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Collins RT, Gravenhorst V, Faury G, Kwiatkowska J, Schmelzer CEH, Schneider H, Waldoch A, Pankau R. Clinical Care for Cardiovascular Disease in Patients With Williams-Beuren Syndrome. J Am Heart Assoc 2024; 13:e036997. [PMID: 39291481 DOI: 10.1161/jaha.124.036997] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 09/19/2024]
Abstract
Williams-Beuren syndrome (WBS) is a congenital multisystem disorder affecting the cardiovascular, central nervous, and musculoskeletal systems. Cardiovascular abnormalities, which consist principally of vascular stenoses, occur in approximately 80% of people with WBS and are the predominant cause of early morbidity and mortality. Supravalvar aortic stenosis and peripheral pulmonary artery stenosis are the most common stenotic lesions in WBS, though other stenoses often occur, including stenoses of the coronary arteries. Approximately one-third of people with WBS undergo cardiovascular interventions. The risk of sudden cardiac death is markedly higher than the general population, with most events occurring in the periprocedural period. Because of the rarity of WBS and the often-complex nature of the cardiovascular abnormalities, most physicians, including cardiologists, have limited experience in caring for patients with WBS. Further, heretofore, clinical cardiovascular management guidelines based on international expert consensus have not been available. This state-of-the-art review provides a comprehensive synopsis of the cardiovascular abnormalities in WBS and presents clinical management guidelines based on the authors' expert consensus.
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Affiliation(s)
- R Thomas Collins
- Department of Pediatrics, Division of Cardiology University of Kentucky College of Medicine Lexington KY USA
| | - Verena Gravenhorst
- Department of Pediatric Cardiology, Intensive Care Medicine and Neonatology University Medical Center, Georg-August-University Göttingen Göttingen Germany
| | - Gilles Faury
- Université Grenoble Alpes, INSERM U1300 CHU Grenoble France
| | - Joanna Kwiatkowska
- Pediatric Cardiology and Congenital Heart Defects Department Medical University of Gdańsk Poland
| | - Christian E H Schmelzer
- Department of Biological and Macromolecular Materials Fraunhofer Institute for Microstructure of Materials and Systems IMWS Halle (Saale) Germany
| | - Heike Schneider
- Department of Pediatric Cardiology, Intensive Care Medicine and Neonatology University Medical Center, Georg-August-University Göttingen Göttingen Germany
| | - Anna Waldoch
- Pediatric Cardiology and Congenital Heart Defects Department Medical University of Gdańsk Poland
| | - Rainer Pankau
- Department of Pediatrics University Medical Center Schleswig-Holstein, Christian-Albrechts-University Kiel Germany
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Deitch AM, Giacone HM, Chubb H, Algaze CA, Lechich KM, Collins RT. Arrhythmias in Williams Syndrome. Am J Cardiol 2023; 195:91-97. [PMID: 37037070 DOI: 10.1016/j.amjcard.2023.03.004] [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: 12/14/2022] [Revised: 02/11/2023] [Accepted: 03/06/2023] [Indexed: 04/12/2023]
Abstract
Williams syndrome (WS) is a congenital, multisystem disorder in which 80% of patients have cardiovascular abnormalities. Sudden cardiac death occurs 25 to 100 times more often in WS than in the general population, and cardiac repolarization is abnormal in WS. We sought to determine the prevalence of primary arrhythmias in patients with WS and whether QTc prolongation impacts arrhythmia risk. We retrospectively reviewed all patients with WS with ambulatory electrocardiogram (ECG) monitoring at our institution between October 2017 and January 2022. The primary outcome was the presence of arrhythmia. Predictors pre-determined for analysis included premature ventricular and atrial complex burden (%), degree of QTc change with varying heart rates, intervals and rhythm on 12-lead ECG, age, gender, symptomatology, and clinical and surgical history. A total of 74 patients (55% female, median age 8 years (3, 13) underwent 108 ambulatory monitors. Arrhythmias were present in 9 patients (12%). Within this group of 9 patients, 18/24 serial monitors were abnormal, and 3/9 patients (33%) had >1 arrhythmia type. Older age (p = 0.002) and symptoms (syncope, p = 0.005) were associated with arrhythmias. Arrhythmia was not associated with the degree of structural heart disease. Atrial tachycardia was the most identified arrhythmia (n = 6; 67% of patients with arrhythmias and 8% of the total cohort). The QTc abnormally increased with higher heart rates in all groups. There was a higher number of premature ventricular and atrial complexes per hour in patients with arrhythmias. In conclusion, atrial arrhythmias were the most common arrhythmia in patients with WS and routine ambulatory ECG and intermittent rhythm monitoring are indicated in WS, particularly given the high risk of sudden cardiac death in WS.
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Affiliation(s)
- Anna M Deitch
- Department of Pediatric Cardiology, Lucile Packard Children's Hospital, Stanford University, Stanford, California.
| | - Heather M Giacone
- Department of Pediatric Cardiology, Lucile Packard Children's Hospital, Stanford University, Stanford, California
| | - Henry Chubb
- Department of Pediatric Cardiology, Lucile Packard Children's Hospital, Stanford University, Stanford, California
| | - Claudia A Algaze
- Department of Pediatric Cardiology, Lucile Packard Children's Hospital, Stanford University, Stanford, California
| | - Kirstie MacMillen Lechich
- Department of Pediatric Cardiology, Lucile Packard Children's Hospital, Stanford University, Stanford, California
| | - R Thomas Collins
- Department of Pediatric Cardiology, Lucile Packard Children's Hospital, Stanford University, Stanford, California
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Algaze CA, Deitch AM, Chubb H, Aziz PF, Collins RT. Importance of Formula-Specific Centile Thresholds for Evaluation of Heart Rate-Corrected QT Prolongation in Williams Syndrome. Am J Cardiol 2022; 183:99-104. [PMID: 36114024 DOI: 10.1016/j.amjcard.2022.07.031] [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: 06/10/2022] [Revised: 07/12/2022] [Accepted: 07/18/2022] [Indexed: 11/30/2022]
Abstract
Patients with Williams syndrome (WS) have a 25- to 100-fold higher risk of sudden death and prolonged heart rate-corrected QT (QTc). A recent study using the Fridericia formula for QT correction suggested that prolongation is principally an issue of heart rate. We used multiple published heart rate correction formulas to reevaluate the prevalence of QTc prolongation in our original dataset from our 2010 study at the Children's Hospital of Philadelphia. The ninety-eighth centile for QTc and corrected JT Interval (JTc) of the control population for each formula were used to set the threshold for prolongation. Prevalence comparison was done with Fisher's exact test. Predictors of longer QTc/JTc were assessed using linear regression models adjusting for age, gender, and heart rate. Adjusted odds of QTc/JTc prolongation were evaluated with conditional logistic regression models matched based on age and heart rate. There were 482 electrocardiograms from 188 patients with WS and 1,522 from normal controls. Patients with WS were younger, with higher heart rates and shorter RR and QRS intervals. WS was associated with longer QTc/JTc compared with controls. There were higher odds of prolonged QTc/JTc in patients with WS than controls using both Bazett and Fridericia formulas. In conclusion, this study confirms the higher prevalence of QTc prolongation in WS compared with controls and highlights the importance of setting appropriate formula-specific upper thresholds for QTc prolongation for accurate diagnosis.
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Affiliation(s)
- Claudia A Algaze
- Division of Pediatric Cardiology, Lucile Packard Children's Hospital, Stanford University School of Medicine, Palo Alto, California.
| | - Anna M Deitch
- Division of Pediatric Cardiology, Lucile Packard Children's Hospital, Stanford University School of Medicine, Palo Alto, California
| | - Henry Chubb
- Division of Pediatric Cardiology, Lucile Packard Children's Hospital, Stanford University School of Medicine, Palo Alto, California
| | - Peter F Aziz
- Department of Pediatric Cardiology, Cleveland Clinic Children's, Cleveland Clinic Lerner College of Medicine, Cleveland, Ohio
| | - R Thomas Collins
- Division of Pediatric Cardiology, Lucile Packard Children's Hospital, Stanford University School of Medicine, Palo Alto, California
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Yokota R, Kwiatkowski DM, Journel C, Adamson GT, Zucker E, Suarez G, Lechich KM, Chaudhuri A, Collins RT. Postoperative Acute Kidney Injury in Williams Syndrome Compared With Matched Controls. Pediatr Crit Care Med 2022; 23:e162-e170. [PMID: 34982759 DOI: 10.1097/pcc.0000000000002872] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES Cardiovascular manifestations occur in over 80% of Williams syndrome (WS) patients and are the leading cause of morbidity and mortality. One-third of patients require cardiovascular surgery. Renal artery stenosis (RAS) is common in WS. No studies have assessed postoperative cardiac surgery-related acute kidney injury (CS-AKI) in WS. Our objectives were to assess if WS patients have higher risk of CS-AKI postoperatively than matched controls and if RAS could contribute to CS-AKI. DESIGN This was a retrospective study of all patients with WS who underwent cardiac surgery at our center from 2010 to 2020. The WS study cohort was compared with a group of controls matched for age, sex, weight, and surgical procedure. SETTING Patients underwent cardiac surgery and postoperative care at Lucile Packard Children's Hospital Stanford. PATIENTS There were 27 WS patients and 43 controls (31% vs 42% female; p = 0.36). Median age was 1.8 years (interquartile range [IQR], 0.7-3.8 yr) for WS and 1.7 years (IQR, 0.8-3.1 yr) for controls. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Postoperative hemodynamics, vasopressor, total volume input, diuretic administration, and urine output were collected in the first 72 hours. Laboratory studies were collected at 8-hour intervals. Multivariable analysis identified predictors of CS-AKI.Controlled for renal perfusion pressure (RPP) and vasoactive inotrope score (VIS), compared with controls, the odds ratio (OR) of CS-AKI in WS was 4.2 (95% CI, 1.1-16; p = 0.034). Higher RPP at postoperative hours 9-16 was associated with decreased OR of CS-AKI (0.88 [0.8-0.96]; p = 0.004). Increased VIS at hour 6 was associated with an increased OR of CS-AKI (1.47 [1.14-1.9]; p = 0.003). Younger age was associated with an increased OR of CS-AKI (1.9 [1.13-3.17]; p = 0.015). CONCLUSIONS The OR of CS-AKI is increased in pediatric patients with WS compared with controls. CS-AKI was associated with VIS at the sixth postoperative hour. Increases in RPP and mean arterial pressure were associated with decreased odds of CS-AKI.
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Affiliation(s)
- Rumi Yokota
- Lucile Packard Children's Hospital Stanford, Palo Alto, CA
| | - David M Kwiatkowski
- Lucile Packard Children's Hospital Stanford, Palo Alto, CA
- Division of Cardiology, Department of Pediatrics, Stanford University School of Medicine, Palo Alto, CA
| | - Chloe Journel
- Lucile Packard Children's Hospital Stanford, Palo Alto, CA
| | - Greg T Adamson
- Lucile Packard Children's Hospital Stanford, Palo Alto, CA
- Division of Cardiology, Department of Pediatrics, Stanford University School of Medicine, Palo Alto, CA
| | - Evan Zucker
- Lucile Packard Children's Hospital Stanford, Palo Alto, CA
- Department of Radiology, Stanford University School of Medicine, Palo Alto, CA
| | | | | | - Abanti Chaudhuri
- Lucile Packard Children's Hospital Stanford, Palo Alto, CA
- Division of Nephrology, Department of Pediatrics, Stanford University School of Medicine, Palo Alto, CA
| | - R Thomas Collins
- Lucile Packard Children's Hospital Stanford, Palo Alto, CA
- Division of Cardiology, Department of Pediatrics, Stanford University School of Medicine, Palo Alto, CA
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Dadlani GH, Mercado C, Roberts V, Blackwelder H, Erickson K, Shrimpton G, Stein J, Morrison C, Stoner S, Bender K, Gronert B, Madueme P. Cardiovascular screening in Williams syndrome. PROGRESS IN PEDIATRIC CARDIOLOGY 2020. [DOI: 10.1016/j.ppedcard.2020.101267] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
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Collins II RT, Collins MG, Schmitz ML, Hamrick JT. Peri-procedural risk stratification and management of patients with Williams syndrome. CONGENIT HEART DIS 2017; 12:133-142. [DOI: 10.1111/chd.12447] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/07/2016] [Accepted: 12/27/2016] [Indexed: 01/10/2023]
Affiliation(s)
- R. Thomas Collins II
- Department of Pediatrics, The University of Arkansas for Medical Sciences, Little Rock, Arkansas, USA
- Department of Internal Medicine, The University of Arkansas for Medical Sciences, Little Rock, Arkansas, USA
| | - Margaret G. Collins
- Department of Dentistry, Arkansas Children's Hospital, Little Rock, Arkansas, USA
| | - Michael L. Schmitz
- Department of Internal Medicine, The University of Arkansas for Medical Sciences, Little Rock, Arkansas, USA
- Department of Anesthesiology, The University of Arkansas for Medical Sciences, Little Rock, Arkansas, USA
| | - Justin T. Hamrick
- Department of Anesthesiology, The University of Arkansas for Medical Sciences, Little Rock, Arkansas, USA
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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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Matisoff AJ, Olivieri L, Schwartz JM, Deutsch N. Risk assessment and anesthetic management of patients with Williams syndrome: a comprehensive review. Paediatr Anaesth 2015; 25:1207-15. [PMID: 26456018 DOI: 10.1111/pan.12775] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 08/13/2015] [Indexed: 01/18/2023]
Abstract
Since the first description in 1961, several case reports have documented an increased incidence of anesthesia-related cardiac arrest in patients with Williams-Beuren syndrome, commonly known as Williams syndrome (WS). Widespread arteriopathy secondary to an elastin gene defect results in various cardiac defects, including supravalvar aortic stenosis (SVAS) and coronary artery anomalies, which can increase the risk of myocardial ischemia. Even though patients with WS are known to have increased risk of adverse events during anesthesia and sedation, they often undergo several procedures that require anesthesia during their lifetimes, and cases of perianesthetic cardiac arrest continue to be reported. To date, no prospective studies have been reported that quantify anesthetic risk in individual patients with WS. In this article, we review the clinical manifestations of WS, propose a consensus, expert-informed method to estimate anesthetic risk based on the current literature, and provide recommendations for periprocedural management of this patient population.
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Affiliation(s)
- Andrew J Matisoff
- Division of Anesthesia, Sedation and Perioperative Medicine, Children's National Health System, George Washington University School of Medicine, Washington, DC, USA
| | - Laura Olivieri
- Division of Cardiology, Children's National Health System, George Washington University School of Medicine, Washington, DC, USA
| | - Jamie M Schwartz
- Division of Anesthesia, Sedation and Perioperative Medicine, Children's National Health System, George Washington University School of Medicine, Washington, DC, USA.,Division of Critical Care, Children's National Health System, George Washington University School of Medicine, Washington, DC, USA
| | - Nina Deutsch
- Division of Anesthesia, Sedation and Perioperative Medicine, Children's National Health System, George Washington University School of Medicine, Washington, DC, USA
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Hornik CP, Collins RT, Jaquiss RDB, Jacobs JP, Jacobs ML, Pasquali SK, Wallace AS, Hill KD. Adverse cardiac events in children with Williams syndrome undergoing cardiovascular surgery: An analysis of the Society of Thoracic Surgeons Congenital Heart Surgery Database. J Thorac Cardiovasc Surg 2015; 149:1516-22.e1. [PMID: 25791950 DOI: 10.1016/j.jtcvs.2015.02.016] [Citation(s) in RCA: 39] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/21/2014] [Revised: 02/02/2015] [Accepted: 02/09/2015] [Indexed: 10/24/2022]
Abstract
OBJECTIVE Patients with Williams syndrome (WS) undergoing cardiac surgery are at risk for major adverse cardiac events (MACE). Prevalence and risk factors for such events have not been well described. We sought to define frequency and risk of MACE in patients with WS using a multicenter clinical registry. METHODS We identified cardiac operations performed in patients with WS using the Society of Thoracic Surgeons Congenital Heart Surgery Database (2000-2012). Operations were divided into 4 groups: isolated supravalvular aortic stenosis, complex left ventricular outflow tract (LVOT), isolated right ventricular outflow tract (RVOT), and combined LVOT/RVOT procedures. The proportion of patients with MACE (in-hospital mortality, cardiac arrest, or postoperative mechanical circulatory support) was described and the association with preoperative factors was examined. RESULTS Of 447 index operations (87 centers), median (interquartile range) age and weight at surgery were 2.4 years (0.6-7.4 years) and 10.6 kg (6.5-21.5 kg), respectively. Mortality occurred in 20 patients (5%). MACE occurred in 41 patients (9%), most commonly after combined LVOT/RVOT (18 out of 87; 21%) and complex LVOT (12 out of 131; 9%) procedures, but not after isolated RVOT procedures. Odds of MACE decreased with age (odds ratio [OR], 0.99; 95% confidence interval [CI], 0.98-0.99), weight (OR, 0.97; 95% CI, 0.93-0.99), but increased in the presence of any preoperative risk factor (OR, 2.08; 95% CI, 1.06-4.00), and in procedures involving coronary artery repair (OR, 5.37; 95% CI, 2.05-14.06). CONCLUSIONS In this multicenter analysis, MACE occurred in 9% of patients with WS undergoing cardiac surgery. Demographic and operative characteristics were associated with risk. Further study is needed to elucidate mechanisms of MACE in this high-risk population.
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Affiliation(s)
- Christoph P Hornik
- Department of Pediatrics, Duke University, Durham, NC; Duke Clinical Research Institute, Duke University, Durham, NC.
| | - Ronnie Thomas Collins
- Division of Pediatric Cardiology, University of Arkansas for Medical Sciences and Arkansas Children's Hospital, Little Rock, Ark
| | - Robert D B Jaquiss
- Department of Pediatrics, Duke University, Durham, NC; Duke Clinical Research Institute, Duke University, Durham, NC
| | - Jeffrey P Jacobs
- Andrews/Daicoff Cardiovascular Program, Johns Hopkins Children's Heart Surgery, St Petersburg, Fla; All Children's Hospital, Tampa, Fla; Florida Hospital for Children, Orlando, Fla
| | - Marshall L Jacobs
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Md
| | - Sara K Pasquali
- Division of Pediatric Cardiology, University of Michigan C.S. Mott Children's Hospital, Ann Arbor, Mich
| | - Amelia S Wallace
- Department of Pediatrics, Duke University, Durham, NC; Duke Clinical Research Institute, Duke University, Durham, NC
| | - Kevin D Hill
- Department of Pediatrics, Duke University, Durham, NC; Duke Clinical Research Institute, Duke University, Durham, NC
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Affiliation(s)
- R. Thomas Collins
- From the Arkansas Children’s Hospital and University of Arkansas for Medical Sciences, Little Rock, AR
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Comparison of electrocardiographic QTc duration in patients with supravalvar aortic stenosis with versus without Williams syndrome. Am J Cardiol 2013; 111:1501-4. [PMID: 23433766 DOI: 10.1016/j.amjcard.2013.01.308] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/21/2012] [Revised: 01/16/2013] [Accepted: 01/16/2013] [Indexed: 11/20/2022]
Abstract
Cardiovascular abnormalities in Williams syndrome (WS) are largely attributable to elastin haploinsufficiency resulting from a large deletion of the elastin-containing region on chromosome 7q11.23. The risk of sudden death in patients with WS is 25- to 100-fold greater than that in the general population. The corrected QT (QTc) interval is prolonged in 14% of patients with WS. Patients with nonsyndromic supravalvar aortic stenosis (NSVAS) have elastin mutations resulting in elastin haploinsufficiency and a vascular phenotype nearly identical to that of WS. No previous studies have evaluated the QTc duration in NSVAS. A retrospective review of all electrocardiograms (ECGs) performed on consecutive patients with NSVAS at Arkansas Children's Hospital from January 1, 1985 to January 1, 2012 was completed. ECGs with nonsinus rhythm or unmeasurable intervals were excluded. The ECGs were read by 1 reader who was unaware of previous readings. A QTc interval of ≥460 ms was defined as prolonged. The NSVAS cohort was compared to previously published WS and control groups using the mixed model for continuous electrocardiographic variables and the generalized estimating equation for binary indicators for prolonged QTc. The generalized estimating equation used bootstrapping with 1,000 replicates. A total of 300 ECGs (median 6, range 1 to 27) from the 35 identified patients with NSVAS met the inclusion criteria. A total of 482 ECGs from patients with WS and 1,522 ECGs from controls were included. The mean age of the patients with NSVAS at ECG was 7.3 ± 6.9 years; 64% were male. The mean QTc duration was 409 ± 20 ms in the NSVAS group, 418 ± 17 ms in the control group (p <0.001), and 436 ± 27 ms in the WS group (p <0.001 compared to the control group). The prevalence of QTc prolongation was 0.3% in the NSVAS group, 2.0% in the control group (p <0.001), and 14.8% in the WS group (p <0.001 compared to controls). No patients with NSVAS died. In conclusion, cardiac repolarization is normal in patients with NSVAS. Elastin haploinsufficiency does not appear to be the etiology of QTc prolongation in patients with WS. The possible contribution of other genes on 7q11.23 to QTc prolongation in WS should be investigated.
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