvard Medical School Boston Massachusetts United States
| | - Daniel S J Costa
- Sydney Medical School The University of Sydney New South Wales Australia.,Pain Management Research Institute Royal North Shore Hospital Sydney New South Wales Australia
| | - Louise Sharpe
- School of Psychology The University of Sydney New South Wales Australia
| | - David S Celermajer
- Sydney Medical School The University of Sydney New South Wales Australia.,Department of Cardiology Royal Prince Alfred Hospital Sydney New South Wales Australia
| | - David S Winlaw
- Heart Centre for Children The Children's Hospital at Westmead Sydney New South Wales Australia.,Sydney Medical School The University of Sydney New South Wales Australia
| | - Jane W Newburger
- Department of Cardiology Boston Children's Hospital Boston Massachusetts United States.,Harvard Medical School Boston Massachusetts United States
| | - Nadine A Kasparian
- Heart Centre for Children The Children's Hospital at Westmead Sydney New South Wales Australia.,Discipline of Paediatrics School of Women's and Children's Health University of New South Wales Medicine The University of New South Wales Sydney New South Wales Australia.,Department of Pediatrics University of Cincinnati College of Medicine Cincinnati Ohio United States.,Cincinnati Children's Center for Heart Disease and the Developing Mind Heart Institute and Division of Behavioral Medicine & Clinical Psychology Cincinnati Children's Hospital Cincinnati Ohio United States
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Karamlou T, Najm HK. Evolution of care pathways for babies with hypoplastic left heart syndrome: integrating mechanistic and clinical process investigation, standardization, and collaborative study. J Thorac Dis 2020; 12:1174-1183. [PMID: 32274198 PMCID: PMC7139006 DOI: 10.21037/jtd.2019.10.75] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Since initial descriptions of staged palliation for hypoplastic left heart syndrome (HLHS) in the 1980’s, much has been learned about the pathophysiology of the single ventricle circulation. New therapies that leverage systems biology and clinical derivatives have been developed. While in-hospital mortality and morbidity for babies with HLHS have continued to improve, there remains a long (and daresay winding) road ahead to achieve ideal outcomes. Important variation in even these abbreviated in-hospital metrics persists among institutions and currently utilized prediction models explain only a small amount of this variation. Moreover, long-term survival and neurodevelopmental health for patients with HLHS are infrequently reported and remain suboptimal despite improved in-hospital outcomes. This focused review will describe the evolution of national outcomes for HLHS over time and the potential factors motivating improved time-related mortality. Emerging modifiable risk-factors that hold promise in terms of moving the needle for long-term success, including social determinants of health and the delineation of genetic profiles, will be discussed. Specifically, this review will integrate contemporary data based on the first murine HLHS models that suggest a genetically elicited modular phenotype with environmental factors known to impact the initial durability of surgical therapies. A comprehensive approach to the management of HLHS, which leverages both proactive transplantation and hybrid palliation, in addition to traditional Norwood palliation, will be emphasized to extend and match management to the complete spectrum of patient risk-profiles. Finally, we will explore the critical role that national collaboratives and quality reporting initiatives have played in improving outcomes and shifting the focus to more meaningful long-term survival and neurodevelopment.
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Affiliation(s)
- Tara Karamlou
- Division of Pediatric Cardiac Surgery, Cleveland Clinic Heart Vascular Institute, Cleveland, OH, USA
| | - Hani K Najm
- Division of Pediatric Cardiac Surgery, Cleveland Clinic Heart Vascular Institute, Cleveland, OH, USA
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Glotzbach KL, Ward JJ, Marietta J, Eckhauser AW, Winter S, Puchalski MD, Miller TA. The Benefits and Bias in Neurodevelopmental Evaluation for Children with Congenital Heart Disease. Pediatr Cardiol 2020; 41:327-333. [PMID: 31865442 DOI: 10.1007/s00246-019-02260-7] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/06/2019] [Accepted: 12/03/2019] [Indexed: 10/25/2022]
Abstract
Neurodevelopmental (ND) impairment is common in children with congenital heart disease (CHD). While routine ND surveillance and evaluation of high-risk patients has become the standard-of-care, capture rate, barriers to referral, and potential patient benefits remain incompletely understood. Electronic data warehouse records from a single center were reviewed to identify all eligible and evaluated patients between July 2015 and December 2017 based on current guidelines for ND screening in CHD. Diagnoses, referring provider, and payor were considered. Potential benefit of the evaluation was defined as receipt of new diagnosis, referral for additional evaluation, or referral for a new service. Contingencies were assessed with Fisher's exact test. In this retrospective, cohort study, of 3434 children identified as eligible for ND evaluation, 135 were evaluated (4%). Appropriate evaluation was affected by diagnostic bias against coarctation of the aorta (CoArc) and favoring hypoplastic left heart syndrome (HLHS) (1.8 vs. 11.9%, p<0.01). Referrals were disproportionally made by a select group of cardiologists, and the rate of ND appointment non-compliance was higher in self-pay compared to insured patients (78% vs 27%, p<0.01). Potential benefit rate was 70-80% amongst individuals with the three most common diagnoses requiring neonatal surgery (CoArc, transposition of the great arteries, and HLHS). Appropriate ND evaluation in CHD is impacted by diagnosis, provider, and insurance status. Potential benefit of ND evaluation is high regardless of diagnosis. Strategies to improve access to ND evaluations and provider understanding of the at-risk population will likely improve longitudinal ND surveillance and clinical benefit.
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Affiliation(s)
- Kristi L Glotzbach
- Department of Pediatrics, Division of Critical Care Medicine, University of Utah, Salt Lake City, UT, USA.
| | - John J Ward
- University of Utah School of Medicine, Salt Lake City, UT, USA
| | - Jennifer Marietta
- Department of Pediatrics, Division of Cardiology, University of Utah, Salt Lake City, UT, USA
| | - Aaron W Eckhauser
- Department of Surgery, Division of Cardiothoracic Surgery, University of Utah, Salt Lake City, UT, USA
| | - Sarah Winter
- Department of Pediatrics, Division of General Pediatrics, University of Utah, Salt Lake City, UT, USA
| | - Michael D Puchalski
- Department of Pediatrics, Division of Cardiology, University of Utah, Salt Lake City, UT, USA
| | - Thomas A Miller
- Department of Pediatrics, Division of Cardiology, University of Utah, Salt Lake City, UT, USA
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50
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de Lange C. Imaging of complications following Fontan circulation in children - diagnosis and surveillance. Pediatr Radiol 2020; 50:1333-1348. [PMID: 32468285 PMCID: PMC7445207 DOI: 10.1007/s00247-020-04682-5] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/02/2020] [Revised: 03/08/2020] [Accepted: 04/16/2020] [Indexed: 12/27/2022]
Abstract
The Fontan operation is performed for various cardiac lesions with single-ventricle physiology. The survival rate of Fontan patients is increasing for adolescents and young adults, with an expected 30-year survival of >80%. Medical health care providers including specialists in organ systems and pediatric radiologists need to improve their knowledge about the Fontan circulation and the various organ complications to monitor care. In this review the author explains the basic anatomical and functional features of Fontan palliation and gives an overview of the multiple long-term organ complications that might present in the pediatric population. These include decreased physical capacity, ventricular dysfunction, atrioventricular valve regurgitation and arrhythmia, as well as protein-losing enteropathy, plastic bronchitis, growth/bone composition disturbances, renal dysfunction, and the recently recognized and important liver fibrosis (Fontan-associated liver disease). Neuropsychological and behavioral deficits occur frequently. This review focuses on the key role of radiology in making the diagnosis of these complications, monitoring therapy and predicting outcomes in the pediatric age group. The author discusses how and when radiology is important in Fontan patients, as well as how new techniques enabling quantitative measures in imaging with US, MRI and CT are adapted for pediatric use, and how they contribute to urgently needed surveillance strategies.
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Affiliation(s)
- Charlotte de Lange
- Department of Radiology and Clinical Physiology, Queen Silvia Children's Hospital, Rondv.10, S-41516, Gothenburg, Sweden. .,Department of Radiology and Nuclear Medicine, Oslo University Hospital, Oslo, Norway.
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