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Lynch A, Jeewa A, Minn S, Arathoon K, Honjo O, Floh A, Hassan A, Jean-St-Michel E. Outcomes of Children With Hypoplastic Left Heart Syndrome and Heart Failure on Medical Therapy. JACC. ADVANCES 2024; 3:100811. [PMID: 38939382 PMCID: PMC11198231 DOI: 10.1016/j.jacadv.2023.100811] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/02/2023] [Revised: 09/05/2023] [Accepted: 11/09/2023] [Indexed: 06/29/2024]
Abstract
Background Systemic right ventricle (RV) dysfunction is associated with lower transplant-free survival (TFS) in hypoplastic left heart syndrome (HLHS), but the likelihood of functional improvement and utility of heart failure (HF) medications is not understood. Objectives The authors aimed to describe TFS, HF medication use, and surgical interventions in HLHS patients with RV dysfunction with and without subsequent improvement in function. Methods The SickKids HF Database is a retrospective cohort that includes all pediatric HLHS patients with RV dysfunction lasting >30 days. We compared TFS, HF medications, and surgical interventions in HLHS patients with and without functional normalization. Results Of 99 patients with HLHS and RV dysfunction, 52% had normalized function for ≥30 days. TFS at 2 years after dysfunction onset was lower in those without normalization (14% vs 78%, P < 0.001). Patients without normalization were less likely to reach target dosing (TD) of HF medications (27% vs 47% on 1 medication at TD, P < 0.001) and undergo Fontan completion (7% vs 53%, P < 0.001). Clinical factors associated with improved TFS were normalization of function for ≥30 days, onset of dysfunction after bidirectional Glenn, and exposure to ACE inhibition. Conclusions Our cohort of HLHS patients with systemic RV dysfunction demonstrated a novel finding of improved TFS in those with functional normalization for ≥30 days. Achieving TD of HF medications was associated with improved outcomes. This may reflect patient stability and tolerance for HF medication more than its therapeutic effect, but it can help inform decisions to proceed with surgical palliation or list for transplant.
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Affiliation(s)
- Aine Lynch
- Division of Cardiology, The Hospital for Sick Children, Toronto, Ontario, Canada
- University of Toronto, Toronto, Ontario, Canada
| | - Aamir Jeewa
- Division of Cardiology, The Hospital for Sick Children, Toronto, Ontario, Canada
- University of Toronto, Toronto, Ontario, Canada
| | - Sunghoon Minn
- Division of Cardiology, The Hospital for Sick Children, Toronto, Ontario, Canada
- University of Toronto, Toronto, Ontario, Canada
| | - Katelyn Arathoon
- Division of Cardiology, The Hospital for Sick Children, Toronto, Ontario, Canada
- University of Toronto, Toronto, Ontario, Canada
| | - Osami Honjo
- University of Toronto, Toronto, Ontario, Canada
- Division of Cardiovascular Surgery, The Labatt Family Heart Centre, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Alejandro Floh
- University of Toronto, Toronto, Ontario, Canada
- Division of Critical Care Medicine, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Ahmed Hassan
- Division of Cardiology, The Hospital for Sick Children, Toronto, Ontario, Canada
- University of Toronto, Toronto, Ontario, Canada
| | - Emilie Jean-St-Michel
- Division of Cardiology, The Hospital for Sick Children, Toronto, Ontario, Canada
- University of Toronto, Toronto, Ontario, Canada
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2
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Geoffrion TR, Fuller SM. High-Risk Anatomic Subsets in Hypoplastic Left Heart Syndrome. World J Pediatr Congenit Heart Surg 2022; 13:593-599. [PMID: 36053102 DOI: 10.1177/21501351221111390] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Despite overall improvements in outcomes for patients with hypoplastic left heart syndrome, there remain anatomic features that can place these patients at higher risk throughout their treatment course. These include severe preoperative obstruction to pulmonary venous return, restrictive atrial septum, coronary fistulae, severe tricuspid regurgitation, smaller ascending aorta diameter (especially if <2 mm), and poor ventricular function. The risk of traditional staged palliation has led to the development of alternative strategies for such patients. To further improve the outcomes, we must continue to diligently examine and study anatomic details in HLHS patients.
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Affiliation(s)
- Tracy R Geoffrion
- Division of Cardiothoracic Surgery, 6567Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Stephanie M Fuller
- Division of Cardiothoracic Surgery, 6567Children's Hospital of Philadelphia, Philadelphia, PA, USA.,Division of Cardiothoracic Surgery, Department of Surgery, 14640Perelman School of Medicine of the University of Pennsylvania, Philadelphia, PA, USA
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3
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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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4
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Merkle-Storms J, Djordjevic I, Weber C, Avgeridou S, Krasivskyi I, Gaisendrees C, Mader N, Kuhn-Régnier F, Kröner A, Bennink G, Sabashnikov A, Trieschmann U, Wahlers T, Menzel C. Impact of Lactate Clearance on Early Outcomes in Pediatric ECMO Patients. ACTA ACUST UNITED AC 2021; 57:medicina57030284. [PMID: 33803807 PMCID: PMC8003148 DOI: 10.3390/medicina57030284] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2021] [Revised: 03/07/2021] [Accepted: 03/15/2021] [Indexed: 11/16/2022]
Abstract
Background and Objectives: Pediatric extracorporeal membrane oxygenation (ECMO) support is often the ultimate therapy for neonatal and pediatric patients with congenital heart defects after cardiac surgery. The impact of lactate clearance in pediatric patients during ECMO therapy on outcomes has been analyzed. Materials andMethods: We retrospectively analyzed data from 41 pediatric vaECMO patients between January 2006 and December 2016. Blood lactate and lactate clearance have been recorded prior to ECMO implantation and 3, 6, 9 and 12 h after ECMO start. Receiver operating characteristic (ROC) analysis was used to identify cut-off levels for lactate clearance. Results: Lactate levels prior to ECMO therapy (9.8 mmol/L vs. 13.5 mmol/L; p = 0.07) and peak lactate levels during ECMO support (10.4 mmol/L vs. 14.7 mmol/L; p = 0.07) were similar between survivors and nonsurvivors. Areas under the curve (AUC) of lactate clearance at 3, 9 h and 12 h after ECMO start were significantly predictive for mortality (p = 0.017, p = 0.049 and p = 0.006, respectively). Cut-off values of lactate clearance were 3.8%, 51% and 56%. Duration of ECMO support and respiratory ventilation was significantly longer in survivors than in nonsurvivors (p = 0.01 and p < 0.001, respectively). Conclusions: Dynamic recording of lactate clearance after ECMO start is a valuable tool to assess outcomes and effectiveness of ECMO application. Poor lactate clearance during ECMO therapy in pediatric patients is a significant marker for higher mortality.
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Affiliation(s)
- Julia Merkle-Storms
- Heart Centre, Department of Cardiothoracic Surgery, University of Cologne, 50924 Cologne, Germany; (C.W.); (S.A.); (I.K.); (C.G.); (N.M.); (F.K.-R.); (A.K.); (G.B.); (A.S.); (T.W.)
- Correspondence: (J.M.-S.); (I.D.)
| | - Ilija Djordjevic
- Heart Centre, Department of Cardiothoracic Surgery, University of Cologne, 50924 Cologne, Germany; (C.W.); (S.A.); (I.K.); (C.G.); (N.M.); (F.K.-R.); (A.K.); (G.B.); (A.S.); (T.W.)
- Correspondence: (J.M.-S.); (I.D.)
| | - Carolyn Weber
- Heart Centre, Department of Cardiothoracic Surgery, University of Cologne, 50924 Cologne, Germany; (C.W.); (S.A.); (I.K.); (C.G.); (N.M.); (F.K.-R.); (A.K.); (G.B.); (A.S.); (T.W.)
| | - Soi Avgeridou
- Heart Centre, Department of Cardiothoracic Surgery, University of Cologne, 50924 Cologne, Germany; (C.W.); (S.A.); (I.K.); (C.G.); (N.M.); (F.K.-R.); (A.K.); (G.B.); (A.S.); (T.W.)
| | - Ihor Krasivskyi
- Heart Centre, Department of Cardiothoracic Surgery, University of Cologne, 50924 Cologne, Germany; (C.W.); (S.A.); (I.K.); (C.G.); (N.M.); (F.K.-R.); (A.K.); (G.B.); (A.S.); (T.W.)
| | - Christopher Gaisendrees
- Heart Centre, Department of Cardiothoracic Surgery, University of Cologne, 50924 Cologne, Germany; (C.W.); (S.A.); (I.K.); (C.G.); (N.M.); (F.K.-R.); (A.K.); (G.B.); (A.S.); (T.W.)
| | - Navid Mader
- Heart Centre, Department of Cardiothoracic Surgery, University of Cologne, 50924 Cologne, Germany; (C.W.); (S.A.); (I.K.); (C.G.); (N.M.); (F.K.-R.); (A.K.); (G.B.); (A.S.); (T.W.)
| | - Ferdinand Kuhn-Régnier
- Heart Centre, Department of Cardiothoracic Surgery, University of Cologne, 50924 Cologne, Germany; (C.W.); (S.A.); (I.K.); (C.G.); (N.M.); (F.K.-R.); (A.K.); (G.B.); (A.S.); (T.W.)
| | - Axel Kröner
- Heart Centre, Department of Cardiothoracic Surgery, University of Cologne, 50924 Cologne, Germany; (C.W.); (S.A.); (I.K.); (C.G.); (N.M.); (F.K.-R.); (A.K.); (G.B.); (A.S.); (T.W.)
| | - Gerardus Bennink
- Heart Centre, Department of Cardiothoracic Surgery, University of Cologne, 50924 Cologne, Germany; (C.W.); (S.A.); (I.K.); (C.G.); (N.M.); (F.K.-R.); (A.K.); (G.B.); (A.S.); (T.W.)
| | - Anton Sabashnikov
- Heart Centre, Department of Cardiothoracic Surgery, University of Cologne, 50924 Cologne, Germany; (C.W.); (S.A.); (I.K.); (C.G.); (N.M.); (F.K.-R.); (A.K.); (G.B.); (A.S.); (T.W.)
| | - Uwe Trieschmann
- Anaesthesiology and Intensive Care Medicine, University of Cologne, 50924 Cologne, Germany; (U.T.); (C.M.)
| | - Thorsten Wahlers
- Heart Centre, Department of Cardiothoracic Surgery, University of Cologne, 50924 Cologne, Germany; (C.W.); (S.A.); (I.K.); (C.G.); (N.M.); (F.K.-R.); (A.K.); (G.B.); (A.S.); (T.W.)
| | - Christoph Menzel
- Anaesthesiology and Intensive Care Medicine, University of Cologne, 50924 Cologne, Germany; (U.T.); (C.M.)
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Foulks MG, Meyer RML, Gold JI, Herrington CS, Kallin K, Menteer J. Postoperative heart failure after stage 1 palliative surgery for single ventricle cardiac disease. Pediatr Cardiol 2019; 40:943-949. [PMID: 30937501 DOI: 10.1007/s00246-019-02093-4] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/11/2018] [Accepted: 03/13/2019] [Indexed: 10/27/2022]
Abstract
Outcomes for patients with single ventricle congenital heart disease (SV-CHD) continue to improve over time. However, the prognosis for patients who develop heart failure immediately after surgery is poorly understood. We conducted a single-center, retrospective cohort study of patients with SV-CHD, who suffered postoperative heart failure. Of 1038 cardiac surgeries performed on 621 SV-CHD patients between 2004 and 2010, 125 patients met inclusion criteria, including non-septatable anatomy, stage 1 surgery, and verified low cardiac output or heart failure state per STS definition. Overall survival was 73.2% at 2 months, 64.9% at 1 year, 60.5% at 2 years, and 54.6% at 4 years. Inotrope dependence beyond 7 days post-op yielded 45% 2-year survival versus 68% for those who weaned from inotropes within 7 days (p = 0.02). Atrioventricular valve regurgitation (AVVR) influenced survival, and patients who developed renal failure or required ECMO fared poorly, even when they survived their hospitalization. Patients with postoperative heart failure and low cardiac output syndrome constitute a high-risk population beyond the term of the initial hospitalization and have an overall mid-term survival of 55% at 4 years. Wean from inotropic therapy is not completely reassuring in this population, as they have ongoing elevated risk of cardiac failure and death in the medium term. Ventricular dysfunction, AVVR, renal failure, and need for ECMO are all important prognostic factors for mid-term mortality. Inotrope dependence for > 7 days has important implications reaching beyond the hospitalization.
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Affiliation(s)
- Michael G Foulks
- Department of Anesthesia, University of Washington Medical Center, Seattle, WA, USA
| | - Rika M L Meyer
- Department of Child and Adolescent Development, California State University, Northridge, CA, USA
| | - Jeffrey I Gold
- Keck School of Medicine, Department of Pediatrics, University of Southern California, Los Angeles, CA, USA
| | - Cynthia S Herrington
- Division of Cardiothoracic Surgery, Children's Hospital Los Angeles, Los Angeles, CA, USA
| | - Kristopher Kallin
- Cardiovascular Surgery, Kaiser Permanente Los Angeles, Los Angeles, CA, USA
| | - JonDavid Menteer
- Division of Cardiology, Children's Hospital Los Angeles, MS#34 4650 W. Sunset Blvd, Los Angeles, CA, 90027, USA.
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6
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Riley AF, Ocampo EC, Hagan J, Lantin-Hermoso MR. Hand-held echocardiography in children with hypoplastic left heart syndrome. CONGENIT HEART DIS 2019; 14:706-712. [PMID: 30973683 DOI: 10.1111/chd.12774] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/07/2018] [Revised: 01/26/2019] [Accepted: 03/17/2019] [Indexed: 11/30/2022]
Abstract
BACKGROUND When performed by cardiologists, hand-held echocardiography (HHE) can assess ventricular systolic function and valve disease in adults, but its accuracy and utility in congenital heart disease is unknown. In hypoplastic left heart syndrome (HLHS), the echocardiographic detection of depressed right ventricular (RV) systolic function and higher grade tricuspid regurgitation (TR) can identify patients who are at increased risk of morbidity and mortality and who may benefit from additional imaging or medical therapies. METHODS Children with HLHS after Stage I or II surgical palliation (Norwood or Glenn procedures) were prospectively enrolled. Subjects underwent HHE by a pediatric cardiologist on the same day as standard echocardiography (SE). Using 4-point scales, bedside HHE assessment of RV systolic function and TR were compared with blinded assessment of offline SE images. Concordance correlation coefficient (CCC) was used to evaluate agreement. RESULTS Thirty-two HHEs were performed on 15 subjects (Stage I: n = 17 and Stage II: n = 15). Median subject age was 3.4 months (14 days-4.2 years). Median weight was 5.9 kg (2.6-15.4 kg). Bedside HHE assessment of RV systolic function and TR severity had substantial agreement with SE (CCC = 0.80, CCC = 0.74, respectively; P < .001). HHE sensitivity and specificity for any grade of depressed RV systolic function were 100% and 92%, respectively, and were 94% and 88% for moderate or greater TR, respectively. Average HHE scan time was 238 seconds. CONCLUSIONS HHE offers a rapid, bedside tool for pediatric cardiologists to detect RV systolic dysfunction and hemodynamically significant TR in HLHS.
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Affiliation(s)
- Alan F Riley
- Section of Pediatric Cardiology, Department of Pediatrics, Texas Children's Hospital, Baylor College of Medicine, Houston, Texas
| | - Elena C Ocampo
- Section of Pediatric Cardiology, Department of Pediatrics, Texas Children's Hospital, Baylor College of Medicine, Houston, Texas
| | - Joseph Hagan
- Newborn Center, Texas Children's Hospital, Houston, Texas
| | - M Regina Lantin-Hermoso
- Section of Pediatric Cardiology, Department of Pediatrics, Texas Children's Hospital, Baylor College of Medicine, Houston, Texas
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7
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Colquitt JL, Loar RW, Morris SA, Feagin DK, Sami S, Pignatelli RH. Serial Strain Analysis Identifies Hypoplastic Left Heart Syndrome Infants at Risk for Cardiac Morbidity and Mortality: A Pilot Study. J Am Soc Echocardiogr 2019; 32:643-650. [PMID: 30803862 DOI: 10.1016/j.echo.2019.01.006] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/14/2018] [Indexed: 11/28/2022]
Abstract
BACKGROUND Validated, objective measures of right ventricular (RV) function assessment in hypoplastic left heart syndrome (HLHS) are needed. In other populations, speckle-tracking echocardiography-derived strain is a sensitive measure that outperforms conventional parameters of RV function. We hypothesized that speckle-tracking echocardiography-derived measures of RV function would be worse in patients with HLHS who have a poor cardiac outcome. METHODS Prospective serial echocardiography was performed in 35 infants with HLHS during the first 6 months of life. Patients not undergoing staged palliation or with other variants of single RV were excluded. Traditional RV measurements and strain analysis were performed from standard apical and basal views. The primary outcome of cardiac death, heart transplantation, or persistent ≥ moderate RV dysfunction was examined using Cox regression analysis, and receiver operating characteristic curve analyses were performed to derive cutoff values. RESULTS At median follow-up of 10.9 months (interquartile range 5.6, 15.2), eight patients reached the outcome and demonstrated worse RV strain measures compared with those without the outcome. A post-Norwood global longitudinal strain (GLS) of > -16% (area under the curve [AUC] = 0.76; P = .04) and pre-Glenn GLS > -13% (AUC, 0.98; P ≤ .01) were highly sensitive and specific for poor outcome. Other thresholds included post-Norwood GLS rate (GLSr) > -1.15 %/s (AUC, 0.78; P = .03), pre-Glenn GLSr = -0.85%/sec (AUC, 0.89; P < .01), post-Glenn circumferential strain rate > -0.85%/sec (AUC, 0.92; P < .01), and GLSr > -0.85%/sec (AUC, 0.84; P = .02). CONCLUSIONS Strain analysis may help identify at-risk HLHS infants. In this pilot study, interstage strain indices were worse in infants with HLHS who had a poor cardiac outcome.
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Affiliation(s)
- John L Colquitt
- Texas Children's Hospital, Baylor College of Medicine, Houston, Texas.
| | - Robert W Loar
- Texas Children's Hospital, Baylor College of Medicine, Houston, Texas
| | - Shaine A Morris
- Texas Children's Hospital, Baylor College of Medicine, Houston, Texas
| | - Douglas K Feagin
- Texas Children's Hospital, Baylor College of Medicine, Houston, Texas
| | - Sarah Sami
- Texas Children's Hospital, Baylor College of Medicine, Houston, Texas
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8
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Kulik TJ, Sleeper LA, VanderPluym C, Sanders SP. Systemic Ventricular Dysfunction Between Stage One and Stage Two Palliation. Pediatr Cardiol 2018; 39:1514-1522. [PMID: 29948029 DOI: 10.1007/s00246-018-1923-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/22/2017] [Accepted: 06/06/2018] [Indexed: 11/28/2022]
Abstract
Infants with a single ventricle can develop systemic ventricular dysfunction (SVD) after stage 1 operation, but available information is sparse. We reviewed our patients having Norwood, Sano, or hybrid procedures to better understand this problem. We conducted a retrospective, case-controlled cohort study of 267 patients having stage1 operation, examining outcomes between stages 1 and 2 (survival and subsequent cardiac surgeries), predictor variables, and histology of hearts explanted at transplantation. SVD developed in 32 (12%) patients and resolved in 13 (41%); mean age of onset was 3.0 ± 1.63 months; median = 2.79. SVD was not associated with cardiac anatomy, type of stage 1 procedure, weight, coronary abnormality, or atrioventricular valve regurgitation. The mean age of resolution = 12.1 ± 9.6 months; median = 6.3, and resolution may have been more likely with a systemic LV than RV (p = 0.067). Outcomes for the entire SVD group were less favorable than for those without, but patients with resolution of SVD had outcomes at least as good those without SVD. Myocardial histology (n = 4) suggested chronic ischemia. The risk of SVD after stage 1, while low, may be a fundamental feature of this patient population. SVD occurs with either a systemic RV or LV, although patients with a systemic LV may be more likely to have resolution than those with an RV. We identified no predictor variables, but histologic findings suggest chronic ischemia may be involved. Given the low incidence of SVD, multi-center studies will be required to better define predictors of onset and resolution.
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Affiliation(s)
- Thomas J Kulik
- Department of Cardiology, Boston Children's Hospital, 300 Longwood Ave., Boston, MA, 02115, USA. .,Division of Cardiac Critical Care, Boston Children's Hospital, 300 Longwood Ave., Boston, MA, 02115, USA. .,The Pulmonary Hypertension Program, Boston Children's Hospital, 300 Longwood Ave., Boston, MA, 02115, USA. .,Harvard Medical School, Boston Children's Hospital, Boston, MA, USA.
| | - Lynn A Sleeper
- Department of Cardiology, Boston Children's Hospital, 300 Longwood Ave., Boston, MA, 02115, USA.,Harvard Medical School, Boston Children's Hospital, Boston, MA, USA
| | - Christina VanderPluym
- Department of Cardiology, Boston Children's Hospital, 300 Longwood Ave., Boston, MA, 02115, USA.,Harvard Medical School, Boston Children's Hospital, Boston, MA, USA
| | - Stephen P Sanders
- Department of Cardiology, Boston Children's Hospital, 300 Longwood Ave., Boston, MA, 02115, USA.,Harvard Medical School, Boston Children's Hospital, Boston, MA, USA
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9
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Jean-St-Michel E, Meza JM, Maguire J, Coles J, McCrindle BW. Survival to Stage II with Ventricular Dysfunction: Secondary Analysis of the Single Ventricle Reconstruction Trial. Pediatr Cardiol 2018. [PMID: 29520465 DOI: 10.1007/s00246-018-1845-4] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Ventricular dysfunction affects survival in patients with single right ventricle (RV), and remains one of the primary indications for heart transplantation. Since it is challenging to predict the capacity of patients with ventricular dysfunction to proceed to the stage II procedure, we sought to identify factors that would be associated with death or heart transplantation without achieving stage II for single RV patients with ventricular dysfunction after Norwood procedure. The Single Ventricle Reconstruction (SVR) trial public-use database was used. Patients with a RV ejection fraction less than 44% or a RV fractional area of change less than 35% on the post-Norwood echocardiogram were included. Parametric risk hazard analysis was used to identify risk factors for death or transplantation without achieving stage II. Of 365 patients with ventricular function measurements on the post-Norwood echocardiogram, 123 (34%) patients had RV dysfunction. The transplantation-free survival was significantly lower for those with ventricular dysfunction compared to those with normal function (log rank Chi-square = 4.23, p = 0.04). Furthermore, having a Blalock-Taussig (BT) shunt, a large RV, a post-Norwood infectious complication, and a surgeon who performs five or less Norwood per year were independent risk factors for death or transplantation without achieving stage II. The predicted 6-month transplantation-free survival for patients with all four identified risk factors was 1% (70% CI 0-13%). Early heart transplantation referral might be considered for post-Norwood patients with BT shunt and RV dysfunction, especially if other high-risk features are present.
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Affiliation(s)
- Emilie Jean-St-Michel
- Division of Cardiology, The Labatt Family Heart Centre, Department of Pediatrics, The Hospital for Sick Children, University of Toronto, 555 University Avenue, Toronto, ON, M5G 1X8, Canada.
| | - James M Meza
- Division of Cardiovascular Surgery, The Labatt Family Heart Centre, Department of Surgery, The Hospital for Sick Children, University of Toronto, 555 University Avenue, Toronto, ON, M5G 1X8, Canada
| | - Jonathon Maguire
- Li Ka Shing Knowledge Institute of St. Michael's hospital, Department of Pediatrics, St. Michael's Hospital, University of Toronto, 30 Bond St, Toronto, ON, M5B1W8, Canada
| | - John Coles
- Division of Cardiovascular Surgery, The Labatt Family Heart Centre, Department of Surgery, The Hospital for Sick Children, University of Toronto, 555 University Avenue, Toronto, ON, M5G 1X8, Canada
| | - Brian W McCrindle
- Division of Cardiology, The Labatt Family Heart Centre, Department of Pediatrics, The Hospital for Sick Children, University of Toronto, 555 University Avenue, Toronto, ON, M5G 1X8, Canada
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10
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Meza JM, Hickey E, McCrindle B, Blackstone E, Anderson B, Overman D, Kirklin JK, Karamlou T, Caldarone C, Kim R, DeCampli W, Jacobs M, Guleserian K, Jacobs JP, Jaquiss R. The Optimal Timing of Stage-2-Palliation After the Norwood Operation. Ann Thorac Surg 2017; 105:193-199. [PMID: 28847537 DOI: 10.1016/j.athoracsur.2017.05.041] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/20/2017] [Revised: 05/11/2017] [Accepted: 05/12/2017] [Indexed: 11/18/2022]
Abstract
BACKGROUND The effect of the timing of stage-2-palliation (S2P) on survival through single ventricle palliation remains unknown. This study investigated the optimal timing of S2P that minimizes pre-S2P attrition and maximizes post-S2P survival. METHODS The Congenital Heart Surgeons' Society's critical left ventricular outflow tract obstruction cohort was used. Survival analysis was performed using multiphase parametric hazard analysis. Separate risk factors for death after the Norwood and after S2P were identified. Based on the multivariable models, infants were stratified as low, intermediate, or high risk. Cumulative 2-year, post-Norwood survival was predicted. Optimal timing was determined using conditional survival analysis and plotted as 2-year, post-Norwood survival versus age at S2P. RESULTS A Norwood operation was performed in 534 neonates from 21 institutions. The S2P was performed in 71%, at a median age of 5.1 months (IQR: 4.3 to 6.0), and 22% died after Norwood. By 5 years after S2P, 10% of infants had died. For low- and intermediate-risk infants, performing S2P after age 3 months was associated with 89% ± 3% and 82% ± 3% 2-year survival, respectively. Undergoing an interval cardiac reoperation or moderate-severe right ventricular dysfunction before S2P were high-risk features. Among high-risk infants, 2-year survival was 63% ± 5%, and even lower when S2P was performed before age 6 months. CONCLUSIONS Performing S2P after age 3 months may optimize survival of low- and intermediate-risk infants. High-risk infants are unlikely to complete three-stage palliation, and early S2P may increase their risk of mortality. We infer that early referral for cardiac transplantation may increase their chance of survival.
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Affiliation(s)
- James M Meza
- Division of Cardiovascular Surgery, The Hospital for Sick Children, Toronto, Ontario
| | - Edward Hickey
- Division of Cardiovascular Surgery, The Hospital for Sick Children, Toronto, Ontario
| | - Brian McCrindle
- Division of Pediatric Cardiology, The Hospital for Sick Children, Toronto, Ontario
| | - Eugene Blackstone
- Division of Thoracic and Cardiovascular Surgery and Quantitative Health Sciences, Cleveland Clinic, Cleveland, Ohio
| | - Brett Anderson
- Division of Cardiology, Morgan-Stanley Children's Hospital/New York Presbyterian Hospital, New York, New York
| | - David Overman
- Division of Pediatric Cardiovascular Surgery, Children's Hospitals and Clinics of Minnesota, Minneapolis, Minnesota
| | - James K Kirklin
- Division of Cardiothoracic Surgery, University of Alabama at Birmingham, Birmingham, Alabama
| | - Tara Karamlou
- Division of Thoracic and Cardiovascular Surgery, Phoenix Children's Hospital, Phoenix, Arizona
| | - Christopher Caldarone
- Division of Cardiovascular Surgery, The Hospital for Sick Children, Toronto, Ontario
| | - Richard Kim
- Division of Cardiothoracic Surgery, Los Angeles Children's Hospital, Los Angeles, California
| | - William DeCampli
- Division of Pediatric Cardiac Surgery, Arnold Palmer Hospital for Children, Orlando, Florida
| | - Marshall Jacobs
- Division of Cardiac Surgery, Johns Hopkins Heart and Vascular Institute, Baltimore, Maryland
| | - Kristine Guleserian
- Division of Cardiovascular Surgery, Niklaus Children's Hospital, Miami, Florida
| | - Jeffrey P Jacobs
- Division of Cardiovascular Surgery, Johns Hopkins All Children's Hospital, St. Petersburg, Florida
| | - Robert Jaquiss
- Division of Pediatric Cardiothoracic Surgery, Children's Medical Center, Dallas, Texas.
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Tadphale SD, Tang X, ElHassan NO, Beam B, Prodhan P. Cavopulmonary Anastomosis During Same Hospitalization as Stage 1 Norwood/Hybrid Palliative Surgery. Ann Thorac Surg 2017; 103:1285-1291. [PMID: 28274521 DOI: 10.1016/j.athoracsur.2017.01.013] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/05/2016] [Revised: 11/27/2016] [Accepted: 01/03/2017] [Indexed: 12/23/2022]
Abstract
BACKGROUND Limited literature has examined characteristics of infants with hypoplastic left heart syndrome (HLHS) who remain hospitalized during the interstage period. We described their epidemiologic characteristics, in-hospital outcomes, and identified risk factors that predict the need for superior cavopulmonary anastomosis (SCPA) during the same hospitalization. METHODS This retrospective multicenter database analysis included infants with HLHS who underwent stage 1 palliation from 2004 through 2013. RESULTS Among 5374 infants with HLHS, 314 (5.8%) underwent SCPA during the same hospitalization as stage 1 palliation. They had a higher incidence of baseline comorbidities, complications, and interventions than infants who were discharged. Despite an overall increase in need for SCPA in the same hospitalization across different eras, there was no significant statistical difference in mortality in the two groups in the same era. Septicemia, necrotizing enterocolitis, modified Blalock-Taussig shunt, cardiac catheterization, cardiopulmonary resuscitation, extracorporeal membrane oxygenation, gastrostomy tube, and antiarrhythmic agents were independently associated with increased odds of undergoing SCPA during the same hospitalization. Patients undergoing right ventricle to pulmonary artery shunt were less likely to remain hospitalized until stage 2 palliation. Nonsurvivors in the SCPA group had greater need for interventions and worse intensive care unit outcomes. CONCLUSIONS Infants with HLHS who remain hospitalized after stage 1 until their stage 2 palliation differ significantly from infants who were discharged. Several clinical characteristics, comorbidities, and need for interventions are associated with the likelihood for undergoing stage 2 palliation during the same hospitalization. Timely identification and intervention of adjustable causes of heart failure may improve outcomes.
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Affiliation(s)
- Sachin D Tadphale
- Pediatric Cardiology, Department of Pediatrics, University of Tennessee Health Science Center, Le Bonheur Children's Hospital, Memphis, Tennessee; Pediatric Critical Care, Department of Pediatrics, University of Tennessee Health Science Center, Le Bonheur Children's Hospital, Memphis, Tennessee.
| | - Xinyu Tang
- Department of Biostatistics, University of Arkansas for Medical Sciences, Arkansas Children's Hospital, Little Rock, Arkansas
| | - Nahed O ElHassan
- Department of Neonatology, University of Arkansas for Medical Sciences, Arkansas Children's Hospital, Little Rock, Arkansas
| | - Brandon Beam
- Department of Pediatric Cardiology, University of Arkansas for Medical Sciences, Arkansas Children's Hospital, Little Rock, Arkansas
| | - Parthak Prodhan
- Department of Pediatric Cardiology, University of Arkansas for Medical Sciences, Arkansas Children's Hospital, Little Rock, Arkansas; Department of Pediatric Critical Care, University of Arkansas for Medical Sciences, Arkansas Children's Hospital, Little Rock, Arkansas
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12
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Mechanically assisted bidirectional cavopulmonary shunt in neonates and infants: An acute human pilot study. J Thorac Cardiovasc Surg 2016; 153:441-447. [PMID: 27817953 DOI: 10.1016/j.jtcvs.2016.09.048] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/15/2016] [Revised: 09/09/2016] [Accepted: 09/14/2016] [Indexed: 11/24/2022]
Abstract
OBJECTIVE Poor survival following surgical palliation for hypoplastic left heart syndrome (HLHS) raises the question of the need for a paradigm shift. This is the first human study to investigate the possibility of primary "in-series" palliation in neonates and infants with HLHS in an acute setting with the aid of 2 types of mechanical assist: superior vena cava (SVC)-to-pulmonary artery (PA) pump assist and SVC-to-right atrium (RA) oxygenation assist. METHODS By rearranging the cannula sites and flow rates for modified ultrafiltration, 2 types of mechanically assisted bidirectional cavopulmonary shunt (BCPS) circulation were simulated for 20 minutes. Three neonates undergoing a stage I Norwood procedure were assigned to SVC-PA pump assist, and 3 infants undergoing stage II BCPS were assigned to SVC-RA oxygenation assist. Hemodynamic parameters, blood gas values, and arterial (SaO2) and regional cerebral tissue (rCTO2) saturations were analyzed. RESULTS All 6 patients completed the study without hemodynamic compromise. In the SVC-PA pump assist group, a mean arterial pressure >40 mm Hg was maintained. SVC pressure was lower (P = .01) and cerebral perfusion pressure (CPP) was higher (P = .03) during the last 10 minutes of assist compared with Norwood physiology. SaO2 >80%, rCTO2 >60%, and mixed venous saturation ≥59% were maintained, comparable to values with Norwood physiology. In the SVC-RA oxygenation assist group, with full or 50% support, mean blood pressure >50 mm Hg, SVC pressure <15 mm Hg, mixed venous saturation >50%, and CPP >40 mm Hg were maintained, which were comparable to BCPS physiology. CONCLUSIONS Two types of mechanical assist to support primary in-series palliation are feasible in the acute setting. Both modes of mechanical assist maintained oxygenation, as well as systemic and cerebral perfusion.
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