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Osawa T, Schaeffer T, Borgmann K, Schmiel M, Staehler H, Di Padua C, Heinisch PP, Piber N, Mutsuga M, Hager A, Ewert P, Hörer J, Ono M. Impact of aortopulmonary collaterals on adverse events after total cavopulmonary connection. Eur J Cardiothorac Surg 2023; 64:ezad408. [PMID: 38070163 DOI: 10.1093/ejcts/ezad408] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/08/2023] [Revised: 11/06/2023] [Accepted: 12/07/2023] [Indexed: 12/22/2023] Open
Abstract
OBJECTIVES Effects of aortopulmonary collaterals (APCs) on outcomes after the total cavopulmonary connection (TCPC) are unclear. This study evaluated the incidence of APCs before and after TCPC and analysed the impacts of APCs on adverse outcomes. METHODS A total of 585 patients, who underwent TCPC from 1994 to 2020 and whose preoperative angiographies were available, were included. Pre-TCPC angiograms in all patients were used for the detection of APCs, and post-TCPC angiograms were evaluated in selected patients. Late adverse events included late death, protein-losing enteropathy (PLE) and plastic bronchitis (PB). RESULTS The median age at TCPC was 2.3 (1.8-3.4) years with a body weight of 12 (11-14) kg. APCs were found in 210 patients (36%) before TCPC and in 81 (14%) after TCPC. The closure of APCs was performed in 59 patients (10%) before TCPC, in 25 (4.2%) at TCPC and in 59 (10%) after TCPC. The occurrences of APCs before and after TCPC were not associated with short-term or mid-term mortality. The APCs before TCPC were associated with chylothorax (P = 0.025), prolonged chest tube duration (P = 0.021) and PB (P = 0.008). The APCs after TCPC were associated with PLE (P < 0.001) and PB (P < 0.001). With APCs following TCPC, freedom from PLE and PB was lower than without (P < 0.001, P < 0.001). CONCLUSIONS APCs before TCPC were associated with chylothorax, prolonged chest tube duration and PB. APCs after TCPC were associated with both PLE and PB. The presence of APCs might affect the lymph drainage system and increase the incidence of chylothorax, PLE and PB.
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Affiliation(s)
- Takuya Osawa
- Department of Congenital and Pediatric Heart Surgery, German Heart Center Munich, Technische Universität München, Munich, Germany
- Division of Congenital and Pediatric Heart Surgery, University Hospital of Munich, Ludwig-Maximilians-Universität, Munich, Germany
- Department of Cardiac Surgery, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Thibault Schaeffer
- Department of Congenital and Pediatric Heart Surgery, German Heart Center Munich, Technische Universität München, Munich, Germany
- Division of Congenital and Pediatric Heart Surgery, University Hospital of Munich, Ludwig-Maximilians-Universität, Munich, Germany
| | - Kristina Borgmann
- Department of Congenital Heart Disease and Pediatric Cardiology, German Heart Center Munich, Technische Universität München, Munich, Germany
| | - Mervin Schmiel
- Department of Congenital and Pediatric Heart Surgery, German Heart Center Munich, Technische Universität München, Munich, Germany
- Division of Congenital and Pediatric Heart Surgery, University Hospital of Munich, Ludwig-Maximilians-Universität, Munich, Germany
| | - Helena Staehler
- Department of Congenital and Pediatric Heart Surgery, German Heart Center Munich, Technische Universität München, Munich, Germany
- Division of Congenital and Pediatric Heart Surgery, University Hospital of Munich, Ludwig-Maximilians-Universität, Munich, Germany
| | - Chiara Di Padua
- Department of Congenital and Pediatric Heart Surgery, German Heart Center Munich, Technische Universität München, Munich, Germany
- Division of Congenital and Pediatric Heart Surgery, University Hospital of Munich, Ludwig-Maximilians-Universität, Munich, Germany
| | - Paul Philipp Heinisch
- Department of Congenital and Pediatric Heart Surgery, German Heart Center Munich, Technische Universität München, Munich, Germany
- Division of Congenital and Pediatric Heart Surgery, University Hospital of Munich, Ludwig-Maximilians-Universität, Munich, Germany
| | - Nicole Piber
- Department of Cardiovascular Surgery, German Heart Center Munich, Technische Universität München, Munich, Germany
| | - Masato Mutsuga
- Department of Cardiac Surgery, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Alfred Hager
- Department of Congenital Heart Disease and Pediatric Cardiology, German Heart Center Munich, Technische Universität München, Munich, Germany
| | - Peter Ewert
- Department of Congenital Heart Disease and Pediatric Cardiology, German Heart Center Munich, Technische Universität München, Munich, Germany
| | - Jürgen Hörer
- Department of Congenital and Pediatric Heart Surgery, German Heart Center Munich, Technische Universität München, Munich, Germany
- Division of Congenital and Pediatric Heart Surgery, University Hospital of Munich, Ludwig-Maximilians-Universität, Munich, Germany
| | - Masamichi Ono
- Department of Congenital and Pediatric Heart Surgery, German Heart Center Munich, Technische Universität München, Munich, Germany
- Division of Congenital and Pediatric Heart Surgery, University Hospital of Munich, Ludwig-Maximilians-Universität, Munich, Germany
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Fogel MA, Donnelly E, Crandell I, Hanlon A, Whitehead KK, Harris M, Partington S, Biko D, Flynn T, Nicolson S, Gaynor JW, Licht D, Vossough A. Cerebral Blood Flow, Brain Injury, and Aortic-Pulmonary Collateral Flow After the Fontan Operation. Am J Cardiol 2023; 208:164-170. [PMID: 37844519 DOI: 10.1016/j.amjcard.2023.08.023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/23/2023] [Revised: 07/31/2023] [Accepted: 08/05/2023] [Indexed: 10/18/2023]
Abstract
Patients with a single ventricle develop aortopulmonary collaterals (APCs) whose flow has been shown to be inversely proportional to cerebral blood flow (CBF) in a previous cross-sectional study. Longitudinal CBF and APC flow in patients with Fontan physiology adjusting for brain injury (BI) has never been reported. Decreased CBF and BI may adversely impact neurodevelopment. A prospective longitudinal cohort of 27 patients with Fontan physiology (aged 10 ± 1.9 years, 74% male) underwent cardiac and brain magnetic resonance imaging 3 to 9 months and 6.0 ± 1.86 years after Fontan operation to measure the CBF and APC flow and to reassess the BI (focal BI, generalized insult, and hemorrhage). CBF was measured using jugular venous flow and APC flow was measured by the difference between aortic flow and caval return. Multivariate modeling was used to assess the relation between the change in APC flow and BI. A strong inverse relation was found between CBF/aortic flow change and APC flow/aortic flow and APC flow/body surface area change (R2 = 0.70 and 0.72 respectively, p <0.02). Overall, the CBF decreased by 9 ± 11% and the APC flow decreased by 0.73 ± 0.67 l/min/m2. The evolution of CBF and APC flow were significantly and inversely related when adjusting for time since Fontan operation, gender, and BI on the multivariate modeling. Every unit increase in APC flow change was associated with an 8% decrease in CBF change. In conclusion, CBF and APC flow change are inversely related across serial imaging, adjusting for time from Fontan operation, gender, and BI. CBF and APC aortic flow decrease over a 6-year period. This may adversely impact neurodevelopment. Because APCs can be embolized, this may be a modifiable risk factor. Clinical trials numbers: NCT02135081 and NCT02919956.
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Affiliation(s)
- Mark A Fogel
- Division of Cardiology, Department of Pediatrics, The Children's Hospital of Philadelphia/The Perelman School of Medicine, The University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania; Department of Radiology, The Children's Hospital of Philadelphia/The Perelman School of Medicine, The University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania.
| | - Elizabeth Donnelly
- Division of Cardiology, Department of Pediatrics, The Children's Hospital of Philadelphia/The Perelman School of Medicine, The University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania
| | - Ian Crandell
- The Center for Biostatistics and Health Data Science, Virginia Polytechnic and State University, Roanoke, Virginia
| | - Alex Hanlon
- The Center for Biostatistics and Health Data Science, Virginia Polytechnic and State University, Roanoke, Virginia
| | - Kevin K Whitehead
- Division of Cardiology, Department of Pediatrics, The Children's Hospital of Philadelphia/The Perelman School of Medicine, The University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania; Department of Radiology, The Children's Hospital of Philadelphia/The Perelman School of Medicine, The University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania
| | - Matthew Harris
- Division of Cardiology, Department of Pediatrics, The Children's Hospital of Philadelphia/The Perelman School of Medicine, The University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania; Department of Radiology, The Children's Hospital of Philadelphia/The Perelman School of Medicine, The University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania
| | - Sara Partington
- Division of Cardiology, Department of Pediatrics, The Children's Hospital of Philadelphia/The Perelman School of Medicine, The University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania
| | - David Biko
- Department of Radiology, The Children's Hospital of Philadelphia/The Perelman School of Medicine, The University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania
| | - Thomas Flynn
- Division of Integrated Behavioral Medicine, Department of Child and Adolescent Psychiatry and Behavioral Sciences, The Children's Hospital of Philadelphia/The Perelman School of Medicine, The University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania
| | - Susan Nicolson
- Department of Anesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia/The Perelman School of Medicine, The University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania
| | - J William Gaynor
- Division of Cardiothoracic Surgery, Department of Surgery, The Children's Hospital of Philadelphia/The Perelman School of Medicine, The University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania
| | - Daniel Licht
- Division of Neurology, The Children's Hospital of Philadelphia/The Perelman School of Medicine, The University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania
| | - Arastoo Vossough
- Department of Radiology, The Children's Hospital of Philadelphia/The Perelman School of Medicine, The University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania
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Davidson H, Zannino D, d’Udekem Y, Cordina R, Orr Y, Konstantinov IE, Weintraub R, Wheaton G, Saundankar J, Salve G, Iyengar A, Alphonso N, Ayer J. Does leaving native antegrade pulmonary blood flow at the time of the superior cavopulmonary connection impact long-term outcomes after the Fontan? JTCVS OPEN 2023; 16:825-835. [PMID: 38204641 PMCID: PMC10775047 DOI: 10.1016/j.xjon.2023.09.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/29/2023] [Revised: 08/08/2023] [Accepted: 09/05/2023] [Indexed: 01/12/2024]
Abstract
Objectives Antegrade pulmonary blood flow (APBF) may be left or eliminated at the time of the superior cavopulmonary connection (SCPC). Our aim was to assess the impact of leaving native APBF at the SCPC on long-term Fontan outcomes. Methods In the Australia and New Zealand Fontan Registry (1985-2021), 587 patients had pre-existing native APBF at the SCPC. At the SCPC, 302 patients had APBF eliminated (APBF-) and 285 patients had APBF maintained (APBF+). The incidence of Fontan failure (composite end point of Fontan takedown, transplant, plastic bronchitis, protein losing enteropathy and death) and atrioventricular (AV) valve repair/replacement post SCPC was compared between the 2 groups. Results Sex, predominant-ventricle morphology, isomerism, primary diagnosis, and age/type of Fontan were similar between groups. APBF- versus APBF+ had a higher incidence of arch obstruction/coarctation (17% vs 7%) and previous pulmonary artery band (54% vs 45%) and a lower rate of Fontan fenestration (27% vs 41%). The risk of Fontan failure was similar between the 2 groups (hazard ratio [HR], 1.01; 95% confidence interval [CI], 0.58-1.78; P = .96). The risk of AV-valve repair/replacement was greater in APBF+ versus APBF- (HR, 2.32; CI, 1.13-4.75; P = .022). The risk of AV-valve repair/replacement remained after adjustment for arch obstruction/coarctation, previous pulmonary artery band and Fontan fenestration (HR, 2.27; CI, 1.07-4.81; P = .033). Conclusions Maintaining APBF at the time of the SCPC does not impact the risk of Fontan failure but may increase the incidence of AV-valve repair and/or replacement post-SCPC.
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Affiliation(s)
- Hannah Davidson
- The Heart Centre for Children, The Children's Hospital at Westmead, Sydney, Australia
- Discipline of Paediatrics and Child Health, The University of Sydney, Sydney, Australia
| | - Diana Zannino
- Heart Research Group, Murdoch Children's Research Institute, Melbourne, Australia
| | - Yves d’Udekem
- Division of Cardiac Surgery, Children's National Hospital, Washington, DC
| | - Rachael Cordina
- Department of Cardiology, Royal Prince Alfred Hospital, Sydney, Australia
- Sydney Medical School, The University of Sydney, Sydney, Australia
| | - Yishay Orr
- The Heart Centre for Children, The Children's Hospital at Westmead, Sydney, Australia
- Discipline of Paediatrics and Child Health, The University of Sydney, Sydney, Australia
| | - Igor E. Konstantinov
- Heart Research Group, Murdoch Children's Research Institute, Melbourne, Australia
- Department of Cardiac Surgery, Royal Children's Hospital Melbourne, Parkville, Australia
| | - Robert Weintraub
- Heart Research Group, Murdoch Children's Research Institute, Melbourne, Australia
- Department of Paediatrics, Faculty of Medicine, The University of Melbourne, Melbourne, Australia
- Department of Paediatric Cardiology, Royal Children's Hospital Melbourne, Parkville, Australia
| | - Gavin Wheaton
- Women's and Children's Hospital, Adelaide, Australia
| | - Jelena Saundankar
- Department of Paediatric Cardiology, Perth Children's Hospital, Perth, Australia
| | - Gananjay Salve
- The Heart Centre for Children, The Children's Hospital at Westmead, Sydney, Australia
| | - Ajay Iyengar
- Greenlane Paediatric and Congenital Cardiac Service, Starship Children's Hospital, Auckland, New Zealand
| | - Nelson Alphonso
- Department of Cardiac Surgery, Queensland Children's Hospital, Brisbane, Australia
| | - Julian Ayer
- The Heart Centre for Children, The Children's Hospital at Westmead, Sydney, Australia
- Discipline of Paediatrics and Child Health, The University of Sydney, Sydney, Australia
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Frieberg P, Sjöberg P, Hedström E, Carlsson M, Liuba P. In vivo hepatic flow distribution by computational fluid dynamics can predict pulmonary flow distribution in patients with Fontan circulation. Sci Rep 2023; 13:18206. [PMID: 37875552 PMCID: PMC10598063 DOI: 10.1038/s41598-023-45396-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2023] [Accepted: 10/19/2023] [Indexed: 10/26/2023] Open
Abstract
In Fontan patients, a lung deprived of hepatic blood may develop pulmonary arterio-venous malformations (PAVMs) resulting in shunting, reduced pulmonary vascular resistance (PVR) and decreased oxygenation. To provide guidance for corrective invasive interventions, we aimed to non-invasively determine how the hepatic to pulmonary blood flow balance correlates with pulmonary flow, PVR, and with oxygen saturation. Magnetic resonance imaging (MRI) data from eighteen Fontan patients (eight females, age 3-14 years) was used to construct patient-specific computational fluid dynamics (CFD) models to calculate the hepatic to pulmonary blood flow. This was correlated with pulmonary vein flow, simulated PVR and oxygen saturation. Clinical applicability of the findings was demonstrated with an interventional patient case. The hepatic to pulmonary blood flow balance correlated with right/left pulmonary vein flow (R2 = 0.50), left/right simulated PVR (R2 = 0.47), and oxygen saturation at rest (R2 = 0.56). In the interventional patient, CFD predictions agreed with post-interventional MRI measurements and with regressions in the cohort. The balance of hepatic blood to the lungs has a continuous effect on PVR and oxygen saturation, even without PAVM diagnosis. MRI combined with CFD may help in planning of surgical and interventional designs affecting the hepatic to pulmonary blood flow balance in Fontan patients.
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Affiliation(s)
- Petter Frieberg
- Clinical Physiology, Department of Clinical Sciences Lund, Lund University, Skåne University Hospital, Lund, Sweden.
| | - Pia Sjöberg
- Clinical Physiology, Department of Clinical Sciences Lund, Lund University, Skåne University Hospital, Lund, Sweden
| | - Erik Hedström
- Clinical Physiology, Department of Clinical Sciences Lund, Lund University, Skåne University Hospital, Lund, Sweden
- Diagnostic Radiology, Department of Clinical Sciences Lund, Lund University, Skåne University Hospital, Lund, Sweden
| | - Marcus Carlsson
- Clinical Physiology, Department of Clinical Sciences Lund, Lund University, Skåne University Hospital, Lund, Sweden
| | - Petru Liuba
- Department of Clinical Sciences Lund, Pediatric Heart Center, Lund University, Skåne University Hospital, Lund, Sweden
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Fahnhorst SE, Brandewie K, Perry T, Opotowsky AR, Lubert AM, Lorts A, Morales DLS, Villa CR. Single Center Experience With Durable Continuous Flow Single Ventricle Assist Device: A Viable Option in Fontan Circulatory Failure. ASAIO J 2023; 69:956-961. [PMID: 37200481 DOI: 10.1097/mat.0000000000001986] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/20/2023] Open
Abstract
Ventricular assist devices are increasingly used for patients with single ventricle physiology. We describe the use of durable, continuous flow, single ventricular assist device (SVAD) therapy in Fontan circulatory failure patients. Retrospective, single-center review of patients with Fontan circulation implanted with a SVAD between 2017 and 2022. Patient characteristics and outcomes were obtained by chart review. Nine patients underwent SVAD implantation (median age 24 years). Most patients had a total cavopulmonary connection; one had an atriopulmonary Fontan. Five patients had a systemic right ventricle. SVAD was most often utilized as bridge to candidacy (67%). Eight patients had at least moderate systemic ventricular systolic dysfunction. SVAD support continued for a median of 65 days (longest duration, 1,105 days) and one patient remains on support at time of submission. Of five patients discharged home, median length of stay after SVAD was 24 days. Six patients were transplanted (median 96 days from SVAD). Two patients died from pretransplant multisystem organ failure before transplant. All transplanted patients remain alive (median time since transplant 593 days). Continuous flow SVAD therapy can be effective for patients with Fontan circulatory failure and systolic dysfunction. Further studies should investigate feasibility and optimal SVAD timing with more advanced Fontan associated end-organ dysfunction.
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Affiliation(s)
- Sarah E Fahnhorst
- From the Heart Institute, Cincinnati Children's Hospital Medical Center, Department of Pediatrics, University of Cincinnati, Cincinnati, Ohio
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Ridderbos FJS, Chan FP, van Melle JP, Ebels T, Feinstein JA, Berger RMF, Willems TP. Quantification of systemic-to-pulmonary collateral flow in univentricular physiology with 4D flow MRI. Cardiol Young 2023; 33:1634-1642. [PMID: 36120930 DOI: 10.1017/s1047951122002840] [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: 11/06/2022]
Abstract
PURPOSE Systemic-to-pulmonary collateral flow is a well-recognised phenomenon in patients with single ventricle physiology, but remains difficult to quantify. The aim was to compare the reported formula's that have been used for calculation of systemic-to-pulmonary-collateral flow to assess their consistency and to quantify systemic-to-pulmonary collateral flow in patients with a Glenn and/or Fontan circulation using four-dimensional flow MRI (4D flow MR). METHODS Retrospective case-control study of Glenn and Fontan patients who had a 4D flow MR study. Flows were measured at the ascending aorta, left and right pulmonary arteries, left and right pulmonary veins, and both caval veins. Systemic-to-pulmonary collateral flow was calculated using two formulas: 1) pulmonary veins - pulmonary arteries and 2) ascending aorta - caval veins. Anatomical identification of collaterals was performed using the 4D MR image set. RESULTS Fourteen patients (n = 11 Fontan, n = 3 Glenn) were included (age 26 [22-30] years). Systemic-to-pulmonary collateral flow was significantly higher in the patients than the controls (n = 10, age 31.2 [15.1-38.4] years) with both formulas: 0.28 [0.09-0.5] versus 0.04 [-0.66-0.21] l/min/m2 (p = 0.036, formula 1) and 0.67 [0.24-0.88] versus -0.07 [-0.16-0.08] l/min/m2 (p < 0.001, formula 2). In patients, systemic-to-pulmonary collateral flow differed significantly between formulas 1 and 2 (13% versus 26% of aortic flow, p = 0.038). In seven patients, veno-venous collaterals were detected and no aortopulmonary collaterals were visualised. CONCLUSION 4D flow MR is able to detect increased systemic-to-pulmonary collateral flow and visualise collaterals vessels in Glenn and Fontan patients. However, the amount of systemic-to-pulmonary collateral flow varies with the formula employed. Therefore, further research is necessary before it could be applied in clinical care.
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Affiliation(s)
- Floris-Jan S Ridderbos
- Department of Radiology, Stanford University Medical Center, Stanford University, Stanford, USA
- Department of Pediatric Cardiology, Center for Congenital Heart Diseases, Beatrix Children's Hospital, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands
| | - Frandics P Chan
- Department of Radiology, Stanford University Medical Center, Stanford University, Stanford, USA
| | - Joost P van Melle
- Department of Cardiology, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands
| | - Tjark Ebels
- Department of Cardiothoracic Surgery, Academic Medical Center, University of Amsterdam, Amsterdam, the Netherlands
- Department of Cardiothoracic Surgery, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands
| | - Jeffrey A Feinstein
- Department of Pediatrics (Cardiology), Stanford University Medical Center / Lucile Packard Children's Hospital, Stanford University, Stanford, USA
| | - Rolf M F Berger
- Department of Pediatric Cardiology, Center for Congenital Heart Diseases, Beatrix Children's Hospital, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands
| | - Tineke P Willems
- Department of Radiology, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands
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7
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Segar DE, Pan AY, McLennan DI, Kindel SJ, Handler SS, Ginde S, Woods RK, Goot BH, Spearman AD. Clinical Variables Associated with Pre-Fontan Aortopulmonary Collateral Burden. Pediatr Cardiol 2023; 44:228-236. [PMID: 36156171 PMCID: PMC10155213 DOI: 10.1007/s00246-022-03014-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/23/2022] [Accepted: 09/18/2022] [Indexed: 01/25/2023]
Abstract
Aortopulmonary collaterals (APCs) develop universally, but to varying degrees, in patients with single ventricle congenital heart disease (CHD). Despite their ubiquitous presence, APCs remain poorly understood. We sought to evaluate the association between APC burden and common non-invasive clinical variables. We conducted a single center, retrospective study of patients with single ventricle CHD and previous Glenn palliation who underwent pre-Fontan cardiac magnetic resonance (CMR) imaging from 3/2018 to 3/2021. CMR was used to quantify APC flow, which was normalized to aortic (APC/QAo) and pulmonary vein (APC/QPV) blood flow. Univariate, multivariable, and classification and regression tree (CART) analyses were done to investigate the potential relationship between CMR-quantified APC burden and clinical variables. A total of 29 patients were included, all of whom had increased APC flow (APC/QAo: 26.9, [22.0, 39.1]%; APC/QPV: 39.4 [33.3, 46.9]%), but to varying degrees (APC/QAo: range 11.9-44.4%; APC/QPV: range 17.7-60.0%). Pulmonary artery size (Nakata index, at pre-Fontan CMR) was the only variable associated with APC flow on multivariable analysis (APC/QAo: p = 0.020, R2 = 0.19; APC/QPV: p = 0.0006, R2 = 0.36) and was the most important variable associated with APC burden identified by CART analysis (size inversely related to APC flow). APC flow is universally increased but highly variable in patients with single ventricle CHD and Glenn circulation. Small branch pulmonary artery size is a key factor associated with increased APC burden; however, the pathogenesis of APCs is likely multifactorial. Further research is needed to better understand APC pathogenesis, including predisposing and mitigating factors.
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Affiliation(s)
- David E Segar
- Division of Cardiology, Department of Pediatrics, Herma Heart Institute, Medical College of Wisconsin, Children's Wisconsin, 9000 West Wisconsin Avenue, Milwaukee, WI, 53226, USA
- Cardiovascular Center, Medical College of Wisconsin, 8701 West Watertown Plank Road, Milwaukee, WI, 53226, USA
| | - Amy Y Pan
- Cardiovascular Center, Medical College of Wisconsin, 8701 West Watertown Plank Road, Milwaukee, WI, 53226, USA
- Division of Quantitative Health Sciences, Department of Pediatrics, Medical College of Wisconsin, Children's Wisconsin, 9000 West Wisconsin Avenue, Milwaukee, WI, 53226, USA
| | - Daniel I McLennan
- Division of Cardiology, Department of Pediatrics, Herma Heart Institute, Medical College of Wisconsin, Children's Wisconsin, 9000 West Wisconsin Avenue, Milwaukee, WI, 53226, USA
- Cardiovascular Center, Medical College of Wisconsin, 8701 West Watertown Plank Road, Milwaukee, WI, 53226, USA
| | - Steven J Kindel
- Division of Cardiology, Department of Pediatrics, Herma Heart Institute, Medical College of Wisconsin, Children's Wisconsin, 9000 West Wisconsin Avenue, Milwaukee, WI, 53226, USA
- Cardiovascular Center, Medical College of Wisconsin, 8701 West Watertown Plank Road, Milwaukee, WI, 53226, USA
| | - Stephanie S Handler
- Division of Cardiology, Department of Pediatrics, Herma Heart Institute, Medical College of Wisconsin, Children's Wisconsin, 9000 West Wisconsin Avenue, Milwaukee, WI, 53226, USA
- Cardiovascular Center, Medical College of Wisconsin, 8701 West Watertown Plank Road, Milwaukee, WI, 53226, USA
| | - Salil Ginde
- Division of Cardiology, Department of Pediatrics, Herma Heart Institute, Medical College of Wisconsin, Children's Wisconsin, 9000 West Wisconsin Avenue, Milwaukee, WI, 53226, USA
- Cardiovascular Center, Medical College of Wisconsin, 8701 West Watertown Plank Road, Milwaukee, WI, 53226, USA
- Division of Cardiology, Department of Medicine, Medical College of Wisconsin, 8701 West Watertown Plank, Milwaukee, WI, 53226, USA
| | - Ronald K Woods
- Cardiovascular Center, Medical College of Wisconsin, 8701 West Watertown Plank Road, Milwaukee, WI, 53226, USA
- Division of Congenital Cardiac Surgery, Department of Surgery, Medical College of Wisconsin, 8701 West Watertown Plank, Milwaukee, WI, 53226, USA
| | - Benjamin H Goot
- Division of Cardiology, Department of Pediatrics, Herma Heart Institute, Medical College of Wisconsin, Children's Wisconsin, 9000 West Wisconsin Avenue, Milwaukee, WI, 53226, USA
- Cardiovascular Center, Medical College of Wisconsin, 8701 West Watertown Plank Road, Milwaukee, WI, 53226, USA
| | - Andrew D Spearman
- Division of Cardiology, Department of Pediatrics, Herma Heart Institute, Medical College of Wisconsin, Children's Wisconsin, 9000 West Wisconsin Avenue, Milwaukee, WI, 53226, USA.
- Cardiovascular Center, Medical College of Wisconsin, 8701 West Watertown Plank Road, Milwaukee, WI, 53226, USA.
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8
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Sun L, Jiang Q, Xie Y, Wang S, Zhang Z. Optical coherence tomography of the pulmonary arteries in children with congenital heart diseases: A systematic review. Pediatr Investig 2022; 6:264-270. [PMID: 36582270 PMCID: PMC9789933 DOI: 10.1002/ped4.12353] [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: 03/25/2022] [Accepted: 10/14/2022] [Indexed: 12/05/2022] Open
Abstract
Importance Optical coherence tomography (OCT) is a high-resolution intravascular imaging tool and has shown promise for providing real-time quantitative and qualitative descriptions of pulmonary vascular structures in vivo in adult pulmonary hypertension (PH), while not popular in pediatric patients with congenital heart diseases (CHD). Objective The aim of this review is to summarize all the available evidence on the use of OCT for imaging pulmonary vascular remodeling in pediatric patients. Methods We conducted the systematic literature resources (Cochran Library database, Medline via PubMed, EMBASE, and Web of Knowledge) from January 2010 to December 2021 and the search terms were "PH", "child", "children", "pediatric", "OCT", "CHD", "pulmonary vessels", "pulmonary artery wall". Studies in which OCT was used to image the pulmonary vessels in pediatric patients with CHD were considered for inclusion. Results Five studies met the inclusion criteria. These five papers discussed the study of OCT in the pulmonary vasculature of different types of CHD, including common simple CHD, complex cyanotic CHD, and Williams-Beuren syndrome. In biventricular anatomy, pulmonary vascular remodeling was primarily reflected by pulmonary intima thickening from two-dimensional OCT. In single-ventricle anatomy, due to the state of hypoxia, the morphology of pulmonary vessels was indirectly reflected by the number and shape of nourishing vessels from three-dimensional OCT. Interpretation OCT may be an adequate imaging procedure for the demonstration of pulmonary vascular structures and provide additional information in pediatric patients.
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Affiliation(s)
- Ling Sun
- Department of Pediatric CardiologyGuangdong Provincial People's HospitalGuangdong Academy of Medical SciencesGuangdong Cardiovascular InstituteGuangdong Provincial Key Laboratory of South China Structural Heart DiseaseGuangzhouGuangdongChina
| | - Qiuping Jiang
- Department of Pediatric CardiologyGuangdong Provincial People's HospitalGuangdong Academy of Medical SciencesGuangdong Cardiovascular InstituteGuangdong Provincial Key Laboratory of South China Structural Heart DiseaseGuangzhouGuangdongChina
| | - Yumei Xie
- Department of Pediatric CardiologyGuangdong Provincial People's HospitalGuangdong Academy of Medical SciencesGuangdong Cardiovascular InstituteGuangdong Provincial Key Laboratory of South China Structural Heart DiseaseGuangzhouGuangdongChina
| | - Shushui Wang
- Department of Pediatric CardiologyGuangdong Provincial People's HospitalGuangdong Academy of Medical SciencesGuangdong Cardiovascular InstituteGuangdong Provincial Key Laboratory of South China Structural Heart DiseaseGuangzhouGuangdongChina
| | - Zhiwei Zhang
- Department of Pediatric CardiologyGuangdong Provincial People's HospitalGuangdong Academy of Medical SciencesGuangdong Cardiovascular InstituteGuangdong Provincial Key Laboratory of South China Structural Heart DiseaseGuangzhouGuangdongChina
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9
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Chaloupecký V, Jičínská D, Tomek V, Materna O, Gebauer R, Poruban R, Antonová P, Adla T, Štefánek M, Illinger V, Kotaška K, Janoušek J. Impact of liver fibrosis and nodules formation on hemodynamics in young adults after total cavopulmonary connection. A magnetic resonance study. Front Cardiovasc Med 2022; 9:986653. [PMID: 36247450 PMCID: PMC9558211 DOI: 10.3389/fcvm.2022.986653] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2022] [Accepted: 09/08/2022] [Indexed: 11/15/2022] Open
Abstract
Background The aim of this study was to analyze the relation between the hepatic fibrosis markers, liver morphology and hemodynamics assessed by magnetic resonance imaging (MRI) after total cavopulmonary connection (TCPC). Materials and methods Adult patients after TCPC performed in childhood between 1993 and 2003 are the subjects of this observational study. The follow-up protocol consisted of clinical and echocardiographic examination, liver elastography, cardiopulmonary exercise test, MRI hemodynamics and liver morphology assessment and direct enhanced liver fibrosis (ELF) test. Results The cohort consisted of 39 patients (46% female) with a median age at study 26 (IQR 23–28) years and interval from TCPC 21 (IQR 20–23) years. There was no correlation between ELF test and any MRI variables, but procollagen III amino-terminal peptide (PIIINP), a single component of ELF test, correlated significantly with ventricular end-diastolic volume (r = 0.33; p = 0.042) and inferior vena cava flow (r = 0.47; p = 0.003). Fifteen (38%) patients with liver nodules had compared to other 24 patients higher end-diastolic volume (ml/m2) 102.8 ± 20.0 vs. 88.2 ± 17.7; p = 0.023, respectively. PIIINP correlated significantly with inferior vena cava flow (r = 0.56; p = 0.030) and with end-diastolic volume (r = 0.53; p = 0.043), but only in patients with liver nodules. Conclusion Gradual progression of liver fibrosis, particularly hepatic arterialization caused by liver nodules formation, increases inferior vena cava flow and subsequent ventricular volume overload may further compromise single ventricle functional reserve in adult patients after TCPC.
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Affiliation(s)
- Václav Chaloupecký
- Children’s Heart Centre, Second Faculty of Medicine, Charles University in Prague and Motol University Hospital, Prague, Czechia
- *Correspondence: Václav Chaloupecký,
| | - Denisa Jičínská
- Children’s Heart Centre, Second Faculty of Medicine, Charles University in Prague and Motol University Hospital, Prague, Czechia
| | - Viktor Tomek
- Children’s Heart Centre, Second Faculty of Medicine, Charles University in Prague and Motol University Hospital, Prague, Czechia
| | - Ondřej Materna
- Children’s Heart Centre, Second Faculty of Medicine, Charles University in Prague and Motol University Hospital, Prague, Czechia
| | - Roman Gebauer
- Children’s Heart Centre, Second Faculty of Medicine, Charles University in Prague and Motol University Hospital, Prague, Czechia
| | - Rudolf Poruban
- Children’s Heart Centre, Second Faculty of Medicine, Charles University in Prague and Motol University Hospital, Prague, Czechia
| | - Petra Antonová
- Department of Cardiovascular Surgery, Second Faculty of Medicine, Charles University in Prague and Motol University Hospital, Prague, Czechia
| | - Theodor Adla
- Department of Radiology, Second Faculty of Medicine, Charles University in Prague and Motol University Hospital, Prague, Czechia
| | - Matěj Štefánek
- Department of Radiology, Second Faculty of Medicine, Charles University in Prague and Motol University Hospital, Prague, Czechia
| | - Vojtěch Illinger
- Department of Rehabilitation and Sports Medicine, Second Faculty of Medicine, Charles University in Prague and Motol University Hospital, Prague, Czechia
| | - Karel Kotaška
- Department of Medical Chemistry and Clinical Biochemistry, Second Faculty of Medicine, Charles University in Prague and Motol University Hospital, Prague, Czechia
| | - Jan Janoušek
- Children’s Heart Centre, Second Faculty of Medicine, Charles University in Prague and Motol University Hospital, Prague, Czechia
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10
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Pulmonary Vascular Sequelae of Palliated Single Ventricle Circulation: Arteriovenous Malformations and Aortopulmonary Collaterals. J Cardiovasc Dev Dis 2022; 9:jcdd9090309. [PMID: 36135454 PMCID: PMC9501802 DOI: 10.3390/jcdd9090309] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2022] [Revised: 09/12/2022] [Accepted: 09/14/2022] [Indexed: 11/16/2022] Open
Abstract
Children and adults with single ventricle congenital heart disease (CHD) develop many sequelae during staged surgical palliation. Universal pulmonary vascular sequelae in this patient population include two inter-related but distinct complications: pulmonary arteriovenous malformations (PAVMs) and aortopulmonary collaterals (APCs). This review highlights what is known and unknown about these vascular sequelae focusing on diagnostic testing, pathophysiology, and areas in need of further research.
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11
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Ghosh RM, Whitehead KK, Harris MA, Kalb E, Chen JM, Partington SL, Biko DM, Faerber J, Fogel MA. Longitudinal Trends of Vascular Flow and Growth in Patients Undergoing Fontan Operation. Ann Thorac Surg 2022; 115:1486-1492. [PMID: 35988737 DOI: 10.1016/j.athoracsur.2022.07.051] [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: 02/07/2022] [Revised: 07/05/2022] [Accepted: 07/19/2022] [Indexed: 11/01/2022]
Abstract
BACKGROUND Single ventricle (SV) patients undergo multiple surgeries with subsequent changes in anatomy and hemodynamics. There is little cardiac magnetic resonance (CMR) data on serial changes in these patients. This study aimed to assess longitudinal changes of SV anatomy and hemodynamics in a large cohort. METHODS Anatomy and flow in SV patients with serial CMRs performed between 2008-2019 at a single institution were retrospectively reviewed. Mixed-effects linear regression was used to estimate changes over time at 3-9 months, 1-5 years, and >5 years after Fontan. RESULTS 119 patients were included (51% with hypoplastic left heart;77% underwent extra-cardiac Fontan). 88 patients had 3 serial CMRs. Indexed right superior vena cava (RSVC), inferior vena cava (IVC), neo-aortic valve and descending aorta area decreased over time (beta -0.19,-0.44,-0.23 respectively;p<0.01) as did indexed RSVC, neo and native aorta and descending aorta flow (beta -0.49,-0.53,-0.59 respectively;p<0.0001). IVC flow and its contribution to total caval flow increased (beta 0.33;p<0.0001). Indexed right and left right pulmonary artery (LPA) flow did not change, however indexed LPA area decreased (beta -0.16;p=0.0014) with time. Systemic to pulmonary collateral flow remained unchanged prior to, and early after Fontan (beta -0.54;p=0.42) but decreased with time from Fontan (beta coefficient -0.22;p<0.0001). CONCLUSIONS In this cohort of longitudinally followed SV patients, there are significant trends in vascular size and flow over time from Fontan. These findings can be used as a framework to interpret serial CMR data in the SV, and non-invasively identify deviations from expected patterns prior to the development of clinical symptoms.
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Affiliation(s)
- Reena M Ghosh
- Division of Cardiology, The Children's Hospital of Philadelphia, Philadelphia PA.
| | - Kevin K Whitehead
- Division of Cardiology, The Children's Hospital of Philadelphia, Philadelphia PA
| | - Matthew A Harris
- Division of Cardiology, The Children's Hospital of Philadelphia, Philadelphia PA
| | - Elizabeth Kalb
- Division of Cardiology, The Children's Hospital of Philadelphia, Philadelphia PA; Division of Cardiology, Ann and Robert Lurie Children's Hospital of Chicago, Chicago IL
| | - Jonathan M Chen
- Division of Cardiothoracic Surgery, The Children's Hospital of Philadelphia, Philadelphia PA
| | - Sara L Partington
- Division of Cardiology, The Children's Hospital of Philadelphia, Philadelphia PA
| | - David M Biko
- Department of Radiology, The Children's Hospital of Philadelphia, Philadelphia PA
| | - Jennifer Faerber
- Department of Biomedical and Health Informatics. The Children's Hospital of Philadelphia, Philadelphia PA
| | - Mark A Fogel
- Division of Cardiology, The Children's Hospital of Philadelphia, Philadelphia PA
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12
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Schmiel M, Kido T, Georgiev S, Burri M, Heinisch PP, Vodiskar J, Strbad M, Ewert P, Hager A, Hörer J, Ono M. Aortopulmonary collaterals in single ventricle: incidence, associated factors and clinical significance. Interact Cardiovasc Thorac Surg 2022; 35:6649621. [PMID: 35876534 PMCID: PMC9318886 DOI: 10.1093/icvts/ivac190] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2022] [Revised: 06/20/2022] [Accepted: 07/22/2022] [Indexed: 11/22/2022] Open
Affiliation(s)
- Melvin Schmiel
- Department of Congenital and Pediatric Heart Surgery, German Heart Center Munich, Technische Universität München , Munich, Germany
- Division of Congenital and Pediatric Heart Surgery, University Hospital of Munich, Ludwig-Maximilians-Universität , Munich, Germany
| | - Takashi Kido
- Department of Congenital and Pediatric Heart Surgery, German Heart Center Munich, Technische Universität München , Munich, Germany
- Division of Congenital and Pediatric Heart Surgery, University Hospital of Munich, Ludwig-Maximilians-Universität , Munich, Germany
| | - Stanimir Georgiev
- Department of Pediatric Cardiology and Congenital Heart Disease, German Heart Center Munich, Technical University of Munich , Munich, Germany
| | - Melchior Burri
- Department of Cardiovascular Surgery, German Heart Center Munich, Technische Universität München , Munich, Germany
| | - Paul Philipp Heinisch
- Department of Congenital and Pediatric Heart Surgery, German Heart Center Munich, Technische Universität München , Munich, Germany
- Division of Congenital and Pediatric Heart Surgery, University Hospital of Munich, Ludwig-Maximilians-Universität , Munich, Germany
| | - Janez Vodiskar
- Department of Congenital and Pediatric Heart Surgery, German Heart Center Munich, Technische Universität München , Munich, Germany
- Division of Congenital and Pediatric Heart Surgery, University Hospital of Munich, Ludwig-Maximilians-Universität , Munich, Germany
| | - Martina Strbad
- Department of Congenital and Pediatric Heart Surgery, German Heart Center Munich, Technische Universität München , Munich, Germany
- Division of Congenital and Pediatric Heart Surgery, University Hospital of Munich, Ludwig-Maximilians-Universität , Munich, Germany
| | - Peter Ewert
- Department of Pediatric Cardiology and Congenital Heart Disease, German Heart Center Munich, Technical University of Munich , Munich, Germany
| | - Alfred Hager
- Department of Pediatric Cardiology and Congenital Heart Disease, German Heart Center Munich, Technical University of Munich , Munich, Germany
| | - Jürgen Hörer
- Department of Congenital and Pediatric Heart Surgery, German Heart Center Munich, Technische Universität München , Munich, Germany
- Division of Congenital and Pediatric Heart Surgery, University Hospital of Munich, Ludwig-Maximilians-Universität , Munich, Germany
| | - Masamichi Ono
- Department of Congenital and Pediatric Heart Surgery, German Heart Center Munich, Technische Universität München , Munich, Germany
- Division of Congenital and Pediatric Heart Surgery, University Hospital of Munich, Ludwig-Maximilians-Universität , Munich, Germany
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13
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Fogel MA, Anwar S, Broberg C, Browne L, Chung T, Johnson T, Muthurangu V, Taylor M, Valsangiacomo-Buechel E, Wilhelm C. Society for Cardiovascular Magnetic Resonance/European Society of Cardiovascular Imaging/American Society of Echocardiography/Society for Pediatric Radiology/North American Society for Cardiovascular Imaging Guidelines for the use of cardiovascular magnetic resonance in pediatric congenital and acquired heart disease : Endorsed by The American Heart Association. J Cardiovasc Magn Reson 2022; 24:37. [PMID: 35725473 PMCID: PMC9210755 DOI: 10.1186/s12968-022-00843-7] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2021] [Accepted: 01/12/2022] [Indexed: 11/16/2022] Open
Abstract
Cardiovascular magnetic resonance (CMR) has been utilized in the management and care of pediatric patients for nearly 40 years. It has evolved to become an invaluable tool in the assessment of the littlest of hearts for diagnosis, pre-interventional management and follow-up care. Although mentioned in a number of consensus and guidelines documents, an up-to-date, large, stand-alone guidance work for the use of CMR in pediatric congenital 36 and acquired 35 heart disease endorsed by numerous Societies involved in the care of these children is lacking. This guidelines document outlines the use of CMR in this patient population for a significant number of heart lesions in this age group and although admittedly, is not an exhaustive treatment, it does deal with an expansive list of many common clinical issues encountered in daily practice.
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Affiliation(s)
- Mark A Fogel
- Departments of Pediatrics (Cardiology) and Radiology, The Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA. .,Division of Cardiology, Department of Pediatrics, The Children's Hospital of Philadelphia, Philadelphia, PA, USA.
| | - Shaftkat Anwar
- Department of Pediatrics (Cardiology) and Radiology, The University of California-San Francisco School of Medicine, San Francisco, USA
| | - Craig Broberg
- Division of Cardiovascular Medicine, Oregon Health and Sciences University, Portland, USA
| | - Lorna Browne
- Department of Radiology, University of Colorado, Denver, USA
| | - Taylor Chung
- Department of Radiology and Biomedical Imaging, The University of California-San Francisco School of Medicine, San Francisco, USA
| | - Tiffanie Johnson
- Department of Pediatrics (Cardiology), Indiana University School of Medicine, Indianapolis, USA
| | - Vivek Muthurangu
- Department of Pediatrics (Cardiology), University College London, London, UK
| | - Michael Taylor
- Department of Pediatrics (Cardiology), University of Cincinnati School of Medicine, Cincinnati, USA
| | | | - Carolyn Wilhelm
- Department of Pediatrics (Cardiology), University Hospitals-Cleveland, Cleaveland, USA
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14
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Fogel MA, Anwar S, Broberg C, Browne L, Chung T, Johnson T, Muthurangu V, Taylor M, Valsangiacomo-Buechel E, Wilhelm C. Society for Cardiovascular Magnetic Resonance/European Society of Cardiovascular Imaging/American Society of Echocardiography/Society for Pediatric Radiology/North American Society for Cardiovascular Imaging Guidelines for the Use of Cardiac Magnetic Resonance in Pediatric Congenital and Acquired Heart Disease: Endorsed by The American Heart Association. Circ Cardiovasc Imaging 2022; 15:e014415. [PMID: 35727874 PMCID: PMC9213089 DOI: 10.1161/circimaging.122.014415] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Abstract
Cardiovascular magnetic resonance has been utilized in the management and care of pediatric patients for nearly 40 years. It has evolved to become an invaluable tool in the assessment of the littlest of hearts for diagnosis, pre-interventional management and follow-up care. Although mentioned in a number of consensus and guidelines documents, an up-to-date, large, stand-alone guidance work for the use of cardiovascular magnetic resonance in pediatric congenital 36 and acquired 35 heart disease endorsed by numerous Societies involved in the care of these children is lacking. This guidelines document outlines the use of cardiovascular magnetic resonance in this patient population for a significant number of heart lesions in this age group and although admittedly, is not an exhaustive treatment, it does deal with an expansive list of many common clinical issues encountered in daily practice.
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Affiliation(s)
- Mark A Fogel
- Departments of Pediatrics (Cardiology) and Radiology, The Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA, (M.A.F.).,Division of Cardiology, Department of Pediatrics, The Children's Hospital of Philadelphia, Philadelphia, PA, USA, (M.A.F.)
| | - Shaftkat Anwar
- Department of Pediatrics (Cardiology) and Radiology, The University of California-San Francisco School of Medicine, San Francisco, USA, (S.A.)
| | - Craig Broberg
- Division of Cardiovascular Medicine, Oregon Health and Sciences University, Portland, USA, (C.B.)
| | - Lorna Browne
- Department of Radiology, University of Colorado, Denver, USA, (L.B.)
| | - Taylor Chung
- Department of Radiology and Biomedical Imaging, The University of California-San Francisco School of Medicine, San Francisco, USA, (T.C.)
| | - Tiffanie Johnson
- Department of Pediatrics (Cardiology), Indiana University School of Medicine, Indianapolis, USA, (T.J.)
| | - Vivek Muthurangu
- Department of Pediatrics (Cardiology), University College London, London, UK, (V.M.)
| | - Michael Taylor
- Department of Pediatrics (Cardiology), University of Cincinnati School of Medicine, Cincinnati, USA, (M.T.)
| | | | - Carolyn Wilhelm
- Department of Pediatrics (Cardiology), University Hospitals-Cleveland, Cleaveland, USA (C.W.)
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15
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Puricelli F, Voges I, Gatehouse P, Rigby M, Izgi C, Pennell DJ, Krupickova S. Performance of Cardiac MRI in Pediatric and Adult Patients with Fontan Circulation. Radiol Cardiothorac Imaging 2022; 4:e210235. [PMID: 35833165 PMCID: PMC9274315 DOI: 10.1148/ryct.210235] [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: 09/05/2021] [Revised: 04/11/2022] [Accepted: 04/18/2022] [Indexed: 06/15/2023]
Abstract
Cardiac MRI has become a widely accepted standard for anatomic and functional assessment of complex Fontan physiology, because it is noninvasive and suitable for comprehensive follow-up evaluation after Fontan completion. The use of cardiac MRI in pediatric and adult patients after completion of the Fontan procedure are described, and a practical and experience-based cardiac MRI protocol for evaluating these patients is provided. The current approach and study protocol in use at the authors' institution are presented, which address technical considerations concerning sequences, planning, and optimal image acquisition in patients with Fontan circulation. Additionally, for each sequence, the information that can be obtained and guidance on how to integrate it into clinical decision-making is discussed. Keywords: Pediatrics, MRI, MRI Functional Imaging, Heart, Congenital © RSNA, 2022.
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16
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Saleh M, Gendy D, Voges I, Nyktari E, Arzanauskaite M. Complex adult congenital heart disease on cross-sectional imaging: an introductory overview. Insights Imaging 2022; 13:78. [PMID: 35467233 PMCID: PMC9038985 DOI: 10.1186/s13244-022-01201-y] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2021] [Accepted: 02/26/2022] [Indexed: 11/16/2022] Open
Abstract
Congenital heart disease is the most common group of congenital pathology. Over the past few decades, advances in surgical treatment have resulted in a rising population of adult patients with repaired complex congenital heart disease. Although the quality of life has greatly improved, a significant proportion of morbidities encountered in clinical practice is now seen in adults rather than in children. These patients often have significant haemodynamic pathophysiology necessitating repeat intervention. CT and MRI are excellent imaging modalities, which help elucidate potential complications that may need urgent management. Although imaging should be performed in specialised centres, occasionally patients may present acutely to emergency departments in hospitals with little experience in managing potentially complex patients. The purpose of this article is to provide an introductory overview to the radiologist who may not be familiar with complex congenital heart disease in adult patients. This educational review has three main sections: (1) a brief overview of the post-operative anatomy and surgical management of the most common complex conditions followed by (2) a discussion on CT/MRI protocols and (3) a review of the various complications and their CT/MRI findings.
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Affiliation(s)
- Mahdi Saleh
- Department of Radiology, Liverpool Heart and Chest Hospital, Liverpool, UK.
| | - David Gendy
- Department of Radiology, Liverpool Heart and Chest Hospital, Liverpool, UK
| | - Inga Voges
- Department of Congenital Heart Disease and Paediatric Cardiology, University Hospital Schleswig-Holstein, Campus Kiel, Kiel, Germany
| | - Eva Nyktari
- Cardiovascular MRI Unit, BIOIATRIKI SA (Biomedicine Group of Companies), Athens, Greece
| | - Monika Arzanauskaite
- Department of Radiology, Liverpool Heart and Chest Hospital, Liverpool, UK.,Cardiovascular Research Center-ICCC, Hospital de la Santa Creu i Sant Pau, IIB-Sant Pau, Barcelona, Spain
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17
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Transcatheter Device Therapy and the Integration of Advanced Imaging in Congenital Heart Disease. CHILDREN 2022; 9:children9040497. [PMID: 35455541 PMCID: PMC9032030 DOI: 10.3390/children9040497] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/01/2022] [Revised: 03/27/2022] [Accepted: 03/29/2022] [Indexed: 01/04/2023]
Abstract
Transcatheter device intervention is now offered as first line therapy for many congenital heart defects (CHD) which were traditionally treated with cardiac surgery. While off-label use of devices is common and appropriate, a growing number of devices are now specifically designed and approved for use in CHD. Advanced imaging is now an integral part of interventional procedures including pre-procedure planning, intra-procedural guidance, and post-procedure monitoring. There is robust societal and industrial support for research and development of CHD-specific devices, and the regulatory framework at the national and international level is patient friendly. It is against this backdrop that we review transcatheter implantable devices for CHD, the role and integration of advanced imaging, and explore the current regulatory framework for device approval.
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18
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Occlusion of aortopulmonary and venovenous collaterals prior to heart or combined heart-liver transplantation in Fontan patients: A single-center experience. INTERNATIONAL JOURNAL OF CARDIOLOGY CONGENITAL HEART DISEASE 2021. [DOI: 10.1016/j.ijcchd.2021.100260] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
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19
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Kocaoglu M, Pednekar A, Tkach JA, Taylor MD. Quantitative assessment of velocity and flow using compressed SENSE in children and young adults with adequate acquired temporal resolution. J Cardiovasc Magn Reson 2021; 23:113. [PMID: 34663351 PMCID: PMC8522244 DOI: 10.1186/s12968-021-00811-7] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2021] [Accepted: 09/03/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Phase contrast (PC) cardiovascular magnetic resonance (CMR) imaging with parallel imaging acceleration is established and validated for measuring velocity and flow. However, additional acceleration to further shorten acquisition times would be beneficial in patients with complex vasculature who need multiple PC-CMR measurements, especially pediatric patients with higher heart rates. METHODS PC-CMR images acquired with compressed sensitivity encoding (C-SENSE) factors of 3 to 6 and standard of care PC-CMR with sensitivity encoding (SENSE) factor of 2 (S2) acquired as part of clinical CMR examinations performed between November 2020 and January 2021 were analyzed retrospectively. The velocity and flow through the ascending aorta (AAo), descending aorta (DAo), and superior vena cava (SVC) in a transverse plane at the level of pulmonary artery bifurcation were compared. Additionally, frequency power distribution and dynamic time warp distance were calculated for these acquisitions. To further validate the adequate temporal resolution requirement, patients with S2 PC-CMR in the same acquisition plane were added in frequency power distribution analysis. RESULTS Twenty-eight patients (25 males; 15.9 ± 1.9 years; body surface area (BSA) 1.7 ± 0.2 m2; heart rate 81 ± 16 bpm) underwent all five PC-CMR acquisitions during the study period. An additional 22 patients (16 males; 17.5 ± 7.7 years; BSA 1.6 ± 0.5 m2; heart rate 91 ± 16 bpm) were included for frequency power spectrum analysis. As expected, scan time decreased with increasing C-SENSE acceleration factor = 3 (37.5 ± 6.5 s, 26.4 ± 7.6%), 4 (28.1 ± 4.9 s, 44.7 ± 5.6%), 5 (21.6 ± 3.6 s, 57.6 ± 4.4%), and 6 (19.1 ± 3.2 s, 62.3 ± 4.2%) relative to SENSE = 2 (51.3 ± 10.1 s) PC-CMR acquisition. Mean peak velocity, net flow, and cardiac output were comparable (p > 0.87) between the five PC-CMR acquisitions with mean differences less than < 4%, < 2%, and < 3% respectively. All individual blood vessels showed a non-significant dependence of difference in fmax99 (< 4 Hz, p > 0.2), and dynamic time warp distance (p > 0.3) on the C-SENSE acceleration factor used. There was a strongly correlated (r = 0.74) increase in fmax99 (10.5 ± 2.2, range: 7.1-16.4 Hz) with increasing heart rate. The computed minimum required cardiac phase number was 15 ± 2.0 (range: 11-20) over the heart rate of 86 ± 15 bpm (range: 58-113 bpm). CONCLUSIONS Stroke volume, cardiac output, and mean peak velocity measurements using PC-CMR with C-SENSE of up to 6 agree with measurements by standard of care PC-CMR with SENSE = 2 and resulted in up to a 65% reduction in acquisition time. Adequate temporal sampling can be ensured by acquiring 20 cardiac phases throughout the entire cardiac cycle over a wide range of pediatric and young adult heart rates.
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Affiliation(s)
- Murat Kocaoglu
- Department of Radiology, Cincinnati Children’s Hospital Medical Center, S1.533, 3333 Burnet Ave, Cincinnati, OH 45229 USA
- Department of Radiology, University of Cincinnati College of Medicine, Cincinnati, OH USA
| | - Amol Pednekar
- Department of Radiology, Cincinnati Children’s Hospital Medical Center, S1.533, 3333 Burnet Ave, Cincinnati, OH 45229 USA
- Department of Radiology, University of Cincinnati College of Medicine, Cincinnati, OH USA
| | - Jean A. Tkach
- Department of Radiology, Cincinnati Children’s Hospital Medical Center, S1.533, 3333 Burnet Ave, Cincinnati, OH 45229 USA
- Department of Radiology, University of Cincinnati College of Medicine, Cincinnati, OH USA
| | - Michael D. Taylor
- The Heart Institute, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH USA
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH USA
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20
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Hayabuchi Y, Homma Y, Kagami S. Three-dimensional imaging of pulmonary arterial vasa vasorum using optical coherence tomography in patients after bidirectional Glenn and Fontan procedures. Eur Heart J Cardiovasc Imaging 2021; 22:941-949. [PMID: 32413104 DOI: 10.1093/ehjci/jeaa098] [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: 11/19/2019] [Revised: 01/31/2020] [Accepted: 04/16/2020] [Indexed: 11/13/2022] Open
Abstract
AIMS We evaluated pulmonary arterial (PA) vasa vasorum (VV) in Fontan candidate patients with a novel three-dimensional (3D) imaging technique using optical coherence tomography (OCT). METHODS AND RESULTS This prospective study assessed the development of adventitial VV in the distal PA of 10 patients with bidirectional Glenn circulation (BDG group, 1.6 ± 0.3 years) and Fontan circulation (Fontan group, 3.3 ± 0.3 years), and in 20 children with normal PA haemodynamics and morphology (Control group, 1.5 ± 0.3 years). We assessed the PA VV with two-dimensional (2D) cross-sectional, multi-planar reconstruction (MPR), and volume rendering (VR) imaging. VV development was evaluated by the VV area/volume ratio, defined as the VV area/volume divided by the adventitial area/volume. Compared to the control group, the observed VV number and diameter on 3D images of MPR and VR were significantly higher, and curved and torturous-shaped VV were more frequently observed in the BDG and Fontan groups (P < 0.001, all). The median VV volume ratio was significantly greater in the BDG than in the control group (3.38% vs. 0.61%; P < 0.001). Although the VV volume ratio decreased significantly after the Fontan procedure (2.64%, P = 0.005 vs. BDG), the ratio remained higher than in the control group (P < 0.001 vs. control). CONCLUSION 3D OCT imaging is a novel method that can be used to evaluate adventitial PA VV and may provide pathophysiological insight into the role of the PA VV in these patients.
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Affiliation(s)
- Yasunobu Hayabuchi
- Department of Pediatrics, Tokushima University, Kuramoto-cho-3, Tokushima 770-8503, Japan
| | - Yukako Homma
- Department of Pediatrics, Tokushima University, Kuramoto-cho-3, Tokushima 770-8503, Japan
| | - Shoji Kagami
- Department of Pediatrics, Tokushima University, Kuramoto-cho-3, Tokushima 770-8503, Japan
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21
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Abnormalities in the Von Willebrand-Angiopoietin Axis Contribute to Dysregulated Angiogenesis and Angiodysplasia in Children With a Glenn Circulation. JACC Basic Transl Sci 2021; 6:222-235. [PMID: 33778210 PMCID: PMC7987544 DOI: 10.1016/j.jacbts.2020.12.014] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/25/2020] [Revised: 12/22/2020] [Accepted: 12/22/2020] [Indexed: 02/08/2023]
Abstract
Children with a bidirectional superior cavopulmonary connection (Glenn circulation) develop dysregulated angiogenesis and pulmonary angiodysplasia in the form of arteriovenous malformations (AVMs). No targeted therapy exists. The von Willebrand factor (vWF)–angiopoietin axis plays a major role in normal angiogenesis, angiodysplasia, and AVM formation in multiple diseases. vWF and angiopoietin-2 (which destabilizes vessel formation) were abnormal in children with a Glenn circulation versus control children. Within Glenn patients, angiopoietin-1 (which stabilizes vessel formation) and angiogenesis were different in the systemic versus pulmonary circulation. Plasma angiopoietin-1 was lower in the pulmonary circulation of Glenn patients with pulmonary AVMs than Glenn patients without AVMs. In parallel, differences in multiple angiogenic and inflammatory signaling peptides were observed between Glenn patients and controls, which indicated derangements in multiple angiogenic pathways in Glenn patients. These findings support the novel hypothesis that abnormal vWF metabolism and angiopoietin signaling dysregulate angiogenesis and contribute to pulmonary AVM formation in children with a Glenn circulation. The vWF-angiopoietin axis may be a target to correct angiogenic imbalance and reduce pulmonary angiodysplasia in Glenn patients.
Children with a bidirectional superior cavopulmonary (Glenn) circulation develop angiodysplasia and pulmonary arteriovenous malformations (AVMs). The von Willebrand factor (vWF)–angiopoietin axis plays a major role in AVM formation in multiple diseases. We observed derangements in global angiogenic signaling, vWF metabolism, angiopoietins, and in vitro angiogenesis in children with a Glenn circulation versus controls and within Glenn pulmonary versus systemic circulations. These findings support the novel hypothesis that abnormalities in the vWF-angiopoietin axis may dysregulate angiogenesis and contribute to Glenn pulmonary AVMs. The vWF-angiopoietin axis may be a target to correct angiogenic imbalance in Glenn patients, for whom no targeted therapy exists.
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Key Words
- ADAMTS-13, a disintegrin and metalloproteinase thrombospondin (motif) #13
- AVM, arteriovenous malformation
- EBM, endothelial basal media
- EGM, endothelial growth media
- Glenn
- HUVEC, human umbilical vein endothelial cell
- IVC, inferior vena cava
- LVAD, left ventricular assist device
- PA, pulmonary artery
- SVC, superior vena cava
- angiogenesis
- angiopoietin
- arteriovenous malformation
- vWF, von Willebrand factor
- von Willebrand factor
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22
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Aortopulmonary Collaterals in Single Ventricle Physiology: Variation in Understanding Occlusion Practice Among Interventional Cardiologists. Pediatr Cardiol 2020; 41:1608-1616. [PMID: 32720087 DOI: 10.1007/s00246-020-02418-8] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/27/2020] [Accepted: 07/18/2020] [Indexed: 10/23/2022]
Abstract
Although aortopulmonary collaterals (APCs) frequently develop in patients with single ventricle palliation, there is a lack of understanding of pathophysiology, natural history, and outcomes with no universal guidelines for management and interventional practice. We conducted a study to assess the views held by interventional congenital cardiologists regarding the hemodynamic impact of APCs in patients with single ventricle palliation, and their embolization practice. An electronic survey using the Pediatric Interventional Cardiology Symposium (PICS) mailing list was conducted between February and March 2019 with one reminder sent 2 weeks after initial invitation for participation. Of the 142 interventional cardiologist respondents, 95 (66.9%) reside in North America and 47 (33.1%) worldwide. We elected to exclude the data from interventionalists outside North America in this analysis as it was not representative of worldwide practice. Hypoxemia was considered to be the most common trigger for development of APCs by 56 (58.9%) respondents. After completion of total cavopulmonary connection, 30 (31.6%) respondents reported the APC burden stays the same while 31 (32.6%) feel it decreases. In evaluating the burden of APC flow, only 4 (4.2%) reported measuring oxygen saturation at different pulmonary artery segments, 21 (22.1%) perform segmental aortic angiograms, and 18 (19%) perform selective bilateral subclavian artery angiograms. A majority of respondents, 71 (74.7%), occlude the feeder vessel at different locations, while 10 (10.5%) occlude only the origin of the vessel. Our study demonstrates significant variation in the understanding of the cause and prognosis of APCs in patients with single ventricle palliation. Furthermore, there is variation in the approach for diagnosis and management among interventional cardiologists. Further studies are required to improve understanding of APCs and develop universal management guidelines.
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23
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Kodama Y, Ishikawa Y, Kuraoka A, Nakamura M, Oda S, Nakano T, Kado H, Sakamoto I, Ohtani K, Ide T, Tsutsui H, Sagawa K. Systemic-to-Pulmonary Collateral Flow Correlates with Clinical Condition Late After the Fontan Procedure. Pediatr Cardiol 2020; 41:1800-1806. [PMID: 32915292 DOI: 10.1007/s00246-020-02450-8] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/27/2020] [Accepted: 08/30/2020] [Indexed: 11/29/2022]
Abstract
In the Fontan circulation, there is a substantial degree of systemic-to-pulmonary collateral flow (SPCF), which can be measured by cardiac magnetic resonance (CMR). However, the correlation between the degree of SPCF and long-term outcomes is not fully understood. We retrospectively studied 321 patients who underwent the Fontan procedure and CMR at a single center. Using CMR, we calculated SPCF as pulmonary blood flow - systemic blood flow. %SPCF was defined as SPCF ÷ pulmonary blood flow. The mean age of patients at CMR was 14.3 ± 7.5 years. The average %SPCF was 13.0% ± 11.0%. With a multivariate analysis, %SPCF was significantly correlated with time (i.e., the longer the time period since the Fontan procedure, the lower the %SPCF) (p = 0.006), previous total anomalous pulmonary vein drainage (p = 0.007), a low pulmonary artery index (Nakata index) before the Fontan procedure (p = 0.04), and older age at the time of the Fontan procedure (p = 0.002). Regarding the findings after the Fontan procedure, %SPCF was significantly correlated with ventricular end-diastolic volume (p < 0.001), ventricular end-systolic volume (p < 0.001), central venous pressure (p < 0.001), plasma brain natriuretic peptide concentration (p < 0.001), hemoptysis (p = 0.009), and poor New York Heart Association functional class (p = 0.007). SPCF was correlated with clinical condition after the Fontan procedure. The importance of sufficient growth of the pulmonary vascular bed should be emphasized because the development of SPCF is believed to result from the poor condition of the pulmonary circulation.
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Affiliation(s)
- Yoshihiko Kodama
- Department of Pediatric Cardiology, Fukuoka Children's Hospital, 5-1-1 Kashiiteriha, Fukuoka, Japan. .,Department of Cardiovascular Medicine, Kyushu University Hospital, Fukuoka, Japan.
| | - Yuichi Ishikawa
- Department of Pediatric Cardiology, Fukuoka Children's Hospital, 5-1-1 Kashiiteriha, Fukuoka, Japan
| | - Ayako Kuraoka
- Department of Pediatric Cardiology, Fukuoka Children's Hospital, 5-1-1 Kashiiteriha, Fukuoka, Japan
| | - Makoto Nakamura
- Department of Pediatric Cardiology, Fukuoka Children's Hospital, 5-1-1 Kashiiteriha, Fukuoka, Japan
| | - Shinichiro Oda
- Department of Cardiovascular Surgery, Fukuoka Children's Hospital, Fukuoka, Japan
| | - Toshihide Nakano
- Department of Cardiovascular Surgery, Fukuoka Children's Hospital, Fukuoka, Japan
| | - Hideaki Kado
- Department of Cardiovascular Surgery, Fukuoka Children's Hospital, Fukuoka, Japan
| | - Ichiro Sakamoto
- Department of Cardiovascular Medicine, Kyushu University Hospital, Fukuoka, Japan
| | - Kisho Ohtani
- Department of Cardiovascular Medicine, Kyushu University Hospital, Fukuoka, Japan
| | - Tomomi Ide
- Department of Cardiovascular Medicine, Kyushu University Hospital, Fukuoka, Japan
| | - Hiroyuki Tsutsui
- Department of Cardiovascular Medicine, Kyushu University Hospital, Fukuoka, Japan
| | - Koichi Sagawa
- Department of Pediatric Cardiology, Fukuoka Children's Hospital, 5-1-1 Kashiiteriha, Fukuoka, Japan
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24
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Harris MA, Glatz AC, Whitehead KK. The value of measuring systemic to pulmonary arterial collateral flow in Fontan patients. Int J Cardiol 2020; 316:104-105. [PMID: 32339544 DOI: 10.1016/j.ijcard.2020.04.061] [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: 04/13/2020] [Accepted: 04/22/2020] [Indexed: 11/30/2022]
Affiliation(s)
- Matthew A Harris
- Children's Hospital of Philadelphia and, The Perelman School of Medicine at the University of Pennsylvania, United States of America.
| | - Andrew C Glatz
- Children's Hospital of Philadelphia and, The Perelman School of Medicine at the University of Pennsylvania, United States of America.
| | - Kevin K Whitehead
- Children's Hospital of Philadelphia and, The Perelman School of Medicine at the University of Pennsylvania, United States of America.
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25
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Schäfer M, Frank BS, Jacobsen R, Rausch CM, Mitchell MB, Jaggers J, Stone ML, Morgan GJ, Browne LP, Barker AJ, Hunter KS, Ivy DD, Younoszai A, Di Maria MV. Patients with Fontan circulation have abnormal aortic wave propagation patterns: A wave intensity analysis study. Int J Cardiol 2020; 322:158-167. [PMID: 32853667 DOI: 10.1016/j.ijcard.2020.08.063] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/21/2020] [Revised: 07/17/2020] [Accepted: 08/17/2020] [Indexed: 01/09/2023]
Abstract
BACKGROUND Elevated systemic afterload in patients with Fontan circulation may lead to impaired single ventricular function. Wave intensity analysis (WIA) enables evaluation of compression and expansion waves traveling through vasculature. We aimed to investigate the unfavorable wave propagation causing excessive afterload may be an important contributor to the overall single ventricle function and to the limited functional capacity in this patient population. METHODS Patients with hypoplastic left heart syndrome (HLHS) (n = 25), single left ventricle (SLV) (n = 24), and normal controls (n = 10) underwent phase-contrast MRI based WIA analysis evaluated in the ascending aorta. Forward compression wave (FCW) representing dP/dt, backward compression wave (BCW) reflecting vascular stiffness, and forward decompression wave (FDW) representing LV relaxation were recorded and indexed to each other. RESULTS FCW was lowest in HLHS patients (1098 mm5/s), and higher in the SLV group (1457 mm5/s), and controls (6457 mm5/s) (P < 0.001). BCW/FCW was increased in HLHS (0.22) and SLV (0.14) groups compared to controls (0.08) (P = 0.003). Peak VO2 correlated with FCW (R = 0.50, P = 0.015), stroke volume (R = 0.72, P < 0.001), and cardiac output (R = 0.44, P = 0.034). CONCLUSIONS Patients with HLHS and SLV have unfavorable aortic WIA patterns with increased BCW/FCW ratio indicating increased systemic afterload due to retrograde compression waves. Reduced FCW and systolic MRI indices correlated with peak VO2 suggesting that abnormal systolic wave propagation may play a role in exercise intolerance for Fontan patients.
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Affiliation(s)
- Michal Schäfer
- Heart Institute, Children's Hospital Colorado, University of Colorado - Denver, Anschutz Medical Campus, USA.
| | - Benjamin S Frank
- Heart Institute, Children's Hospital Colorado, University of Colorado - Denver, Anschutz Medical Campus, USA
| | - Roni Jacobsen
- Heart Institute, Children's Hospital Colorado, University of Colorado - Denver, Anschutz Medical Campus, USA
| | - Christopher M Rausch
- Heart Institute, Children's Hospital Colorado, University of Colorado - Denver, Anschutz Medical Campus, USA
| | - Max B Mitchell
- Division of Pediatric Cardiothoracic Surgery, Department of Surgery, University of Colorado - Denver, Anschutz Medical Campus, USA
| | - James Jaggers
- Division of Pediatric Cardiothoracic Surgery, Department of Surgery, University of Colorado - Denver, Anschutz Medical Campus, USA
| | - Matthew L Stone
- Division of Pediatric Cardiothoracic Surgery, Department of Surgery, University of Colorado - Denver, Anschutz Medical Campus, USA
| | - Gareth J Morgan
- Heart Institute, Children's Hospital Colorado, University of Colorado - Denver, Anschutz Medical Campus, USA
| | - Lorna P Browne
- Department of Radiology, Children's Hospital Colorado, University of Colorado - Denver, Anschutz Medical Campus, USA
| | - Alex J Barker
- Department of Radiology, Children's Hospital Colorado, University of Colorado - Denver, Anschutz Medical Campus, USA; Department of Bioengineering, University of Colorado - Denver, Anschutz Medical Campus, USA
| | - Kendall S Hunter
- Heart Institute, Children's Hospital Colorado, University of Colorado - Denver, Anschutz Medical Campus, USA; Department of Bioengineering, University of Colorado - Denver, Anschutz Medical Campus, USA
| | - D Dunbar Ivy
- Heart Institute, Children's Hospital Colorado, University of Colorado - Denver, Anschutz Medical Campus, USA
| | - Adel Younoszai
- Heart Institute, Children's Hospital Colorado, University of Colorado - Denver, Anschutz Medical Campus, USA
| | - Michael V Di Maria
- Heart Institute, Children's Hospital Colorado, University of Colorado - Denver, Anschutz Medical Campus, USA
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26
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Michel M, Dubowy KO, Entenmann A, Karall D, Adam MG, Zlamy M, Odri Komazec I, Geiger R, Niederwanger C, Salvador C, Müller U, Laser KT, Scholl-Bürgi S. Targeted metabolomic analysis of serum amino acids in the adult Fontan patient with a dominant left ventricle. Sci Rep 2020; 10:8930. [PMID: 32488174 PMCID: PMC7265548 DOI: 10.1038/s41598-020-65852-x] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2019] [Accepted: 05/11/2020] [Indexed: 12/12/2022] Open
Abstract
Growing interest lies in the assessment of the metabolic status of patients with a univentricular circulation after Fontan operation, especially in changes of amino acid metabolism. Using targeted metabolomic examinations, we investigated amino acid metabolism in a homogeneous adult Fontan-patient group with a dominant left ventricle, seeking biomarker patterns that might permit better understanding of Fontan pathophysiology and early detection of subtle ventricular or circulatory dysfunction. We compared serum amino acid levels (42 analytes; AbsoluteIDQ p180 kit, Biocrates Life Sciences, Innsbruck, Austria) in 20 adult Fontan patients with a dominant left ventricle and those in age- and sex-matched biventricular controls. Serum concentrations of asymmetric dimethylarginine, methionine sulfoxide, glutamic acid, and trans-4-hydroxyproline and the methionine sulfoxide/methionine ratio (Met-SO/Met) were significantly higher and serum concentrations of asparagine, histidine, taurine, and threonine were significantly lower in patients than in controls. Met-SO/Met values exhibited a significant negative correlation with oxygen uptake during exercise. The alterations in amino acid metabolome that we found in Fontan patients suggest links between Fontan pathophysiology, altered cell energy metabolism, oxidative stress, and endothelial dysfunction like those found in biventricular patients with congestive heart failure. Studies of extended amino acid metabolism may allow better understanding of Fontan pathophysiology that will permit early detection of subtle ventricular or circulatory dysfunction in Fontan patients.
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Affiliation(s)
- Miriam Michel
- Department of Pediatrics III, Division of Pediatric Cardiology, Medical University of Innsbruck, Anichstraße 35, 6020, Innsbruck, Austria. .,Center of Pediatric Cardiology and Congenital Heart Disease, Heart and Diabetes Center North Rhine-Westphalia, Ruhr-University of Bochum, Georgstraße 11, 32545, Bad Oeynhausen, Germany.
| | - Karl-Otto Dubowy
- Center of Pediatric Cardiology and Congenital Heart Disease, Heart and Diabetes Center North Rhine-Westphalia, Ruhr-University of Bochum, Georgstraße 11, 32545, Bad Oeynhausen, Germany
| | - Andreas Entenmann
- Department of Pediatrics I, Division of Gastroenterology and Hepatology, Medical University of Innsbruck, Anichstraße 35, 6020, Innsbruck, Austria
| | - Daniela Karall
- Department of Pediatrics I, Division of Inherited Metabolic Disorders, Medical University of Innsbruck, Anichstraße 35, 6020, Innsbruck, Austria
| | - Mark Gordian Adam
- Biocrates Life Sciences AG, Eduard-Bodem-Gasse 8, 6020, Innsbruck, Austria
| | - Manuela Zlamy
- Department of Pediatrics I, Division of Inherited Metabolic Disorders, Medical University of Innsbruck, Anichstraße 35, 6020, Innsbruck, Austria
| | - Irena Odri Komazec
- Department of Pediatrics III, Division of Pediatric Cardiology, Medical University of Innsbruck, Anichstraße 35, 6020, Innsbruck, Austria
| | - Ralf Geiger
- Department of Pediatrics III, Division of Pediatric Cardiology, Medical University of Innsbruck, Anichstraße 35, 6020, Innsbruck, Austria
| | - Christian Niederwanger
- Department of Pediatrics I, Division of Inherited Metabolic Disorders, Medical University of Innsbruck, Anichstraße 35, 6020, Innsbruck, Austria
| | - Christina Salvador
- Department of Pediatrics I, Division of Inherited Metabolic Disorders, Medical University of Innsbruck, Anichstraße 35, 6020, Innsbruck, Austria
| | - Udo Müller
- Biocrates Life Sciences AG, Eduard-Bodem-Gasse 8, 6020, Innsbruck, Austria
| | - Kai Thorsten Laser
- Center of Pediatric Cardiology and Congenital Heart Disease, Heart and Diabetes Center North Rhine-Westphalia, Ruhr-University of Bochum, Georgstraße 11, 32545, Bad Oeynhausen, Germany
| | - Sabine Scholl-Bürgi
- Department of Pediatrics I, Division of Inherited Metabolic Disorders, Medical University of Innsbruck, Anichstraße 35, 6020, Innsbruck, Austria
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27
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Hart MR, Whiteside W, Yu S, Lowery R, Dorfman AL, Ghadimi Mahani M, Agarwal PP, Lu JC. Differences in Pulmonary and Systemic Flow Measurements by Cardiac Magnetic Resonance vs Cardiac Catheterization and Relation to Collateral Flow in Single Ventricle Patients. Pediatr Cardiol 2020; 41:885-891. [PMID: 32100056 DOI: 10.1007/s00246-020-02327-w] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/30/2019] [Accepted: 02/17/2020] [Indexed: 11/29/2022]
Abstract
Both cardiac magnetic resonance (CMR) and cardiac catheterization (cath) may assess patients with single ventricle physiology prior to stage II or Fontan palliation. However, development of significant aortopulmonary collaterals may invalidate assumptions of the Fick method. We compared CMR and cath flow measurements and evaluated the relation to collateral flow. This single-center study included all pre-stage II and pre-Fontan patients between 2010 and 2017 with CMR and cath within 1 month. Pulmonary (Qp) and systemic flow (Qs) by cath were calculated by Fick method. CMR Qp was calculated by total pulmonary venous flow, and Qs by total vena caval flow. Collateral flow by CMR was the difference of pulmonary vein and pulmonary artery flow. In 26 studies (16 pre-stage II and 10 pre-Fontan) in 21 patients, collateral flow was higher in pre-Fontan patients (1.8 ± 0.6 vs 0.9 ± 0.8 L/min/m2, p = 0.01). Overall, CMR and cath had good agreement for Qs and Qp:Qs, with moderate correlation (r = 0.44, p = 0.02 for Qs, r = 0.48, p = 0.02 for Qp:Qs). In pre-Fontan but not in pre-stage II patients, CMR had higher Qp (mean difference - 1.71 L/min/m2) and Qp:Qs (mean difference - 0.36). The underestimation of cath Qp correlated with amount of collateral flow (r = - 0.47, p = 0.02). Neither cath nor CMR flow measurements correlated with outcomes in this small cohort. In conclusion, collaterals lead to systematically higher Qp and Qp:Qs measurements by CMR vs cath in single ventricle patients. Measurements may not be used interchangeably, with potential clinical significance in estimating pulmonary vascular resistance. Further study is necessary to evaluate possible relation to clinical outcomes.
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Affiliation(s)
- Michael R Hart
- Division of Pediatric Cardiology, Department of Pediatrics, Maine Medical Center, Portland, ME, USA
| | - Wendy Whiteside
- Division of Pediatric Cardiology, Department of Pediatrics, University of Michigan, Ann Arbor, MI, USA
| | - Sunkyung Yu
- Division of Pediatric Cardiology, Department of Pediatrics, University of Michigan, Ann Arbor, MI, USA
| | - Ray Lowery
- Division of Pediatric Cardiology, Department of Pediatrics, University of Michigan, Ann Arbor, MI, USA
| | - Adam L Dorfman
- Division of Pediatric Cardiology, Department of Pediatrics, University of Michigan, Ann Arbor, MI, USA.,Section of Pediatric Radiology, Department of Radiology, University of Michigan, Ann Arbor, MI, USA
| | - Maryam Ghadimi Mahani
- Section of Pediatric Radiology, Department of Radiology, University of Michigan, Ann Arbor, MI, USA.,Division of Cardiothoracic Radiology, Department of Radiology, University of Michigan, Ann Arbor, MI, USA
| | - Prachi P Agarwal
- Division of Cardiothoracic Radiology, Department of Radiology, University of Michigan, Ann Arbor, MI, USA
| | - Jimmy C Lu
- Division of Pediatric Cardiology, Department of Pediatrics, University of Michigan, Ann Arbor, MI, USA. .,Section of Pediatric Radiology, Department of Radiology, University of Michigan, Ann Arbor, MI, USA. .,C.S. Mott Children's Hospital, University of Michigan Congenital Heart Center, 11th floor, 1540 E. Hospital Dr., Ann Arbor, MI, 48109, USA.
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28
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Ibe DO, Rapp JB, Whitehead KK, Otero HJ, Smith CL, Fogel MA, Biko DM. Pearls and Pitfalls in Pediatric Fontan Operation Imaging. Semin Ultrasound CT MR 2020; 41:442-450. [PMID: 32980091 DOI: 10.1053/j.sult.2020.05.009] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
Abstract
The Fontan operation or the total cavopulmonary connection is a palliative surgery for single ventricle congenital heart disease where the systemic venous return circumvents a pumping chamber and flows directly into the pulmonary circuit. With surgical and medical advances, there has been improvement in life expectancy of these patients, however, it has also resulted in unique complications from the physiology that requires diligent surveillance. A critical component relies on optimal imaging for diagnosis and treatment of these complications. This article describes the normal anatomy of the Fontan circulation, current imaging modalities and techniques, and frequently encountered complications seen when imaging the patients who have undergone Fontan palliation.
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Affiliation(s)
- Donald O Ibe
- Department of Radiology, Silhouette Diagnostic Consultants, Abuja, Nigeria
| | - Jordan B Rapp
- Department of Radiology, Children's Hospital of Philadelphia, Philadelphia, PA; Perelman School of Medicine at The University of Pennsylvania, Philadelphia, PA
| | - Kevin K Whitehead
- Perelman School of Medicine at The University of Pennsylvania, Philadelphia, PA; Division of Cardiology, Children's Hospital of Philadelphia, Philadelphia, PA
| | - Hansel J Otero
- Department of Radiology, Children's Hospital of Philadelphia, Philadelphia, PA; Division of Cardiology, Children's Hospital of Philadelphia, Philadelphia, PA
| | - Christopher L Smith
- Perelman School of Medicine at The University of Pennsylvania, Philadelphia, PA; Division of Cardiology, Children's Hospital of Philadelphia, Philadelphia, PA
| | - Mark A Fogel
- Perelman School of Medicine at The University of Pennsylvania, Philadelphia, PA; Division of Cardiology, Children's Hospital of Philadelphia, Philadelphia, PA
| | - David M Biko
- Department of Radiology, Children's Hospital of Philadelphia, Philadelphia, PA; Division of Cardiology, Children's Hospital of Philadelphia, Philadelphia, PA.
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29
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Schäfer M, Frank BS, Humphries SM, Hunter KS, Carmody KL, Jacobsen R, Mitchell MB, Jaggers J, Stone ML, Morgan GJ, Barker AJ, Browne LP, Ivy DD, Younoszai A, Di Maria MV. Flow profile characteristics in Fontan circulation are associated with the single ventricle dilation and function: principal component analysis study. Am J Physiol Heart Circ Physiol 2020; 318:H1032-H1040. [PMID: 32167782 DOI: 10.1152/ajpheart.00686.2019] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
The Fontan circulation is characterized as a nonpulsatile flow propagation without a pressure-generating ventricle. However, flow through the Fontan circulation still exhibits oscillatory waves as a result of pressure changes generated by the systemic single ventricle. Identification of discrete flow patterns through the Fontan circuit may be important to understand single ventricle performance. Ninety-seven patients with Fontan circulation underwent phase-contrast MRI of the right pulmonary artery, yielding subject-specific flow waveforms. Principal component (PC) analysis was performed on preprocessed flow waveforms. Principal components were then correlated with standard MRI indices of function, volume, and aortopulmonary collateral flow. The first principal component (PC) described systolic versus diastolic-dominant flow through the Fontan circulation, accounting for 31.3% of the variance in all waveforms. The first PC correlated with end-diastolic volume (R = 0.34, P = 0.001), and end-systolic volume (R = 0.30, P = 0.003), cardiac index (R = 0.51, P < 0.001), and the amount of aortopulmonary collateral flow (R = 0.25, P = 0.027)-lower ventricular volumes and a smaller volume of collateral flow-were associated with diastolic-dominant cavopulmonary flow. The second PC accounted for 19.5% of variance and described late diastolic acceleration versus deceleration and correlated with ejection fraction-diastolic deceleration was associated with higher ejection fraction. Principal components describing the diastolic flow variations in pulmonary arteries are related to the single ventricle function and volumes. Particularly, diastolic-dominant flow without late acceleration appears to be related to preserved ventricular volume and function, respectively.NEW & NOTEWORTHY The exact physiological significance of flow oscillations of phasic and temporal flow variations in Fontan circulation is unknown. With the use of principal component analysis, we discovered that flow variations in the right pulmonary artery of Fontan patients are related to the single ventricle function and volumes. Particularly, diastolic-dominant flow without late acceleration appears to be related to more ideal ventricular volume and systolic function, respectively.
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Affiliation(s)
- Michal Schäfer
- Division of Cardiology, Heart Institute, Children's Hospital Colorado, University of Colorado Denver, Anschutz Medical Campus, Denver, Colorado
| | - Benjamin S Frank
- Division of Cardiology, Heart Institute, Children's Hospital Colorado, University of Colorado Denver, Anschutz Medical Campus, Denver, Colorado
| | | | - Kendall S Hunter
- Department of Bioengineering, College of Engineering and Applied Sciences, University of Colorado Denver, Anschutz Medical Campus, Denver, Colorado
| | - Katherine L Carmody
- Division of Cardiology, Heart Institute, Children's Hospital Colorado, University of Colorado Denver, Anschutz Medical Campus, Denver, Colorado
| | - Roni Jacobsen
- Division of Cardiology, Heart Institute, Children's Hospital Colorado, University of Colorado Denver, Anschutz Medical Campus, Denver, Colorado
| | - Max B Mitchell
- Section of Congenital Heart Surgery, Heart Institute, Children's Hospital Colorado, University of Colorado Denver, Anschutz Medical Campus, Denver, Colorado
| | - James Jaggers
- Section of Congenital Heart Surgery, Heart Institute, Children's Hospital Colorado, University of Colorado Denver, Anschutz Medical Campus, Denver, Colorado
| | - Matthew L Stone
- Section of Congenital Heart Surgery, Heart Institute, Children's Hospital Colorado, University of Colorado Denver, Anschutz Medical Campus, Denver, Colorado
| | - Gareth J Morgan
- Division of Cardiology, Heart Institute, Children's Hospital Colorado, University of Colorado Denver, Anschutz Medical Campus, Denver, Colorado
| | - Alex J Barker
- Department of Bioengineering, College of Engineering and Applied Sciences, University of Colorado Denver, Anschutz Medical Campus, Denver, Colorado.,Department of Radiology, Children's Hospital Colorado, University of Colorado Denver, Anschutz Medical Campus, Denver, Colorado
| | - Lorna P Browne
- Department of Radiology, Children's Hospital Colorado, University of Colorado Denver, Anschutz Medical Campus, Denver, Colorado
| | - D Dunbar Ivy
- Division of Cardiology, Heart Institute, Children's Hospital Colorado, University of Colorado Denver, Anschutz Medical Campus, Denver, Colorado
| | - Adel Younoszai
- Division of Cardiology, Heart Institute, Children's Hospital Colorado, University of Colorado Denver, Anschutz Medical Campus, Denver, Colorado
| | - Michael V Di Maria
- Division of Cardiology, Heart Institute, Children's Hospital Colorado, University of Colorado Denver, Anschutz Medical Campus, Denver, Colorado
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Budts W, Ravekes WJ, Danford DA, Kutty S. Diastolic Heart Failure in Patients With the Fontan Circulation. JAMA Cardiol 2020; 5:590-597. [DOI: 10.1001/jamacardio.2019.5459] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Affiliation(s)
- Werner Budts
- University Hospitals Leuven, Congenital and Structural Cardiology, Catholic University of Leuven, Leuven, Belgium
| | - William J. Ravekes
- The Helen B. Taussig Heart Center, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - David A. Danford
- Pediatric Cardiology, University of Nebraska College of Medicine, Omaha
| | - Shelby Kutty
- The Helen B. Taussig Heart Center, Johns Hopkins University School of Medicine, Baltimore, Maryland
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Garcia AM, Beatty JT, Nakano SJ. Heart failure in single right ventricle congenital heart disease: physiological and molecular considerations. Am J Physiol Heart Circ Physiol 2020; 318:H947-H965. [PMID: 32108525 PMCID: PMC7191494 DOI: 10.1152/ajpheart.00518.2019] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/04/2019] [Revised: 02/13/2020] [Accepted: 02/19/2020] [Indexed: 12/27/2022]
Abstract
Because of remarkable surgical and medical advances over the past several decades, there are growing numbers of infants and children living with single ventricle congenital heart disease (SV), where there is only one functional cardiac pumping chamber. Nevertheless, cardiac dysfunction (and ultimately heart failure) is a common complication in the SV population, and pharmacological heart failure therapies have largely been ineffective in mitigating the need for heart transplantation. Given that there are several inherent risk factors for ventricular dysfunction in the setting of SV in addition to probable differences in molecular adaptations to heart failure between children and adults, it is perhaps not surprising that extrapolated adult heart failure medications have had limited benefit in children with SV heart failure. Further investigations into the molecular mechanisms involved in pediatric SV heart failure may assist with risk stratification as well as development of targeted, efficacious therapies specific to this patient population. In this review, we present a brief overview of SV anatomy and physiology, with a focus on patients with a single morphological right ventricle requiring staged surgical palliation. Additionally, we discuss outcomes in the current era, risk factors associated with the progression to heart failure, present state of knowledge regarding molecular alterations in end-stage SV heart failure, and current therapeutic interventions. Potential avenues for improving SV outcomes, including identification of biomarkers of heart failure progression, implications of personalized medicine and stem cell-derived therapies, and applications of novel models of SV disease, are proposed as future directions.
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Affiliation(s)
- Anastacia M Garcia
- Division of Cardiology, Department of Pediatrics, University of Colorado Denver, Aurora, Colorado
| | - Jonathan-Thomas Beatty
- Division of Cardiology, Department of Medicine, University of Colorado Denver, Aurora, Colorado
| | - Stephanie J Nakano
- Division of Cardiology, Department of Pediatrics, University of Colorado Denver, Aurora, Colorado
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Fogel MA, Trusty PM, Nicolson S, Spray T, Gaynor JW, Whitehead KK, Yoganathan AP. Cross-Sectional Magnetic Resonance and Modeling Comparison From Just After Fontan to the Teen Years. Ann Thorac Surg 2019; 109:574-582. [PMID: 31518584 DOI: 10.1016/j.athoracsur.2019.07.066] [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: 03/19/2019] [Revised: 07/15/2019] [Accepted: 07/22/2019] [Indexed: 11/16/2022]
Abstract
BACKGROUND Little is known of baseline anatomic, hemodynamic, and fluid dynamic cardiac magnetic resonance data in single-ventricle patients immediately after Fontan. A comparison from that time point to the teen years can demonstrate clinical course, potentially predict future events, and may shed some light regarding how to optimize outcome. This cross-sectional study is meant to characterize these variables from just after Fontan to the teenage years. METHODS The anatomy, flows, and computational fluid dynamic modeling of 22 patients 3 to 9 months after Fontan (age 3 ± 1.1 years) and 25 teens (age 16 ± 1.8 years) were compared. Significance was defined as P less than .05. RESULTS The percentage of Fontan pathway stenosis was greater with cardiac index and fenestration flow while caval return was lower in teens than in younger patients (for Fontan pathway stenosis, 43% vs 21%, P = .009); however, hepatic flow distribution was more evenly distributed in older patients. Pulmonary artery size kept up with somatic growth. In the teen group, indexed power loss (R = .39), percentage of Fontan pathway stenosis (R = .62), and particle resident time (R = .42) deteriorated as time from Fontan increased (P < .04 for all). CONCLUSIONS There are mostly aspects of deterioration with a few bright spots of stability in anatomy, blood flow, and fluid dynamic variables in Fontan patients from the postoperative period to the teenage years. Most notably, Fontan pathway stenosis increases with decreasing flows while pulmonary artery size and hepatic flow distribution remain stable or improved. These data may be aid in designing improved Fontan reconstruction to optimize clinical outcome and to understand future complications.
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Affiliation(s)
- Mark A Fogel
- Division of Cardiology, Department of Pediatrics, The Children's Hospital of Philadelphia/The University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania; Department of Radiology, The Children's Hospital of Philadelphia/The University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania.
| | - Phillip M Trusty
- Department of Biomedical Engineering, The Georgia Institute of Technology, Atlanta, Georgia
| | - Susan Nicolson
- Department of Anesthesia, The Children's Hospital of Philadelphia/The University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania
| | - Thomas Spray
- Department of Cardiothoracic Surgery, The Children's Hospital of Philadelphia/The University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania
| | - J William Gaynor
- Department of Cardiothoracic Surgery, The Children's Hospital of Philadelphia/The University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania
| | - Kevin K Whitehead
- Division of Cardiology, Department of Pediatrics, The Children's Hospital of Philadelphia/The University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania; Department of Radiology, The Children's Hospital of Philadelphia/The University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania
| | - Ajit P Yoganathan
- Department of Biomedical Engineering, The Georgia Institute of Technology, Atlanta, Georgia
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Hoang TT, Manso PH, Edman S, Mercer-Rosa L, Mitchell LE, Sewda A, Swartz MD, Fogel MA, Agopian AJ, Goldmuntz E. Genetic variants of HIF1α are associated with right ventricular fibrotic load in repaired tetralogy of Fallot patients: a cardiovascular magnetic resonance study. J Cardiovasc Magn Reson 2019; 21:51. [PMID: 31422771 PMCID: PMC6699069 DOI: 10.1186/s12968-019-0555-2] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2019] [Accepted: 06/14/2019] [Indexed: 11/21/2022] Open
Abstract
BACKGROUND Studies suggest that right ventricular (RV) fibrosis is associated with RV remodeling and long-term outcomes in patients with tetralogy of Fallot (TOF). Pre-operative hypoxia may increase expression of hypoxia inducible factor-1-alpha (HIF1α) and promote transforming growth factor β1 (TGFβ1)-mediated fibrosis. We hypothesized that there would be associations between: (1) RV fibrosis and RV function, (2) HIF1α variants and RV fibrosis, and (3) HIF1α variants and RV function among post-surgical TOF cases. METHODS We retrospectively measured post-surgical fibrotic load (indexed volume and fibrotic score) from 237 TOF cases who had existing cardiovascular magnetic resonance imaging using late gadolinium enhancement (LGE), and indicators of RV remodeling (i.e., ejection fraction [RVEF] and end-diastolic volume indexed [RVEDVI]). Genetic data were available in 125 cases. Analyses were conducted using multivariable linear mixed-effects regression with a random intercept and multivariable generalized Poisson regression with a random intercept. RESULTS Indexed fibrotic volume and fibrotic score significantly decreased RVEF by 1.6% (p = 0.04) and 0.9% (p = 0.03), respectively. Indexed fibrotic volume and score were not associated with RVEDVI. After adjusting for multiple comparisons, 6 of the 48 HIF1α polymorphisms (representing two unique signals) were associated with fibrotic score. None of the HIF1α polymorphisms were associated with indexed fibrotic volume, RVEDVI, or RVEF. CONCLUSION The association of some HIF1α polymorphisms and fibrotic score suggests that HIF1α may modulate the fibrotic response in TOF.
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Affiliation(s)
- Thanh T. Hoang
- Department of Epidemiology, Human Genetics, and Environmental Sciences, UTHealth School of Public Health, Houston, TX USA
| | - Paulo Henrique Manso
- Department of Pediatrics, Ribeiro Preto Medical School USP, Ribeirao Preto, Brazil
| | - Sharon Edman
- Division of Cardiology, Children’s Hospital of Philadelphia, Abramson Research Center 702A, 3615 Civic Center Boulevard, Philadelphia, PA 19104 USA
| | - Laura Mercer-Rosa
- Division of Cardiology, Children’s Hospital of Philadelphia, Abramson Research Center 702A, 3615 Civic Center Boulevard, Philadelphia, PA 19104 USA
- Department of Pediatrics, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA USA
| | - Laura E. Mitchell
- Department of Epidemiology, Human Genetics, and Environmental Sciences, UTHealth School of Public Health, Houston, TX USA
| | - Anshuman Sewda
- Department of Genetics and Genomic Sciences, Icahn School of Medicine at Mount Sinai, New York, NY USA
| | - Michael D. Swartz
- Department of Biostatistics and Data Science, UTHealth School of Public Health, Houston, TX USA
| | - Mark A. Fogel
- Division of Cardiology, Children’s Hospital of Philadelphia, Abramson Research Center 702A, 3615 Civic Center Boulevard, Philadelphia, PA 19104 USA
- Department of Pediatrics, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA USA
| | - A. J. Agopian
- Department of Epidemiology, Human Genetics, and Environmental Sciences, UTHealth School of Public Health, Houston, TX USA
| | - Elizabeth Goldmuntz
- Division of Cardiology, Children’s Hospital of Philadelphia, Abramson Research Center 702A, 3615 Civic Center Boulevard, Philadelphia, PA 19104 USA
- Department of Pediatrics, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA USA
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Hayabuchi Y, Homma Y, Kagami S. Optical coherence tomography for observing development of pulmonary arterial vasa vasorum after bidirectional cavopulmonary connection in children. PLoS One 2019; 14:e0215146. [PMID: 30958848 PMCID: PMC6453465 DOI: 10.1371/journal.pone.0215146] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2019] [Accepted: 03/27/2019] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND Hypoxia and low pulmonary arterial (PA) blood flow stimulate the development of systemic-to-pulmonary collateral blood vessels, which can be an adverse factor when performing the Fontan operation. The aim of this study was to use optical coherence tomography (OCT) to elucidate the morphological changes in PA vasculature after creation of a bidirectional cavopulmonary connection (BCPC) in children. METHODS This prospective study evaluated PA wall thickness and development of PA vasa vasorum (VV) in the distal PA of eight patients (BCPC group, 1.3 ± 0.3 years) and 20 age-matched children with normal pulmonary artery hemodynamics and morphology (Control group, 1.4 ± 0.3 years). VV development was defined by the VV area ratio, defined as the VV area divided by the adventitial area in cross-sectional images. RESULTS There was no significant difference in PA wall thickness between the BCPC and control groups (0.12 ± 0.03 mm vs. 0.12 ± 0.02 mm, respectively). The VV area ratio was significantly greater in the BCPC group than in the Control group (14.5 ± 3.5% vs. 5.3 ± 1.6%, respectively; p<0.0001). CONCLUSION OCT is a promising new tool for evaluating PA pathology, including the development of VV in patients after BCPC.
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Affiliation(s)
- Yasunobu Hayabuchi
- Department of Pediatrics, Tokushima University, Kuramoto-cho-3, Tokushima, Japan
- * E-mail:
| | - Yukako Homma
- Department of Pediatrics, Tokushima University, Kuramoto-cho-3, Tokushima, Japan
| | - Shoji Kagami
- Department of Pediatrics, Tokushima University, Kuramoto-cho-3, Tokushima, Japan
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Trusty PM, Wei Z, Rychik J, Russo PA, Surrey LF, Goldberg DJ, Fogel MA, Yoganathan AP. Impact of hemodynamics and fluid energetics on liver fibrosis after Fontan operation. J Thorac Cardiovasc Surg 2018; 156:267-275. [DOI: 10.1016/j.jtcvs.2018.02.078] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/12/2017] [Revised: 11/29/2017] [Accepted: 02/04/2018] [Indexed: 10/17/2022]
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Ono M, Beran E, Burri M, Cleuziou J, Pabst von Ohain J, Röhlig C, Strbad M, Hager A, Hörer J, Lange R. Outcomes of a total cavopulmonary connection in patients with impaired ventricular function†. Eur J Cardiothorac Surg 2018; 54:55-62. [DOI: 10.1093/ejcts/ezx505] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/13/2017] [Accepted: 12/20/2017] [Indexed: 11/14/2022] Open
Affiliation(s)
- Masamichi Ono
- Department of Cardiovascular Surgery, German Heart Center Munich at the Technical University of Munich, Munich, Germany
| | - Elisabeth Beran
- Department of Cardiovascular Surgery, German Heart Center Munich at the Technical University of Munich, Munich, Germany
| | - Melchior Burri
- Department of Cardiovascular Surgery, German Heart Center Munich at the Technical University of Munich, Munich, Germany
| | - Julie Cleuziou
- Department of Cardiovascular Surgery, German Heart Center Munich at the Technical University of Munich, Munich, Germany
| | - Jelena Pabst von Ohain
- Department of Cardiovascular Surgery, German Heart Center Munich at the Technical University of Munich, Munich, Germany
| | - Christoph Röhlig
- Department of Pediatric Cardiology and Congenital Heart Disease, German Heart Center Munich at the Technical University of Munich, Munich, Germany
| | - Martina Strbad
- Department of Cardiovascular Surgery, German Heart Center Munich at the Technical University of Munich, Munich, Germany
| | - Alfred Hager
- Department of Pediatric Cardiology and Congenital Heart Disease, German Heart Center Munich at the Technical University of Munich, Munich, Germany
| | - Jürgen Hörer
- Department of Congenital Heart Disease, Marie Lannelongue Hospital, Les Plessis-Robinson, France
| | - Rüdiger Lange
- Department of Cardiovascular Surgery, German Heart Center Munich at the Technical University of Munich, Munich, Germany
- Institute for Translational Cardiac Surgery, Department of Cardiovascular Surgery, German Heart Center Munich at the Technical University of Munich, Munich, Germany
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Casella SL, Kaza A, del Nido P, Lock JE, Marshall AC. Targeted Increase in Pulmonary Blood Flow in a Bidirectional Glenn Circulation. Semin Thorac Cardiovasc Surg 2018; 30:182-188. [DOI: 10.1053/j.semtcvs.2018.02.001] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/01/2018] [Indexed: 11/11/2022]
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Windsor J, Townsley MM, Briston D, Villablanca PA, Alegria JR, Ramakrishna H. Fontan Palliation for Single-Ventricle Physiology: Perioperative Management for Noncardiac Surgery and Analysis of Outcomes. J Cardiothorac Vasc Anesth 2017; 31:2296-2303. [DOI: 10.1053/j.jvca.2017.04.003] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/29/2017] [Indexed: 12/14/2022]
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Mkrtchyan N, Frank Y, Steinlechner E, Calavrezos L, Meierhofer C, Hager A, Martinoff S, Ewert P, Stern H. Aortopulmonary collateral flow quantification by MR at rest and during continuous submaximal exercise in patients with total cavopulmonary connection. J Magn Reson Imaging 2017; 47:1509-1516. [PMID: 29105891 DOI: 10.1002/jmri.25889] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2017] [Accepted: 10/24/2017] [Indexed: 11/08/2022] Open
Abstract
BACKGROUND Aortopulmonary collateral flow is considered to have significant impact on the outcome of patients with single ventricle circulation and total cavopulmonary connection (TCPC). There is little information on collateral flow during exercise. PURPOSE To quantify aortopulmonary collateral flow at rest and during continuous submaximal exercise in clinical patients doing well with TCPC. STUDY TYPE Prospective, case controlled. POPULATION Thirteen patients with TCPC (17 (11-37) years) and 13 age and sex-matched healthy controls (18 (11-38) years). FIELD STRENGTH 1.5T; free breathing; phase sensitive gradient echo sequence. ASSESSMENT Blood flow in the ascending and descending aorta and superior vena cava were measured at rest and during continuous submaximal physical exercise in patients and controls. Systemic blood flow (Qs ) was assumed to be represented by the sum of flow in the superior caval vein (Qsvc ) and the descending aorta (QAoD ) at the diaphragm level. Aortopulmonary collateral flow (Qcoll ) was calculated by subtracting Qs from flow in the ascending aorta (QAoA ). STATISTICS Mann-Whitney U-test and Wilcoxon test for comparison between groups and between rest and exercise. RESULTS Absolute collateral flow in TCPC patients at rest was 0.4 l/min/m2 (-0.1-1.2), corresponding to 14% (-2-42) of Qs . Collateral flow did not change during exercise (difference -0.01 (-0.7-1.0) l/min/m2 , P = 0.97). TCPC patients had significantly lower Qs at rest (2.5 (1.6-4.1) vs. 3.5 (2.6-4.8) l/min/m2 , P = 0.001) and during submaximal exercise (3.2 (2.0-6.0) vs. 4.8 (3.3-6.9) l/min/m2 , P = 0.001), compared to healthy controls. The increase in Qs with exercise was also significantly lower in patients than in healthy controls (median 0.6 vs. 1.2 l/min/m2 , P < 0.02). DATA CONCLUSION Clinical patients doing well with TCPC have significant aortopulmonary collateral flow at rest (14% of Qs ) compared to healthy controls, which does not change during submaximal exercise. LEVEL OF EVIDENCE 2 Technical Efficacy: Stage 3 J. Magn. Reson. Imaging 2018;47:1509-1516.
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Affiliation(s)
- Naira Mkrtchyan
- Department of Pediatric Cardiology and Congenital Heart Disease, Deutsches Herzzentrum München an der Technischen Universität München, München, Germany
| | - Yvonne Frank
- Department of Pediatric Cardiology and Congenital Heart Disease, Deutsches Herzzentrum München an der Technischen Universität München, München, Germany
| | - Eva Steinlechner
- Department of Pediatric Cardiology and Congenital Heart Disease, Deutsches Herzzentrum München an der Technischen Universität München, München, Germany
| | - Lenika Calavrezos
- Department of Pediatric Cardiology and Congenital Heart Disease, Deutsches Herzzentrum München an der Technischen Universität München, München, Germany
| | - Christian Meierhofer
- Department of Pediatric Cardiology and Congenital Heart Disease, Deutsches Herzzentrum München an der Technischen Universität München, München, Germany
| | - Alfred Hager
- Department of Pediatric Cardiology and Congenital Heart Disease, Deutsches Herzzentrum München an der Technischen Universität München, München, Germany
| | - Stefan Martinoff
- Department of Radiology, Deutsches Herzzentrum München an der Technischen Universität München, München, Germany
| | - Peter Ewert
- Department of Pediatric Cardiology and Congenital Heart Disease, Deutsches Herzzentrum München an der Technischen Universität München, München, Germany
| | - Heiko Stern
- Department of Pediatric Cardiology and Congenital Heart Disease, Deutsches Herzzentrum München an der Technischen Universität München, München, Germany
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Frieberg P, Sjöberg P, Revstedt J, Heiberg E, Liuba P, Carlsson M. Simulation of aortopulmonary collateral flow in Fontan patients for use in prediction of interventional outcomes. Clin Physiol Funct Imaging 2017; 38:622-629. [PMID: 28782911 DOI: 10.1111/cpf.12457] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2017] [Accepted: 07/05/2017] [Indexed: 11/28/2022]
Abstract
PURPOSE Patients with complex congenital heart disease may need to be converted to a Fontan circulation with systemic venous return surgically connected to the pulmonary circulation. These patients frequently form aortopulmonary collaterals (APC), that is arterial inflows to the pulmonary artery vascular tree. The aim of this study was to develop a method to calculate the effect of APC on the pulmonary flow distribution based on magnetic resonance imaging (MRI) measurements and computational fluid dynamics simulations in order to enable prediction of interventional outcomes in Fontan patients. METHODS Patient-specific models of 11 patients were constructed in a 3D-design software based on MRI segmentations. APC flow was quantified as the difference between pulmonary venous flow and pulmonary artery flow, measured by MRI. A method was developed to include the modulating effect of the APC flow by calculating the patient-specific relative pulmonary vascular resistance. Simulations, including interventions with a Y-graft replacement and a stent dilatation, were validated against MRI results. RESULTS The bias between simulated and MRI-measured fraction of blood to the left lung was 2·9 ± 5·3%. Including the effects of the APC flow in the simulation (n = 6) reduced simulation error from 9·8 ± 7·0% to 5·2 ± 6·3%. Preliminary findings in two patients show that the effect of surgical and catheter interventions could be predicted using the demonstrated methods. CONCLUSIONS The work demonstrates a novel method to include APC flow in predictive simulations of Fontan hemodynamics. APC flow was found to have a significant contribution to the pulmonary flow distribution in Fontan patients.
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Affiliation(s)
- Petter Frieberg
- Department of Clinical Sciences Lund, Clinical Physiology, Skane University Hospital, Lund University, Lund, Sweden
| | - Pia Sjöberg
- Department of Clinical Sciences Lund, Clinical Physiology, Skane University Hospital, Lund University, Lund, Sweden
| | - Johan Revstedt
- Department of Energy Sciences, Faculty of Engineering, Lund University, Lund, Sweden
| | - Einar Heiberg
- Department of Clinical Sciences Lund, Clinical Physiology, Skane University Hospital, Lund University, Lund, Sweden.,Department of Biomedical Engineering, Faculty of Engineering, Lund University, Lund, Sweden.,Center for Mathematics, Faculty of Engineering, Lund University, Lund, Sweden
| | - Petru Liuba
- Department of Clinical Sciences Lund, Pediatric Heart Center, Skane University Hospital, Lund University, Lund, Sweden
| | - Marcus Carlsson
- Department of Clinical Sciences Lund, Clinical Physiology, Skane University Hospital, Lund University, Lund, Sweden.,Department of Medical Imaging and Physiology, Skane University Hospital, Lund, Sweden
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Averin K, Byrnes JW, Benscoter DT, Whiteside W, DeSena H, Hirsch R, Goldstein BH. Life-threatening airway bleeding after palliation of single ventricle congenital heart disease. Heart 2017; 104:254-260. [DOI: 10.1136/heartjnl-2017-311764] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/27/2017] [Revised: 07/06/2017] [Accepted: 07/07/2017] [Indexed: 11/03/2022] Open
Abstract
ObjectiveTo describe acute and mid-term outcomes following presentation with, and treatment for, life-threatening airway bleeding (hemoptysis) in palliated single ventricle congenital heart disease (SV-CHD).MethodsCase series of patients with SV-CHD who presented to a large congenital heart centre with hemoptysis between 2004 and 2015.ResultsTwenty-one episodes of hemoptysis occurred in 12 patients (58% female, median 10.5 (IQR 7.2, 16.4) years). First hemoptysis episode occurred after Fontan completion (n=8), after superior cavopulmonary anastomosis (SCPA, n=3) and in one shunt-dependent patient. Bronchoscopy was performed in conjunction with catheterisation in 14/21 (67%) initial catheterisations. A specific anatomic source of airway bleeding was identified in 95% of bronchoscopy cases and was uniformly distributed in all lobar segments. Transcatheter intervention with systemic-to-pulmonary collateral artery (SPC) occlusion was performed in 28/30 catheterisations. Apart from increased airway bleeding during interventional bronchoscopy (37%), there were no procedural complications. Median hospital length of stay was 9.0 (3.5, 14.5) days with patients undergoing 1.0 (1.0,2.0) catheterisations per episode of hemoptysis. Two SCPA patients did not survive to discharge. During a median follow-up of 32.5 (12.5, 87.5) months, freedom from mortality was 75%, with all three deaths occurring in the SCPA group by 4 months posthemoptysis. Recurrent hemoptysis occurred in 60% of patients.ConclusionsDespite the potentially life-threatening nature of hemoptysis in patients with SV-CHD, a policy of bronchoscopic evaluation and transcatheter treatment is safe and may contribute to low mortality at mid-term follow-up in Fontan patients. Hemoptysis in SCPA patients may portend a poor prognosis. Recurrent hemoptysis is common.
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Differentiation of Impaired From Preserved Hemodynamics in Patients With Fontan Circulation Using Real-time Phase-velocity Cardiovascular Magnetic Resonance. J Thorac Imaging 2017; 32:159-168. [PMID: 28346330 PMCID: PMC5538303 DOI: 10.1097/rti.0000000000000261] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Supplemental Digital Content is available in the text. Purpose: Progressive impairment of hemodynamics in patients with Fontan circulation is common, multifactorial, and associated with decreased quality of life and increased morbidity. We sought to assess hemodynamic differences between patients with preserved (preserved Fontans) and those with impaired circulation (impaired Fontans) after pulmonary vasodilation using oxygen and under forced breathing conditions. Materials and Methods: Real-time phase-contrast cardiovascular magnetic resonance was performed using non–ECG triggered echo-planar imaging (temporal resolution=24 to 28 ms) in the ascending aorta (AAo) and superior vena cava (SVC)/inferior vena cava (IVC) on room air, after 100% oxygen inhalation (4 L/min; 10 min) and on forced breathing in 29 Fontan patients (17.2±7.3 y) and in 32 controls on room air (13.4±3.7 y). The simultaneously recorded patients’ respiratory cycle was divided into 4 segments (expiration, end-expiration, inspiration, and end-inspiration) to generate respiratory-dependent stroke volumes (SVs). The imaging data were matched with physiological data and analyzed with home-made software. Results: The mean SVi (AAo) was 46.1±11.1 mL/m2 in preserved Fontans versus 30.4±6.2 mL/m2 in impaired Fontans (P=0.002) and 51.1±6.9 mL/m2 in controls (P=0.107). The cutoff value for differentiation of Fontan groups was SVi (AAo, end-expiratory) of 32.1 mL/m2. After hyperoxygenation, the mean SVi (AAo) increased to 48.7±12.7 mL/m2 in preserved Fontans (P=0.045) but remained unchanged in impaired Fontans (31.1±5.8 mL/m2, P=0.665). Simultaneously, heart rates decreased from 75.2±15.9 to 70.8±16.4 bpm (preserved; P=0.000) but remained unchanged in impaired circulation (baseline: 84.1±9.8 bpm, P=0.612). Compared with physiological respiration, forced breathing increased the maximum respiratory-related cardiac index difference (ΔCImax) in preserved Fontans (SVC: 2.5-fold, P=0.000; and IVC: 1.8-fold, P=0.000) and to a lower extent in impaired Fontans (both veins, 1.5-fold; P(SVC)=0.011, P(IVC)=0.013). There was no impact on mean blood flow. Conclusions: Oxygen affected the pulmonary vascular system by vasodilation and increased SVi in preserved Fontans but had no effect on impaired Fontans. Forced breathing increased ΔCImax but did not change the mean blood flow by sole activation of the ventilatory pump. End-expiratory aortic SVi represents a valuable measure for classifying the severity of Fontan hemodynamics impairment.
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Burchill LJ, Huang J, Tretter JT, Khan AM, Crean AM, Veldtman GR, Kaul S, Broberg CS. Noninvasive Imaging in Adult Congenital Heart Disease. Circ Res 2017; 120:995-1014. [DOI: 10.1161/circresaha.116.308983] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/01/2016] [Revised: 02/17/2017] [Accepted: 02/17/2017] [Indexed: 11/16/2022]
Abstract
Multimodality cardiovascular imaging plays a central role in caring for patients with congenital heart disease (CHD). CHD clinicians and scientists are interested not only in cardiac morphology but also in the maladaptive ventricular responses and extracellular changes predisposing to adverse outcomes in this population. Expertise in the applications, strengths, and pitfalls of these cardiovascular imaging techniques as they relate to CHD is essential. The purpose of this article is to provide an overview of cardiovascular imaging in CHD. We focus on the role of 3 widely used noninvasive imaging techniques in CHD—echocardiography, cardiac magnetic resonance imaging, and cardiac computed tomography. Consideration is given to the common goals of cardiac imaging in CHD, including assessment of structural and residual heart disease before and after surgery, quantification of ventricular volume and function, stress imaging, shunt quantification, and tissue characterization. Extracardiac imaging is highlighted as an increasingly important aspect of CHD care.
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Affiliation(s)
- Luke J. Burchill
- From the Knight Cardiovascular Institute (L.J.B., A.M.K., S.K., C.S.B.), Doernbecher Children’s Hospital (J.H.), Oregon Health and Science University, Portland; The Heart Institute, Cincinnati Children’s Hospital Medical Center, OH (J.T.T., G.R.V.); Department of Cardiology, Heart Lung and Vascular Institute, University of Cincinnati Medical Center, OH (A.M.C.); Department of Cardiology, Cincinnati Children’s Hospital, OH (A.M.C.); Department of Cardiology (A.M.C.) and Joint Department of Medical
| | - Jennifer Huang
- From the Knight Cardiovascular Institute (L.J.B., A.M.K., S.K., C.S.B.), Doernbecher Children’s Hospital (J.H.), Oregon Health and Science University, Portland; The Heart Institute, Cincinnati Children’s Hospital Medical Center, OH (J.T.T., G.R.V.); Department of Cardiology, Heart Lung and Vascular Institute, University of Cincinnati Medical Center, OH (A.M.C.); Department of Cardiology, Cincinnati Children’s Hospital, OH (A.M.C.); Department of Cardiology (A.M.C.) and Joint Department of Medical
| | - Justin T. Tretter
- From the Knight Cardiovascular Institute (L.J.B., A.M.K., S.K., C.S.B.), Doernbecher Children’s Hospital (J.H.), Oregon Health and Science University, Portland; The Heart Institute, Cincinnati Children’s Hospital Medical Center, OH (J.T.T., G.R.V.); Department of Cardiology, Heart Lung and Vascular Institute, University of Cincinnati Medical Center, OH (A.M.C.); Department of Cardiology, Cincinnati Children’s Hospital, OH (A.M.C.); Department of Cardiology (A.M.C.) and Joint Department of Medical
| | - Abigail M. Khan
- From the Knight Cardiovascular Institute (L.J.B., A.M.K., S.K., C.S.B.), Doernbecher Children’s Hospital (J.H.), Oregon Health and Science University, Portland; The Heart Institute, Cincinnati Children’s Hospital Medical Center, OH (J.T.T., G.R.V.); Department of Cardiology, Heart Lung and Vascular Institute, University of Cincinnati Medical Center, OH (A.M.C.); Department of Cardiology, Cincinnati Children’s Hospital, OH (A.M.C.); Department of Cardiology (A.M.C.) and Joint Department of Medical
| | - Andrew M. Crean
- From the Knight Cardiovascular Institute (L.J.B., A.M.K., S.K., C.S.B.), Doernbecher Children’s Hospital (J.H.), Oregon Health and Science University, Portland; The Heart Institute, Cincinnati Children’s Hospital Medical Center, OH (J.T.T., G.R.V.); Department of Cardiology, Heart Lung and Vascular Institute, University of Cincinnati Medical Center, OH (A.M.C.); Department of Cardiology, Cincinnati Children’s Hospital, OH (A.M.C.); Department of Cardiology (A.M.C.) and Joint Department of Medical
| | - Gruschen R. Veldtman
- From the Knight Cardiovascular Institute (L.J.B., A.M.K., S.K., C.S.B.), Doernbecher Children’s Hospital (J.H.), Oregon Health and Science University, Portland; The Heart Institute, Cincinnati Children’s Hospital Medical Center, OH (J.T.T., G.R.V.); Department of Cardiology, Heart Lung and Vascular Institute, University of Cincinnati Medical Center, OH (A.M.C.); Department of Cardiology, Cincinnati Children’s Hospital, OH (A.M.C.); Department of Cardiology (A.M.C.) and Joint Department of Medical
| | - Sanjiv Kaul
- From the Knight Cardiovascular Institute (L.J.B., A.M.K., S.K., C.S.B.), Doernbecher Children’s Hospital (J.H.), Oregon Health and Science University, Portland; The Heart Institute, Cincinnati Children’s Hospital Medical Center, OH (J.T.T., G.R.V.); Department of Cardiology, Heart Lung and Vascular Institute, University of Cincinnati Medical Center, OH (A.M.C.); Department of Cardiology, Cincinnati Children’s Hospital, OH (A.M.C.); Department of Cardiology (A.M.C.) and Joint Department of Medical
| | - Craig S. Broberg
- From the Knight Cardiovascular Institute (L.J.B., A.M.K., S.K., C.S.B.), Doernbecher Children’s Hospital (J.H.), Oregon Health and Science University, Portland; The Heart Institute, Cincinnati Children’s Hospital Medical Center, OH (J.T.T., G.R.V.); Department of Cardiology, Heart Lung and Vascular Institute, University of Cincinnati Medical Center, OH (A.M.C.); Department of Cardiology, Cincinnati Children’s Hospital, OH (A.M.C.); Department of Cardiology (A.M.C.) and Joint Department of Medical
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