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Duarte VE, Singh MN. Genetic syndromes associated with congenital heart disease. Heart 2023:heartjnl-2023-323126. [PMID: 38040449 DOI: 10.1136/heartjnl-2023-323126] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/03/2023] Open
Abstract
Congenital heart defects are the most common type of birth defect, affecting 1% of live births. The underlying cause of congenital heart disease is frequently unknown. However, advances in human genetics and genome technologies have helped expand congenital heart disease pathogenesis knowledge during the last few decades. When the cardiac defects are part of a genetic syndrome, they are associated with extracardiac conditions and require multidisciplinary care and surveillance. Some genetic syndromes can have subtle clinical findings and remain undiagnosed well into adulthood. Each syndrome is associated with specific congenital and acquired comorbidities and a particular clinical risk profile. A timely diagnosis is essential for risk stratification, surveillance of associated conditions and counselling, particularly during family planning. However, genetic testing and counselling indications can be challenging to identify in clinical practice. This document intends to provide an overview of the most clinically relevant syndromes to consider, focusing on the phenotype and genotype diagnosis, outcome data, clinical guidelines and implications for care.
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Affiliation(s)
- Valeria E Duarte
- Houston Methodist Debakey Heart and Vascular Center, Houston, Texas, USA
- Department of Cardiology, Boston Children's Hospital, Boston, Massachusetts, USA
| | - Michael N Singh
- Department of Cardiology, Boston Children's Hospital, Boston, Massachusetts, USA
- Cardiology, Brigham and Women's Hospital, Boston, Massachusetts, USA
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2
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Dimopoulos K, Constantine A, Clift P, Condliffe R, Moledina S, Jansen K, Inuzuka R, Veldtman GR, Cua CL, Tay ELW, Opotowsky AR, Giannakoulas G, Alonso-Gonzalez R, Cordina R, Capone G, Namuyonga J, Scott CH, D’Alto M, Gamero FJ, Chicoine B, Gu H, Limsuwan A, Majekodunmi T, Budts W, Coghlan G, Broberg CS, Constantine A, Clift P, Condliffe R, Moledina S, Jansen K. Cardiovascular Complications of Down Syndrome: Scoping Review and Expert Consensus. Circulation 2023; 147:425-441. [PMID: 36716257 PMCID: PMC9977420 DOI: 10.1161/circulationaha.122.059706] [Citation(s) in RCA: 20] [Impact Index Per Article: 20.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
Cardiovascular disease is a leading cause of morbidity and mortality in individuals with Down syndrome. Congenital heart disease is the most common cardiovascular condition in this group, present in up to 50% of people with Down syndrome and contributing to poor outcomes. Additional factors contributing to cardiovascular outcomes include pulmonary hypertension; coexistent pulmonary, endocrine, and metabolic diseases; and risk factors for atherosclerotic disease. Moreover, disparities in the cardiovascular care of people with Down syndrome compared with the general population, which vary across different geographies and health care systems, further contribute to cardiovascular mortality; this issue is often overlooked by the wider medical community. This review focuses on the diagnosis, prevalence, and management of cardiovascular disease encountered in people with Down syndrome and summarizes available evidence in 10 key areas relating to Down syndrome and cardiac disease, from prenatal diagnosis to disparities in care in areas of differing resource availability. All specialists and nonspecialist clinicians providing care for people with Down syndrome should be aware of best clinical practice in all aspects of care of this distinct population.
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Affiliation(s)
- Konstantinos Dimopoulos
- Adult Congenital Heart Centre and Centre for Pulmonary Hypertension, Royal Brompton Hospital, Royal Brompton and Harefield Hospitals, Guy’s and St Thomas’ NHS Foundation Trust, London, United Kingdom (K.D., A.C.).,National Heart and Lung Institute, Imperial College London, United Kingdom (K.D., A.C.)
| | - Andrew Constantine
- Adult Congenital Heart Centre and Centre for Pulmonary Hypertension, Royal Brompton Hospital, Royal Brompton and Harefield Hospitals, Guy’s and St Thomas’ NHS Foundation Trust, London, United Kingdom (K.D., A.C.).,National Heart and Lung Institute, Imperial College London, United Kingdom (K.D., A.C.)
| | - Paul Clift
- Department of Cardiology, Queen Elizabeth Hospital Birmingham, United Kingdom (P.C.)
| | - Robin Condliffe
- Pulmonary Vascular Disease Unit, Royal Hallamshire Hospital, Sheffield, United Kingdom (R.C.)
| | - Shahin Moledina
- National Paediatric Pulmonary Hypertension Service UK, Great Ormond Street Hospital for Children NHS Foundation Trust, London, United Kingdom (S.M.).,Institute of Cardiovascular Science, University College London, United Kingdom (S.M.)
| | - Katrijn Jansen
- Adult Congenital and Paediatric Heart Unit, Freeman Hospital Newcastle Upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, United Kingdom (K.J.).,Population Health Sciences Institute, Newcastle University, Newcastle upon Tyne, United Kingdom (K.J.)
| | - Ryo Inuzuka
- Department of Pediatrics, The University of Tokyo Hospital, Japan (R.I.)
| | - Gruschen R. Veldtman
- Scottish Adult Congenital Cardiac Service, Golden Jubilee Hospital, Glasgow, Scotland, United Kingdom (G.R.V.)
| | - Clifford L. Cua
- The Heart Center, Nationwide Children’s Hospital, Columbus, OH (C.L.C.)
| | - Edgar Lik Wui Tay
- Department of Cardiology, National University Hospital Singapore (E.T.L.W.)
| | - Alexander R. Opotowsky
- The Heart Institute, Department of Pediatrics, Cincinnati Children’s Hospital, University of Cincinnati College of Medicine, OH (A.R.O.)
| | - George Giannakoulas
- Department of Cardiology, AHEPA University Hospital School of Medicine, Aristotle University of Thessaloniki, Greece (G.G.)
| | - Rafael Alonso-Gonzalez
- Division of Cardiology, Toronto General Hospital, University Health Network, Peter Munk Cardiovascular Center, University of Toronto, Canada (R.A.-G.).,Toronto Adult Congenital Heart Disease Program, Canada (R.A.-G.)
| | - Rachael Cordina
- Department of Cardiology, Royal Prince Alfred Hospital and Sydney Medical School, University of Sydney, New South Wales, Australia (R.C.)
| | - George Capone
- Down Syndrome Clinical and Research Center, Kennedy Krieger Institute, Baltimore, MD (G. Capone).,Johns Hopkins School of Medicine, Baltimore, MD (G. Capone)
| | - Judith Namuyonga
- Department of Paediatric Cardiology, Uganda Heart Institute, Kampala (J.N.).,Department of Paediatrics and Child Health, Makerere University College of Health Sciences, Kampala, Uganda (J.N.)
| | | | - Michele D’Alto
- Department of Cardiology, University “L. Vanvitelli”–Monaldi Hospital, Naples, Italy (M.D.)
| | - Francisco J. Gamero
- Department of Cardiovascular Surgery, Benjamin Bloom Children’s Hospital, El Salvador (F.J.G.)
| | - Brian Chicoine
- Advocate Medical Group Adult Down Syndrome Center, Park Ridge, IL (B.C.)
| | - Hong Gu
- Department of Pediatric Cardiology, Beijing Anzhen Hospital, Capital Medical University, China (H.G.)
| | - Alisa Limsuwan
- Division of Pediatric Cardiology, Department of Pediatrics, Ramathibodi Hospital, Mahidol University, Bangkok, Thailand (A.L.)
| | - Tosin Majekodunmi
- Department of Cardiology, Euracare Multi-specialist Hospital, Nigeria (T.M.)
| | - Werner Budts
- Division of Congenital and Structural Cardiology, University Hospitals Leuven, and Department of Cardiovascular Science, Catholic University Leuven, Belgium (W.B.)
| | - Gerry Coghlan
- Department of Cardiology, Royal Free Hospital, London, United Kingdom (G. Coghlan)
| | - Craig S. Broberg
- Knight Cardiovascular Institute, Oregon Health and Science University, Portland (C.S.B.)
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3
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Alkattan HN, Ardah HI, Arifi AA, Yelbuz TM. The evolving treatment of congenital heart disease in patient with Down syndrome: Current state of knowledge. J Card Surg 2022; 37:3760-3768. [PMID: 35989531 DOI: 10.1111/jocs.16875] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2022] [Accepted: 07/20/2022] [Indexed: 11/30/2022]
Abstract
OBJECTIVES Children with Down syndrome are usually seen as not worthy of high-risk cardiac surgery. Through this review, we try to show the results of curative and palliative surgery for functional single ventricle syndrome in patients with Down syndrome, as there is currently no standard protocol for the treatment of this category of patients. METHODS An exhaustive search of all related published medical literature included the following domains: Down syndrome and diagnosis, Down syndrome and taxonomy, Down syndrome, and natural history, Down syndrome and cardiovascular abnormalities, Down syndrome and pulmonary hypertension, Down syndrome and institutionalization, Down syndrome and surgical repair, Down syndrome, and single ventricle palliation, Down syndrome and Glenn, Down syndrome, and Fontan. RESULTS 12 articles were included from 775 identified. Low-risk cardiac surgery procedure should be provided for Down syndrome with a balanced ventricular septal defect. There is no universal agreement about the surgical approach for Down syndrome with unbalanced ventricular septal defects, but it can be performed at relatively low risk. CONCLUSIONS TCPC in Down syndrome patients could be a relatively low-risk procedure if patients are prepared well and their pulmonary vascular resistance is low. Randomized prospective studies are required to show the long-term impact of TCPC palliation and develop a better understanding of standardized care of these patients.
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Affiliation(s)
- Hani N Alkattan
- Department of Cardiac Sciences, Ministry of the National Guard - Health Affairs, Riyadh, Saudi Arabia.,Department of Cardiac Science, King Abdulaziz Medical City, King Abdullah International Medical Research Center, Riyadh, Saudi Arabia.,Department of Cardiac Science, King Abdulaziz Medical City, King Saud bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia
| | - Husam I Ardah
- Department of Cardiac Science, King Abdulaziz Medical City, King Abdullah International Medical Research Center, Riyadh, Saudi Arabia.,Department of Cardiac Science, King Abdulaziz Medical City, King Saud bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia
| | - Ahmed A Arifi
- Department of Cardiac Sciences, Ministry of the National Guard - Health Affairs, Riyadh, Saudi Arabia.,Department of Cardiac Science, King Abdulaziz Medical City, King Abdullah International Medical Research Center, Riyadh, Saudi Arabia.,Department of Cardiac Science, King Abdulaziz Medical City, King Saud bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia
| | - Talat M Yelbuz
- Department of Cardiac Sciences, Ministry of the National Guard - Health Affairs, Riyadh, Saudi Arabia.,Department of Cardiac Science, King Abdulaziz Medical City, King Abdullah International Medical Research Center, Riyadh, Saudi Arabia.,Department of Cardiac Science, King Abdulaziz Medical City, King Saud bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia
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4
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Sainathan S, Said SM, Agala CB, Mullinari L, Sharma M. National outcomes of the Fontan operation with endocardial cushion defect. J Card Surg 2022; 37:3151-3158. [PMID: 35788993 DOI: 10.1111/jocs.16742] [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: 01/16/2022] [Revised: 04/22/2022] [Accepted: 06/13/2022] [Indexed: 11/30/2022]
Abstract
BACKGROUND The traditional outcomes of the Fontan operation (FO) in endocardial cushion defect (ECD) patients have been suboptimal. Previous studies have been limited by the smaller number of ECD patients, longer study period with an era effect, and do not directly compare short-term outcomes of FO in ECD patients with non-ECD patients. Our study aims to address these shortcomings. METHODS A retrospective analysis of the Kids Inpatient Database (2009, 2012, and 2016) for the FO was done. The groups were divided into those who underwent FO with ECD as compared to non-ECD diagnosis. The data were abstracted for demographics, clinical characteristics, and operative outcomes. Standard statistical tests were used. RESULTS Three thousand three hundred eighty patients underwent the FO of which 360 patients (11%) were FO-ECD. ECD patients were more likely to have Down syndrome, Heterotaxy syndrome, transposition/DORV, and TAPVR as compared to non-ECD patients. FO-ECD had a higher discharge-mortality (2.84% vs. 0.45%, p = .04). The length of stay (16 vs. 13 days, p = .05) and total charges incurred ($283, 280 vs. $234, 106, p = .03) for the admission were higher in the FO-ECD as compared to non-ECD patients. In multivariable analysis, ECD diagnosis, cardiac arrest, acute kidney injury, and postoperative hemorrhage were predictors of mortality. CONCLUSION Contemporary outcomes for FO are excellent with very low overall operative mortality. However, the outcomes in ECD patients are inferior with higher operative mortality than in non-ECD patients. The occurrence of postoperation complications and a diagnosis of ECD were predictive of a negative outcome.
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Affiliation(s)
- Sandeep Sainathan
- Department of Surgery, Section of Pediatric Cardiothoracic Surgery, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA.,Department of Surgery, Section of Pediatric Cardiothoracic Surgery, University of Miami, Miami, Florida, USA
| | - Sameh M Said
- Department of Surgery, Section of Pediatric Cardiothoracic Surgery, University of Minnesota, Minneapolis, Minnesota, USA
| | - Chris B Agala
- Department of Surgery/Biostatistics, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Leonardo Mullinari
- Department of Surgery, Section of Pediatric Cardiothoracic Surgery, University of Miami, Miami, Florida, USA
| | - Mahesh Sharma
- Department of Surgery, Section of Pediatric Cardiothoracic Surgery, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
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5
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Rodríguez MR, DiNardo JA. Biventricular Repair as an Alternative to Single Ventricle Palliation in the Child with Hypoplastic Left Heart Structures: What the Anesthesiologist Should Know. J Cardiothorac Vasc Anesth 2022; 36:3927-3938. [DOI: 10.1053/j.jvca.2022.06.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/21/2022] [Revised: 06/04/2022] [Accepted: 06/13/2022] [Indexed: 11/11/2022]
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Otsuka M, Kodama Y, Kuraoka A, Ishikawa Y, Nakamura M, Nakano T, Kado H, Umemoto S, Ishikita A, Sakamoto I, Ide T, Tsutsui H, Sagawa K. Hemodynamic Characteristics After Fontan Procedure in Patients with Down's Syndrome. Pediatr Cardiol 2022; 43:360-365. [PMID: 34498105 DOI: 10.1007/s00246-021-02727-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/09/2021] [Accepted: 09/01/2021] [Indexed: 11/25/2022]
Abstract
Patients with Down's syndrome (DS) are generally regarded as not being good candidates for the Fontan procedure. However, detailed hemodynamic changes over time are not fully clarified. A retrospective chart review of all patients with DS who underwent the Fontan procedure and 5 times that number of Fontan patients without DS performed in Fukuoka Children's Hospital and Kyushu University Hospital. Seven Fontan patients with DS were identified, and 35 Fontan patients without DS were recruited. During the mean observational periods of 14.7 years and 15.0 years (DS and non-DS, respectively) after the Fontan procedure, only one DS patient died. Central venous pressure (CVP) and transpulmonary pressure gradient significantly increased, and arterial oxygen saturation significantly decreased over time in DS patients after the Fontan procedure compared with those without DS. CVP in DS patients after the Fontan procedure increased over time compared with non-DS patients. Better management including the efficacy of Pulmonary arterial hypertension-specific therapy should be clarified in further studies.
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Affiliation(s)
- Masakazu Otsuka
- Department of Pediatric Cardiology, Fukuoka Children's Hospital, 5-1-1 Kashiiteriha Higashi-ku, Fukuoka, 813-0017, Japan
| | - Yoshihiko Kodama
- Department of Pediatric Cardiology, Fukuoka Children's Hospital, 5-1-1 Kashiiteriha Higashi-ku, Fukuoka, 813-0017, Japan. .,Department of Cardiovascular Medicine, Kyushu University Hospital, 3-1-1 Maidashi Higashi-ku, Fukuoka, 812-8582, Japan.
| | - Ayako Kuraoka
- Department of Pediatric Cardiology, Fukuoka Children's Hospital, 5-1-1 Kashiiteriha Higashi-ku, Fukuoka, 813-0017, Japan
| | - Yuichi Ishikawa
- Department of Pediatric Cardiology, Fukuoka Children's Hospital, 5-1-1 Kashiiteriha Higashi-ku, Fukuoka, 813-0017, Japan
| | - Makoto Nakamura
- Department of Pediatric Cardiology, Fukuoka Children's Hospital, 5-1-1 Kashiiteriha Higashi-ku, Fukuoka, 813-0017, Japan
| | - Toshihide Nakano
- Department of Cardiovascular Surgery, Fukuoka Children's Hospital, 5-1-1 Kashiiteriha Higashi-ku, Fukuoka, 813-0017, Japan
| | - Hideaki Kado
- Department of Cardiovascular Surgery, Fukuoka Children's Hospital, 5-1-1 Kashiiteriha Higashi-ku, Fukuoka, 813-0017, Japan
| | - Shintaro Umemoto
- Department of Cardiovascular Medicine, Kyushu University Hospital, 3-1-1 Maidashi Higashi-ku, Fukuoka, 812-8582, Japan
| | - Ayako Ishikita
- Department of Cardiovascular Medicine, Kyushu University Hospital, 3-1-1 Maidashi Higashi-ku, Fukuoka, 812-8582, Japan
| | - Ichiro Sakamoto
- Department of Cardiovascular Medicine, Kyushu University Hospital, 3-1-1 Maidashi Higashi-ku, Fukuoka, 812-8582, Japan
| | - Tomomi Ide
- Department of Cardiovascular Medicine, Kyushu University Hospital, 3-1-1 Maidashi Higashi-ku, Fukuoka, 812-8582, Japan
| | - Hiroyuki Tsutsui
- Department of Cardiovascular Medicine, Kyushu University Hospital, 3-1-1 Maidashi Higashi-ku, Fukuoka, 812-8582, Japan
| | - Koichi Sagawa
- Department of Pediatric Cardiology, Fukuoka Children's Hospital, 5-1-1 Kashiiteriha Higashi-ku, Fukuoka, 813-0017, Japan
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7
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Rao PS. Single Ventricle-A Comprehensive Review. CHILDREN (BASEL, SWITZERLAND) 2021; 8:441. [PMID: 34073809 PMCID: PMC8225092 DOI: 10.3390/children8060441] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/28/2021] [Revised: 05/20/2021] [Accepted: 05/21/2021] [Indexed: 02/06/2023]
Abstract
In this paper, the author enumerates cardiac defects with a functionally single ventricle, summarizes single ventricle physiology, presents a summary of management strategies to address the single ventricle defects, goes over the steps of staged total cavo-pulmonary connection, cites the prevalence of inter-stage mortality, names the causes of inter-stage mortality, discusses strategies to address the inter-stage mortality, reviews post-Fontan issues, and introduces alternative approaches to Fontan circulation.
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Affiliation(s)
- P Syamasundar Rao
- McGovern Medical School, University of Texas-Houston, Children's Memorial Hermann Hospital, 6410 Fannin Street, UTPB Suite # 425, Houston, TX 77030, USA
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8
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Bush D, Galambos C, Dunbar Ivy D. Pulmonary hypertension in children with Down syndrome. Pediatr Pulmonol 2021; 56:621-629. [PMID: 32049444 DOI: 10.1002/ppul.24687] [Citation(s) in RCA: 22] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/16/2019] [Accepted: 01/23/2020] [Indexed: 12/26/2022]
Abstract
Individuals with Down syndrome (DS) have an increased risk of developing pulmonary hypertension (PH). In this review, we explore the epidemiology and clinical characteristics of PH in the population with DS and examine genetic, molecular and clinical contributions to the condition. The presence of an additional copy of chromosome 21 (trisomy 21) increases the risk of developing PH in children with DS through many mechanisms, including increased hemodynamic stress in those with congenital heart disease, hypoxemia through impaired ventilation to perfusion matching secondary to developmental lung abnormalities, pulmonary hypoplasia from pulmonary vascular endothelial dysfunction, and an increase in pulmonary vascular resistance often related to pulmonary comorbidities. We review recent studies looking at novel biomarkers that may help diagnose, predict or monitor PH in the population with DS and examine current cardiopulmonary guidelines for monitoring children with DS. Finally, we review therapeutic interventions specific to PH in individuals with DS. Contemporary work has identified exciting mechanistic pathways including the upregulation of antiangiogenic factors and interferon activity, which may lead to additional biomarkers or therapeutic opportunities. Throughout the manuscript, we identify gaps in our knowledge of the condition as it relates to the population with DS and offer suggestions for future clinical, translational, and basic science research.
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Affiliation(s)
- Douglas Bush
- Department of Pediatrics, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Csaba Galambos
- Department of Pathology and Laboratory Medicine, University of Colorado School of Medicine, Aurora, Colorado
| | - David Dunbar Ivy
- Department of Pediatrics, University of Colorado School of Medicine, Aurora, Colorado
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9
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Allen P, Anderson BR, Bacha E, LaPar DJ. Trisomy 21 Patients Undergoing Cavopulmonary Connections Need Improved Preoperative and Postoperative Care. Ann Thorac Surg 2020; 112:2012-2019. [PMID: 33161018 DOI: 10.1016/j.athoracsur.2020.10.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/15/2020] [Revised: 08/15/2020] [Accepted: 10/05/2020] [Indexed: 11/28/2022]
Abstract
BACKGROUND Patients with trisomy 21 (T21) often have elevated pulmonary vascular resistance, which may result in a suboptimal cavopulmonary connection (CPC) after a Glenn or Fontan operation. The purpose of this study was to assess, in a nationwide, multiinstitution cohort of patients with CPC, the impact of T21 on patient morbidity, mortality, and resource use. METHODS A total of 23,271 pediatric patients with CPC (2004 to 2019) at 50 US hospitals were evaluated using the Pediatric Health Information System database. Univariable and multivariable regression analyses were used to assess risk-adjusted associations between Down syndrome and other risk factors and postoperative measures of morbidity, mortality, lengths of stay, and cost of hospitalization. RESULTS The overall prevalence of T21 among patients who had undergone Glenn and Fontan procedures was 1.5% (199 of 13,268) and 0.8% (78 of 1003), respectively. Among both CPC cohorts, T21 status significantly increased unadjusted mortality, hospital lengths of stay, and total costs of hospitalization compared with the non-T21 CPC cohort (all P < .001). Patients with T21 also had a higher incidence of prolonged mechanical ventilation compared with patients without T21 in both Glenn and Fontan groups (P < .001). Multivariable regression analysis further estimated that patients with T21 are associated with a 5.5-fold increase in mortality (P < .001) compared with patients without T21. Finally, patients with T21 had increased long-term mortality compared with their peers. CONCLUSIONS T21 significantly increases risk-adjusted morbidity, inpatient mortality, long-term mortality, and resource use after cavopulmonary connections. Further investigation is needed to clarify modifiable patient-level and center-specific risk factors to improve outcomes for patients with T21.
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Affiliation(s)
- Philip Allen
- Division of Pediatric Cardiac Surgery, Columbia University College of Physicians and Surgeons, New York, New York
| | - Brett R Anderson
- Division of Pediatric Cardiology, Columbia University College of Physicians and Surgeons, New York, New York
| | - Emile Bacha
- Division of Pediatric Cardiac Surgery, Columbia University College of Physicians and Surgeons, New York, New York
| | - Damien J LaPar
- Division of Pediatric Cardiac Surgery, Columbia University College of Physicians and Surgeons, New York, New York.
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10
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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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11
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Baban A, Olivini N, Cantarutti N, Calì F, Vitello C, Valentini D, Adorisio R, Calcagni G, Alesi V, Di Mambro C, Villani A, Dallapiccola B, Digilio MC, Marino B, Carotti A, Drago F. Differences in morbidity and mortality in Down syndrome are related to the type of congenital heart defect. Am J Med Genet A 2020; 182:1342-1350. [PMID: 32319738 DOI: 10.1002/ajmg.a.61586] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2019] [Revised: 02/24/2020] [Accepted: 03/16/2020] [Indexed: 12/19/2022]
Abstract
Morbidity and mortality in Down syndrome (DS) are mainly related to congenital heart defects (CHDs). While CHDs with high prevalence in DS (typical CHDs), such as endocardial cushion defects, have been extensively described, little is known about the impact of less common CHDs (atypical CHDs), such as aortic coarctation and univentricular hearts. In our single-center study, we analyzed, in observational, retrospective manner, data regarding cardiac features, surgical management, and outcomes of a cohort of DS patients. Literature review was performed to investigate previously reported studies on atypical CHDs in DS. Patients with CHDs were subclassified as having typical or atypical CHDs. Statistical analysis was performed for comparison between the groups. The study population encompassed 859 DS patients, 72.2% with CHDs, of which 4.7% were atypical. Statistical analysis showed a significant excess in multiple surgeries, all-cause mortality and cardiac mortality in patients with atypical CHDs (p = .0067, p = .0038, p = .0001, respectively). According to the Kaplan-Meier method, survival at 10 and 40 years was significantly higher in typical CHDs (99 and 98% vs. 91 and 84%, log rank <0.05). Among atypical CHDs, it seems that particularly multiple complex defects in univentricular physiology associate with a worse outcome. This may be due to the surgical difficulty in managing univentricular hearts with multiple defects concurring to the clinical picture or to the severity of associated defects themselves. Further studies need to address this specific issue, also considering the higher pulmonary pressures, infective complications, and potential comorbidities in DS patients.
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Affiliation(s)
- Anwar Baban
- Pediatric Cardiology and Cardiac Arrhythmias Unit, Department of Pediatric Cardiology and Cardiac Surgery, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
| | - Nicole Olivini
- Pediatric Cardiology and Cardiac Arrhythmias Unit, Department of Pediatric Cardiology and Cardiac Surgery, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
| | - Nicoletta Cantarutti
- Pediatric Cardiology and Cardiac Arrhythmias Unit, Department of Pediatric Cardiology and Cardiac Surgery, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
| | - Federica Calì
- Pediatric Cardiology and Cardiac Arrhythmias Unit, Department of Pediatric Cardiology and Cardiac Surgery, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
| | - Carmen Vitello
- Pediatric Cardiology and Cardiac Arrhythmias Unit, Department of Pediatric Cardiology and Cardiac Surgery, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
| | - Diletta Valentini
- Pediatric and Infectious Disease Unit, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
| | - Rachele Adorisio
- Pediatric Cardiology and Cardiac Arrhythmias Unit, Department of Pediatric Cardiology and Cardiac Surgery, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
| | - Giulio Calcagni
- Pediatric Cardiology and Cardiac Arrhythmias Unit, Department of Pediatric Cardiology and Cardiac Surgery, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
| | - Viola Alesi
- Medical Genetics Unit, Medical Genetics Laboratory, Pediatric Cardiology, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
| | - Corrado Di Mambro
- Pediatric Cardiology and Cardiac Arrhythmias Unit, Department of Pediatric Cardiology and Cardiac Surgery, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
| | - Alberto Villani
- Pediatric and Infectious Disease Unit, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
| | - Bruno Dallapiccola
- Scientific Directorate, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
| | - Maria Cristina Digilio
- Medical Genetics Unit, Medical Genetics Laboratory, Pediatric Cardiology, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
| | - Bruno Marino
- Department of Pediatrics, Sapienza University of Rome, Rome, Italy
| | - Adriano Carotti
- Pediatric Cardiac Surgery Unit, Department of Pediatric Cardiology and Cardiac Surgery, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
| | - Fabrizio Drago
- Pediatric Cardiology and Cardiac Arrhythmias Unit, Department of Pediatric Cardiology and Cardiac Surgery, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
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12
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Sarno LA, Walters HL, Bondarenko I, Thomas R, Kobayashi D. Significant Improvements in Mortality After the Fontan Operation in Children With Down Syndrome. Ann Thorac Surg 2019; 109:835-841. [PMID: 31525348 DOI: 10.1016/j.athoracsur.2019.07.085] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/05/2019] [Revised: 07/21/2019] [Accepted: 07/23/2019] [Indexed: 10/26/2022]
Abstract
BACKGROUND Down syndrome (DS) is considered a risk factor for mortality associated with the Fontan operation. The objective was to show the contemporary short-term outcome of the Fontan operation for a functionally univentricular heart in patients with DS and non-DS, along with an analysis of significant predictors for in-hospital mortality. METHODS This was a retrospective study using The Society of Thoracic Surgeons Congenital Database to assess in-hospital mortality and its predictors in patients with DS and non-DS undergoing the Fontan operation over 16 years (2001-2016). The primary outcome was in-hospital mortality. Statistical analysis was performed using univariable and multivariable logistic regression models. RESULTS Our study cohort consisted of 12,074 patients (81 DS and 11,993 non-DS). The overall in-hospital mortality rate significantly improved in the recent era (2009-2016): 2.4% to 1.3%, P < .001. The DS group had a higher in-hospital mortality rate (12.3% vs 1.6%, P < .001) with an odds ratio of 8.6 (95% confidence interval, 4.4-17.0). The DS group had a higher 30-day mortality rate, a longer median postoperative length of stay, and a higher incidence of postoperative complications. The multivariable model showed that DS was the strongest predictor of in-hospital mortality, with an odds ratio of 11.6 (95% confidence interval, 5.1-26.4), adjusted for other significant variables including era effect, weight, and primary cardiac diagnosis. CONCLUSIONS The in-hospital mortality for the Fontan operation significantly improved in the contemporary era. DS was a significant risk factor for in-hospital morbidity and mortality associated with the Fontan operation.
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Affiliation(s)
- Lauren A Sarno
- Division of Cardiology, Children's Hospital of Michigan, Department of Pediatrics, Wayne State University School of Medicine, Detroit, Michigan
| | - Henry L Walters
- Department of Cardiovascular Surgery, Children's Hospital of Michigan, Department of Surgery, Wayne State University School of Medicine, Detroit, Michigan
| | - Igor Bondarenko
- Department of Cardiovascular Surgery, Children's Hospital of Michigan, Department of Surgery, Wayne State University School of Medicine, Detroit, Michigan
| | - Ronald Thomas
- Division of Cardiology, Children's Hospital of Michigan, Department of Pediatrics, Wayne State University School of Medicine, Detroit, Michigan
| | - Daisuke Kobayashi
- Division of Cardiology, Children's Hospital of Michigan, Department of Pediatrics, Wayne State University School of Medicine, Detroit, Michigan.
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13
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Khoshhal SQ. Surgical palliation of univentricular heart disease in children with Down's syndrome: A systematic review. J Taibah Univ Med Sci 2019; 14:1-7. [PMID: 31435384 PMCID: PMC6694996 DOI: 10.1016/j.jtumed.2018.10.006] [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: 07/11/2018] [Revised: 10/27/2018] [Accepted: 10/28/2018] [Indexed: 11/27/2022] Open
Abstract
Objectives No standard protocol is available for the management of children with Down's syndrome (DS) and a functional single ventricle. This review attempts to determine the outcomes of the single ventricular surgical palliation pathway in high-risk children with DS. Methods Several databases were searched using the following MeSH terms: ‘Congenital heart disease’, ‘Atrioventricular septal defect’, ‘Balanced AVSD’, ‘Unbalanced AVSD’, ‘Down's syndrome’, ‘Univentricular repair’, ‘bidirectional Glenn procedure’, and ‘Fontan procedure’. A structured algorithm was used for the selection of studies for an in-depth analysis. Results There was no universal agreement on the best surgical approach for unbalanced atrioventricular septal defect in DS. The majority of paediatric cardiac surgeons did not recommend the complete Fontan procedure; conversely, the use of a Glenn shunt (superior cavopulmonary connection) was preferred. Conclusions Careful assessment of the suitability for Fontan surgery, including the absence of elevated pulmonary vascular resistance, pulmonary arterial anatomy, and function of the dominant ventricle, is mandatory. A staged surgical procedure ending with complete Fontan repair provides acceptable medium-term results.
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Affiliation(s)
- Saad Q Khoshhal
- Taibah University, Medical College - Paediatric Department, Almadinah Almunawwarah, KSA
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14
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Peterson JK, Setty SP, Knight JH, Thomas AS, Moller JH, Kochilas LK. Postoperative and long-term outcomes in children with Trisomy 21 and single ventricle palliation. CONGENIT HEART DIS 2019; 14:854-863. [PMID: 31332952 DOI: 10.1111/chd.12823] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/17/2019] [Revised: 05/17/2019] [Accepted: 07/08/2019] [Indexed: 11/29/2022]
Abstract
OBJECTIVE Patients with Trisomy 21 (T21) and single ventricle (SV) physiology present unique challenges compared to euploidic counterparts. This study reports postoperative and long-term outcomes in patients with T21 and SV palliation. DESIGN This retrospective cohort study from the Pediatric Cardiac Care Consortium (PCCC) included patients with T21 (<21 years old) that underwent surgical palliation for SV between 1982 and 2008 and control patients without known genetic anomaly following Fontan palliation for similar diagnoses. Kaplan-Meier survival plots were created based on death events obtained from the PCCC and by linkage with the National Death Index (NDI) and the Organ Procurement and Transplantation Network (OPTN) through 2014 for patients with adequate identifiers. RESULTS We identified 118 children with T21 who underwent initial surgical SV palliation. Among 90 (75.6%) patients surviving their first surgery, 66 (73.3%) underwent Glenn anastomosis and 25 (27.8%) completed Fontan palliation with in-hospital survival of 80.3% and 76.0%, respectively. Fifty-three patients had sufficient identifiers for PCCC-NDI-OPTN linkage. Ten-year survival, conditioned on discharge alive after the Fontan procedure, was 66.7% compared to 92.2% for 51 controls without genetic anomaly (P = .001). Median age at death for T21 patients following initial surgical SV palliation was 2.69 years (IQR 1.34-7.12) with most deaths (89.2%) attributed to the underlying congenital heart disease (CHD). CONCLUSIONS Children with T21 and SV are at high risk for procedural and long-term mortality related to their genetic condition and underlying CHD. Nevertheless, a select group of patients can successfully complete Glenn or Fontan palliation, reaching satisfactory long-term survival.
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Affiliation(s)
- Jennifer K Peterson
- Children's Heart Institute, MemorialCare Miller Children's and Women's Hospital, Long Beach, California
| | - Shaun P Setty
- Children's Heart Institute, MemorialCare Miller Children's and Women's Hospital, Long Beach, California.,Memorial Heart and Vascular Institute, Long Beach Memorial Medical Center, Long Beach, California
| | - Jessica H Knight
- Department of Epidemiology and Biostatistics, University of Georgia College of Public Health, Athens, Georgia
| | - Amanda S Thomas
- Department of Pediatrics, Emory University School of Medicine, Atlanta, Georgia
| | - James H Moller
- Departments of Pediatrics and Medicine, University of Minnesota, Minneapolis, Minnesota
| | - Lazaros K Kochilas
- Department of Pediatrics, Emory University School of Medicine, Atlanta, Georgia.,Children's Healthcare of Atlanta, Atlanta, Georgia
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15
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Buchwald MA, Laasner U, Balmer C, Cannizzaro V, Latal B, Bernet V. Comparison of postoperative chylothorax in infants and children with trisomy 21 and without dysmorphic syndrome: Is there a difference in clinical outcome? J Pediatr Surg 2019; 54:1298-1302. [PMID: 30057209 DOI: 10.1016/j.jpedsurg.2018.06.032] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/04/2018] [Revised: 06/25/2018] [Accepted: 06/25/2018] [Indexed: 10/28/2022]
Abstract
INTRODUCTION Children with trisomy 21 are prone to postoperative chylothorax, caused by malformation of the lymphatic system, after cardiac surgery. The clinical course of patients diagnosed with postoperative chylothorax and trisomy 21 was compared to that of patients without dysmorphic syndromes. Additionally, differences between the groups in composition, amount, and duration of chyle were analyzed to better understand chylothorax in patients with trisomy 21. MATERIALS AND METHODS Retrospective cohort study using inpatient clinical databases during a 10-year period. RESULTS A total of 2255 patients underwent cardiac operations during the period, of whom 160 (7.1%) patients were diagnosed with trisomy 21. Chylothorax developed in 122 children; 89 patients were included in our study. Of 160 trisomy 21 patients, 27 (16.9%) developed postoperative chylothorax compared to 62 (3%) of 2095 patients without dysmorphic syndromes (p = <0.001). Time on ventilation, stay in intensive care, hospital stay, mortality, and composition of chylous effusion did not differ between groups. The rate of thrombosis was significantly lower (p = 0.02) in the trisomy 21 group. CONCLUSION Children with trisomy 21 and congenital heart disease are more prone to developing chylothorax after heart surgery than those without dysmorphic syndromes. However if they develop this postoperative complication, mortality, chylous composition, time in ICU, and duration of hospital stay is not different to from that of other infants or children with this complication. This is important information for the medical specialists involved and is helpful in counseling parents of children with trisomy 21 undergoing heart surgery. LEVEL OF EVIDENCE This is a treatment study evidence level III.
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Affiliation(s)
- Marc-André Buchwald
- Department of Neonatology and Pediatric Intensive Care, University Children's Hospital Zurich, Children's Research Center Division, Zurich, Switzerland; Child Development Center, University Children's Hospital Zurich, Children's Research Center Division, Zurich, Switzerland
| | - Ursula Laasner
- Department of Neonatology and Pediatric Intensive Care, University Children's Hospital Zurich, Children's Research Center Division, Zurich, Switzerland
| | - Christian Balmer
- Department of Pediatric Cardiology, University Children's Hospital Zurich, Children's Research Center Division, Zurich, Switzerland
| | - Vincenzo Cannizzaro
- Department of Neonatology and Pediatric Intensive Care, University Children's Hospital Zurich, Children's Research Center Division, Zurich, Switzerland
| | - Beatrice Latal
- Child Development Center, University Children's Hospital Zurich, Children's Research Center Division, Zurich, Switzerland
| | - Vera Bernet
- Department of Neonatology and Pediatric Intensive Care, University Children's Hospital Zurich, Children's Research Center Division, Zurich, Switzerland.
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Rao PS, Harris AD. Recent advances in managing septal defects: ventricular septal defects and atrioventricular septal defects. F1000Res 2018; 7. [PMID: 29770201 PMCID: PMC5931264 DOI: 10.12688/f1000research.14102.1] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/20/2018] [Indexed: 12/18/2022] Open
Abstract
This review discusses the management of ventricular septal defects (VSDs) and atrioventricular septal defects (AVSDs). There are several types of VSDs: perimembranous, supracristal, atrioventricular septal, and muscular. The indications for closure are moderate to large VSDs with enlarged left atrium and left ventricle or elevated pulmonary artery pressure (or both) and a pulmonary-to-systemic flow ratio greater than 2:1. Surgical closure is recommended for large perimembranous VSDs, supracristal VSDs, and VSDs with aortic valve prolapse. Large muscular VSDs may be closed by percutaneous techniques. A large number of devices have been used in the past for VSD occlusion, but currently Amplatzer Muscular VSD Occluder is the only device approved by the US Food and Drug Administration for clinical use. A hybrid approach may be used for large muscular VSDs in small babies. Timely intervention to prevent pulmonary vascular obstructive disease (PVOD) is germane in the management of these babies. There are several types of AVSDs: partial, transitional, intermediate, and complete. Complete AVSDs are also classified as balanced and unbalanced. All intermediate and complete balanced AVSDs require surgical correction, and early repair is needed to prevent the onset of PVOD. Surgical correction with closure of atrial septal defect and VSD, along with repair and reconstruction of atrioventricular valves, is recommended. Palliative pulmonary artery banding may be considered in babies weighing less than 5 kg and those with significant co-morbidities. The management of unbalanced AVSDs is more complex, and staged single-ventricle palliation is the common management strategy. However, recent data suggest that achieving two-ventricle repair may be a better option in patients with suitable anatomy, particularly in patients in whom outcomes of single-ventricle palliation are less than optimal. The majority of treatment modes in the management of VSDs and AVSDs are safe and effective and prevent the development of PVOD and cardiac dysfunction.
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Affiliation(s)
- P Syamasundar Rao
- University of Texas-Houston McGovern Medical School, Children Memorial Hermann Hospital, Houston, USA
| | - Andrea D Harris
- Pediatrix Cardiology Associates of New Mexico, Albuquerque, USA
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17
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Russell MW, Chung WK, Kaltman JR, Miller TA. Advances in the Understanding of the Genetic Determinants of Congenital Heart Disease and Their Impact on Clinical Outcomes. J Am Heart Assoc 2018; 7:e006906. [PMID: 29523523 PMCID: PMC5907537 DOI: 10.1161/jaha.117.006906] [Citation(s) in RCA: 67] [Impact Index Per Article: 11.2] [Reference Citation Analysis] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Affiliation(s)
- Mark W Russell
- Division of Pediatric Cardiology, University of Michigan, Ann Arbor, MI
| | - Wendy K Chung
- Departments of Pediatrics and Medicine, Columbia University, New York, NY
| | - Jonathan R Kaltman
- Division of Cardiovascular Sciences, National Heart, Lung, and Blood Institute, Bethesda, MD
| | - Thomas A Miller
- Department of Pediatrics, University of Utah, Salt Lake City, UT
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18
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Polimenakos AC, Subramanian S, ElZein C, Ilbawi MN. Attrition in patients with single ventricle and trisomy 21: outcomes after a total cavopulmonary connection. Interact Cardiovasc Thorac Surg 2017; 24:747-754. [PMID: 28453807 DOI: 10.1093/icvts/ivw413] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2016] [Accepted: 11/07/2016] [Indexed: 11/13/2022] Open
Abstract
OBJECTIVES Data are limited regarding the management of children with trisomy 21 (T21) syndrome and a functional single ventricle (FSV). We evaluated patients with T21 and a FSV who had a total cavopulmonary connection (TCPC). METHODS From September 1999 to August 2012, 139 patients with a FSV underwent a TCPC. Sixty-five had unbalanced atrioventricular septal defect. Thirteen had T21. Three (of 13) had heterotaxy syndrome. The mean age at the Fontan operation was 27.6 ± 12.1 months. RESULTS The initial procedure was pulmonary artery banding in 9 patients, systemic-to-pulmonary shunt in 2 and Damus-Kaye-Stansel/Norwood procedure in 2. Median follow-up was 69 months (interquartile range 25-75, 21-99). There was 1 death after a Damus-Kaye-Stansel/Norwood procedure and one interstage death after a bidirectional Glenn procedure. Nine (of 11) survivors underwent a Fontan operation. A fenestrated Fontan procedure was the predominate operation in 78%. One patient was deemed unsuitable for a Fontan operation. There was 1 takedown and 1 late death after the Fontan operation. Heterotaxy syndrome did not affect outcome ( P > 0.05). There was no statistical difference in the pre-Fontan McGoon ratio, hospital length of stay, duration of pleural drainage and Fontan-related adverse events between patients with a dominant right ventricle and those with a left ( P > 0.05). CONCLUSIONS A TCPC in patients with T21 and an FSV is associated with reproducible, satisfactory outcomes. An assisted-Glenn procedure with pulsatile pulmonary blood flow and a fenestrated Fontan may be associated with attenuated perioperative morbidity and late attrition.
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Affiliation(s)
- Anastasios C Polimenakos
- Division of Pediatric Cardiovascular Surgery, Advocate Children's Hospital, Oak Lawn, IL, USA.,Division of Pediatric Cardiothoracic Surgery, Children's Hospital of Georgia Heart Center, Medical College of Georgia, Augusta, GA, USA
| | - Sujata Subramanian
- Division of Pediatric Cardiovascular Surgery, Advocate Children's Hospital, Oak Lawn, IL, USA
| | - Chawki ElZein
- Division of Pediatric Cardiovascular Surgery, Advocate Children's Hospital, Oak Lawn, IL, USA
| | - Michel N Ilbawi
- Division of Pediatric Cardiovascular Surgery, Advocate Children's Hospital, Oak Lawn, IL, USA
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19
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Pulmonary vascular disease in a failed Fontan patient with Down’s syndrome. Gen Thorac Cardiovasc Surg 2017; 66:299-302. [DOI: 10.1007/s11748-017-0809-6] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2017] [Accepted: 08/03/2017] [Indexed: 10/19/2022]
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20
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Nathan M, Emani S, IJsselhof R, Liu H, Gauvreau K, del Nido P. Mid-term outcomes in unbalanced complete atrioventricular septal defect: role of biventricular conversion from single-ventricle palliation†. Eur J Cardiothorac Surg 2017; 52:565-572. [DOI: 10.1093/ejcts/ezx129] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/07/2016] [Accepted: 03/04/2017] [Indexed: 12/28/2022] Open
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21
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Chan T, Di Gennaro J, Wechsler SB, Bratton SL. Complex Chronic Conditions Among Children Undergoing Cardiac Surgery. Pediatr Cardiol 2016; 37:1046-56. [PMID: 27033243 DOI: 10.1007/s00246-016-1387-6] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/08/2016] [Accepted: 03/21/2016] [Indexed: 11/25/2022]
Abstract
Children with complex chronic conditions (CCCs) require a disproportionate amount of inpatient resources and are at increased risk of mortality during hospital admissions. This study examines the impact of non-cardiac, comorbid complex chronic conditions on outcomes in children undergoing congenital heart surgery. All admissions associated with a congenital cardiac surgical procedure in the Kids' Inpatient Database from 1997 to 2012 were examined. Children were classified by the number as well as type (genetic vs. non-genetic) of CCC. Baseline demographics as well as proportion of total inpatient days and total hospitalization charges was assessed. Multivariate regression models examining occurrence of a complication, mortality, prolonged length of stay and high hospitalization charges were constructed. In multivariate models, an increasing number of CCC was associated with increased risk of mortality and complications (mortality: 1 CCC: odds ratio (OR) = 1.17, 95 % CI = 1.03-1.33); ≥2 CCC: OR = 1.54, 95 % CI = 1.26-1.87). Additionally, the presence of a genetic CCC was protective against mortality (OR = 0.71, 95 % CI = 0.56-0.89) while non-genetic CCCs were associated with mortality (OR = 1.62, 95 % CI = 1.41-1.88) and high resource utilization. Over time, the proportion of genetic CCC remained stable while non-genetic CCC increased in prevalence. Complex chronic conditions have a varying association with mortality, morbidity and resource utilization in children undergoing congenital heart surgery. While genetic CCCs were not associated with poor outcomes, non-genetic CCCs were risk factors for morbidity and mortality. These findings suggest that pre-surgical counseling and surgical planning should account for the type of non-cardiac comorbid conditions.
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Affiliation(s)
- Titus Chan
- Pediatric Critical Care Medicine/The Heart Center, Seattle Children's Hospital, University of Washington, 4800 Sand Point Way NE, M/S: FA.2.112, Seattle, WA, 98105, USA.
| | - Jane Di Gennaro
- Pediatric Critical Care Medicine/The Heart Center, Seattle Children's Hospital, University of Washington, 4800 Sand Point Way NE, M/S: FA.2.112, Seattle, WA, 98105, USA
| | | | - Susan L Bratton
- Pediatric Critical Care Medicine, University of Utah, Primary Children's Medical Center, Salt Lake City, UT, USA
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22
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Colquitt JL, Morris SA, Denfield SW, Fraser CD, Wang Y, Kyle WB. Survival in Children With Down Syndrome Undergoing Single-Ventricle Palliation. Ann Thorac Surg 2016; 101:1834-41. [DOI: 10.1016/j.athoracsur.2015.11.047] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/22/2015] [Revised: 10/06/2015] [Accepted: 11/17/2015] [Indexed: 11/27/2022]
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23
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Abstract
CHD is frequently associated with a genetic syndrome. These syndromes often present specific cardiovascular and non-cardiovascular co-morbidities that confer significant peri-operative risks affecting multiple organ systems. Although surgical outcomes have improved over time, these co-morbidities continue to contribute substantially to poor peri-operative mortality and morbidity outcomes. Peri-operative morbidity may have long-standing ramifications on neurodevelopment and overall health. Recognising the cardiovascular and non-cardiovascular risks associated with specific syndromic diagnoses will facilitate expectant management, early detection of clinical problems, and improved outcomes--for example, the development of syndrome-based protocols for peri-operative evaluation and prophylactic actions may improve outcomes for the more frequently encountered syndromes such as 22q11 deletion syndrome.
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24
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Ono Y, Mitsushita N. Case studies of patients successfully and unsuccessfully managed pre- and post-Fontan procedure. Int Heart J 2015; 56 Suppl:S31-4. [PMID: 25787796 DOI: 10.1536/ihj.14-353] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
As a result of advances and modifications in surgical procedures and the development of drugs for pulmonary arterial hypertension, many patients who have undergone Fontan procedures are able to enjoy good quality of life, without pulmonary arterial hypertension and severe complications. In Shizuoka Children's Hospital, drugs for pulmonary arterial hypertension have long been given to Fontan candidates and patients with established Fontan circulation to maintain sufficient pulmonary blood flow and suppress pulmonary arterial hypertension. We present three typical cases that were treated with anti-pulmonary hypertensive drugs before or after Fontan procedure. The first case had asplenia syndrome, and a single ventricle with major aortopulmonary collateral arteries. Anti-pulmonary hypertensive therapy permitted a Fontan procedure and maintained a good long-term quality of life. The second case was a Down syndrome patient who had progressive cyanosis after a Fontan operation. Anti-pulmonary hypertensive therapy improved cyanosis. The third case suffered from protein-losing enteropathy, for which all procedures and medical therapies were ineffective. Fontan candidates and patients with Fontan circulation have varied anatomical backgrounds and pulmonary properties. We must identify the conditions that lead to successful Fontan procedure and Fontan circulation correction, as well as conditions that result in failed Fontan procedure and poorly-controlled Fontan circulation.
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Affiliation(s)
- Yasuo Ono
- Department of Cardiology, Shizuoka Children's Hospital
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25
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Abstract
BACKGROUND Of the children with Down syndrome 40-50% have cardiac defects and the majority of these cardiac defects are amenable to biventricular repair. The outcome of single ventricle palliation is improving; nonetheless, there are limited data on Down syndrome patients with associated high-risk factors undergoing single ventricle palliation. Our aim was to study the outcomes of children with Down syndrome and high-risk factors on the single ventricle palliation pathway. METHODS A retrospective study on all patients with Down syndrome on the single ventricle palliation pathway from 2005 until 2011 was conducted. Operative, clinical, echocardiographic, haemodynamic data, and follow-up data were reviewed. RESULTS A total of 310 patients underwent at least one single ventricle surgical intervention. Of those, eight patients had Down syndrome, five of which had associated risk factors - low birth weight, high pulmonary vascular resistance, pulmonary vein stenosis, significant atrioventricular valve regurgitation, and extracardiac anomalies. Mortality in the high-risk group was 80% (4/5), compared with 33% (1/3) in the non-high-risk patients. Overall, after a median follow-up period of 138 days (8-576 days), only 37.5% (3/8) of patients were alive. CONCLUSION Despite many improvements in the care of single ventricle patients, the fate of those with Down syndrome and associated high-risk factors remains poor. Further multicentre longer-term studies are needed to validate and quantify the cumulative effects of negative prognostic factors in this complex group of patients.
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Evans JM, Dharmar M, Meierhenry E, Marcin JP, Raff GW. Association Between Down Syndrome and In-Hospital Death Among Children Undergoing Surgery for Congenital Heart Disease. Circ Cardiovasc Qual Outcomes 2014; 7:445-52. [DOI: 10.1161/circoutcomes.113.000764] [Citation(s) in RCA: 42] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Jacqueline M. Evans
- From the Department of Pediatrics (J.M.E., M.D., J.P.M.), School of Medicine (E.M.), and Department of Surgery (G.W.R.), University of California Davis Children’s Hospital, Sacramento
| | - Madan Dharmar
- From the Department of Pediatrics (J.M.E., M.D., J.P.M.), School of Medicine (E.M.), and Department of Surgery (G.W.R.), University of California Davis Children’s Hospital, Sacramento
| | - Erin Meierhenry
- From the Department of Pediatrics (J.M.E., M.D., J.P.M.), School of Medicine (E.M.), and Department of Surgery (G.W.R.), University of California Davis Children’s Hospital, Sacramento
| | - James P. Marcin
- From the Department of Pediatrics (J.M.E., M.D., J.P.M.), School of Medicine (E.M.), and Department of Surgery (G.W.R.), University of California Davis Children’s Hospital, Sacramento
| | - Gary W. Raff
- From the Department of Pediatrics (J.M.E., M.D., J.P.M.), School of Medicine (E.M.), and Department of Surgery (G.W.R.), University of California Davis Children’s Hospital, Sacramento
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27
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Outcome of univentricular repair in patients with Down syndrome. J Thorac Cardiovasc Surg 2013; 146:1349-52. [DOI: 10.1016/j.jtcvs.2013.02.017] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/22/2012] [Revised: 01/26/2013] [Accepted: 02/12/2013] [Indexed: 11/19/2022]
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Nathan M, Liu H, Pigula FA, Fynn-Thompson F, Emani S, Baird CA, Marx G, Mayer JE, del Nido PJ. Biventricular Conversion After Single-Ventricle Palliation in Unbalanced Atrioventricular Canal Defects. Ann Thorac Surg 2013; 95:2086-95; discussion 2095-6. [DOI: 10.1016/j.athoracsur.2013.01.075] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/10/2012] [Revised: 01/24/2013] [Accepted: 01/29/2013] [Indexed: 11/26/2022]
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Overman DM, Dummer KB, Moga FX, Gremmels DB. Unbalanced atrioventricular septal defect: defining the limits of biventricular repair. Semin Thorac Cardiovasc Surg Pediatr Card Surg Annu 2013; 16:32-36. [PMID: 23561815 DOI: 10.1053/j.pcsu.2013.01.009] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/02/2023]
Abstract
Unbalanced atrioventricular septal defect (uAVSD) is a challenging lesion with suboptimal outcomes in the current era. Severe forms of uAVSD mandate univentricular repair with well-documented outcomes. Determining the feasibility of biventricular repair (BVR) in patients with moderate forms of uAVSD is difficult. Ventricular hypoplasia has traditionally formed the cornerstone of defining uAVSD. However, malalignment of the atrioventricular junction and related derangements of the anatomy and physiology of the atrioventricular inflow play a central role in establishing and sustaining a biventricular end state. Atrioventricular valve index, left ventricular inflow index, and right ventricle/left ventricle inflow angle are important recently described measures of inflow physiology. Additional patient anatomic and physiologic factors that impact BVR feasibility undoubtedly exist. A recently launched Congenital Heart Surgeons Society prospective inception cohort study will address these and other issues that impair our ability to predict BVR feasibility in uAVSD.
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Affiliation(s)
- David M Overman
- Division of Cardiac Surgery, The Children's Heart Clinic, Minneapolis, MN 55404, USA.
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