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Kritpracha P, Riviere B, Puelz C. Predicting the effects of surgically determined parameters on exercise tolerance in Fontan patients. Med Eng Phys 2024; 128:104152. [PMID: 38749828 DOI: 10.1016/j.medengphy.2024.104152] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2023] [Revised: 02/15/2024] [Accepted: 03/11/2024] [Indexed: 05/26/2024]
Abstract
The Fontan physiology is a surgically created circulation for patients with a single functioning ventricle. Patients with this circulation tend to have lower exercise tolerance compared to those with a normal circulation. Important computational and experimental work has been done to investigate this reduction in exercise tolerance. However, there are few systematic modeling studies that focus on the effect of several surgically determined parameters within the same framework. We propose a mathematical model to describe the Fontan circulation under exercise. We then formulate a heuristic based on clinical data from Fontan patients to estimate exercise tolerance. The model is used to investigate the effect of three important surgically determined parameters on exercise tolerance: the systemic arterial compliance, the systemic-venous to pulmonary-venous fenestration, and the resistance of the total cavopulmonary connection.
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Affiliation(s)
- Poom Kritpracha
- Department of Computational Applied Mathematics and Operations Research, Rice University, Houston, TX, USA; Department of Applied Mathematics, University of Colorado Boulder, Boulder, CO, USA
| | - Beatrice Riviere
- Department of Computational Applied Mathematics and Operations Research, Rice University, Houston, TX, USA
| | - Charles Puelz
- Department of Pediatrics, Division of Cardiology, Baylor College of Medicine and Texas Children's Hospital, Houston, TX, USA.
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2
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Yoneyama F, Kalustian AB, McKenzie ED, Heinle JS, Doan TT, Binsalamah Z. Long-Term Outcomes of Ascending Sliding Arch Aortoplasty. World J Pediatr Congenit Heart Surg 2024:21501351241232071. [PMID: 38465582 DOI: 10.1177/21501351241232071] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/12/2024]
Abstract
Background: Coarctation of the aorta can be associated with significant hypoplasia of the aortic arch. In contrast to patch aortoplasty, ascending sliding arch aortoplasty uses viable autologous tissue for potential growth in children. We reviewed the mid- to long-term outcomes of this technique. Methods: Between 2002 and 2023, 28 patients underwent ascending sliding arch aortoplasty for the patients with coarctation of the aorta (n = 22) and interrupted aortic arch (n = 2). Four patients underwent previous surgical coarctation repair at other institutions. The median patient age and body weight were 28.5 months (3 weeks to 15.6 years) and 13.4 kg (3.7-70 kg), respectively. Results: Although one patient had a recurrent nerve injury postoperatively, there were no other major morbidities or mortalities. The last follow-up echocardiography demonstrated that the mean peak velocity improved from 3.9 ± 0.6 to 0.9 ± 0.8 m/s, and the pressure gradient improved from 63.6 ± 21.5 to 7.1 ± 7.7 mm Hg. The postoperative diameters of the ascending aorta, proximal arch, distal arch, and isthmus all increased significantly. The mean postoperative length of stay was 5.9 ± 2.1 days, and the median follow-up time was 7.3 years (10 days to 20.5 years). No reoperation or catheterization-based intervention was performed for residual coarctation. Conclusions: Ascending sliding arch aortoplasty is safe and effective for treating coarctation of the aorta with aortic arch hypoplasia. This technique is applicable for children ranging in size from neonates to older children (or adolescents), recurrent coarctation cases, and provides complete relief of narrowing by utilizing viable native aortic tissue.
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Affiliation(s)
- Fumiya Yoneyama
- Department of Congenital Heart Surgery, Texas Children's Hospital, Baylor College of Medicine, Houston, TX, USA
| | - Alyssa B Kalustian
- Department of Congenital Heart Surgery, Texas Children's Hospital, Baylor College of Medicine, Houston, TX, USA
| | - E Dean McKenzie
- Department of Congenital Heart Surgery, Texas Children's Hospital, Baylor College of Medicine, Houston, TX, USA
| | - Jeffrey S Heinle
- Department of Congenital Heart Surgery, Texas Children's Hospital, Baylor College of Medicine, Houston, TX, USA
| | - Tam T Doan
- Department of Pediatric Cardiology, Texas Children's Hospital, Baylor College of Medicine, Houston, TX, USA
| | - Ziyad Binsalamah
- Department of Congenital Heart Surgery, Texas Children's Hospital, Baylor College of Medicine, Houston, TX, USA
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3
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Gartenberg AJ, Okunowo O, Dori Y, Smith CL, Gaynor JW, Mascio CE, Rome JJ, Gillespie MJ, Glatz AC, O'Byrne ML. Association of Interstage Monitoring Era and Likelihood of Hemodynamic Compromise at Intervention for Recoarctation Following the Norwood Operation. J Am Heart Assoc 2023:e029112. [PMID: 37421284 PMCID: PMC10382097 DOI: 10.1161/jaha.122.029112] [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: 12/05/2022] [Accepted: 05/10/2023] [Indexed: 07/10/2023]
Abstract
Background Intensive monitoring has been associated with a lower death rate between the Norwood operation and superior cavopulmonary connection, possibly due to early identification and effective treatment of residual anatomic lesions like recoarctation before lasting harm occurs. Methods and Results Neonates undergoing a Norwood operation and receiving interstage care at a single center between January 1, 2005, and September 18, 2020, were studied. In those with recoarctation, we evaluated association of era ([1] preinterstage monitoring, [2] a transitional phase, [3] current era) and likelihood of hemodynamic compromise (progression to moderate or greater ventricular dysfunction/atrioventricular valve regurgitation, initiation/escalation of vasoactive/respiratory support, cardiac arrest preceding catheterization, or interstage death with recoarctation on autopsy). We also analyzed whether era was associated with technical success of transcatheter recoarctation interventions, major adverse events, and transplant-free survival. A total of 483 subjects were studied, with 22% (n=106) treated for recoarctation during the interstage period. Number of catheterizations per Norwood increased (P=0.005) over the interstage eras, with no significant change in the proportion of subjects with recoarctation (P=0.36). In parallel, there was a lower likelihood of hemodynamic compromise in subjects with recoarctation that was not statistically significant (P=0.06), with a significant difference in the proportion with ventricular dysfunction at intervention (P=0.002). Rates of technical success, procedural major adverse events, and transplant-free survival did not differ (P>0.05). Conclusions Periods with interstage monitoring were associated with increased referral for catheterization but also reduced likelihood of ventricular dysfunction (and a suggestion of lower likelihood of hemodynamic compromise) in subjects with recoarctation. Further study is needed to guide optimal interstage care of this vulnerable population.
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Affiliation(s)
- Ari J Gartenberg
- Division of Cardiology, The Children's Hospital of Philadelphia and Department of Pediatrics Perelman School of Medicine at the University of Pennsylvania Philadelphia PA
| | - Oluwatimilehin Okunowo
- Department of Biomedical and Health Informatics, Data Science and Biostatistics Unit The Children's Hospital of Philadelphia Philadelphia PA
| | - Yoav Dori
- Division of Cardiology, The Children's Hospital of Philadelphia and Department of Pediatrics Perelman School of Medicine at the University of Pennsylvania Philadelphia PA
| | - Christopher L Smith
- Division of Cardiology, The Children's Hospital of Philadelphia and Department of Pediatrics Perelman School of Medicine at the University of Pennsylvania Philadelphia PA
| | - J William Gaynor
- Division of Cardiothoracic Surgery The Children's Hospital of Philadelphia and Department of Surgery Perelman School of Medicine at the University of Pennsylvania Philadelphia PA
| | - Christopher E Mascio
- Division of Cardiothoracic Surgery Department of Surgery West Virginia University Children's Hospital West Virginia University Medical School Morgantown WV
| | - Jonathan J Rome
- Division of Cardiology, The Children's Hospital of Philadelphia and Department of Pediatrics Perelman School of Medicine at the University of Pennsylvania Philadelphia PA
| | - Matthew J Gillespie
- Division of Cardiology, The Children's Hospital of Philadelphia and Department of Pediatrics Perelman School of Medicine at the University of Pennsylvania Philadelphia PA
| | - Andrew C Glatz
- Division of Cardiology St. Louis Children's Hospital St. Louis MO
- Department of Pediatrics Washington University School of Medicine St. Louis MO
| | - Michael L O'Byrne
- Division of Cardiology, The Children's Hospital of Philadelphia and Department of Pediatrics Perelman School of Medicine at the University of Pennsylvania Philadelphia PA
- Clinical Futures, The Children's Hospital of Philadelphia and Department of Pediatrics Perelman School of Medicine at the University of Pennsylvania Philadelphia PA
- Leonard Davis Institute and Center for Cardiovascular Outcomes, Quality, and Evaluative Research Perelman School of Medicine at the University of Pennsylvania Philadelphia PA
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4
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A computational study of aortic reconstruction in single ventricle patients. Biomech Model Mechanobiol 2023; 22:357-377. [PMID: 36335184 PMCID: PMC10174275 DOI: 10.1007/s10237-022-01650-w] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2022] [Accepted: 10/12/2022] [Indexed: 11/06/2022]
Abstract
Patients with hypoplastic left heart syndrome (HLHS) are born with an underdeveloped left heart. They typically receive a sequence of surgeries that result in a single ventricle physiology called the Fontan circulation. While these patients usually survive into early adulthood, they are at risk for medical complications, partially due to their lower than normal cardiac output, which leads to insufficient cerebral and gut perfusion. While clinical imaging data can provide detailed insight into cardiovascular function within the imaged region, it is difficult to use these data for assessing deficiencies in the rest of the body and for deriving blood pressure dynamics. Data from patients used in this paper include three-dimensional, magnetic resonance angiograms (MRA), time-resolved phase contrast cardiac magnetic resonance images (4D-MRI) and sphygmomanometer blood pressure measurements. The 4D-MRI images provide detailed insight into velocity and flow in vessels within the imaged region, but they cannot predict flow in the rest of the body, nor do they provide values of blood pressure. To remedy these limitations, this study combines the MRA, 4D-MRI, and pressure data with 1D fluid dynamics models to predict hemodynamics in the major systemic arteries, including the cerebral and gut vasculature. A specific focus is placed on studying the impact of aortic reconstruction occurring during the first surgery that results in abnormal vessel morphology. To study these effects, we compare simulations for an HLHS patient with simulations for a matched control patient that has double outlet right ventricle (DORV) physiology with a native aorta. Our results show that the HLHS patient has hypertensive pressures in the brain as well as reduced flow to the gut. Wave intensity analysis suggests that the HLHS patient has irregular circulatory function during light upright exercise conditions and that predicted wall shear stresses are lower than normal, suggesting the HLHS patient may have hypertension.
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Sano S, Sano T, Kobayashi Y, Kotani Y, Kouretas PC, Kasahara S. Journey Toward Improved Long-Term Outcomes After Norwood-Sano Procedure: Focus on the Aortic Arch Reconstruction. World J Pediatr Congenit Heart Surg 2022; 13:581-587. [PMID: 36053099 DOI: 10.1177/21501351221116766] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
The disadvantage of right ventricle-to-pulmonary artery (RV-PA) shunt is the need for more unplanned interventions to address stenosis in the shunt or branch pulmonary arteries, as compared to the modified Blalock-Taussig shunt group. Ring-enforced RV-PA PTFE conduit and dunk technique minimized these complications and right ventricle (RV) damage. Aortic arch obstruction increases afterload and leads to ventricular dysfunction and tricuspid regurgitation; therefore, most surgeons prefer to use homograft, autologous pericardium, or bovine pericardium to reconstruct the neoaorta. Artificial materials decrease the elastic properties, increase wall stiffness, and decrease the distensibility of the aorta; and as a result, RV function gradually deteriorates. This inelastic reconstructed aorta may be one of the reasons why long-term outcomes after the Fontan procedure are worse in hypoplastic left heart syndrome (HLHS) patients, in comparison to non-HLHS. Reconstruction of the neoaorta without any patch materials, or at least techniques that largely minimize the use of non-autologous materials, will offer a further refinement of our ability to optimize ventriculoarterial coupling and thereby long-term RV function.
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Affiliation(s)
- Shunji Sano
- Division of Pediatric Cardiac Surgery, Pediatric Heart Disease & Adult Congenital Heart Disease Center, 13059Showa University Hospital, Tokyo, Japan
| | - Toshikazu Sano
- Division of Pediatric Cardiac Surgery, Pediatric Heart Disease & Adult Congenital Heart Disease Center, 13059Showa University Hospital, Tokyo, Japan
| | - Yasuyuki Kobayashi
- Department of Cardiovascular Surgery, 12997Okayama University Hospital, Okayama, Japan
| | - Yasuhiro Kotani
- Department of Cardiovascular Surgery, 12997Okayama University Hospital, Okayama, Japan
| | - Peter C Kouretas
- Division of Pediatric Cardiothoracic Surgery, Department of Surgery, 1439University California San Francisco, San Francisco, CA, USA
| | - Shingo Kasahara
- Department of Cardiovascular Surgery, 12997Okayama University Hospital, Okayama, Japan
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de Vecchi A, Faraci A, Fernandes JF, Marlevi D, Bellsham-Revell H, Hussain T, Laji N, Ruijsink B, Wong J, Razavi R, Anderson D, Salih C, Pushparajah K, Nordsletten D, Lamata P. Unlocking the Non-invasive Assessment of Conduit and Reservoir Function in the Aorta. J Cardiovasc Transl Res 2022; 15:1075-1085. [PMID: 35199256 PMCID: PMC9622527 DOI: 10.1007/s12265-022-10221-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/18/2021] [Accepted: 02/14/2022] [Indexed: 11/06/2022]
Abstract
Aortic surgeries in congenital conditions, such as hypoplastic left heart syndrome (HLHS), aim to restore and maintain the conduit and reservoir functions of the aorta. We proposed a method to assess these two functions based on 4D flow MRI, and we applied it to study the aorta in pre-Fontan HLHS. Ten pre-Fontan HLHS patients and six age-matched controls were studied to derive the advective pressure difference and viscous dissipation for conduit function, and pulse wave velocity and elastic modulus for reservoir function. The reconstructed neo-aorta in HLHS subjects achieved a good conduit function at a cost of an impaired reservoir function (69.7% increase of elastic modulus). The native descending HLHS aorta displayed enhanced reservoir (elastic modulus being 18.4% smaller) but impaired conduit function (three-fold increase in peak advection). A non-invasive and comprehensive assessment of aortic conduit and reservoir functions is feasible and has potentially clinical relevance in congenital vascular conditions.
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Affiliation(s)
- Adelaide de Vecchi
- School of Biomedical Engineering and Imaging Sciences, King's College London, 5th Floor Becket House, Lambeth Palace Road, London, SE1 7EU, UK
| | - Alessandro Faraci
- School of Biomedical Engineering and Imaging Sciences, King's College London, 5th Floor Becket House, Lambeth Palace Road, London, SE1 7EU, UK
| | - Joao Filipe Fernandes
- School of Biomedical Engineering and Imaging Sciences, King's College London, 5th Floor Becket House, Lambeth Palace Road, London, SE1 7EU, UK
| | - David Marlevi
- Massachusetts Institute of Technology, Cambridge, MA, USA
| | - Hannah Bellsham-Revell
- Department of Congenital Heart Disease, Evelina London Children's Hospital, Guy's & St Thomas' Hospitals, London, SE1 7EH, UK
| | - Tarique Hussain
- Pediatric Cardiology, UT Southwestern, Children's Medical Center Dallas, 1935 Medical District Dr, Dallas, TX, 75235, USA
| | - Nidhin Laji
- School of Biomedical Engineering and Imaging Sciences, King's College London, 5th Floor Becket House, Lambeth Palace Road, London, SE1 7EU, UK
| | - Bram Ruijsink
- School of Biomedical Engineering and Imaging Sciences, King's College London, 5th Floor Becket House, Lambeth Palace Road, London, SE1 7EU, UK
| | - James Wong
- School of Biomedical Engineering and Imaging Sciences, King's College London, 5th Floor Becket House, Lambeth Palace Road, London, SE1 7EU, UK
| | - Reza Razavi
- School of Biomedical Engineering and Imaging Sciences, King's College London, 5th Floor Becket House, Lambeth Palace Road, London, SE1 7EU, UK
| | - David Anderson
- Department of Congenital Heart Disease, Evelina London Children's Hospital, Guy's & St Thomas' Hospitals, London, SE1 7EH, UK
| | - Caner Salih
- Department of Congenital Heart Disease, Evelina London Children's Hospital, Guy's & St Thomas' Hospitals, London, SE1 7EH, UK
| | - Kuberan Pushparajah
- School of Biomedical Engineering and Imaging Sciences, King's College London, 5th Floor Becket House, Lambeth Palace Road, London, SE1 7EU, UK
| | - David Nordsletten
- School of Biomedical Engineering and Imaging Sciences, King's College London, 5th Floor Becket House, Lambeth Palace Road, London, SE1 7EU, UK.,Department of Biomedical Engineering and Cardiac Surgery, University of Michigan, Ann Arbor, MI, USA
| | - Pablo Lamata
- School of Biomedical Engineering and Imaging Sciences, King's College London, 5th Floor Becket House, Lambeth Palace Road, London, SE1 7EU, UK.
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Sano S, Sano T, Kouretas PC. Reassessing our journey towards improved long-term outcomes in hypoplastic left heart syndrome: let's re-focus on the aortic arch. Eur J Cardiothorac Surg 2021; 60:1417-1418. [PMID: 34529772 DOI: 10.1093/ejcts/ezab244] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Affiliation(s)
- Shunji Sano
- Division of Pediatric Cardio-thoracic Surgery, Department of Surgery, University California San Francisco, San Francisco, CA 94143, USA
| | - Toshikazu Sano
- Division of Pediatric Cardio-thoracic Surgery, Department of Surgery, University California San Francisco, San Francisco, CA 94143, USA
| | - Peter C Kouretas
- Division of Pediatric Cardio-thoracic Surgery, Department of Surgery, University California San Francisco, San Francisco, CA 94143, USA
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Arterial Stiffness in Congenital Heart Disease. Heart Lung Circ 2021; 30:1602-1612. [PMID: 34420886 DOI: 10.1016/j.hlc.2021.07.018] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2021] [Revised: 07/20/2021] [Accepted: 07/20/2021] [Indexed: 01/22/2023]
Abstract
Transposition of the great arteries (TGA), coarctation of the aorta (CoA), single ventricle (SV) and tetralogy of Fallot (ToF) are forms of congenital heart disease (CHD). Despite advances in treatment, cardiovascular and cerebrovascular complications in patients with repaired CHD occur earlier in life compared to healthy subjects. A factor that may contribute to this increased risk is elevated arterial stiffness. This systematic review provides a critical assessment of current evidence on central arterial stiffness in patients with CHD compared to healthy controls. In July 2020, Medline OVID, EMBASE and Scopus were searched using keywords and MeSH terms. Articles were included if they reported indices of aortic or carotid artery stiffness in patients with TGA, CoA, SV or ToF, and compared these to controls. Additional studies were screened from the reference lists of included articles. Of 1,033 studies identified, 43 were included in the final review. Most studies identified at least one index of central arterial stiffness, commonly in the aortic root or ascending aorta, that was higher in patients with CHD compared to controls. The commonly reported surrogate markers of stiffness were pulse wave velocity, aortic distensibility and the β stiffness index. There was a relatively small number of original studies, and synthesis of data was limited by methodological heterogeneity, highlighting the need for further studies with standardised methods. However, there was consistent evidence of early and/or accelerated arterial stiffening in CHD patients, which may contribute to the increased risk of adverse cardiovascular and cerebrovascular events in this population.
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Stone ML, Schäfer M, DiMaria MV, von Alvensleben JC, Campbell DN, Jaggers J, Mitchell MB. Diastolic inflow is associated with inefficient ventricular flow dynamics in Fontan patients. J Thorac Cardiovasc Surg 2021; 163:1195-1207. [DOI: 10.1016/j.jtcvs.2021.06.064] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/06/2021] [Revised: 06/17/2021] [Accepted: 06/17/2021] [Indexed: 12/17/2022]
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Kobayashi Y, Kotani Y, Kawabata T, Kuroko Y, Sano S, Kasahara S. Does the size of pulmonary artery impact on recoarctation of the aorta after the Norwood procedure without patch? Interact Cardiovasc Thorac Surg 2021; 33:765-772. [PMID: 34164672 DOI: 10.1093/icvts/ivab170] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2020] [Revised: 05/01/2021] [Accepted: 05/12/2021] [Indexed: 11/12/2022] Open
Abstract
OBJECTIVES This study aimed to evaluate whether recoarctation of the aorta (reCoA) after the Norwood procedure for hypoplastic left heart syndrome correlates with pre- and postoperative anatomic factors. METHODS This retrospective study included 48 patients who underwent Norwood procedure with right ventricle-to-pulmonary artery conduit between 2009 and 2017. Anatomical factors such as preoperative length, diameter of the main pulmonary artery (MPA), and postoperative neoaortic arch angle stratified by arch reconstruction technique were analysed using the receiver operating characteristic analysis. RESULTS Eleven patients needed surgical intervention for reCoA at stage 2. Out of the 30 patients who underwent direct anastomosis during arch reconstruction, 7 developed reCoA. Seven patients received the full patch augmentation (patch augmentation for both lesser and greater curvatures) and were all spared from reCoA. Among the patients who had direct anastomosis, the preoperative MPA length was correlated with the postoperative arch angle (P = 0.021) and was associated with the occurrence of reCoA (P = 0.002) and the best cutoff value for MPA length was 10 mm. The postoperative arch angle was also correlated with the incidence of reCoA (P < 0.001) and was larger in patients who underwent the full patch augmentation than in patients who had direct anastomosis (126° vs 112°, P = 0.005) despite comparable MPA length. CONCLUSIONS ReCoA after the Norwood procedure correlates with MPA length when a direct anastomosis was used. Direct anastomosis can be considered in patients with a longer preoperative MPA. In other cases, the full patch augmentation should be considered for obtaining a large and smooth neoaortic arch.
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Affiliation(s)
- Yasuyuki Kobayashi
- Department of Cardiovascular Surgery, Okayama University Hospital, Okayama, Japan
| | - Yasuhiro Kotani
- Department of Cardiovascular Surgery, Okayama University Hospital, Okayama, Japan
| | - Takuya Kawabata
- Department of Cardiovascular Surgery, Okayama University Hospital, Okayama, Japan
| | - Yosuke Kuroko
- Department of Cardiovascular Surgery, Okayama University Hospital, Okayama, Japan
| | - Shunji Sano
- Department of Pediatric Cardiothoracic Surgery, University of California, San Francisco, CA, USA
| | - Shingo Kasahara
- Department of Cardiovascular Surgery, Okayama University Hospital, Okayama, Japan
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Primeaux J, Salavitabar A, Lu JC, Grifka RG, Figueroa CA. Characterization of Post-Operative Hemodynamics Following the Norwood Procedure Using Population Data and Multi-Scale Modeling. Front Physiol 2021; 12:603040. [PMID: 34054563 PMCID: PMC8155503 DOI: 10.3389/fphys.2021.603040] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2020] [Accepted: 04/19/2021] [Indexed: 11/22/2022] Open
Abstract
Children with hypoplastic left heart syndrome (HLHS) must undergo multiple surgical stages to reconstruct the anatomy to a sustainable single ventricle system. Stage I palliation, or the Norwood procedure, provides circulation to both pulmonary and systemic vasculature. The aorta is reconstructed and attached to the right ventricle and a fraction of systemic flow is redirected to the pulmonary arteries (PAs) through a systemic-to-PA shunt. Despite abundant hemodynamic data available 4-5 months after Norwood palliation, data is very scarce immediately following stage I. This data is critical in determining post-operative success. In this work, we combined population data and computational fluid dynamics (CFD) to characterize hemodynamics immediately following stage I (post-stage I) and prior to stage II palliation (pre-stage II). A patient-specific model was constructed as a baseline geometry, which was then scaled to reflect population-based morphological data at both time-points. Population-based hemodynamic data was then used to calibrate each model to reproduce blood flow representative of HLHS patients. The post-stage I simulation produced a PA pressure of 22 mmHg and high-frequency oscillations within the flow field indicating highly disturbed hemodynamics. Despite PA mean pressure dropping to 14 mmHg, the pre-stage II model also produced high-frequency flow components and PA wall shear stress increases. These suboptimal conditions may be necessary to ensure adequate PA flow throughout the pre-stage II period, as the shunt becomes relatively smaller compared to the patient's somatic growth. In the future, CFD can be used to optimize shunt design and minimize these suboptimal conditions.
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Affiliation(s)
- Jonathan Primeaux
- Department of Biomedical Engineering, University of Michigan, Ann Arbor, MI, United States
| | - Arash Salavitabar
- C.S. Mott Children’s Hospital, University of Michigan Congenital Heart Center, Ann Arbor, MI, United States
| | - Jimmy C. Lu
- C.S. Mott Children’s Hospital, University of Michigan Congenital Heart Center, Ann Arbor, MI, United States
| | | | - C. Alberto Figueroa
- Department of Biomedical Engineering, University of Michigan, Ann Arbor, MI, United States
- Department of Surgery, University of Michigan, Ann Arbor, MI, United States
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12
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Asada S, Yamagishi M, Maeda Y, Itatani K, Fujita S, Hongu H, Nakatsuji H, Yaku H. Chimney reconstruction provides a wider subaortic space and reduces the risk of pulmonary artery compression in the Norwood-type aortic arch reconstruction without patch supplementation. Eur J Cardiothorac Surg 2021; 60:1408-1416. [PMID: 33890109 DOI: 10.1093/ejcts/ezab184] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/01/2020] [Revised: 03/01/2021] [Accepted: 03/09/2021] [Indexed: 11/14/2022] Open
Abstract
OBJECTIVES Pulmonary artery (PA) compression by the neoaorta is a serious complication after the Norwood-type palliation (NP) for hypoplastic left heart syndrome. Either excess patch tailoring or limited use of autologous tissue may cause narrowing of the subaortic space. The chimney technique could theoretically provide a wide subaortic space. METHODS Twenty-nine patients with both pre- and post-NP computed tomography data available of the 37 consecutive patients who underwent NP in our institution were reviewed. Arch height, arch width, sinus of Valsalva diameter, area under the neoaortic arch and arch angle were measured. These patients were divided according to the neo-arch reconstruction technique, chimney reconstruction technique (CR) or conventional direct reconstruction technique (DR). RESULTS Median age and weight at NP were 2.1 months and 3.5 kg, respectively. Twenty-two patients underwent previous bilateral PA banding. During NP, 17 CR and 12 DR were performed. Four patients in the DR group developed PA compression. No neoaortic arch dilatation was found in either group. Post-NP arch width, area under the neo-arch and the arch angle were significantly larger in the CR group. Pre-NP arch height was significantly smaller in DR patients with PA compression than in those without. CONCLUSIONS The chimney technique decreased the risk of PA compression and provided a wider subaortic space and a less acute arch angle. This technique had no short-term effect on the neoaortic root. Small preoperative arch height is a potential risk factor for PA compression in DR, and the chimney technique could be an effective solution.
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Affiliation(s)
- Satoshi Asada
- Department of Pediatric Cardiovascular Surgery, Children's Medical Center, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - Masaaki Yamagishi
- Department of Pediatric Cardiovascular Surgery, Children's Medical Center, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - Yoshinobu Maeda
- Department of Pediatric Cardiovascular Surgery, Children's Medical Center, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - Keiichi Itatani
- Department of Pediatric Cardiovascular Surgery, Children's Medical Center, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - Shuhei Fujita
- Department of Pediatric Cardiovascular Surgery, Children's Medical Center, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - Hisayuki Hongu
- Department of Pediatric Cardiovascular Surgery, Children's Medical Center, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - Hiroki Nakatsuji
- Department of Pediatric Cardiovascular Surgery, Children's Medical Center, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - Hitoshi Yaku
- Division of Cardiovascular Surgery, Department of Surgery, Kyoto Prefectural University of Medicine, Kyoto, Japan
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High-degree Norwood neoaortic tapering is associated with abnormal flow conduction and elevated flow-mediated energy loss. J Thorac Cardiovasc Surg 2021; 162:1791-1804. [PMID: 33653609 DOI: 10.1016/j.jtcvs.2021.01.111] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/12/2020] [Revised: 01/14/2021] [Accepted: 01/25/2021] [Indexed: 11/20/2022]
Abstract
OBJECTIVE The Norwood neoaortic arch biomechanical properties are abnormal due to reduced vessel wall compliance and abnormal geometry. Others have previously described neoaortic geometric distortion by the degree of diameter reduction (tapering) and associated this with mismatched ventricular-neoaortic coupling, abnormal flow hemodynamic parameters, and worse patient outcome. Our purposes were to investigate the influence of neoaortic tapering (ie, diameter reduction) on flow-mediated viscous energy loss (EL') in post-Norwood palliated hypoplastic left heart syndrome patients, and correlate flow-geometry with single ventricle power generation. METHODS Twenty-six palliated hypoplastic left heart syndrome patients underwent comprehensive cardiac evaluation with 4-dimensional-flow magnetic resonance imaging. Patients were grouped into high- (group H, n = 13) and low- (group L, n = 13) degree neoaortic tapering using the median cutoff value of neoaortic diameter variance. EL' was calculated along standardized segments using 4-dimensional-flow magnetic resonance imaging. Flow-mediated power loss as a percentage of total power generated by the single ventricle was determined. RESULTS Group H had a higher prevalence of abnormal recirculating flow in the neoaorta and elevated neoaortic EL' in the ascending aorta (1.0 vs 0.6 mW; P = .004). Group H EL' was increased across the entire thoracic aorta (2.6 vs 1.3 mW; P = .002) and accounted for 0.7% of generated ventricular power versus 0.3% in group L (P = .024). EL' directly correlated with the degree of ascending aortic dilation (R = 0.49; P = .012). CONCLUSIONS Patients with high degree neoaortic tapering have more perturbed flow through the neoaorta and increased EL'. Flow-mediated energy loss due to abnormal flow represents irreversibly wasted power generated by the single right ventricle. In patients with high-degree neoaortic tapering, EL' was more than 2-fold greater than low-degree tapering patients. These data suggest that oversizing the Norwood neoaortic reconstruction should be avoided and that patients with distorted neoaortic geometry may warrant increased surveillance for single-ventricle deterioration.
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Alphonso N, Angelini A, Barron DJ, Bellsham-Revell H, Blom NA, Brown K, Davis D, Duncan D, Fedrigo M, Galletti L, Hehir D, Herberg U, Jacobs JP, Januszewska K, Karl TR, Malec E, Maruszewski B, Montgomerie J, Pizzaro C, Schranz D, Shillingford AJ, Simpson JM. Guidelines for the management of neonates and infants with hypoplastic left heart syndrome: The European Association for Cardio-Thoracic Surgery (EACTS) and the Association for European Paediatric and Congenital Cardiology (AEPC) Hypoplastic Left Heart Syndrome Guidelines Task Force. Eur J Cardiothorac Surg 2020; 58:416-499. [DOI: 10.1093/ejcts/ezaa188] [Citation(s) in RCA: 24] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Affiliation(s)
- Nelson Alphonso
- Queensland Pediatric Cardiac Service, Queensland Children’s Hospital, University of Queensland, Brisbane, QLD, Australia
| | - Annalisa Angelini
- Department of Cardiac, Thoracic Vascular Sciences and Public health, University of Padua Medical School, Padua, Italy
| | - David J Barron
- Department of Cardiovascular Surgery, Hospital for Sick Children, University of Toronto, Toronto, ON, Canada
| | | | - Nico A Blom
- Division of Pediatric Cardiology, Department of Pediatrics, Leiden University Medical Center, Leiden, Netherlands
| | - Katherine Brown
- Paediatric Intensive Care, Heart and Lung Division, Great Ormond Street Hospital NHS Foundation Trust, London, UK
| | - Deborah Davis
- Department of Anesthesiology, Thomas Jefferson University, Philadelphia, PA, USA
- Nemours Cardiac Center, A.I. Du Pont Hospital for Children, Wilmington, DE, USA
| | - Daniel Duncan
- Nemours Cardiac Center, A.I. Du Pont Hospital for Children, Wilmington, DE, USA
| | - Marny Fedrigo
- Department of Cardiac, Thoracic Vascular Sciences and Public Health, University of Padua Medical School, Padua, Italy
| | - Lorenzo Galletti
- Unit of Pediatric Cardiac Surgery, Bambino Gesù Children's Hospital, Rome, Italy
| | - David Hehir
- Division of Cardiology, Children’s Hospital of Philadelphia, Philadelphia, PA, USA
| | - Ulrike Herberg
- Department of Pediatric Cardiology, University Hospital Bonn, Bonn, Germany
| | | | - Katarzyna Januszewska
- Division of Pediatric Cardiac Surgery, University Hospital Muenster, Westphalian-Wilhelm’s-University, Muenster, Germany
| | | | - Edward Malec
- Division of Pediatric Cardiac Surgery, University Hospital Muenster, Westphalian-Wilhelm’s-University, Muenster, Germany
| | - Bohdan Maruszewski
- Department for Pediatric Cardiothoracic Surgery, Children's Memorial Health Institute, Warsaw, Poland
| | - James Montgomerie
- Department of Anesthesia, Birmingham Children’s Hospital, Birmingham, UK
| | - Christian Pizzaro
- Nemours Cardiac Center, A.I. Du Pont Hospital for Children, Wilmington, DE, USA
- Department of Surgery, Thomas Jefferson University, Philadelphia, PA, USA
| | - Dietmar Schranz
- Pediatric Heart Center, Justus-Liebig University, Giessen, Germany
| | - Amanda J Shillingford
- Division of Cardiology, Children's Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
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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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Sano S, Kouretas PC, Kobayashi Y, Kotani Y, Kasahara S. How to Reconstruct Neo-Aortic Arch Without Patch at Norwood-Sano Procedure. ACTA ACUST UNITED AC 2020. [DOI: 10.1053/j.optechstcvs.2020.07.004] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
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Biko DM, Gaynor JW, Partington SL, Harris MA, Whitehead KK, Trusty P, Yoganathan AP, Fogel MA. Relationship of Aortic Stiffness to Exercise and Ventricular Volumes in Single Ventricles. Ann Thorac Surg 2019; 108:574-580. [PMID: 30959013 DOI: 10.1016/j.athoracsur.2019.03.019] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/29/2018] [Revised: 02/24/2019] [Accepted: 03/04/2019] [Indexed: 11/26/2022]
Abstract
BACKGROUND Patients with single ventricle (SV) may often undergo aortic reconstruction that creates a stiff large vessel, increasing afterload and affecting exercise performance. The objective of this study was to determine the relationship of pulse wave velocity (PWV) and distensibility in reconstructed and normal aortic arches after Fontan with exercise variables. METHODS PWV and distensibility of the descending aorta at the level of the diaphragm (DAo) were calculated with real-time exercise cardiac magnetic resonance in 48 patients with SV after Fontan (18 after aortic reconstruction; 30 without aortic reconstruction) and compared with metabolic exercise stress test variables. RESULTS PWV was greater in the reconstructed group than in the non-reconstructed group (median 4.4 m/s [range: 2.3 to 9.8 m/s] versus 3.6 [range: 2.6 to 6.3 m/s], respectively, p = 0.003). Statistically significant inverse correlations were found between PWV and end-diastolic, end-systolic, and stroke volumes at rest and at exercise in the reconstructed group. In addition, inverse correlations also existed in the reconstructed group between distensibility of the DAo and the exercise variables such as peak oxygen pulse (R = 0.56, p = 0.02), peak oxygen consumption (R = 0.63, p = 0.008), oxygen consumption at ventilatory anaerobic threshold (R = 0.48, p = 0.04), and peak work (R = 0.54, p = 0.02). Similar correlations were not seen in patients with non-reconstructed aortas. CONCLUSIONS Patients with SV with reconstructed aortas have increased aortic stiffness, increasing afterload on the ventricle. Native DAo stiffness distal to the reconstruction is inversely correlated with exercise performance, presumably to decrease impedance mismatch to maintain homogeneity of the aortic wall. This information suggests a possible mechanism for decreased exercise performance in patients with SV with aortic reconstructions.
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Affiliation(s)
- David M Biko
- Department of Radiology, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania; Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania.
| | - J William Gaynor
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania; Division of Cardiothoracic Surgery, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Sara L Partington
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania; Division of Cardiology, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Matthew A Harris
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania; Division of Cardiology, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Kevin K Whitehead
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania; Division of Cardiology, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Phillip Trusty
- Cardiovascular Fluid Mechanics Laboratory, Wallace H. Coulter Department of Biomedical Engineering, Georgia Institute of Technology, Atlanta, Georgia
| | - Ajit P Yoganathan
- Cardiovascular Fluid Mechanics Laboratory, Wallace H. Coulter Department of Biomedical Engineering, Georgia Institute of Technology, Atlanta, Georgia
| | - Mark A Fogel
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania; Division of Cardiology, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
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Abstract
A bicuspid aortic valve and/or coarctation of the aorta (COA) are often associated with dilatation of the ascending aorta and para-coarctation. Congenital heart diseases (CHD), such as truncus arteriosus, transposition of the great arteries (TGA), tetralogy of Fallot (TOF), hypoplastic left heart syndrome (HLHS), single ventricle with pulmonary stenosis/atresia and the Fontan procedure, are also associated with aortic root dilatation, aneurysm and rarely, dissection, which can be fatal and require aortic valve and root surgery. A significant subset of adults with complex CHD exhibit progressive dilatation of the aortic root even after repair due to aortic medial degeneration. Medial degeneration in the ascending aorta is prevalent among the above CHD. In Marfan syndrome, bicuspid aortic valve and COA, medial degeneration is more extensive and severe than in another complex CHD. Accordingly, the incidence of ascending aortic dilatation, dissection and rupture is higher in the former. This aortic medial degeneration in CHD may either be intrinsic or secondary to the increased volume overload of the aortic root due to right-to-left shunting, or a combination of both. The association of aortic pathophysiological abnormalities, aortic dilatation and aorto-ventricular interaction is clinically referred to as "aortopathy". The major purpose of medical treatment for aortopathy is to reduce the structural changes within the aortic wall and slow down the progression of aortic dilatation to reduce the risk of cardiovascular events. Several medications have been studied, including β-blockers, angiotensin II type I (AT1) receptor blockers (ARBs) and Ca-antagonists. However, the results, except for Marfan syndrome, are limited. In aortopathy, concomitant aortic valve and aortic root repair/replacement is required. The Bentall operation comprises root replacement with an aortic tube graft and mechanical valve, and has been widely applied. On the other hand, valve-sparing operations have been developed in order to preserve the aortic valve.
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Affiliation(s)
- Koichiro Niwa
- Department of Cardiology, Cardiovascular Center, St Luke's International Hospital, Tokyo, Japan
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Logoteta J, Ruppel C, Hansen J, Fischer G, Becker K, Kramer HH, Uebing A. Ventricular function and ventriculo-arterial coupling after palliation of hypoplastic left heart syndrome: A comparative study with Fontan patients with LV morphology. Int J Cardiol 2017; 227:691-697. [DOI: 10.1016/j.ijcard.2016.10.076] [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: 09/20/2016] [Accepted: 10/28/2016] [Indexed: 11/25/2022]
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Kim YY, Rathod RH, Gauvreau K, Keenan EM, del Nido P, Geva T. Factors associated with severe aortic dilation in patients with Fontan palliation. Heart 2016; 103:280-286. [DOI: 10.1136/heartjnl-2016-309615] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/08/2016] [Revised: 07/20/2016] [Accepted: 07/21/2016] [Indexed: 11/04/2022] Open
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The technique matters, it's just not clear how. J Thorac Cardiovasc Surg 2016; 152:480-1. [DOI: 10.1016/j.jtcvs.2016.03.066] [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: 03/28/2016] [Accepted: 03/30/2016] [Indexed: 11/22/2022]
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23
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Plummer ST, Hornik CP, Baker H, Fleming GA, Foerster S, Ferguson ME, Glatz AC, Hirsch R, Jacobs JP, Lee KJ, Lewis AB, Li JS, Martin M, Porras D, Radtke WAK, Rhodes JF, Vincent JA, Zampi JD, Hill KD. Maladaptive aortic properties after the Norwood procedure: An angiographic analysis of the Pediatric Heart Network Single Ventricle Reconstruction Trial. J Thorac Cardiovasc Surg 2016; 152:471-479.e3. [PMID: 27167022 DOI: 10.1016/j.jtcvs.2016.03.091] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/03/2015] [Revised: 03/07/2016] [Accepted: 03/13/2016] [Indexed: 11/28/2022]
Abstract
OBJECTIVES Aortic arch reconstruction in children with single ventricle lesions may predispose to circulatory inefficiency and maladaptive physiology leading to increased myocardial workload. We sought to describe neoaortic anatomy and physiology, risk factors for abnormalities, and impact on right ventricular function in patients with single right ventricle lesions after arch reconstruction. METHODS Prestage II aortic angiograms from the Pediatric Heart Network Single Ventricle Reconstruction trial were analyzed to define arch geometry (Romanesque [normal], crenel [elongated], or gothic [angular]), indexed neoaortic dimensions, and distensibility. Comparisons were made with 50 single-ventricle controls without prior arch reconstruction. Factors associated with ascending neoaortic dilation, reduced distensibility, and decreased ventricular function on the 14-month echocardiogram were evaluated using univariate and multivariable logistic regression. RESULTS Interpretable angiograms were available for 326 of 389 subjects (84%). Compared with controls, study subjects more often demonstrated abnormal arch geometry (67% vs 22%, P < .01) and had increased ascending neoaortic dilation (Z score 3.8 ± 2.2 vs 2.6 ± 2.0, P < .01) and reduced distensibility index (2.2 ± 1.9 vs 8.0 ± 3.8, P < .01). Adjusted odds of neoaortic dilation were increased in subjects with gothic arch geometry (odds ratio [OR], 3.2 vs crenel geometry, P < .01) and a right ventricle-pulmonary artery shunt (OR, 3.4 vs Blalock-Taussig shunt, P < .01) but were decreased in subjects with aortic atresia (OR, 0.7 vs stenosis, P < .01) and those with recoarctation (OR, 0.3 vs no recoarctation, P = .04). No demographic, anatomic, or surgical factors predicted reduced distensibility. Neither dilation nor distensibility predicted reduced right ventricular function. CONCLUSIONS After Norwood surgery, the reconstructed neoaorta demonstrates abnormal anatomy and physiology. Further study is needed to evaluate the longer-term impact of these features.
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Affiliation(s)
| | | | | | | | | | - M Eric Ferguson
- Children's Healthcare of Atlanta, Emory University School of Medicine, Atlanta, Ga
| | | | - Russel Hirsch
- Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Jeffrey P Jacobs
- Johns Hopkins Children's Heart Surgery, All Children's Hospital and Florida Hospital for Children, St Petersburg, Tampa, and Orlando, Fla
| | - Kyong-Jin Lee
- Hospital for Sick Children, Toronto, Ontario, Canada
| | - Alan B Lewis
- Children's Hospital Los Angeles, Los Angeles, Calif
| | | | - Mary Martin
- University of Utah School of Medicine, Salt Lake City, Utah
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Voges I, Jerosch-Herold M, Wegner P, Hart C, Gabbert D, Al Bulushi A, Fischer G, Andrade AC, Pham HM, Kristo I, Kramer HH, Rickers C. Frequent Dilatation of the Descending Aorta in Children With Hypoplastic Left Heart Syndrome Relates to Decreased Aortic Arch Elasticity. J Am Heart Assoc 2015; 4:e002107. [PMID: 26438562 PMCID: PMC4845122 DOI: 10.1161/jaha.115.002107] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Background Patients with hypoplastic left heart syndrome after a Norwood operation show dilatation and reduced distensibility of the reconstructed proximal aorta. Cardiac magnetic resonance imaging (CMR) and angiographic examinations indicate that the native descending aorta (DAo) is also dilated, but this has not been studied in detail. Methods and Results Seventy‐nine children with hypoplastic left heart syndrome in Fontan circulation (aged 6.3±3.2 years) and 18 control participants (aged 6.8±2.4 years) underwent 3.0‐tesla CMR. Gradient‐echo cine and phase‐contrast imaging was applied to measure cross‐sectional areas (CSAs), distensibility, pulse wave velocity, and the incremental elastic modulus of the thoracic aorta. CSA of the DAo in patients was also compared with published percentiles for aortic CSA. Patients had significantly larger CSA of the DAo at the level of pulmonary artery bifurcation (229.1±97.2 versus 175.7±24.3 mm/m2, P=0.04) and the diaphragm (196.2±66.0 versus 142.6±16.7 mm/m2, P<0.01). In 41 patients (52%), CSA of the DAo was >95th percentile level for control participants, and the incremental elastic modulus of the aortic arch and the DAo was higher than in patients with normal CSAs (arch: 90.1±64.3 versus 45.6±38.9 m/s; DAo: 86.3±53.7 versus 47.1±47.6 m/s; P<0.01). Incremental elastic modulus of the aortic arch and the DAo correlated with the CSA of the DAo (arch: r=0.5; DAo: r=0.49; P<0.01). Conclusions Children with hypoplastic left heart syndrome frequently show dilatation of their DAo associated with increased stiffness of the aortic arch. Higher aortic impedance increases the afterload of the systemic circulation and likely contributes to the burden of the systemic right ventricle.
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Affiliation(s)
- Inga Voges
- Department of Congenital Heart Disease and Pediatric Cardiology, University Hospital of Schleswig-Holstein, Kiel, Germany (I.V., P.W., C.H., D.G., A.A.B., G.F., A.C.A., H.M.P., I.K., H.H.K., C.R.)
| | - Michael Jerosch-Herold
- Department of Radiology, Brigham & Women's Hospital & Harvard Medical School, Boston, MA (M.J.H.)
| | - Philip Wegner
- Department of Congenital Heart Disease and Pediatric Cardiology, University Hospital of Schleswig-Holstein, Kiel, Germany (I.V., P.W., C.H., D.G., A.A.B., G.F., A.C.A., H.M.P., I.K., H.H.K., C.R.)
| | - Christopher Hart
- Department of Congenital Heart Disease and Pediatric Cardiology, University Hospital of Schleswig-Holstein, Kiel, Germany (I.V., P.W., C.H., D.G., A.A.B., G.F., A.C.A., H.M.P., I.K., H.H.K., C.R.)
| | - Dominik Gabbert
- Department of Congenital Heart Disease and Pediatric Cardiology, University Hospital of Schleswig-Holstein, Kiel, Germany (I.V., P.W., C.H., D.G., A.A.B., G.F., A.C.A., H.M.P., I.K., H.H.K., C.R.)
| | - Abdullah Al Bulushi
- Department of Congenital Heart Disease and Pediatric Cardiology, University Hospital of Schleswig-Holstein, Kiel, Germany (I.V., P.W., C.H., D.G., A.A.B., G.F., A.C.A., H.M.P., I.K., H.H.K., C.R.)
| | - Gunther Fischer
- Department of Congenital Heart Disease and Pediatric Cardiology, University Hospital of Schleswig-Holstein, Kiel, Germany (I.V., P.W., C.H., D.G., A.A.B., G.F., A.C.A., H.M.P., I.K., H.H.K., C.R.)
| | - Ana Cristina Andrade
- Department of Congenital Heart Disease and Pediatric Cardiology, University Hospital of Schleswig-Holstein, Kiel, Germany (I.V., P.W., C.H., D.G., A.A.B., G.F., A.C.A., H.M.P., I.K., H.H.K., C.R.)
| | - Hoang Minh Pham
- Department of Congenital Heart Disease and Pediatric Cardiology, University Hospital of Schleswig-Holstein, Kiel, Germany (I.V., P.W., C.H., D.G., A.A.B., G.F., A.C.A., H.M.P., I.K., H.H.K., C.R.)
| | - Ines Kristo
- Department of Congenital Heart Disease and Pediatric Cardiology, University Hospital of Schleswig-Holstein, Kiel, Germany (I.V., P.W., C.H., D.G., A.A.B., G.F., A.C.A., H.M.P., I.K., H.H.K., C.R.)
| | - Hans-Heiner Kramer
- Department of Congenital Heart Disease and Pediatric Cardiology, University Hospital of Schleswig-Holstein, Kiel, Germany (I.V., P.W., C.H., D.G., A.A.B., G.F., A.C.A., H.M.P., I.K., H.H.K., C.R.)
| | - Carsten Rickers
- Department of Congenital Heart Disease and Pediatric Cardiology, University Hospital of Schleswig-Holstein, Kiel, Germany (I.V., P.W., C.H., D.G., A.A.B., G.F., A.C.A., H.M.P., I.K., H.H.K., C.R.)
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Elevated Aortic Augmentation Index in Children Following Fontan Palliation: Evidence of Stiffer Arteries? Pediatr Cardiol 2015; 36:1232-8. [PMID: 25832849 DOI: 10.1007/s00246-015-1151-3] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/08/2014] [Accepted: 03/24/2015] [Indexed: 10/23/2022]
Abstract
Children born with a functional single ventricle who undergo Fontan palliation are prone to early pump failure. Whether they develop early arterial stiffness with resultant increase in afterload is not well known. We hypothesized that the aortic stiffness is higher in pediatric Fontan patients when compared to healthy controls. A prospective study was conducted at the Children's Hospital of Michigan. Twenty-two Fontan patients (aged 6-21 years) were compared with 22 healthy controls (aged 9-17 years) selected from children referred to our clinic who had normal cardiac anatomy and function on the echocardiogram. Aortic stiffness was assessed noninvasively by measuring the aortic augmentation index (AAI) using applanation tonometry (Sphygmocor, Atcor, IL). AAI was calculated as AP/PP where augmentation pressure (AP) is the increase in aortic systolic blood pressure (BP) and pulse pressure (PP) is the difference between aortic systolic and diastolic BP. Ten patients (45 %) had hypoplastic left ventricle, and 11 (50 %) had undergone aortic arch surgery. The median AAI was significantly higher in Fontan patients when compared to controls (12.5, IQR 4.8, 17.3 vs 0, IQR -6.3, 5.8; p = 0.0003). History of aortic arch surgery and single ventricle morphology did not have a significant impact on AAI. Pediatric patients who undergo Fontan palliation have significantly higher AAI, a marker of aortic stiffness and increased afterload, compared to healthy controls. Larger longitudinal studies are warranted to elucidate the possible contribution of elevated AAI on pump failure in these patients.
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Ventriculoarterial coupling in palliated hypoplastic left heart syndrome: Noninvasive assessment of the effects of surgical arch reconstruction and shunt type. J Thorac Cardiovasc Surg 2014; 148:1526-33. [DOI: 10.1016/j.jtcvs.2014.02.012] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/12/2013] [Revised: 01/21/2014] [Accepted: 02/03/2014] [Indexed: 11/23/2022]
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Biglino G, Giardini A, Hsia TY, Figliola R, Taylor AM, Schievano S. Modeling single ventricle physiology: review of engineering tools to study first stage palliation of hypoplastic left heart syndrome. Front Pediatr 2013; 1:31. [PMID: 24400277 PMCID: PMC3864195 DOI: 10.3389/fped.2013.00031] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/29/2013] [Accepted: 10/11/2013] [Indexed: 12/27/2022] Open
Abstract
First stage palliation of hypoplastic left heart syndrome, i.e., the Norwood operation, results in a complex physiological arrangement, involving different shunting options (modified Blalock-Taussig, RV-PA conduit, central shunt from the ascending aorta) and enlargement of the hypoplastic ascending aorta. Engineering techniques, both computational and experimental, can aid in the understanding of the Norwood physiology and their correct implementation can potentially lead to refinement of the decision-making process, by means of patient-specific simulations. This paper presents some of the available tools that can corroborate clinical evidence by providing detailed insight into the fluid dynamics of the Norwood circulation as well as alternative surgical scenarios (i.e., virtual surgery). Patient-specific anatomies can be manufactured by means of rapid prototyping and such models can be inserted in experimental set-ups (mock circulatory loops) that can provide a valuable source of validation data as well as hydrodynamic information. Such models can be tuned to respond to differing the patient physiologies. Experimental set-ups can also be compatible with visualization techniques, like particle image velocimetry and cardiovascular magnetic resonance, further adding to the knowledge of the local fluid dynamics. Multi-scale computational models include detailed three-dimensional (3D) anatomical information coupled to a lumped parameter network representing the remainder of the circulation. These models output both overall hemodynamic parameters while also enabling to investigate the local fluid dynamics of the aortic arch or the shunt. As an alternative, pure lumped parameter models can also be employed to model Stage 1 palliation, taking advantage of a much lower computational cost, albeit missing the 3D anatomical component. Finally, analytical techniques, such as wave intensity analysis, can be employed to study the Norwood physiology, providing a mechanistic perspective on the ventriculo-arterial coupling for this specific surgical scenario.
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Affiliation(s)
- Giovanni Biglino
- Centre for Cardiovascular Imaging, UCL Institute of Cardiovascular Science , London , UK ; Cardiorespiratory Unit, Great Ormond Street Hospital for Children, NHS Foundation Trust , London , UK
| | - Alessandro Giardini
- Cardiorespiratory Unit, Great Ormond Street Hospital for Children, NHS Foundation Trust , London , UK
| | - Tain-Yen Hsia
- Cardiorespiratory Unit, Great Ormond Street Hospital for Children, NHS Foundation Trust , London , UK
| | - Richard Figliola
- Departments of Bioengineering and Mechanical Engineering, Clemson University , Clemson, SC , USA
| | - Andrew M Taylor
- Centre for Cardiovascular Imaging, UCL Institute of Cardiovascular Science , London , UK ; Cardiorespiratory Unit, Great Ormond Street Hospital for Children, NHS Foundation Trust , London , UK
| | - Silvia Schievano
- Centre for Cardiovascular Imaging, UCL Institute of Cardiovascular Science , London , UK ; Cardiorespiratory Unit, Great Ormond Street Hospital for Children, NHS Foundation Trust , London , UK
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Schlangen J, Fischer G, Petko C, Hansen JH, Voges I, Rickers C, Kramer HH, Uebing A. Arterial elastance and its impact on intrinsic right ventricular function in palliated hypoplastic left heart syndrome. Int J Cardiol 2013; 168:5385-9. [DOI: 10.1016/j.ijcard.2013.08.052] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/13/2013] [Revised: 07/24/2013] [Accepted: 08/18/2013] [Indexed: 10/26/2022]
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Biglino G, Schievano S, Steeden JA, Ntsinjana H, Baker C, Khambadkone S, de Leval MR, Hsia TY, Taylor AM, Giardini A. Reduced ascending aorta distensibility relates to adverse ventricular mechanics in patients with hypoplastic left heart syndrome: noninvasive study using wave intensity analysis. J Thorac Cardiovasc Surg 2012; 144:1307-13; discussion 1313-4. [PMID: 23031685 DOI: 10.1016/j.jtcvs.2012.08.028] [Citation(s) in RCA: 42] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/11/2012] [Revised: 08/01/2012] [Accepted: 08/07/2012] [Indexed: 11/16/2022]
Abstract
OBJECTIVE To evaluate the aortic arch elastic properties and ventriculoarterial coupling efficiency in patients with single ventricle physiology, with and without a surgically reconstructed arch. METHODS We studied 21 children with single ventricle physiology after bidirectional superior cavopulmonary surgery: 10 with hypoplastic left heart syndrome, who underwent surgical arch reconstruction, and 11 with other types of single ventricle physiology but without arch reconstruction. All children underwent pre-Fontan magnetic resonance imaging. No patient exhibited aortic recoarctation. Data on aortic wave speed, aortic distensibility and wave intensity profiles were all extracted from the magnetic resonance imaging studies using an in-house-written plug-in for the Digital Imaging and Communications in Medicine viewer OsiriX. RESULTS Children with hypoplastic left heart syndrome had significantly greater wave speed (P = .002), and both stiffer (P = .004) and larger (P < .0001) ascending aortas than the patients with a nonreconstructed arch. Aortic distensibility was not influenced by ventricular stroke volume but depended on a combination of increased aortic diameter and abnormal wall mechanical properties. Those with hypoplastic left heart syndrome had a lower peak wave intensity and reduced energy carried by the forward compression and the forward expansion waves, even after correction for stroke volume, suggesting an abnormal systolic and diastolic function. Lower wave energy was associated with an increased aortic diameter. CONCLUSIONS Using a novel, noninvasive technique based on image analysis, we have demonstrated that aortic arch reconstruction in children with hypoplastic left heart syndrome is associated with reduced aortic distensibility and unfavorable ventricular-vascular coupling compared with those with single ventricle physiology without aortic arch reconstruction.
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Affiliation(s)
- Giovanni Biglino
- Centre for Cardiovascular Imaging, UCL Institute of Cardiovascular Science, London, United Kingdom
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Influence of surgical arch reconstruction methods on single ventricle workload in the Norwood procedure. J Thorac Cardiovasc Surg 2012; 144:130-8. [PMID: 21907359 DOI: 10.1016/j.jtcvs.2011.08.013] [Citation(s) in RCA: 67] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/24/2011] [Accepted: 08/04/2011] [Indexed: 11/23/2022]
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Abstract
Interventional cardiology plays a key role in the diagnosis and management of patients with functionally univentricular physiology after the various stages of surgical palliation. The interventions performed are widely variable in type, including angioplasty of stenotic vessels and implantation of stents in stenotic vessels; closure of defects such as collaterals, leaks in baffles, and fenestrations; creation of fenestration; and more. In the setting of venous hypertension associated with stenosis at the Fontan baffle, conduit, or pulmonary arteries, stent implantation is often preferred, as the aim is to eliminate completely the narrowing, given that relatively mild stenosis can have a significant detrimental hemodynamic effect in patients with functionally univentricular circulation. The procedure is highly successful. In patients who fail after Fontan procedure, creation of a fenestration is often performed, with variable technique depending on the underlying anatomic substrate. To increase chances of patency of the fenestration, implantation of a stent is often required, particularly in the setting of an extracardiac conduit. For those patients with cyanosis and favorable Fontan hemodynamics, closure of the fenestration is performed using atrial septal occluder devices with high success rate. Coils compatible with magnetic resonance imaging are used widely to treat collateral vessels, although on occasion other specific embolization tools are required, such as particles or vascular plugs. Postoperative arch obstruction is successfully managed with angioplasty at a younger age, while implantation of a stent in the aorta is reserved for older patients. Specifics of these interventional procedures as applied to the population of patients with functionally univentricular hearts are described in this manuscript.
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Porras D, Brown DW, Marshall AC, Del Nido P, Bacha EA, McElhinney DB. Factors associated with subsequent arch reintervention after initial balloon aortoplasty in patients with Norwood procedure and arch obstruction. J Am Coll Cardiol 2011; 58:868-76. [PMID: 21835324 DOI: 10.1016/j.jacc.2010.12.050] [Citation(s) in RCA: 38] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/02/2010] [Revised: 11/15/2010] [Accepted: 12/23/2010] [Indexed: 10/17/2022]
Abstract
OBJECTIVES The aim of this study was to determine whether there are identifiable factors associated with increased risk for aortic arch reintervention in patients who have undergone balloon aortoplasty (BD) for aortic arch obstruction (COA) after the Norwood procedure (NP). BACKGROUND BD has been shown to be an effective acute therapy for COA after the NP. However, recurrent obstruction requiring repeat intervention is not uncommon. METHODS All patients who underwent BD as the initial intervention for COA after the NP from to January 1993 to May 2009 were retrospectively analyzed (n = 116). RESULTS The median age at initial BD was 4.5 months. The median follow-up period was 3.4 years. Procedures were considered acutely successful in 92% of patients, with a median gradient reduction overall from 24 to 3 mm Hg (p < 0.0001) and a COA diameter increase of 52% (p < 0.0001). By Kaplan-Meier analysis, freedom from reintervention was 69% at 1 year and 58% at 5 years, and freedom from reoperation was 82% at 1 year and 79% at 5 years. By Cox regression analysis, proximal arch obstruction, age <3 months at BD, moderate or greater ventricular dysfunction, moderate or greater atrioventricular valve regurgitation on pre-catheterization echocardiography, and higher post-BD coarctation gradient were associated with shorter freedom from reoperation. CONCLUSIONS Despite a high acute success rate, a significant proportion of patients treated with BD for post-NP COA underwent reintervention during follow-up. The risk for arch reintervention is highest in patients with proximal arch obstruction, those age <3 months at the time of BD, and those with less successful acute results.
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Affiliation(s)
- Diego Porras
- Department of Cardiology, Children's Hospital Boston, Harvard Medical School, Boston, Massachusetts, USA
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Giardini A, Biglino G, Hsia TY. Letter by Giardini et al regarding article, "Maladaptive aortic properties in children after palliation of hypoplastic left heart syndrome assessed by cardiovascular magnetic resonance imaging". Circulation 2011; 123:e594; author reply e595. [PMID: 21576677 DOI: 10.1161/circulationaha.110.002949] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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Kutty S, Burke RP, Hannan RL, Zahn EM. Hybrid aortic reconstruction for treatment of recurrent aortic obstruction after stage 1 single ventricle palliation: Medium term outcomes and results of redilation. Catheter Cardiovasc Interv 2011; 78:93-100. [DOI: 10.1002/ccd.22964] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/14/2010] [Accepted: 12/29/2010] [Indexed: 11/08/2022]
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McKenzie ED, Klysik M, Morales DLS, Heinle JS, Fraser CD, Kovalchin J. Ascending sliding arch aortoplasty: a novel technique for repair of arch hypoplasia. Ann Thorac Surg 2011; 91:805-10. [PMID: 21353003 DOI: 10.1016/j.athoracsur.2010.10.038] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/24/2010] [Revised: 10/14/2010] [Accepted: 10/18/2010] [Indexed: 10/18/2022]
Abstract
BACKGROUND Coarctation of the aorta (CoA) is often associated with clinically significant hypoplasia of the aortic arch. Historically, patch aortoplasty or bypass procedures have been the preferred techniques when arch augmentation is required in children beyond infancy. While safe and effective, these approaches require prosthetic or biologic material without the potential for growth, or normal endothelial and physiologic elastic function. This retrospective study reviews the use of a novel technique, ascending sliding arch aortoplasty, that utilizes viable autologous tissue for repair of arch obstruction in children beyond infancy. METHODS Between April 2002 and January 2007, 8 patients ranging in age from 18 months to 15 years underwent repair of CoA with arch hypoplasia using ascending sliding arch aortoplasty. All patients were approached through median sternotomy, utilizing cardiopulmonary bypass and selective antegrade cerebral perfusion. RESULTS There was no mortality or major morbidity. One toddler had pneumonia, resulting in an increased length of stay. Median duration of hospitalization was 5.8 days, ranging from 3 to 10 days. No patient had evidence of residual obstruction or recurrent CoA at a mean follow-up interval of 36 months. CONCLUSIONS Ascending sliding arch aortoplasty for CoA with arch obstruction in children beyond infancy is a safe technique that can be accomplished without deep hypothermic circulatory arrest. There is no evidence of recurrence at midterm follow-up. Because the augmentation is accomplished with viable autologous aortic tissue, the potential for growth, preserved elasticity and endothelial function, and resistance to infection make this method attractive for use in the young.
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Affiliation(s)
- E Dean McKenzie
- Division of Congenital Heart Surgery, Department of Surgery, Baylor College of Medicine, Texas Children's Hospital, Houston, Texas 77030, USA.
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Voges I, Jerosch-Herold M, Hedderich J, Westphal C, Hart C, Helle M, Scheewe J, Pardun E, Kramer HH, Rickers C. Maladaptive aortic properties in children after palliation of hypoplastic left heart syndrome assessed by cardiovascular magnetic resonance imaging. Circulation 2010; 122:1068-76. [PMID: 20805434 DOI: 10.1161/circulationaha.109.889733] [Citation(s) in RCA: 56] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
BACKGROUND The status of the reconstructed aorta in hypoplastic left heart syndrome is considered an important determinant of long-term prognosis. Therefore, we assessed the anatomy, elastic properties, and viability of the aorta and right ventricular function in patients with hypoplastic left heart syndrome by cardiovascular magnetic resonance imaging. METHODS AND RESULTS Cardiovascular magnetic resonance imaging was performed in 40 patients with hypoplastic left heart syndrome (age, 6.0±2.2 years) and 13 control subjects (age, 6.6±2.2 years). Aortic dimensions and distensibility were calculated at different locations of the aorta using gradient-echo cine imaging at 3.0 T. Additionally, pulse-wave velocity, right ventricular ejection fraction, and aortic late gadolinium enhancement for viability assessment were measured. Compared with control subjects, patients with hypoplastic left heart syndrome had increased axial diameters of the aortic root (36.0±5.5 versus 24.1±2.7 mm/m(2); P<0.01), ascending aorta (32.0±5.0 versus 21.3±1.5 mm/m(2); P<0.01), and transverse aortic arch (22.7±5.2 versus 18.7±2.5 mm/m(2); P<0.01). Wall distensibility was reduced in the ascending aorta (4.1±2.4 versus 13.5±7.2 10(-3) mm Hg(-1); P<0.01) and transverse aortic arch (5.4±3.6 versus 10.3±3.5 10(-3) mm Hg(-1); P<0.01). Pulse-wave velocity trended higher in patients (P=0.06). Reduced distensibility in the ascending aorta correlated with the amount of late gadolinium enhancement in a volume that included the aortic root and the ascending aorta (r=-0.72, P<0.01), and both parameters correlated with decreased right ventricular ejection fraction. CONCLUSIONS Adverse aortic properties post palliation of hypoplastic left heart syndrome manifest themselves by aortic dilatation, decreased distensibility, and increased volume of nonviable aortic wall tissue. The negative association between aortic late gadolinium enhancement and right ventricular ejection fraction suggests unfavorable aortic-ventricular coupling. The potential impact of these findings on long-term right ventricular function should be evaluated in future studies.
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Affiliation(s)
- Inga Voges
- Department of Congenital Heart Disease and Pediatric Cardiology, University Hospital of Schleswig-Holstein, Kiel, Germany
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Prakash A, Powell AJ, Geva T. Multimodality Noninvasive Imaging for Assessment of Congenital Heart Disease. Circ Cardiovasc Imaging 2010; 3:112-25. [PMID: 20086225 DOI: 10.1161/circimaging.109.875021] [Citation(s) in RCA: 93] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Affiliation(s)
- Ashwin Prakash
- From the Department of Cardiology, Children’s Hospital Boston, Department of Pediatrics, Harvard Medical School, Boston, Mass
| | - Andrew J. Powell
- From the Department of Cardiology, Children’s Hospital Boston, Department of Pediatrics, Harvard Medical School, Boston, Mass
| | - Tal Geva
- From the Department of Cardiology, Children’s Hospital Boston, Department of Pediatrics, Harvard Medical School, Boston, Mass
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Fahey M, Ko HH, Srivastava S, Lai WW, Chatterjee S, Parness IA, Lytrivi ID. A comparison of echocardiographic techniques in determination of arterial elasticity in the pediatric population. Echocardiography 2009; 26:567-73. [PMID: 19452610 DOI: 10.1111/j.1540-8175.2008.00849.x] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
BACKGROUND Many methods are used to measure arterial elasticity in children using echocardiography. There is no data to support the equivalence of the different techniques. The goal of this study was to evaluate the reproducibility of several techniques used to measure arterial elasticity using echocardiography. METHODS Aortic distension in two different sites (arterial distension) through the cardiac cycle was measured by (four) two-dimensional (2D) and M-mode echocardiographic techniques in 20 children without significant structural heart disease. These measurements combined with noninvasive blood pressure measurements were used to calculate arterial elastic indices. Arterial elasticity was expressed in terms of distensibility and stiffness. Data were collected by two sonographers and interpreted by two reviewers. Paired Student's t-test and Pitman's test for equality of variance for correlated observations were used to detect differences between different sonographers, different reviewers, and different techniques. RESULTS No significant difference in the measured elasticity between sonographers or reviewers was observed. There was a somewhat increased variance in two of the four techniques evaluated. There was no significant difference in elasticity measured using different techniques to evaluate the same arterial site, although a significantly decreased elasticity was noted from measurements taken in the proximal ascending aorta as compared with the distal ascending aorta. CONCLUSIONS Many echocardiographic techniques produce reproducible measurements of arterial elasticity. There may be intrinsic differences in arterial elasticity between different segments of the ascending aorta, which have not been previously described in children with normal cardiac anatomy. Comparisons of data from separate studies must take these differences into account.
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Affiliation(s)
- Michael Fahey
- Division of Pediatric Cardiology, Mount Sinai Hospital, New York, New York 10019, USA.
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Larrazabal LA, Selamet Tierney ES, Brown DW, Gauvreau K, Vida VL, Bergersen L, Pigula FA, del Nido PJ, Bacha EA. Ventricular function deteriorates with recurrent coarctation in hypoplastic left heart syndrome. Ann Thorac Surg 2008; 86:869-74; discussion 869-74. [PMID: 18721575 PMCID: PMC11227908 DOI: 10.1016/j.athoracsur.2008.04.074] [Citation(s) in RCA: 50] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/10/2008] [Revised: 04/17/2008] [Accepted: 04/21/2008] [Indexed: 11/27/2022]
Abstract
BACKGROUND Recurrent coarctation (re-CoA) after stage I palliation in hypoplastic left heart syndrome (HLHS) is deleterious. We studied whether re-CoA had an effect on ventricular systolic function. METHODS Retrospectively reviewed were HLHS patients surviving stage I Norwood palliation (stage I) and cavopulmonary shunt (CPS) between January 2004 and February 2007. Echocardiographic right ventricular fractional area change (RV-FAC) was used to evaluate ventricular systolic function after stage I, before CPS, and before Fontan procedures. Cardiac catheterization and magnetic resonance imaging data before CPS were reviewed to assess re-CoA, using a coarctation index (CI = isthmus diameter/descending aortic diameter). RESULTS Fifty-one patients were included, and 21 had a CI of less than 0.75 (mean, 0.82 +/- 0.19; 21). Twelve patients required arch balloon dilation between CPS and Fontan. The change of RV-FAC for all patients between stage I and CPS was -2.2% +/- 9.6%. Pearson correlation coefficient demonstrated a significant correlation between lower CI values and lower RV-FAC at the pre-CPS echocardiogram (r = .35, p = 0.03); and lower CI values and greater decrease in RV-FAC between stage I and pre-CPS evaluation (r = 0.40, p = 0.018). At follow-up pre-Fontan, RV-FAC for patients who underwent balloon dilation for re-CoA recovered to a level that was inferior but not significantly different from that of patients who did not need balloon dilation. CONCLUSIONS Recurrent aortic arch obstruction after stage I for HLHS is associated with worse RV systolic function at the time of stage II operation. Timely intervention on the re-CoA results in recovery of RV function.
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Affiliation(s)
- Luis Alesandro Larrazabal
- Department of Cardiac Surgery, Children's Hospital Boston, Harvard Medical School, Boston, Massachusetts 02115, USA
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