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El Khoudary SR, Fabio A, Yester JW, Steinhauser ML, Christopher AB, Gyngard F, Adams PS, Morell VO, Viegas M, Da Silva JP, Da Silva LF, Castro-Medina M, McCormick A, Reyes-Múgica M, Barlas M, Liu H, Thomas D, Ammanamanchi N, Sada R, Cuda M, Hartigan E, Groscost DK, Kühn B. Design and rationale of a clinical trial to increase cardiomyocyte division in infants with tetralogy of Fallot. Int J Cardiol 2021; 339:36-42. [PMID: 34265312 DOI: 10.1016/j.ijcard.2021.07.020] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/06/2021] [Revised: 07/02/2021] [Accepted: 07/08/2021] [Indexed: 12/20/2022]
Abstract
BACKGROUND Patients with Tetralogy of Fallot with pulmonary stenosis (ToF/PS), the most common form of cyanotic congenital heart disease (CHD), develop adverse right ventricular (RV) remodeling, leading to late heart failure and arrhythmia. We recently demonstrated that overactive β-adrenergic receptor signaling inhibits cardiomyocyte division in ToF/PS infants, providing a conceptual basis for the hypothesis that treatment with the β-adrenergic receptor blocker, propranolol, early in life would increase cardiomyocyte division. No data are available in ToF/PS infants on the efficacy of propranolol as a possible novel therapeutic option to increase cardiomyocyte division and potentially reduce adverse RV remodeling. METHODS Using a randomized, double-blind, placebo-controlled trial, we will evaluate the effect of propranolol administration on reactivating cardiomyocyte proliferation to prevent adverse RV remodeling in 40 infants with ToF/PS. Propranolol administration (1 mg/kg po QID) will begin at 1 month of age and last until surgical repair. The primary endpoint is cardiomyocyte division, quantified after 15N-thymidine administration with Multi-isotope Imaging Mass Spectrometry (MIMS) analysis of resected myocardial specimens. The secondary endpoints are changes in RV myocardial and cardiomyocyte hypertrophy. CONCLUSION This trial will be the first study in humans to assess whether cardiomyocyte proliferation can be pharmacologically increased. If successful, the results could introduce a paradigm shift in the management of patients with ToF/PS from a purely surgical approach, to synergistic medical and surgical management. It will provide the basis for future multi-center randomized controlled trials of propranolol administration in infants with ToF/PS and other types of CHD with RV hypertension. CLINICAL TRIAL REGISTRATION The trial protocol was registered at clinicaltrials.gov (NCT04713657).
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Affiliation(s)
- Samar R El Khoudary
- Epidemiology Data Center, Graduate School of Public Health, University of Pittsburgh
| | - Anthony Fabio
- Epidemiology Data Center, Graduate School of Public Health, University of Pittsburgh
| | - Jessie W Yester
- Division of Cardiology, UPMC Children's Hospital of Pittsburgh and Department of Pediatrics, 4401 Penn Ave, Pittsburgh, PA 15224, USA; Pediatric Institute for Heart Regeneration and Therapeutics (I-HRT), UPMC Children's Hospital of Pittsburgh and Department of Pediatrics, 4401 Penn Ave, Pittsburgh, PA 15224, USA
| | - Matthew L Steinhauser
- Aging Institute, University of Pittsburgh, Bridgeside Point 1, 5th Floor, 100 Technology Drive, Pittsburgh, PA 15219, USA; UPMC Heart and Vascular Institute, UPMC Presbyterian, 200 Lothrop St., Pittsburgh, PA 15213, USA
| | - Adam B Christopher
- Division of Cardiology, UPMC Children's Hospital of Pittsburgh and Department of Pediatrics, 4401 Penn Ave, Pittsburgh, PA 15224, USA
| | - Frank Gyngard
- Center for NanoImaging, Division of Genetics, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, 65 Landsdowne St, Rm 535, Cambridge, MA 02139, USA
| | - Phillip S Adams
- Department of Anesthesiology and Perioperative Medicine, UPMC Children's Hospital of Pittsburgh, 4401 Penn Ave, Pittsburgh, PA 15224, USA
| | - Victor O Morell
- Pediatric Cardiothoracic Surgery, UPMC Children's Hospital of Pittsburgh, 4401 Penn Ave, Pittsburgh, PA 15224, USA
| | - Melita Viegas
- Pediatric Cardiothoracic Surgery, UPMC Children's Hospital of Pittsburgh, 4401 Penn Ave, Pittsburgh, PA 15224, USA
| | - Jose P Da Silva
- Pediatric Cardiothoracic Surgery, UPMC Children's Hospital of Pittsburgh, 4401 Penn Ave, Pittsburgh, PA 15224, USA
| | - Luciana F Da Silva
- Pediatric Cardiothoracic Surgery, UPMC Children's Hospital of Pittsburgh, 4401 Penn Ave, Pittsburgh, PA 15224, USA
| | - Mario Castro-Medina
- Pediatric Cardiothoracic Surgery, UPMC Children's Hospital of Pittsburgh, 4401 Penn Ave, Pittsburgh, PA 15224, USA
| | - Andrew McCormick
- Vascular Anomaly Center, UPMC Children's Hospital of Pittsburgh and Department of Pediatrics, 4401 Penn Ave, Pittsburgh, PA 15224, USA
| | - Miguel Reyes-Múgica
- Division of Pediatric Pathology, UPMC Children's Hospital of Pittsburgh, University of Pittsburgh School of Medicine, Pittsburgh, PA 15224, USA
| | - Michelle Barlas
- Investigational Drug Service, UPMC Children's Hospital of Pittsburgh and Department of Pediatrics, 4401 Penn Ave, Pittsburgh, PA 15224, USA
| | - Honghai Liu
- Division of Cardiology, UPMC Children's Hospital of Pittsburgh and Department of Pediatrics, 4401 Penn Ave, Pittsburgh, PA 15224, USA; Pediatric Institute for Heart Regeneration and Therapeutics (I-HRT), UPMC Children's Hospital of Pittsburgh and Department of Pediatrics, 4401 Penn Ave, Pittsburgh, PA 15224, USA
| | - Dawn Thomas
- Clinical Research Support Services (CRSS), UPMC Children's Hospital of Pittsburgh and Department of Pediatrics, 4401 Penn Ave, Pittsburgh, PA 15224, USA
| | - Niyatie Ammanamanchi
- Division of Cardiology, UPMC Children's Hospital of Pittsburgh and Department of Pediatrics, 4401 Penn Ave, Pittsburgh, PA 15224, USA; Pediatric Institute for Heart Regeneration and Therapeutics (I-HRT), UPMC Children's Hospital of Pittsburgh and Department of Pediatrics, 4401 Penn Ave, Pittsburgh, PA 15224, USA
| | - Rachel Sada
- Clinical Research Support Services (CRSS), UPMC Children's Hospital of Pittsburgh and Department of Pediatrics, 4401 Penn Ave, Pittsburgh, PA 15224, USA
| | - Megan Cuda
- Clinical Research Support Services (CRSS), UPMC Children's Hospital of Pittsburgh and Department of Pediatrics, 4401 Penn Ave, Pittsburgh, PA 15224, USA
| | - Elizabeth Hartigan
- Clinical Research Support Services (CRSS), UPMC Children's Hospital of Pittsburgh and Department of Pediatrics, 4401 Penn Ave, Pittsburgh, PA 15224, USA
| | - David K Groscost
- Division of Cardiology, UPMC Children's Hospital of Pittsburgh and Department of Pediatrics, 4401 Penn Ave, Pittsburgh, PA 15224, USA
| | - Bernhard Kühn
- Division of Cardiology, UPMC Children's Hospital of Pittsburgh and Department of Pediatrics, 4401 Penn Ave, Pittsburgh, PA 15224, USA; Pediatric Institute for Heart Regeneration and Therapeutics (I-HRT), UPMC Children's Hospital of Pittsburgh and Department of Pediatrics, 4401 Penn Ave, Pittsburgh, PA 15224, USA; McGowan Institute of Regenerative Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA 15219, USA.
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Multi-detector computed tomography in the assessment of tetralogy of Fallot patients: is it a must? Egypt Heart J 2020; 72:17. [PMID: 32266511 PMCID: PMC7138870 DOI: 10.1186/s43044-020-00047-3] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2019] [Accepted: 02/28/2020] [Indexed: 11/10/2022] Open
Abstract
Background Tetralogy of Fallot (TOF) accounts for 10% of all CHD. It classically consists of ventricular septal defect (VSD), aortic overriding, right ventricular outflow tract (RVOT) obstruction, and RV hypertrophy. There are many anatomic variants, associated intracardiac and extracardiac anomalies that must be taken into consideration when imaging and planning the surgical procedure needed. Multi-detector computed tomography (MDCT), with its high spatial and temporal resolution, has a pivotal role in the evaluation of complex anatomical findings in both unrepaired and repaired TOF patients. Main body Though MDCT has a limited role in the initial diagnosis of TOF, it is particularly important when there is a question about anatomy of pulmonary arteries (PAs) (whether sizable, hypoplastic, or atretic), presence of major aorto-pulmonary collaterals (MAPCAs) and presence of additional VSDs. Additionally, MDCT is crucial in the diagnosis of different anatomical variants of TOF. TOF patients with absent pulmonary valve classically have hugely dilated PAs which raise an important question about the degree and severity of airways compression. This question can be accurately answered by MDCT. TOF with double-outlet RV (DORV) has variable degrees of aortic override which can be assessed by MDCT. An atrio-ventricular septal defect (AVSD) is seen in about 13% of TOF cases and typically occurs in patients with Down syndrome. MDCT can assess the size and extent of inlet VSD and size of both ventricles (balanced or unbalanced AVSD). Coronary artery anomalies are common and important association. MDCT can identify the presence of a major coronary artery crossing the RVOT, a left anterior descending (LAD) from RCA, or a dual LAD. The clinical importance of these anomalies is its susceptibility to injury during ventriculotomy incision required for TOF repair necessitating changing the usual approach of surgery. Patients with reduced pulmonary blood flow undergo a systemic to pulmonary shunt. MDCT can assess the patency of the shunt, stenotic, or occluded segments. In surgically repaired TOF patients, MDCT can identify the sequalae and long-term complications including residual RVOT obstruction, conduit stenosis, RVOT patch aneurysm, RVH, and aortic root dilatation. Conclusion MDCT is a safe and reliable imaging modality that provides accurate assessment of anatomical variants and associated anomalies of TOF.
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Kaley VR, Aregullin EO, Samuel BP, Vettukattil JJ. Trends in the off-label use of β-blockers in pediatric patients. Pediatr Int 2019; 61:1071-1080. [PMID: 31571355 DOI: 10.1111/ped.14015] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/14/2018] [Revised: 06/10/2019] [Accepted: 09/24/2019] [Indexed: 11/30/2022]
Abstract
The use of US Food and Drug Administration (FDA)-approved drugs for the treatment of an unapproved indication or in an unapproved age group, or at doses or route of administration not indicated on the label is known as off-label use. Off-label use may be beneficial in circumstances when the standard-of-care treatment has failed, and/or no other FDA-approved medications are available for a particular condition. In pediatric patients, off-label use may increase the risk of adverse events as pharmacokinetic and pharmacodynamic data are limited in children. Approximately 73% of off-label drugs currently prescribed for various conditions do not have sufficient scientific evidence for safety and efficacy. For example, β-blockers are a class of drugs with FDA-approval for very few indications in pediatrics but are commonly used for various off-label indications. Interestingly, the proportion of off-label use of β-blockers in adults is at about 52% (66.2 million) of the total number of β-blockers prescribed. The frequency of off-label use of β-blockers in children is also high with limited data on the indications as well as safety and efficacy. We present trends in off-label use of β-blockers in children to discuss drug safety and efficacy and include recommendations for pediatric providers.
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Affiliation(s)
- Vishal R Kaley
- Congenital Heart Center, Spectrum Health Helen DeVos Children's Hospital, Grand Rapids, Michigan, USA
| | - E Oliver Aregullin
- Congenital Heart Center, Spectrum Health Helen DeVos Children's Hospital, Grand Rapids, Michigan, USA.,College of Human Medicine, Michigan State University, Grand Rapids, Michigan, USA
| | - Bennett P Samuel
- Congenital Heart Center, Spectrum Health Helen DeVos Children's Hospital, Grand Rapids, Michigan, USA
| | - Joseph J Vettukattil
- Congenital Heart Center, Spectrum Health Helen DeVos Children's Hospital, Grand Rapids, Michigan, USA.,College of Human Medicine, Michigan State University, Grand Rapids, Michigan, USA
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van der Bom T, Luijendijk P, Bouma BJ, Koolbergen DR, de Groot JR, Mulder BJM. Treatment of congenital heart disease: risk-reducing measures in young adults. Future Cardiol 2011; 7:227-40. [DOI: 10.2217/fca.11.5] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
Adults with congenital heart disease form a new and relatively young population, since surgical treatment of heart defects became available three to four decades ago. Owing to improved survival this population is steadily growing in number and age. Little is known regarding long-term survival; however, late complications occur frequently. During adulthood, almost half of the patients have one or more complication, such as endocarditis, stroke, systemic or pulmonary hypertension, aortic aneurysm or dissection and arrhythmias. Heart failure and sudden cardiac death are the main causes of death. Treatment of adults with congenital heart disease is aimed at the reduction of symptoms, but also at minimizing the risk and severity of late complications. In this article the most recent advances in the treatment of congenital heart disease will be discussed. The main focus of the article will be on pharmacological, interventional and surgical interventions that reduce the risk of heart failure, arrhythmias, vascular complications, pulmonary hypertension and endocarditis.
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Affiliation(s)
- Teun van der Bom
- Department of Cardiology, Academic Medical Center, Amsterdam, The Netherlands
- Interuniversity Cardiology Institute of The Netherlands, Utrecht, The Netherlands
| | - Paul Luijendijk
- Department of Cardiology, Academic Medical Center, Amsterdam, The Netherlands
- Interuniversity Cardiology Institute of The Netherlands, Utrecht, The Netherlands
| | - Berto J Bouma
- Department of Cardiology, Academic Medical Center, Amsterdam, The Netherlands
| | - Dave R Koolbergen
- Department of Cardio-thoracic Surgery, Academic Medical Center, Amsterdam, The Netherlands
| | - Joris R de Groot
- Department of Cardiology, Academic Medical Center, Amsterdam, The Netherlands
| | - Barbara JM Mulder
- Department of Cardiology, Academic Medical Center, Amsterdam, The Netherlands
- Interuniversity Cardiology Institute of The Netherlands, Utrecht, The Netherlands
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