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Fetcu S, Osawa T, Klawonn F, Schaeffer T, Röhlig C, Staehler H, Di Padua C, Heinisch PP, Piber N, Hager A, Ewert P, Hörer J, Ono M. Longitudinal analysis of systemic ventricular function and atrioventricular valve function after the Norwood procedure. Eur J Cardiothorac Surg 2024; 65:ezae058. [PMID: 38383053 DOI: 10.1093/ejcts/ezae058] [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: 08/14/2023] [Revised: 11/20/2023] [Accepted: 02/20/2024] [Indexed: 02/23/2024] Open
Abstract
OBJECTIVES To evaluate longitudinal systemic ventricular function and atrioventricular valve regurgitation in patients after the neonatal Norwood procedure. METHODS Serial postoperative echocardiographic images before Fontan completion were assessed in neonates who underwent the Norwood procedure between 2001 and 2020. Ventricular function and atrioventricular valve regurgitation were compared between patients with modified Blalock-Taussig shunt and right ventricle to pulmonary artery conduit. RESULTS A total of 335 patients were identified including 273 hypoplastic left heart syndrome and 62 of its variants. Median age at Norwood was 8 (7-12) days. Modified Blalock-Taussig shunt was performed in 171 patients and the right ventricle to pulmonary artery conduit in 164 patients. Longitudinal ventricular function and atrioventricular valve regurgitation were evaluated using a total of 4352 echocardiograms. After the Norwood procedure, ventricular function was initially worse (1-30 days) but thereafter better (30 days to stage II) in the right ventricle to pulmonary artery conduit group (P < 0.001). After stage II, the ventricular function was inferior in the right ventricle to the pulmonary artery conduit group (P < 0.001). Atrioventricular valve regurgitation between the Norwood procedure and stage II was more frequent in the modified Blalock-Taussig shunt group (P < 0.001). After stage II, there was no significant difference in atrioventricular valve regurgitation between the groups (P = 0.171). CONCLUSIONS The effect of shunt type on haemodynamics after the Norwood procedure seems to vary according to the stage of palliation. After the Norwood, the modified Blalock-Taussig shunt is associated with poorer ventricular function and worse atrioventricular valve regurgitation compared to right ventricle to pulmonary artery conduit. Whereas, after stage II, modified Blalock-Taussig shunt is associated with better ventricular function and comparable atrioventricular valve regurgitation, compared to the right ventricle to pulmonary artery conduit.
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Affiliation(s)
- Stefan Fetcu
- Department of Congenital and Pediatric Heart Surgery, German Heart Center Munich, Technische Universität München, Munich, Germany
- Division of Congenital and Pediatric Heart Surgery, University Hospital of Munich, Ludwig-Maximilians-Universität, Munich, Germany
| | - Takuya Osawa
- Department of Congenital and Pediatric Heart Surgery, German Heart Center Munich, Technische Universität München, Munich, Germany
- Division of Congenital and Pediatric Heart Surgery, University Hospital of Munich, Ludwig-Maximilians-Universität, Munich, Germany
| | - Frank Klawonn
- Department of Biostatistics, Helmholtz Center for Infection Research, Braunschweig, Germany
- Department of Computer Science, Ostfalia University, Wolfenbüttel, Germany
| | - Thibault Schaeffer
- Department of Congenital and Pediatric Heart Surgery, German Heart Center Munich, Technische Universität München, Munich, Germany
- Division of Congenital and Pediatric Heart Surgery, University Hospital of Munich, Ludwig-Maximilians-Universität, Munich, Germany
| | - Christoph Röhlig
- Department of Congenital Heart Disease and Pediatric Cardiology, German Heart Center Munich, Technische Universität München, Munich, Germany
| | - Helena Staehler
- Department of Congenital and Pediatric Heart Surgery, German Heart Center Munich, Technische Universität München, Munich, Germany
- Division of Congenital and Pediatric Heart Surgery, University Hospital of Munich, Ludwig-Maximilians-Universität, Munich, Germany
| | - Chiara Di Padua
- Department of Congenital and Pediatric Heart Surgery, German Heart Center Munich, Technische Universität München, Munich, Germany
- Division of Congenital and Pediatric Heart Surgery, University Hospital of Munich, Ludwig-Maximilians-Universität, Munich, Germany
| | - Paul Philipp Heinisch
- Department of Congenital and Pediatric Heart Surgery, German Heart Center Munich, Technische Universität München, Munich, Germany
- Division of Congenital and Pediatric Heart Surgery, University Hospital of Munich, Ludwig-Maximilians-Universität, Munich, Germany
| | - Nicole Piber
- Department of Cardiovascular Surgery, German Heart Center Munich, Technische Universität München, Munich, Germany
| | - Alfred Hager
- Department of Congenital Heart Disease and Pediatric Cardiology, German Heart Center Munich, Technische Universität München, Munich, Germany
| | - Peter Ewert
- Department of Congenital Heart Disease and Pediatric Cardiology, German Heart Center Munich, Technische Universität München, Munich, Germany
| | - Jürgen Hörer
- Department of Congenital and Pediatric Heart Surgery, German Heart Center Munich, Technische Universität München, Munich, Germany
- Division of Congenital and Pediatric Heart Surgery, University Hospital of Munich, Ludwig-Maximilians-Universität, Munich, Germany
| | - Masamichi Ono
- Department of Congenital and Pediatric Heart Surgery, German Heart Center Munich, Technische Universität München, Munich, Germany
- Division of Congenital and Pediatric Heart Surgery, University Hospital of Munich, Ludwig-Maximilians-Universität, Munich, Germany
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DiLorenzo MP, Grosse-Wortmann L. Myocardial Fibrosis in Congenital Heart Disease and the Role of MRI. Radiol Cardiothorac Imaging 2023; 5:e220255. [PMID: 37404787 PMCID: PMC10316299 DOI: 10.1148/ryct.220255] [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: 10/27/2022] [Revised: 04/10/2023] [Accepted: 04/17/2023] [Indexed: 07/06/2023]
Abstract
Progress in the field of congenital heart surgery over the last century can only be described as revolutionary. Recent improvements in patient outcomes have been achieved through refinements in perioperative care. In the current and future eras, the preservation and restoration of myocardial health, beginning with the monitoring of tissue remodeling, will be central to improving cardiac outcomes. Visualization and quantification of fibrotic myocardial remodeling is one of the greatest assets that cardiac MRI brings to the field of cardiology, and its clinical use within the field of congenital heart disease (CHD) has been an area of particular interest in the last few decades. This review summarizes the physical underpinnings of myocardial tissue characterization in CHD, with an emphasis on T1 parametric mapping and late gadolinium enhancement. It describes methods and suggestions for obtaining images, extracting quantitative and qualitative data, and interpreting the results for children and adults with CHD. The tissue characterization observed in different lesions is used to examine the causes and pathomechanisms of fibrotic remodeling in this population. Similarly, the clinical consequences of elevated imaging biomarkers of fibrosis on patient health and outcomes are explored. Keywords: Pediatrics, MR Imaging, Cardiac, Heart, Congenital, Tissue Characterization, Congenital Heart Disease, Cardiac MRI, Parametric Mapping, Fibrosis, Late Gadolinium Enhancement © RSNA, 2023.
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Garcia AM, Toni LS, Miyano CA, Sparagna GC, Jonscher R, Phillips EK, Karimpour-Fard A, Chapman HL, Baybayon-Grandgeorge AN, Pietra AE, Selner E, Chatfield KC, Stauffer BL, Sucharov CC, Miyamoto SD. Cardiac Transcriptome Remodeling and Impaired Bioenergetics in Single-Ventricle Congenital Heart Disease. JACC Basic Transl Sci 2023; 8:258-279. [PMID: 37034285 PMCID: PMC10077120 DOI: 10.1016/j.jacbts.2022.09.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/11/2022] [Revised: 09/28/2022] [Accepted: 09/28/2022] [Indexed: 01/13/2023]
Abstract
The mechanisms responsible for heart failure in single-ventricle congenital heart disease are unknown. Using explanted heart tissue, we showed that failing single-ventricle hearts have dysregulated metabolic pathways, impaired mitochondrial function, decreased activity of carnitine palmitoyltransferase activity, and altered functioning of the tricarboxylic acid cycle. Interestingly, nonfailing single-ventricle hearts demonstrated an intermediate metabolic phenotype suggesting that they are vulnerable to development of heart failure in the future. Mitochondrial targeted therapies and treatments aimed at normalizing energy generation could represent a novel approach to the treatment or prevention of heart failure in this vulnerable group of patients.
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Affiliation(s)
- Anastacia M. Garcia
- Division of Cardiology, Department of Pediatrics, University of Colorado Anschutz Medical Campus, Children’s Hospital Colorado, Aurora, Colorado, USA
| | - Lee S. Toni
- Division of Cardiology, Department of Medicine, University of Colorado Anschutz Medical Campus, Aurora, Colorado, USA
| | - Carissa A. Miyano
- Division of Cardiology, Department of Medicine, University of Colorado Anschutz Medical Campus, Aurora, Colorado, USA
| | - Genevieve C. Sparagna
- Division of Cardiology, Department of Medicine, University of Colorado Anschutz Medical Campus, Aurora, Colorado, USA
| | - Raleigh Jonscher
- Division of Cardiology, Department of Medicine, University of Colorado Anschutz Medical Campus, Aurora, Colorado, USA
| | - Elisabeth K. Phillips
- Division of Cardiology, Department of Medicine, University of Colorado Anschutz Medical Campus, Aurora, Colorado, USA
| | - Anis Karimpour-Fard
- Department of Pharmacology, University of Colorado Anschutz Medical Campus, Aurora, Colorado, USA
| | - Hailey L. Chapman
- Division of Cardiology, Department of Pediatrics, University of Colorado Anschutz Medical Campus, Children’s Hospital Colorado, Aurora, Colorado, USA
| | | | - Ashley E. Pietra
- Division of Cardiology, Department of Pediatrics, University of Colorado Anschutz Medical Campus, Children’s Hospital Colorado, Aurora, Colorado, USA
| | - Emma Selner
- Division of Cardiology, Department of Pediatrics, University of Colorado Anschutz Medical Campus, Children’s Hospital Colorado, Aurora, Colorado, USA
| | - Kathryn C. Chatfield
- Division of Cardiology, Department of Pediatrics, University of Colorado Anschutz Medical Campus, Children’s Hospital Colorado, Aurora, Colorado, USA
| | - Brian L. Stauffer
- Division of Cardiology, Department of Medicine, University of Colorado Anschutz Medical Campus, Aurora, Colorado, USA
- Division of Cardiology, Department of Medicine, Denver Health and Hospital Authority, Denver, Colorado, USA
| | - Carmen C. Sucharov
- Division of Cardiology, Department of Medicine, University of Colorado Anschutz Medical Campus, Aurora, Colorado, USA
| | - Shelley D. Miyamoto
- Division of Cardiology, Department of Pediatrics, University of Colorado Anschutz Medical Campus, Children’s Hospital Colorado, Aurora, Colorado, USA
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O'Byrne ML, McHugh KE, Huang J, Song L, Griffis H, Anderson BR, Bucholz EM, Chanani NK, Elhoff JJ, Handler SS, Jacobs JP, Li JS, Lewis AB, McCrindle BW, Pinto NM, Sassalos P, Spar DS, Pasquali SK, Glatz AC. Cumulative In-Hospital Costs Associated With Single-Ventricle Palliation. JACC. ADVANCES 2022; 1:100029. [PMID: 38939312 PMCID: PMC11198056 DOI: 10.1016/j.jacadv.2022.100029] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/16/2022] [Revised: 04/20/2022] [Accepted: 04/22/2022] [Indexed: 06/29/2024]
Abstract
Background In the SVR (Single Ventricle Reconstruction) Trial, 1-year survival in recipients of right ventricle to pulmonary artery shunts (RVPAS) was superior to that in those receiving modified Blalock-Taussig-Thomas shunts (MBTTS), but not in subsequent follow-up. Cost analysis is an expedient means of evaluating value and morbidity. Objectives The purpose of this study was to evaluate differences in cumulative hospital costs between RVPAS and MBTTS. Methods Clinical data from SVR and costs from Pediatric Health Information Systems database were combined. Cumulative hospital costs and cost-per-day-alive were compared serially at 1, 3, and 5 years between RVPAS and MBTTS. Potential associations between patient-level factors and cost were explored with multivariable models. Results In total, 303 participants (55% of the SVR cohort) from 9 of 15 sites were studied (48% MBTTS). Observed total costs at 1 year were lower for MBTTS ($701,260 ± 442,081) than those for RVPAS ($804,062 ± 615,068), a difference that was not statistically significant (P = 0.10). Total costs were also not significantly different at 3 and 5 years (P = 0.21 and 0.32). Similarly, cost-per-day-alive did not differ significantly for either group at 1, 3, and 5 years (all P > 0.05). In analyses of transplant-free survivors, total costs and cost-per-day-alive were higher for RVPAS at 1 year (P = 0.05 for both) but not at 3 and 5 years (P > 0.05 for all). In multivariable models, aortic atresia and prematurity were associated with increased cost-per-day-alive across follow-up (P < 0.05). Conclusions Total costs do not differ significantly between MBTTS and RVPAS. The magnitude of longitudinal costs underscores the importance of efforts to improve outcomes in this vulnerable population.
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Affiliation(s)
- Michael L. O'Byrne
- Division of Cardiology, The Children's Hospital of Philadelphia and Department of Pediatrics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, USA
- Center for Pediatric Clinical Effectiveness, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
- Leonard Davis Institute of Health Economics and Cardiovascular Outcomes, Quality, and Evaluative Research Center, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Kimberly E. McHugh
- Division of Cardiology, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Jing Huang
- Division of Cardiology, The Children's Hospital of Philadelphia and Department of Pediatrics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, USA
- Department of Biostatistics, Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine, Philadelphia, Pennsylvania, USA
| | - Lihai Song
- Data Science and Biostatistics Unit, Department of Biomedical and Health Informatics, The Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Heather Griffis
- Data Science and Biostatistics Unit, Department of Biomedical and Health Informatics, The Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Brett R. Anderson
- Division of Cardiology, New York-Presbyterian Morgan-Stanley Children’s Hospital/Columbia University Irving Medical Center, New York, New York, USA
| | - Emily M. Bucholz
- Department of Cardiology, Children’s Hospital Boston and Harvard University Medical School, Boston, Massachusetts, USA
| | - Nikhil K. Chanani
- Children’s Healthcare of Atlanta, Sibley Heart Center and Emory University School of Medicine, Atlanta, Georgia, USA
| | - Justin J. Elhoff
- Sections of Critical Care and Cardiology, Texas Children’s Hospital and Baylor College of Medicine, Houston, Texas, USA
| | | | - Jeffery P. Jacobs
- Division of Cardiothoracic Surgery, Departments of Surgery and Pediatrics, Congenital Heart Center, University of Florida, Gainesville, Florida, USA
| | - Jennifer S. Li
- Division of Pediatric Cardiology, Duke University School of Medicine, Durham, North Carolina, USA
| | - Alan B. Lewis
- Division of Cardiology, Department of Pediatrics, Children’s Hospital of Los Angeles, Keck School of Medicine of University of Southern California, Los Angeles, California, USA
| | - Brian W. McCrindle
- Department of Pediatrics, Labatt Family Heart Centre, The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
| | - Nelangi M. Pinto
- Division of Cardiology, Primary Children’s Hospital and University of Utah School of Medicine, Salt Lake City, Utah, USA
| | - Peter Sassalos
- Division of Pediatric Cardiothoracic Surgery, C.S. Mott Children’s Hospital and University of Michigan School of Medicine, Ann Arbor, Michigan, USA
| | - David S. Spar
- The Heart Institute, Cincinnati Children’s Hospital Medical Center and Department of Pediatrics, University of Cincinnati School of Medicine, Cincinnati, Ohio, USA
| | - Sara K. Pasquali
- Division of Cardiology, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio, USA
| | - Andrew C. Glatz
- Division of Cardiology, The Children's Hospital of Philadelphia and Department of Pediatrics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, USA
- Center for Pediatric Clinical Effectiveness, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
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5
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Piber N, Ono M, Palm J, Kido T, Burri M, Röhlig C, Strbad M, Cleuziou J, Lemmer J, Dilber D, Klawonn F, Ewert P, Hager A, Hörer J. Influence of Shunt Type on Survival and Right Heart Function after the Norwood Procedure for Aortic Atresia. Semin Thorac Cardiovasc Surg 2021; 34:1300-1310. [PMID: 34838954 DOI: 10.1053/j.semtcvs.2021.11.012] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2021] [Accepted: 11/18/2021] [Indexed: 12/28/2022]
Abstract
The study objective was to compare the results after Norwood procedure between modified Blalock-Taussig shunt (MBTS) and right ventricle-to-pulmonary artery conduit (RVPAC) according to Sano in patients with hypoplastic left heart syndrome (HLHS) and aortic atresia (AA). A total of 146 neonates with HLHS and AA who underwent the Norwood procedure at our institution between 2001 and 2020 were divided into 2 groups according to shunt type (MBTS or RVPAC). Survival after the Norwood procedure was compared between the groups. Longitudinal right ventricular and tricuspid valve function in each group were evaluated using cubic splines method. RVPAC was performed in 103 patients and MBTS in 43 according to surgeon preference. There were no differences in the 30-day mortality rates (16.5% vs 16.3%, P = 0.973). Survival at 0.5, 1 and 3 years was 79.6%, 74.6%, and 68.9% in RVPAC and 66.8%, 64.3%, and 58.5% in MBTS (P = 0.293). Among 23 patients undergoing tricuspid valve procedure, different mechanisms of tricuspid regurgitation were observed between the groups. Longitudinal analysis revealed greater prevalence of late right ventricular dysfunction in RVPAC patients. In 77 patients who completed Fontan procedure, the postoperative N-terminal pro B-type natriuretic peptide value was significantly higher in RVPAC vs MBTS (554 vs 276 ng/L, P = 0.007). No survival advantage of RVPAC over MBTS was observed in neonates with HLHS and AA undergoing the Norwood procedure. Longitudinal analysis demonstrated a greater prevalence of right ventricular dysfunction and higher N-terminal pro B-type natriuretic peptide values during late follow-up in patients with RVPAC.
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Affiliation(s)
- Nicole Piber
- Department of Congenital and Pediatric Heart Surgery, German Heart Center Munich, Technische Universität München, Division of Congenital and Pediatric Heart Surgery, University Hospital of Munich, Ludwig-Maximilians-Universität, Munich, Germany
| | - Masamichi Ono
- Department of Congenital and Pediatric Heart Surgery, German Heart Center Munich, Technische Universität München, Division of Congenital and Pediatric Heart Surgery, University Hospital of Munich, Ludwig-Maximilians-Universität, Munich, Germany.
| | - Jonas Palm
- Department of Pediatric Cardiology and Congenital Heart Disease, German Heart Center Munich Technische Universität München, Munich, Germany
| | - Takashi Kido
- Department of Congenital and Pediatric Heart Surgery, German Heart Center Munich, Technische Universität München, Division of Congenital and Pediatric Heart Surgery, University Hospital of Munich, Ludwig-Maximilians-Universität, Munich, Germany
| | - Melchior Burri
- Department of Cardiovascular Surgery, German Heart Center Munich, Technische Universität München, Munich, Germany
| | - Christoph Röhlig
- Department of Pediatric Cardiology and Congenital Heart Disease, German Heart Center Munich Technische Universität München, Munich, Germany
| | - Martina Strbad
- Department of Congenital and Pediatric Heart Surgery, German Heart Center Munich, Technische Universität München, Division of Congenital and Pediatric Heart Surgery, University Hospital of Munich, Ludwig-Maximilians-Universität, Munich, Germany
| | - Julie Cleuziou
- Department of Congenital and Pediatric Heart Surgery, German Heart Center Munich, Technische Universität München, Division of Congenital and Pediatric Heart Surgery, University Hospital of Munich, Ludwig-Maximilians-Universität, Munich, Germany
| | - Julia Lemmer
- Department of Pediatric Cardiology and Congenital Heart Disease, German Heart Center Munich Technische Universität München, Munich, Germany
| | - Daniel Dilber
- Department of Pediatrics, University Hospital Centre Zagreb, School of medicine Zagreb, Zagreb, Croatia
| | - Frank Klawonn
- Biostatistics, Helmholtz Center for Infection Research, Braunschweig, Germany; Department of Computer Science, Ostfalia University, Wolfenbüttel, Germany
| | - Peter Ewert
- Department of Pediatric Cardiology and Congenital Heart Disease, German Heart Center Munich Technische Universität München, Munich, Germany
| | - Alfred Hager
- Department of Pediatric Cardiology and Congenital Heart Disease, German Heart Center Munich Technische Universität München, Munich, Germany
| | - Jürgen Hörer
- Department of Congenital and Pediatric Heart Surgery, German Heart Center Munich, Technische Universität München, Division of Congenital and Pediatric Heart Surgery, University Hospital of Munich, Ludwig-Maximilians-Universität, Munich, Germany
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Bichell DP. Commentary: Right ventriculotomy: Less is still more. JTCVS Tech 2021; 8:124-125. [PMID: 34401830 PMCID: PMC8350950 DOI: 10.1016/j.xjtc.2021.06.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2021] [Revised: 05/31/2021] [Accepted: 06/07/2021] [Indexed: 11/17/2022] Open
Affiliation(s)
- David P. Bichell
- Department of Cardiac Surgery, Monroe Carell Jr. Children's Hospital, Vanderbilt University Medical Center, Nashville, Tenn
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Bhatla P, Kumar TS, Makadia L, Winston B, Bull C, Nielsen JC, Williams D, Chakravarti S, Ohye RG, Mosca RS. Periscopic technique in Norwood operation is associated with better preservation of early ventricular function. JTCVS Tech 2021; 8:116-123. [PMID: 34401829 PMCID: PMC8350951 DOI: 10.1016/j.xjtc.2021.05.014] [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: 07/31/2020] [Accepted: 05/13/2021] [Indexed: 11/16/2022] Open
Abstract
Objective Although the right ventricle (RV) to pulmonary artery conduit in stage 1 Norwood operation results in improved interstage survival, the long-term effects of the ventriculotomy used in the traditional technique remain a concern. The periscopic technique (PT) of RV to pulmonary artery conduit placement has been described as an alternative technique to minimize RV injury. A retrospective study was performed to compare the effects of traditional technique and PT on ventricular function following Norwood operation. Methods A retrospective study of all patients who underwent Norwood operation from 2012 to 2019 was performed. Patients with baseline RV dysfunction and significant tricuspid valve regurgitation were excluded. Prestage 2 echocardiograms were reviewed by a blinded experienced imager for quantification of RV function (sinus and infundibular RV fractional area change) as well as for regional conduit site wall dysfunction (normal or abnormal, including hypokinesia, akinesia, or dyskinesia). Wilcoxon rank-sum tests were used to assess differences in RV infundibular and RV sinus ejection fraction and the Fisher exact test was used to assess differences in regional wall dysfunction. Results Twenty-two patients met inclusion criteria. Eight underwent traditional technique and 14 underwent PT. Median infundibular RV fractional area change was 49% and 37% (P = .02) and sinus RV fractional area change was 50% and 41% for PT and traditional technique (P = .007) respectively. Similarly qualitative regional RV wall function was better preserved in PT (P = .002). Conclusions The PT for RV to pulmonary artery conduit in Norwood operation results in better preservation of early RV global and regional systolic function. Whether or not this benefit translates to improved clinical outcome still needs to be studied.
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Affiliation(s)
- Puneet Bhatla
- Division of Pediatric Cardiology, New York University Langone Medical Center, New York, NY.,Department of Radiology, New York University Langone Medical Center, New York, NY
| | - Tk Susheel Kumar
- Department of Cardiac Surgery, New York University Langone Medical Center, New York, NY
| | - Luv Makadia
- Department of Pediatrics, New York University Langone Medical Center, New York, NY
| | - Brandon Winston
- Department of Cardiac Surgery, New York University Langone Medical Center, New York, NY
| | - Catherine Bull
- Department of Cardiac Surgery, New York University Langone Medical Center, New York, NY
| | - James C Nielsen
- Division of Pediatric Cardiology, New York University Langone Medical Center, New York, NY
| | - David Williams
- Department of Cardiac Surgery, New York University Langone Medical Center, New York, NY
| | - Sujata Chakravarti
- Division of Pediatric Cardiology, New York University Langone Medical Center, New York, NY
| | - Richard G Ohye
- Department of Cardiac Surgery, Mott Children's Hospital, Ann Arbor, Mich
| | - Ralph S Mosca
- Department of Cardiac Surgery, New York University Langone Medical Center, New York, NY
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Alphonso N, Angelini A, Barron DJ, Bellsham-Revell H, Blom NA, Brown K, Davis D, Duncan D, Fedrigo M, Galletti L, Hehir D, Herberg U, Jacobs JP, Januszewska K, Karl TR, Malec E, Maruszewski B, Montgomerie J, Pizzaro C, Schranz D, Shillingford AJ, Simpson JM. Guidelines for the management of neonates and infants with hypoplastic left heart syndrome: The European Association for Cardio-Thoracic Surgery (EACTS) and the Association for European Paediatric and Congenital Cardiology (AEPC) Hypoplastic Left Heart Syndrome Guidelines Task Force. Eur J Cardiothorac Surg 2020; 58:416-499. [DOI: 10.1093/ejcts/ezaa188] [Citation(s) in RCA: 24] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Affiliation(s)
- Nelson Alphonso
- Queensland Pediatric Cardiac Service, Queensland Children’s Hospital, University of Queensland, Brisbane, QLD, Australia
| | - Annalisa Angelini
- Department of Cardiac, Thoracic Vascular Sciences and Public health, University of Padua Medical School, Padua, Italy
| | - David J Barron
- Department of Cardiovascular Surgery, Hospital for Sick Children, University of Toronto, Toronto, ON, Canada
| | | | - Nico A Blom
- Division of Pediatric Cardiology, Department of Pediatrics, Leiden University Medical Center, Leiden, Netherlands
| | - Katherine Brown
- Paediatric Intensive Care, Heart and Lung Division, Great Ormond Street Hospital NHS Foundation Trust, London, UK
| | - Deborah Davis
- Department of Anesthesiology, Thomas Jefferson University, Philadelphia, PA, USA
- Nemours Cardiac Center, A.I. Du Pont Hospital for Children, Wilmington, DE, USA
| | - Daniel Duncan
- Nemours Cardiac Center, A.I. Du Pont Hospital for Children, Wilmington, DE, USA
| | - Marny Fedrigo
- Department of Cardiac, Thoracic Vascular Sciences and Public Health, University of Padua Medical School, Padua, Italy
| | - Lorenzo Galletti
- Unit of Pediatric Cardiac Surgery, Bambino Gesù Children's Hospital, Rome, Italy
| | - David Hehir
- Division of Cardiology, Children’s Hospital of Philadelphia, Philadelphia, PA, USA
| | - Ulrike Herberg
- Department of Pediatric Cardiology, University Hospital Bonn, Bonn, Germany
| | | | - Katarzyna Januszewska
- Division of Pediatric Cardiac Surgery, University Hospital Muenster, Westphalian-Wilhelm’s-University, Muenster, Germany
| | | | - Edward Malec
- Division of Pediatric Cardiac Surgery, University Hospital Muenster, Westphalian-Wilhelm’s-University, Muenster, Germany
| | - Bohdan Maruszewski
- Department for Pediatric Cardiothoracic Surgery, Children's Memorial Health Institute, Warsaw, Poland
| | - James Montgomerie
- Department of Anesthesia, Birmingham Children’s Hospital, Birmingham, UK
| | - Christian Pizzaro
- Nemours Cardiac Center, A.I. Du Pont Hospital for Children, Wilmington, DE, USA
- Department of Surgery, Thomas Jefferson University, Philadelphia, PA, USA
| | - Dietmar Schranz
- Pediatric Heart Center, Justus-Liebig University, Giessen, Germany
| | - Amanda J Shillingford
- Division of Cardiology, Children's Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
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9
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Garcia AM, Beatty JT, Nakano SJ. Heart failure in single right ventricle congenital heart disease: physiological and molecular considerations. Am J Physiol Heart Circ Physiol 2020; 318:H947-H965. [PMID: 32108525 PMCID: PMC7191494 DOI: 10.1152/ajpheart.00518.2019] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/04/2019] [Revised: 02/13/2020] [Accepted: 02/19/2020] [Indexed: 12/27/2022]
Abstract
Because of remarkable surgical and medical advances over the past several decades, there are growing numbers of infants and children living with single ventricle congenital heart disease (SV), where there is only one functional cardiac pumping chamber. Nevertheless, cardiac dysfunction (and ultimately heart failure) is a common complication in the SV population, and pharmacological heart failure therapies have largely been ineffective in mitigating the need for heart transplantation. Given that there are several inherent risk factors for ventricular dysfunction in the setting of SV in addition to probable differences in molecular adaptations to heart failure between children and adults, it is perhaps not surprising that extrapolated adult heart failure medications have had limited benefit in children with SV heart failure. Further investigations into the molecular mechanisms involved in pediatric SV heart failure may assist with risk stratification as well as development of targeted, efficacious therapies specific to this patient population. In this review, we present a brief overview of SV anatomy and physiology, with a focus on patients with a single morphological right ventricle requiring staged surgical palliation. Additionally, we discuss outcomes in the current era, risk factors associated with the progression to heart failure, present state of knowledge regarding molecular alterations in end-stage SV heart failure, and current therapeutic interventions. Potential avenues for improving SV outcomes, including identification of biomarkers of heart failure progression, implications of personalized medicine and stem cell-derived therapies, and applications of novel models of SV disease, are proposed as future directions.
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Affiliation(s)
- Anastacia M Garcia
- Division of Cardiology, Department of Pediatrics, University of Colorado Denver, Aurora, Colorado
| | - Jonathan-Thomas Beatty
- Division of Cardiology, Department of Medicine, University of Colorado Denver, Aurora, Colorado
| | - Stephanie J Nakano
- Division of Cardiology, Department of Pediatrics, University of Colorado Denver, Aurora, Colorado
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10
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Mahle WT, Hu C, Trachtenberg F, Menteer J, Kindel SJ, Dipchand AI, Richmond ME, Daly KP, Henderson HT, Lin KY, McCulloch M, Lal AK, Schumacher KR, Jacobs JP, Atz AM, Villa CR, Burns KM, Newburger JW. Heart failure after the Norwood procedure: An analysis of the Single Ventricle Reconstruction Trial. J Heart Lung Transplant 2018; 37:879-885. [PMID: 29571602 DOI: 10.1016/j.healun.2018.02.009] [Citation(s) in RCA: 40] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2017] [Revised: 02/13/2018] [Accepted: 02/14/2018] [Indexed: 11/28/2022] Open
Abstract
BACKGROUND Heart failure results in significant morbidity and mortality in young children with hypoplastic left heart syndrome (HLHS) after the Norwood procedure. METHODS We studied subjects enrolled in the prospective Single Ventricle Reconstruction (SVR) Trial who survived to hospital discharge after a Norwood operation and were followed up to age 6 years. The primary outcome was heart failure, defined as heart transplant listing after Norwood hospitalization, death attributable to heart failure, or symptomatic heart failure (New York Heart Association [NYHA] Class IV). Multivariate modeling was undertaken using Cox regression methodology to determine variables associated with heart failure. RESULTS Of the 461 subjects discharged home following a Norwood procedure, 66 (14.3%) met the criteria for heart failure. Among these, 15 died from heart failure, 39 were listed for transplant (22 had a transplant, 12 died after listing, and 5 were alive and not yet transplanted), and 12 had NYHA Class IV heart failure but were never listed. The median age at heart failure identification was 1.28 (interquartile range 0.30 to 4.69) years. Factors associated with early heart failure included post-Norwood lower fractional area change, need for extracorporeal membrane oxygenation, non-Hispanic ethnicity, Norwood perfusion type, and total support time (p < 0.05). CONCLUSIONS By 6 years of age, heart failure developed in nearly 15% of children after the Norwood procedure. Although transplant listing was common, many patients died from heart failure before receiving a transplant or without being listed. Shunt type did not impact the risk of developing heart failure.
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Affiliation(s)
- William T Mahle
- Children's Healthcare of Atlanta and Department of Pediatrics, Division of Cardiology Emory University Atlanta, GA (W.T.M).
| | - Chenwei Hu
- New England Research Institutes, Watertown, MA (F.T., C.H.)
| | | | - JonDavid Menteer
- Children's Hospital Los Angeles and Department of Pediatrics, Division of Cardiology University of Southern California, Los Angeles, CA (J.M.)
| | - Steven J Kindel
- Children's Hospital of Wisconsin, Milwaukee and Department of Pediatrics, Division of Cardiology University of Wisconsin Milwaukee, WI (S.J.K.)
| | - Anne I Dipchand
- The Hospital for Sick Children and Department of Pediatrics, Division of Cardiology University of Toronto, Toronto, Ontario (A.I.D.)
| | - Marc E Richmond
- Morgan Stanley Children's Hospital of New York Presbyterian Columbia University Medical Center and Department of Pediatrics, Division of Cardiology Columbia University, New York, NY (M.E.R.)
| | - Kevin P Daly
- Boston Children's Hospital and Department of Pediatrics Cardiology Harvard School of Medicine, Boston, MA (K.PD., J.W.N.)
| | - Heather T Henderson
- Duke University Hospital and Department of Pediatrics, Division of Cardiology Duke University, Durham, NC (H.T.H.)
| | - Kimberly Y Lin
- Children's Hospital of Philadelphia and Department of Pediatrics, Division of Cardiology University of Pennsylvania, Philadelphia, PA (K.L.)
| | - Michael McCulloch
- Alfred I. DuPont Hospital for Children and Department of Pediatrics, Division of Cardiology Thomas Jefferson University, Wilmington, DE (M.M.)
| | - Ashwin K Lal
- Primary Children's Medical Center and Department of Pediatrics, Division of Cardiology University of Utah, Salt Lake City, UT (A.K.L.)
| | - Kurt R Schumacher
- University of Michigan Health System and Department of Pediatrics, Division of Cardiology University of Michigan, Ann Arbor, MI (K.S.)
| | - Jeffrey P Jacobs
- Johns Hopkins All Children's Heart Institute and Department of Surgery, Division of Cardiothoracic Surgery, St. Petersburg, FL (J.P.J.)
| | - Andrew M Atz
- Department of Pediatrics, Division of Cardiology Medical University of South Carolina, Charleston, SC (A.M.A.)
| | - Chet R Villa
- Cincinnati Children's Hospital Medical Center and Department of Pediatrics, Division of Cardiology University of Cincinnati, Cincinnati, OH (C.R.V.)
| | - Kristin M Burns
- National Heart, Lung, and Blood Institute, Bethesda, MD (K.M.B.)
| | - Jane W Newburger
- Boston Children's Hospital and Department of Pediatrics Cardiology Harvard School of Medicine, Boston, MA (K.PD., J.W.N.)
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11
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Cao JY, Phan K, Ayer J, Celermajer DS, Winlaw DS. Long term survival of hypoplastic left heart syndrome infants: Meta-analysis comparing outcomes from the modified Blalock-Taussig shunt and the right ventricle to pulmonary artery shunt. Int J Cardiol 2018; 254:107-116. [PMID: 29407078 DOI: 10.1016/j.ijcard.2017.10.040] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/13/2017] [Revised: 10/09/2017] [Accepted: 10/12/2017] [Indexed: 12/29/2022]
Abstract
BACKGROUND Stage 1 palliation of hypoplastic left heart syndrome (HLHS) involves the Norwood procedure combined with a modified Blalock-Taussig shunt (mBTS) or right ventricle to pulmonary artery shunt (RVPAS). Short-term survival has been described previously, whereas longer-term outcomes remain a subject of debate. This meta-analysis aimed to describe the short and long-term survival outcomes of these two shunts, and explore factors that might influence survival. METHODS Medline, Cochrane Libraries and EMBASE were systematically searched, and 32 studies were included for statistical synthesis, comprising 1348 mBTS and 1258 RVPAS patients. RESULTS While early in-hospital survival was superior in the RVPAS group (RR=1.5, p<0.05, 95% CI: 1.21-1.85), this difference was lost from 2years post-stage 1 palliation (RR=0.91, p>0.05, 95% CI: 0.79-1.04), and maintained unchanged up to 6years. This shift in survival was also reflected in inter-stage survival, with superior RVPAS outcomes between stage 1 and 2 (RR=1.62, p<0.05, 95% CI: 1.39-1.88), and equivalent outcomes between stage 2 and 3. Potential contributors to this included a significantly higher rate of pulmonary artery stenosis in the RVPAS group and an increased requirement for shunt re-intervention in this group prior to stage 2. CONCLUSIONS Despite early advantages, RVPAS and mBTS for palliation of hypoplastic left heart syndrome produced comparable long-term survival. The RVPAS patients experienced more pulmonary artery stenosis and requirement for shunt re-intervention. The impact of shunt type on quality and survival with a Fontan is yet to be assessed.
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Affiliation(s)
- Jacob Y Cao
- Sydney Medical School, University of Sydney, Sydney, Australia
| | - Kevin Phan
- Sydney Medical School, University of Sydney, Sydney, Australia; NeuroSpine Surgery Research Group (NSURG), Prince of Wales Private Hospital, Sydney, Australia
| | - Julian Ayer
- Sydney Medical School, University of Sydney, Sydney, Australia; The Heart Centre for Children, The Children's Hospital at Westmead, Sydney, NSW, Australia
| | - David S Celermajer
- Sydney Medical School, University of Sydney, Sydney, Australia; Cardiology, Royal Prince Alfred Hospital, Sydney, NSW, Australia
| | - David S Winlaw
- Sydney Medical School, University of Sydney, Sydney, Australia; The Heart Centre for Children, The Children's Hospital at Westmead, Sydney, NSW, Australia.
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12
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Wong J, Lamata P, Rathod RH, Bertaud S, Dedieu N, Bellsham-Revell H, Pushparajah K, Razavi R, Hussain T, Schaeffter T, Powell AJ, Geva T, Greil GF. Right ventricular morphology and function following stage I palliation with a modified Blalock-Taussig shunt versus a right ventricle-to-pulmonary artery conduit. Eur J Cardiothorac Surg 2016; 51:50-57. [PMID: 27422888 PMCID: PMC5226069 DOI: 10.1093/ejcts/ezw227] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/31/2016] [Revised: 05/17/2016] [Accepted: 05/28/2016] [Indexed: 12/24/2022] Open
Abstract
OBJECTIVES The Norwood procedure for hypoplastic left heart syndrome (HLHS) is performed either via a right ventricle-to-pulmonary artery (RVPA) conduit or a modified Blalock–Taussig (MBT) shunt. Cardiac magnetic resonance (CMR) data was used to assess the effects of the RVPA conduit on ventricular shape and function through a computational analysis of anatomy and assessment of indices of strain. METHODS A retrospective analysis of 93 CMR scans of subjects with HLHS was performed (59 with MBT shunt, 34 with RVPA conduit), incorporating data at varying stages of surgery from two congenital centres. Longitudinal and short-axis cine images were used to create a computational cardiac atlas and assess global strain. RESULTS Those receiving an RVPA conduit had significant differences (P< 0.0001) in the shape of the RV corresponding to increased ventricular dilatation (P = 0.001) and increased sphericity (P = 0.006). Differences were evident only following completion of stage II surgery. Despite preserved ejection fraction in both groups, functional strain in the RVPA conduit group compared with that in the MBT shunt group was reduced across multiple ventricular axes, including a reduced systolic longitudinal strain rate (P< 0.0001), reduced diastolic longitudinal strain rate (P = 0.0001) and reduced midventricular systolic circumferential strain (P < 0.0001). CONCLUSIONS Computational modelling analysis reveals differences in ventricular remodelling in patients with HLHS undergoing an RVPA conduit insertion with focal scarring and volume loading leading to decreased functional markers of strain. The need for continued surveillance is warranted, as deleterious effects may not become apparent until later years.
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Affiliation(s)
- James Wong
- Department of Imaging Sciences, Kings College London, St Thomas' Hospital, London, UK
| | - Pablo Lamata
- Department of Imaging Sciences, Kings College London, St Thomas' Hospital, London, UK
| | - Rahul H Rathod
- Boston Children's Hospital, Harvard Medical School, Boston, USA
| | - Sophie Bertaud
- Department of Imaging Sciences, Kings College London, St Thomas' Hospital, London, UK
| | - Nathalie Dedieu
- Department of Imaging Sciences, Kings College London, St Thomas' Hospital, London, UK
| | | | - Kuberan Pushparajah
- Department of Imaging Sciences, Kings College London, St Thomas' Hospital, London, UK
| | - Reza Razavi
- Department of Imaging Sciences, Kings College London, St Thomas' Hospital, London, UK
| | - Tarique Hussain
- Department of Imaging Sciences, Kings College London, St Thomas' Hospital, London, UK
| | - Tobias Schaeffter
- Department of Imaging Sciences, Kings College London, St Thomas' Hospital, London, UK
| | - Andrew J Powell
- Boston Children's Hospital, Harvard Medical School, Boston, USA
| | - Tal Geva
- Boston Children's Hospital, Harvard Medical School, Boston, USA
| | - Gerald F Greil
- Department of Imaging Sciences, Kings College London, St Thomas' Hospital, London, UK
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13
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Bogarapu S, Puchalski MD, Everitt MD, Williams RV, Weng HY, Menon SC. Novel Cardiac Magnetic Resonance Feature Tracking (CMR-FT) Analysis for Detection of Myocardial Fibrosis in Pediatric Hypertrophic Cardiomyopathy. Pediatr Cardiol 2016; 37:663-73. [PMID: 26833321 DOI: 10.1007/s00246-015-1329-8] [Citation(s) in RCA: 39] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/15/2015] [Accepted: 12/15/2015] [Indexed: 12/16/2022]
Abstract
Myocardial fibrosis is a risk factor for sudden cardiac death in hypertrophic cardiomyopathy (HCM) and is conventionally identified by cardiac magnetic resonance imaging (CMR) using late gadolinium enhancement (LGE). This study evaluates utility of a novel 16-segment CMR feature tracking (CMR-FT) technique for measuring left ventricular (LV) strain (S) and strain rate (SR) on non-contrast cine images to detect myocardial fibrosis in pediatric HCM. We hypothesized that CMR-FT-derived S and SR will accurately differentiate HCM patients with and without myocardial fibrosis. Consecutive children with HCM who underwent CMR with LGE at our institution from 2006 to 2014 were included. Global and regional longitudinal, radial and circumferential S and SR of the LV in 2D and 3D were obtained using a CMR-FT software. Comparisons were made between HCM patients with (+LGE) and without (-LGE) delayed enhancement. Of the 29 HCM patients (mean age 13.5 ± 6.1 years; 52 % males), 11 (40 %) patients (mean age 17.5 ± 8.4 years) had +LGE. Global longitudinal, circumferential and radial S and SR were lower in +LGE compared to -LGE patients, in both 2D and 3D. Regional analysis revealed lower segmental S and SR in the septum with fibrosis compared to free wall without fibrosis. A global longitudinal S of ≤ -12.8 had 91 % sensitivity and 89 % specificity for detection of LGE. In pediatric HCM patients with myocardial fibrosis, global LV longitudinal, circumferential and radial S and SR were reduced, specifically in areas of fibrosis. A global longitudinal S of ≤ -12.8 detected patients with fibrosis with high degree of accuracy. This novel CMR-FT technique may be useful to identify myocardial fibrosis and risk-stratify pediatric HCM without use of contrast agents.
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Affiliation(s)
- Soujanya Bogarapu
- Division of Pediatric Cardiology, Department of Pediatrics, University of Utah, 81 N Mario Capecchi Drive, Salt Lake City, UT, 84113, USA
| | - Michael D Puchalski
- Division of Pediatric Cardiology, Department of Pediatrics, University of Utah, 81 N Mario Capecchi Drive, Salt Lake City, UT, 84113, USA
| | - Melanie D Everitt
- Division of Pediatric Cardiology, Children's Hospital Colorado, Aurora, CO, USA
| | - Richard V Williams
- Division of Pediatric Cardiology, Department of Pediatrics, University of Utah, 81 N Mario Capecchi Drive, Salt Lake City, UT, 84113, USA
| | - Hsin-Yi Weng
- Study Design and Biostatistics Center, University of Utah School of Medicine, Salt Lake City, UT, USA
| | - Shaji C Menon
- Division of Pediatric Cardiology, Department of Pediatrics, University of Utah, 81 N Mario Capecchi Drive, Salt Lake City, UT, 84113, USA.
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14
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Ravishankar C, Gerstenberger E, Sleeper LA, Atz AM, Affolter JT, Bradley TJ, Gaynor JW, Goldstein BH, Henderson HT, Jacobs JP, Lewis AB, Dunbar-Masterson C, Menon SC, Pemberton VL, Petit CJ, Pike NA, Pizarro C, Schumacher KR, Williams IA, Newburger JW. Factors affecting Fontan length of stay: Results from the Single Ventricle Reconstruction trial. J Thorac Cardiovasc Surg 2015; 151:669-675.e1. [PMID: 26519244 DOI: 10.1016/j.jtcvs.2015.09.061] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/29/2015] [Revised: 08/20/2015] [Accepted: 09/04/2015] [Indexed: 10/23/2022]
Abstract
BACKGROUND In the Single Ventricle Reconstruction trial, infants with hypoplastic left heart syndrome (HLHS) who received a right-ventricle-to-pulmonary-artery shunt (RVPAS) versus a modified Blalock-Taussig shunt (MBTS) had lower early postoperative mortality, but more complications at 14 months. We explored the effect of shunt type and other patient, medical, and surgical factors on postoperative length of stay (LOS) after the Fontan operation. METHODS Fontan postoperative course was ascertained from medical record review. Cox proportional hazards modeling was used to identify factors associated with LOS. RESULTS Of 327 subjects who underwent Fontan, 323 were analyzed (1 death, 1 biventricular repair, 2 with missing data). Median age and weight at Fontan were 2.8 years (interquartile range [IQR]: 2.3, 3.4) and 12.7 kg (IQR: 11.4, 14.1), respectively. Fontan type was extracardiac in 55% and lateral tunnel in 45%; 87% were fenestrated. The RVPAS and MBTS subjects had similar LOS (median 11 days [IQR: 9, 18] vs 10 days [IQR: 9, 13]; P = .23). Independent risk factors for longer LOS were treatment center (P < .01), LOS at stage II (hazard ratio [HR] 1.02 for each additional day; P < .01), and pre-Fontan complications (HR 1.03 for each additional complication; P = .04). Use of deep hypothermic circulatory arrest at Fontan (HR 0.64; P = .02) was independently associated with shorter LOS. When center was excluded from the model, pre-Fontan complications and use of circulatory arrest were no longer significant; instead, older age at stage II (HR 1.08 for each additional month; P = .01) predicted longer LOS. In 254 subjects who had a pre-Fontan echocardiogram, at least moderate tricuspid regurgitation was independently associated with longer LOS, both with center (HR 1.72; P < .01) and without center in the model (HR 1.49; P = .02). CONCLUSIONS In this multicenter prospective cohort of subjects with HLHS, Norwood shunt type was not associated with Fontan LOS. Rather, global measures of earlier medical complexity indicate greater likelihood of longer LOS after the Fontan operation.
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Affiliation(s)
- Chitra Ravishankar
- Department of Pediatrics, Children's Hospital of Philadelphia, Philadelphia, Pa.
| | | | | | - Andrew M Atz
- Department of Pediatrics, Medical University of South Carolina, Charleston, SC
| | - Jeremy T Affolter
- Department of Critical Care Medicine, The Children's Hospital of Wisconsin, Milwaukee, Wis
| | - Timothy J Bradley
- Department of Pediatrics, Hospital for Sick Children, Toronto, Ontario, Canada
| | - J William Gaynor
- Division of Cardiothoracic Surgery, Children's Hospital of Philadelphia, Philadelphia, Pa
| | - Bryan H Goldstein
- Department of Pediatrics, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | | | - Jeffrey P Jacobs
- Division of Cardiothoracic Surgery, Congenital Heart Institute of Florida, St Petersburg, Fla
| | - Alan B Lewis
- Department of Pediatrics, Children's Hospital of Los Angeles, Los Angeles, Calif
| | | | - Shaji C Menon
- University of Utah, Department of Pediatrics, Salt Lake City, Utah
| | - Victoria L Pemberton
- National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, Md
| | | | - Nancy A Pike
- Department of Nursing, University of California, Los Angeles, Los Angeles, Calif
| | - Christian Pizarro
- Division of Cardiothoracic Surgery, Alfred I. DuPont Hospital for Children, Wilmington, Del
| | - Kurt R Schumacher
- Department of Pediatrics, University of Michigan Health Center, Ann Arbor, Mich
| | - Ismee A Williams
- Department of Pediatrics, Columbia University Medical Center, New York, NY
| | - Jane W Newburger
- Department of Cardiology, Boston Children's Hospital, Boston, Mass
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15
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Ruotsalainen H, Bellsham-Revell H, Bell A, Pihkala J, Ojala T, Simpson J. Right ventricular systolic function in hypoplastic left heart syndrome: a comparison of velocity vector imaging and magnetic resonance imaging. Eur Heart J Cardiovasc Imaging 2015; 17:687-92. [PMID: 26323279 DOI: 10.1093/ehjci/jev196] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/05/2015] [Accepted: 07/14/2015] [Indexed: 11/13/2022] Open
Abstract
AIMS Velocity vector imaging (VVI) is an echocardiographic technique based on speckle tracking, which has been validated for the left ventricle (LV). It has not been validated to assess the systemic right ventricle (RV) in patients with hypoplastic left heart syndrome (HLHS). The aim of this study was to evaluate whether VVI measurements reliably reflect RV systolic function in patients with HLHS when compared with RV ejection fraction (EF) calculated using magnetic resonance imaging (MRI). METHODS AND RESULTS In this prospective study, 49 children with HLHS underwent transthoracic echocardiography and cardiac MRI under the same general anaesthetic as a part of routine assessment between the different stages of palliative surgery. Global RV fractional area change (FAC-VVI), strain (S), strain rate (SR), and peak systolic velocity (V) were analysed from the apical four-chamber view using the VVI technique. MRI-derived EF was calculated from a short-axis cine stack of images. Intra- and interobserver reproducibility was excellent for all VVI parameters (intraclass correlation coefficient >0.9). All VVI-derived parameters, except myocardial velocity, correlated with MRI-derived EF (FAC-VVI: R = 0.7, P < 0.001; S: R = -0.5, P < 0.001; SR: R = 0.5, P = 0.001, and V: R = 0.1, P = 0.4). CONCLUSIONS All VVI-derived parameters, except V, correlate with MRI-derived EF, with FAC being the best predictor of it. Reproducibility of all VVI parameters is excellent. VVI provides a useful tool for the follow-up of RV function during the staged treatment protocol for HLHS.
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Affiliation(s)
- Hanna Ruotsalainen
- Department of Pediatric Cardiology, Children's Hospital, University Hospital of Helsinki and University of Helsinki, Stenbackinkatu 11, PL 281, Helsinki 00029 HUS, Finland Department of Pediatrics, Kuopio University Hospital, Kuopio, Finland
| | | | - Aaron Bell
- Department of Congenital Heart Disease, Evelina London Children's Hospital, London, UK
| | - Jaana Pihkala
- Department of Pediatric Cardiology, Children's Hospital, University Hospital of Helsinki and University of Helsinki, Stenbackinkatu 11, PL 281, Helsinki 00029 HUS, Finland
| | - Tiina Ojala
- Department of Pediatric Cardiology, Children's Hospital, University Hospital of Helsinki and University of Helsinki, Stenbackinkatu 11, PL 281, Helsinki 00029 HUS, Finland
| | - John Simpson
- Department of Congenital Heart Disease, Evelina London Children's Hospital, London, UK
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16
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Ventriculoarterial coupling in palliated hypoplastic left heart syndrome: Noninvasive assessment of the effects of surgical arch reconstruction and shunt type. J Thorac Cardiovasc Surg 2014; 148:1526-33. [DOI: 10.1016/j.jtcvs.2014.02.012] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/12/2013] [Revised: 01/21/2014] [Accepted: 02/03/2014] [Indexed: 11/23/2022]
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17
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Koestenberger M, Ravekes W, Nagel B, Avian A, Heinzl B, Cvirn G, Fritsch P, Fandl A, Rehak T, Gamillscheg A. Reference values of the right ventricular outflow tract systolic excursion in 711 healthy children and calculation of z-score values. Eur Heart J Cardiovasc Imaging 2014; 15:980-6. [DOI: 10.1093/ehjci/jeu041] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/06/2023] Open
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