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Voges I, Raimondi F, McMahon CJ, Ait-Ali L, Babu-Narayan SV, Botnar RM, Burkhardt B, Gabbert DD, Grosse-Wortmann L, Hasan H, Hansmann G, Helbing WA, Krupickova S, Latus H, Martini N, Martins D, Muthurangu V, Ojala T, van Ooij P, Pushparajah K, Rodriguez-Palomares J, Sarikouch S, Grotenhuis HB, Greil FG. Clinical impact of novel CMR technology on patients with congenital heart disease. A scientific statement of the Association for European Pediatric and Congenital Cardiology (AEPC) and the European Association of Cardiovascular Imaging (EACVI) of the ESC. Eur Heart J Cardiovasc Imaging 2024:jeae172. [PMID: 38985851 DOI: 10.1093/ehjci/jeae172] [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: 06/28/2024] [Accepted: 07/01/2024] [Indexed: 07/12/2024] Open
Abstract
Cardiovascular magnetic resonance (CMR) imaging is recommended in patients with congenital heart disease (CHD) in clinical practice guidelines as the imaging standard for a large variety of diseases. As CMR is evolving, novel techniques are becoming available. Some of them are already used clinically, whereas others still need further evaluation. In this statement the authors give an overview of relevant new CMR techniques for the assessment of CHD. Studies with reference values for these new techniques are listed in the supplement.
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Affiliation(s)
- Inga Voges
- Department of Congenital Heart Disease and Pediatric Cardiology, University Hospital Schleswig-Holstein, Campus Kiel, Germany
- German Center for Cardiovascular Research (DZHK), partner site Hamburg/Lübeck/Kiel, Germany
| | | | - Colin J McMahon
- Department of Paediatric Cardiology, Children's Health Ireland at Crumlin, Dublin 12, Ireland
| | - Lamia Ait-Ali
- Institute of clinical Physiology CNR, Massa, Italy
- Heart Hospital, G. Monastery foundation, Massa, Italy
| | - Sonya V Babu-Narayan
- Royal Brompton Hospital, Part of Guy's and St Thomas' NHS Foundation Trust, Sydney Street, London, SW3 6NP, UK
- National Heart and Lung Institute, Imperial College, London, England
| | - René M Botnar
- School of Biomedical Engineering and Imaging Sciences, King's College London, St. Thomas' Hospital, London, UK
- Institute for Biological and Medical Engineering and School of Engineering, Pontificia Universidad Católica de Chile, Santiago, Chile
| | - Barbara Burkhardt
- Pediatric Heart Center, University Children's Hospital Zurich, Zurich, Switzerland
| | - Dominik D Gabbert
- Department of Congenital Heart Disease and Pediatric Cardiology, University Hospital Schleswig-Holstein, Campus Kiel, Germany
- German Center for Cardiovascular Research (DZHK), partner site Hamburg/Lübeck/Kiel, Germany
| | - Lars Grosse-Wortmann
- Division of Cardiology, Oregon Health and Science University Hospital, Portland, Oregon, United States
| | - Hosan Hasan
- Department of Pediatric Cardiology and Critical Care, Hannover Medical School, Hannover, Germany
- European Pediatric Pulmonary Vascular Disease Network, Berlin, Germany
| | - Georg Hansmann
- Department of Pediatric Cardiology and Critical Care, Hannover Medical School, Hannover, Germany
- European Pediatric Pulmonary Vascular Disease Network, Berlin, Germany
| | - Willem A Helbing
- Department of Pediatrics, division of cardiology, and department of Radiology, Erasmus MC-Sophia children's hospital, Rotterdam, the Netherlands
| | - Sylvia Krupickova
- Royal Brompton Hospital, Part of Guy's and St Thomas' NHS Foundation Trust, Sydney Street, London, SW3 6NP, UK
- National Heart and Lung Institute, Imperial College, London, England
- Department of Paediatric Cardiology, Royal Brompton Hospital, Sydney Street, London, SW3 6NP, UK
| | - Heiner Latus
- Clinic for Pediatric Cardiology and Congenital Heart Disease Klinikum Stuttgart Germany
| | - Nicola Martini
- Department of Radiology, Fondazione G. Monasterio CNR-Regione Toscana, Pisa, Italy
- U.O.C. Bioingegneria, Fondazione G. Monasterio CNR-Regione Toscana, Pisa, Italy
| | - Duarte Martins
- Pediatric Cardiology Department, Hospital de Santa Cruz, Centro Hospitalar Lisboa Ocidental, Lisbon, Portugal
| | - Vivek Muthurangu
- Centre for Translational Cardiovascular Imaging, Institute of Cardiovascular Science, University College London, London, United Kingdom
| | - Tiina Ojala
- New Children's Hospital Pediatric Research Center, Helsinki University Hospital, Helsinki, Finland
| | - Pim van Ooij
- Department of Radiology & Nuclear Medicine, Amsterdam University Medical Center, location AMC, Amsterdam, the Netherlands
- Department of Pediatric Cardiology, Wilhelmina Children's Hospital/University Medical Center Utrecht, Utrecht, the Netherlands
| | - Kuberan Pushparajah
- School of Biomedical Engineering and Imaging Sciences, King's College London, St. Thomas' Hospital, London, UK
- Department of Congenital Heart Disease, Evelina London Children's Hospital, Westminster Bridge Road, London, SE1 7EH, UK
| | - Jose Rodriguez-Palomares
- CIBER Cardiovascular, Instituto de Salud Carlos III, Madrid, Spain
- European Reference Network for Rare and Low Prevalence Complex Diseases of the Heart, Amsterdam, the Netherlands
- Servicio de Cardiología, Hospital Universitario Vall Hebrón. Institut de Recerca Vall Hebrón (VHIR). Departamento de Medicina, Universitat Autònoma de Barcelona. Barcelona. Spain
| | - Samir Sarikouch
- Department for Cardiothoracic, Transplant, and Vascular Surgery, Hannover Medical School, Hannover, Germany
| | - Heynric B Grotenhuis
- Department of Pediatric Cardiology, Wilhelmina Children's Hospital/University Medical Center Utrecht, Utrecht, the Netherlands
| | - F Gerald Greil
- Department of Pediatrics, UT Southwestern/Children's Health, 1935 Medical District Drive B3.09, Dallas, TX 75235
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Lanser CNG, van Poecke WHA, Scheffers LE, van den Berg LE, Helbing WA. Stress imaging in patients with a Fontan circulation: A systematic review. Int J Cardiol 2023; 391:131192. [PMID: 37479147 DOI: 10.1016/j.ijcard.2023.131192] [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: 06/11/2023] [Accepted: 07/14/2023] [Indexed: 07/23/2023]
Abstract
INTRODUCTION The aims of this study were to provide an overview of the cardiac stress response in Fontan patients and of the use, safety and clinical value of stress imaging in Fontan patients. METHODS Studies evaluating cardiac function using stress imaging in Fontan patients published up until 12 December 2021 were included in this review. RESULTS From 1603 potential studies, 32 studies met the inclusion criteria. In total, stress imaging tests of 728 Fontan patients were included. Cardiac function was most often measured using physical stress (61%), all other studies used dobutamine-induced stress. Stroke volume (SV) increased in most studies (71%), mean SV at rest ranged from 27 mL/m2 to 60 mL/m2 versus 27 mL/m2 to 101 mL/m2 during stress, and increased with an average of 4%. Ejection fraction increased in almost all studies, whereas both end-systolic volume and end-diastolic volume decreased during stress. Higher heart rates were obtained with physical stress (82-180) compared to dobutamine induced stress (73-128). Compared to controls, increases in heartrate and SV were lower and end-diastolic volume decreased abnormally in 75% of reporting studies. No major adverse events were reported. Poorer cardiac stress response was related to decreased exercise capacity and higher risk for long-term (adverse) outcomes in Fontan patients. DISCUSSION Cardiac stress response in Fontan patients differs from healthy subjects, reflected by lower increases in heart rate, diminished preload and decreased cardiac output, especially during higher levels of exercise. Stress imaging is safe, however the added clinical value needs to be investigated in more detail.
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Affiliation(s)
- Charlotte N G Lanser
- Department of Pediatrics, division of Pediatric Cardiology, Erasmus MC - Sophia Children's Hospital, Rotterdam, Netherlands
| | - Wessel H A van Poecke
- Department of Pediatrics, division of Pediatric Cardiology, Erasmus MC - Sophia Children's Hospital, Rotterdam, Netherlands
| | - Linda E Scheffers
- Department of Pediatrics, division of Pediatric Cardiology, Erasmus MC - Sophia Children's Hospital, Rotterdam, Netherlands
| | - Linda E van den Berg
- Department of Orthopedics and Sports Medicine, Erasmus MC - Sophia Children's Hospital, Rotterdam, Netherlands
| | - Willem A Helbing
- Department of Pediatrics, division of Pediatric Cardiology, Erasmus MC - Sophia Children's Hospital, Rotterdam, Netherlands; Department of Radiology, Erasmus MC - Sophia Children's Hospital, Rotterdam, Netherlands.
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Ringgaard S, Hjortdal VE. Editorial for "Improved Tricuspid Valve Function, Preload Recruitment and Ventricular Efficiency During Submaximal Exercise in Patients With Unoperated Ebstein's Anomaly: An MRI Study". J Magn Reson Imaging 2021; 55:1851-1852. [PMID: 34618994 DOI: 10.1002/jmri.27952] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2021] [Accepted: 09/29/2021] [Indexed: 11/07/2022] Open
Affiliation(s)
| | - Vibeke E Hjortdal
- Department of Clinical Medicine, Copenhagen University, Copenhagen, Denmark
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van der Woude SFS, Rijnberg FM, Hazekamp MG, Jongbloed MRM, Kenjeres S, Lamb HJ, Westenberg JJM, Roest AAW, Wentzel JJ. The Influence of Respiration on Blood Flow in the Fontan Circulation: Insights for Imaging-Based Clinical Evaluation of the Total Cavopulmonary Connection. Front Cardiovasc Med 2021; 8:683849. [PMID: 34422920 PMCID: PMC8374887 DOI: 10.3389/fcvm.2021.683849] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2021] [Accepted: 07/05/2021] [Indexed: 12/18/2022] Open
Abstract
Congenital heart disease is the most common birth defect and functionally univentricular heart defects represent the most severe end of this spectrum. The Fontan circulation provides an unique solution for single ventricle patients, by connecting both caval veins directly to the pulmonary arteries. As a result, the pulmonary circulation in Fontan palliated patients is characterized by a passive, low-energy circulation that depends on increased systemic venous pressure to drive blood toward the lungs. The absence of a subpulmonary ventricle led to the widely believed concept that respiration, by sucking blood to the pulmonary circulation during inspiration, is of great importance as a driving force for antegrade blood flow in Fontan patients. However, recent studies show that respiration influences pulsatility, but has a limited effect on net forward flow in the Fontan circulation. Importantly, since MRI examination is recommended every 2 years in Fontan patients, clinicians should be aware that most conventional MRI flow sequences do not capture the pulsatility of the blood flow as a result of the respiration. In this review, the unique flow dynamics influenced by the cardiac and respiratory cycle at multiple locations within the Fontan circulation is discussed. The impact of (not) incorporating respiration in different MRI flow sequences on the interpretation of clinical flow parameters will be covered. Finally, the influence of incorporating respiration in advanced computational fluid dynamic modeling will be outlined.
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Affiliation(s)
- Séline F S van der Woude
- Department of Cardiology, Biomedical Engineering, Biomechanics Laboratory, Rotterdam, Netherlands
| | - Friso M Rijnberg
- Department of Cardiothoracic Surgery, Leiden University Medical Center, Leiden, Netherlands
| | - Mark G Hazekamp
- Department of Cardiothoracic Surgery, Leiden University Medical Center, Leiden, Netherlands
| | - Monique R M Jongbloed
- Department of Anatomy, Embryology and Cardiology, Leiden University Medical Center, Leiden, Netherlands
| | - Sasa Kenjeres
- Department of Chemical Engineering, Faculty of Applied Sciences, Delft University of Technology and J. M. Burgerscentrum Research School for Fluid Mechanics, Delft, Netherlands
| | - Hildo J Lamb
- Department of Radiology, Leiden University Medical Center, Leiden, Netherlands
| | - Jos J M Westenberg
- Department of Radiology, Leiden University Medical Center, Leiden, Netherlands
| | - Arno A W Roest
- Department of Pediatric Cardiology, Leiden University Medical Center, Leiden, Netherlands
| | - Jolanda J Wentzel
- Department of Cardiology, Biomedical Engineering, Biomechanics Laboratory, Rotterdam, Netherlands
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Engineering Perspective on Cardiovascular Simulations of Fontan Hemodynamics: Where Do We Stand with a Look Towards Clinical Application. Cardiovasc Eng Technol 2021; 12:618-630. [PMID: 34114202 DOI: 10.1007/s13239-021-00541-y] [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: 09/20/2020] [Accepted: 04/30/2021] [Indexed: 01/02/2023]
Abstract
BACKGROUND Cardiovascular simulations for patients with single ventricles undergoing the Fontan procedure can assess patient-specific hemodynamics, explore surgical advances, and develop personalized strategies for surgery and patient care. These simulations have not yet been broadly accepted as a routine clinical tool owing to a number of limitations. Numerous approaches have been explored to seek innovative solutions for improving methodologies and eliminating these limitations. PURPOSE This article first reviews the current state of cardiovascular simulations of Fontan hemodynamics. Then, it will discuss the technical progress of Fontan simulations with the emphasis of its clinical impact, noting that substantial improvements have been made in the considerations of patient-specific anatomy, flow, and blood rheology. The article concludes with insights into potential future directions involving clinical validation, uncertainty quantification, and computational efficiency. The advancements in these aspects could promote the clinical usage of Fontan simulations, facilitating its integration into routine clinical practice.
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Power LC, Gusso S, Hornung TS, Jefferies C, Derraik JGB, Hofman PL, O'Grady GL. Exercise Cardiac Magnetic Resonance Imaging in Boys With Duchenne Muscular Dystrophy Without Cardiac Disease. Pediatr Neurol 2021; 117:35-43. [PMID: 33662889 DOI: 10.1016/j.pediatrneurol.2020.12.011] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/19/2020] [Revised: 12/23/2020] [Accepted: 12/24/2020] [Indexed: 11/19/2022]
Abstract
BACKGROUND Duchenne muscular dystrophy is caused by mutations in the DMD gene, resulting in cardiomyopathy in all affected children by 18 years. Although cardiomyopathy is now the leading cause of mortality in these children, there is ongoing debate regarding timely diagnosis, secondary prevention, and treatment of this condition. The purpose of this study was to use exercise cardiac magnetic resonance imaging in asymptomatic young boys with Duchenne muscular dystrophy to describe their heart function and compare this with healthy controls. METHODS We studied 11 boys with Duchenne muscular dystrophy aged 8.6 to 13.9 years and 11 healthy age- and sex-matched controls. RESULTS Compared with the controls, boys with Duchenne muscular dystrophy had lower ejection fraction at rest (57% versus 63%; P = 0.004). During submaximal exercise, they reached similar peak tachycardia but increased their heart rate and cardiac output only half as much as controls (P = 0.003 and P = 0.014, respectively). End-systolic volume remained higher in boys with Duchenne muscular dystrophy both at rest and during exercise. When transthoracic echocardiography was compared with cardiac magnetic resonance imaging, 45% of the echocardiograms had suboptimal or poor views in the Duchenne muscular dystrophy group. CONCLUSIONS Boys with Duchenne muscular dystrophy had abnormalities in left ventricular systolic function that were exaggerated by exercise stress. Exercise cardiac magnetic resonance imaging is feasible in a select population of children with Duchenne muscular dystrophy, and it has the potential to unmask early signs of cardiomyopathy.
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Affiliation(s)
- Lisa C Power
- Paediatric Neurology Department, Starship Children's Hospital, Auckland, New Zealand; Paediatric Endocrinology Department, Starship Children's Hospital, Auckland, New Zealand; Liggins Institute, University of Auckland, Auckland, New Zealand
| | - Silmara Gusso
- Department of Exercise Sciences, University of Auckland, Auckland, New Zealand
| | - Tim S Hornung
- Paediatric Cardiology Department, Starship Children's Hospital, Auckland, New Zealand
| | - Craig Jefferies
- Paediatric Endocrinology Department, Starship Children's Hospital, Auckland, New Zealand
| | - José G B Derraik
- Liggins Institute, University of Auckland, Auckland, New Zealand; Department of Women's and Children's Health, Uppsala University, Uppsala, Sweden
| | - Paul L Hofman
- Paediatric Endocrinology Department, Starship Children's Hospital, Auckland, New Zealand; Liggins Institute, University of Auckland, Auckland, New Zealand
| | - Gina L O'Grady
- Paediatric Neurology Department, Starship Children's Hospital, Auckland, New Zealand.
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Trankle CR, Canada JM, Jordan JH, Truong U, Hundley WG. Exercise Cardiovascular Magnetic Resonance: A Review. J Magn Reson Imaging 2021; 55:720-754. [PMID: 33655592 DOI: 10.1002/jmri.27580] [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: 12/10/2020] [Revised: 02/11/2021] [Accepted: 02/12/2021] [Indexed: 11/10/2022] Open
Abstract
While pharmacologic stress cardiovascular magnetic resonance imaging (MRI) is a robust noninvasive tool in the diagnosis and prognostication of epicardial coronary artery disease, clinical guidelines recommend exercise-based testing in those patients who can exercise. This review describes the development of exercise cardiovascular MRI protocols, summarizes the insights across various patient populations, and highlights future research initiatives. LEVEL OF EVIDENCE: 5 TECHNICAL EFFICACY: Stage 2.
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Affiliation(s)
- Cory R Trankle
- Division of Cardiology, Pauley Heart Center, Virginia Commonwealth University, Richmond, Virginia, USA
| | - Justin M Canada
- Division of Cardiology, Pauley Heart Center, Virginia Commonwealth University, Richmond, Virginia, USA
| | - Jennifer H Jordan
- Division of Cardiology, Pauley Heart Center, Virginia Commonwealth University, Richmond, Virginia, USA.,Department of Biomedical Engineering, Virginia Commonwealth University, Richmond, Virginia, USA
| | - Uyen Truong
- Division of Pediatric Cardiology, Children's Hospital of Richmond, Virginia Commonwealth University, Richmond, Virginia, USA
| | - W Gregory Hundley
- Division of Cardiology, Pauley Heart Center, Virginia Commonwealth University, Richmond, Virginia, USA
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8
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Araujo JJ. Stress Echocardiography in Pediatric and Adult Congenital Heart Disease: A Complement in Anatomical and Functional Assessment. Curr Probl Cardiol 2020; 46:100762. [PMID: 33373837 DOI: 10.1016/j.cpcardiol.2020.100762] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2020] [Accepted: 11/24/2020] [Indexed: 10/22/2022]
Abstract
Functional classification of children and adults with repaired and unrepaired congenital heart disease is a challenge for clinicians, due to the heterogeneity of congenital heart disease. Functional studies may be complemented with a stress echocardiogram, which analyzes the hemodynamic behavior of surgical repair zones, residuals, and sequelae. The integration of the anatomical and functional classification criteria developed for congenital heart disease and the results of a stress echocardiogram can establish a more precise functional classification. Stress echocardiograms also provide early diagnosis of functional complications of the congenital heart, allowing timely management decisions. This paper reviews the most important aspects of stress echocardiograms in pediatric and adult congenital heart disease, seeking to spark cardiologists' interest in extending its applications in congenital heart disease.
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Affiliation(s)
- John Jairo Araujo
- Cochair Adult Congenital Heart Disease Council in Inter American Society of Cardiology, Departament Pediatric and Adult Congenital Heart Disease, Somer Incare Cardiovascular Center Rionegro, Colombia, Cardiologist Echocardilogist in Pediatric and Adult Congenital Heart Disease.
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9
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Chen X, Yuan H, Liu J, Zhang N, Zhou C, Huang M, Jian Q, Zhuang J. Hemodynamic Effects of Additional Pulmonary Blood Flow on Glenn and Fontan Circulation. Cardiovasc Eng Technol 2020; 11:268-282. [PMID: 32072439 DOI: 10.1007/s13239-020-00459-x] [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: 06/19/2019] [Accepted: 02/10/2020] [Indexed: 10/25/2022]
Abstract
PURPOSE Additional pulmonary blood flow (APBF) can provide better pulsating blood flow and systemic arterial oxygen saturation, while low blood pulsation and low oxygen saturation are defects of the Fontan and Glenn procedure. Studying the hemodynamic effect of APBF is beneficial for clinical decisions. This study aimed to explore the effect on particle washout, as well as the differences among the sensitivities of both different hemodynamic parameters and different procedures to APBF. METHODS The patient-specific clinical datasets of a patient who underwent bilateral bidirectional Glenn (BBDG) with APBF were enrolled in this study, and using these datasets, Glenn- and Fontan-type artery models were reconstructed. A series of parameters, including the total caval flow pulsatility index (TCPI), indexed energy loss (iPL), wall shear stress (WSS), systemic arterial oxygen saturation (Satart), particle washout time (WOT), pressure in the right superior vena cava (PRSVC), pulmonary flow distribution (PFD) and hepatic flow distribution (HFD), were computed from computational fluid dynamic (CFD) simulation to evaluate the hemodynamic effect of APBF. RESULTS The result showed that APBF led to better iPL and Satart but worse PRSVC and heart load accompanied by a great impact on HFD, making hepatic flow easier to perfuse the side without MPA and APBF. The increase in the APBF rate also effectively results in larger flow pulsation, region velocity, and wall shear stress and lower WOT, and this effect may be more effective for patients with persistent left superior vena cava (PLSVC). However, APBF might have little effect on PFD. Furthermore, APBF might affect WOT, iPL and HFD more significantly than PRSVC and has a greater improvement effect in patients with poorer iPL and WOT. CONCLUSIONS Moderate APBF is not only a measure to promote pulmonary artery growth and systemic arterial oxygen saturation but also an effective method against endothelial dysfunction and thrombosis. However, moderate APBF is patient-specific and should be determined based on hemodynamic preference that leads to desired patient outcomes, and care should be taken to prevent PRSVC and heart load from being too high as well as an imbalance in HFD.
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Affiliation(s)
- Xiangyu Chen
- School of Mechanical and Automotive Engineering, South China University of Technology, Guangzhou, 510000, China
| | - Haiyun Yuan
- Guangdong Provincial Key Laboratory of South China Structural Heart Disease, Department of Cardiovascular Surgery, Guangdong Provincial People's Hospital, Guangdong Cardiovascular Institute, Guangdong Academy of Medical Sciences, Guangzhou, 510000, China
| | - Jiawei Liu
- School of Mechanical and Automotive Engineering, South China University of Technology, Guangzhou, 510000, China
| | - Neichuan Zhang
- School of Mechanical and Automotive Engineering, South China University of Technology, Guangzhou, 510000, China
| | - Chengbin Zhou
- Guangdong Provincial Key Laboratory of South China Structural Heart Disease, Department of Cardiovascular Surgery, Guangdong Provincial People's Hospital, Guangdong Cardiovascular Institute, Guangdong Academy of Medical Sciences, Guangzhou, 510000, China
| | - Meiping Huang
- Guangdong Provincial Key Laboratory of South China Structural Heart Disease, Department of Catheterization Lab, Guangdong Provincial People's Hospital, Guangdong Cardiovascular Institute, Guangdong Academy of Medical Sciences, Guangzhou, China
| | - Qifei Jian
- School of Mechanical and Automotive Engineering, South China University of Technology, Guangzhou, 510000, China.
| | - Jian Zhuang
- Guangdong Provincial Key Laboratory of South China Structural Heart Disease, Department of Cardiovascular Surgery, Guangdong Provincial People's Hospital, Guangdong Cardiovascular Institute, Guangdong Academy of Medical Sciences, Guangzhou, 510000, China.
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Zentner D, Celermajer DS, Gentles T, d’Udekem Y, Ayer J, Blue GM, Bridgman C, Burchill L, Cheung M, Cordina R, Culnane E, Davis A, du Plessis K, Eagleson K, Finucane K, Frank B, Greenway S, Grigg L, Hardikar W, Hornung T, Hynson J, Iyengar AJ, James P, Justo R, Kalman J, Kasparian N, Le B, Marshall K, Mathew J, McGiffin D, McGuire M, Monagle P, Moore B, Neilsen J, O’Connor B, O’Donnell C, Pflaumer A, Rice K, Sholler G, Skinner JR, Sood S, Ward J, Weintraub R, Wilson T, Wilson W, Winlaw D, Wood A. Management of People With a Fontan Circulation: a Cardiac Society of Australia and New Zealand Position statement. Heart Lung Circ 2020; 29:5-39. [DOI: 10.1016/j.hlc.2019.09.010] [Citation(s) in RCA: 24] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2019] [Accepted: 09/16/2019] [Indexed: 02/07/2023]
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Power LC, O'Grady GL, Hornung TS, Jefferies C, Gusso S, Hofman PL. Imaging the heart to detect cardiomyopathy in Duchenne muscular dystrophy: A review. Neuromuscul Disord 2018; 28:717-730. [PMID: 30119965 DOI: 10.1016/j.nmd.2018.05.011] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2017] [Revised: 05/24/2018] [Accepted: 05/29/2018] [Indexed: 01/16/2023]
Abstract
Duchenne Muscular Dystrophy is the most common paediatric neuromuscular disorder. Mutations in the DMD gene on the X-chromosome result in progressive skeletal muscle weakness as the main clinical manifestation. However, cardiac muscle is also affected, with cardiomyopathy becoming an increasingly recognised cause of morbidity, and now the leading cause of mortality in this group. The diagnosis of cardiomyopathy has often been made late due to technical limitations in transthoracic echocardiograms and delayed symptomatology in less mobile patients. Increasingly, evidence supports earlier pharmacological intervention in cardiomyopathy to improve outcomes. However, the optimal timing of initiation remains uncertain, and the benefits of prophylactic therapy are unproven. Current treatment guidelines suggest initiation of therapy once cardiac dysfunction is detected. This review focuses on new and evolving techniques for earlier detection of Duchenne muscular dystrophy-associated cardiomyopathy. Transthoracic echocardiography or cardiac magnetic resonance imaging performed under physiological stress (dobutamine or exercise), can unmask early cardiac dysfunction. Cardiac magnetic resonance imaging can define cardiac function with greater accuracy and reliability than an echocardiogram, and is not limited by body habitus. Improved imaging techniques, used in a timely fashion, offer the potential for early detection of cardiomyopathy and improved long-term outcomes.
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Affiliation(s)
- Lisa C Power
- Paediatric Neurology Department, Starship Children's Hospital, Auckland, New Zealand; Paediatric Endocrinology Department, Starship Children's Hospital, Auckland, New Zealand; Liggins Institute, University of Auckland, Auckland, New Zealand
| | - Gina L O'Grady
- Paediatric Neurology Department, Starship Children's Hospital, Auckland, New Zealand.
| | - Tim S Hornung
- Paediatric Cardiology Department, Starship Children's Hospital, Auckland, New Zealand
| | - Craig Jefferies
- Paediatric Endocrinology Department, Starship Children's Hospital, Auckland, New Zealand
| | - Silmara Gusso
- Liggins Institute, University of Auckland, Auckland, New Zealand
| | - Paul L Hofman
- Paediatric Endocrinology Department, Starship Children's Hospital, Auckland, New Zealand; Liggins Institute, University of Auckland, Auckland, New Zealand
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Rudski LG, Gargani L, Armstrong WF, Lancellotti P, Lester SJ, Grünig E, D'Alto M, Åström Aneq M, Ferrara F, Saggar R, Saggar R, Naeije R, Picano E, Schiller NB, Bossone E. Stressing the Cardiopulmonary Vascular System: The Role of Echocardiography. J Am Soc Echocardiogr 2018; 31:527-550.e11. [PMID: 29573927 DOI: 10.1016/j.echo.2018.01.002] [Citation(s) in RCA: 34] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/07/2017] [Indexed: 01/06/2023]
Abstract
The cardiopulmonary vascular system represents a key determinant of prognosis in several cardiorespiratory diseases. Although right heart catheterization is considered the gold standard for assessing pulmonary hemodynamics, a comprehensive noninvasive evaluation including left and right ventricular reserve and function and cardiopulmonary interactions remains highly attractive. Stress echocardiography is crucial in the evaluation of many cardiac conditions, typically coronary artery disease but also heart failure and valvular heart disease. In stress echocardiographic applications beyond coronary artery disease, the assessment of the cardiopulmonary vascular system is a cornerstone. The possibility of coupling the left and right ventricles with the pulmonary circuit during stress can provide significant insight into cardiopulmonary physiology in healthy and diseased subjects, can support the diagnosis of the etiology of pulmonary hypertension and other conditions, and can offer valuable prognostic information. In this state-of-the-art document, the topic of stress echocardiography applied to the cardiopulmonary vascular system is thoroughly addressed, from pathophysiology to different stress modalities and echocardiographic parameters, from clinical applications to limitations and future directions.
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Affiliation(s)
- Lawrence G Rudski
- Azrieli Heart Center and Center for Pulmonary Vascular Diseases, Jewish General Hospital, McGill University, Montreal, Quebec, Canada
| | - Luna Gargani
- Institute of Clinical Physiology, National Research Council, Pisa, Italy
| | - William F Armstrong
- Department of Internal Medicine, Division of Cardiovascular Disease, University of Michigan Medical Center, Ann Arbor, Michigan
| | - Patrizio Lancellotti
- Department of Cardiology, University of Liège Hospital, GIGA-Cardiovascular Sciences, Liège, Belgium
| | - Steven J Lester
- Division of Cardiovascular Diseases, Mayo Clinic, Scottsdale, Arizona
| | - Ekkehard Grünig
- Centre for Pulmonary Hypertension, University Hospital Heidelberg, Heidelberg, Germany
| | - Michele D'Alto
- Department of Cardiology, Second University of Naples-Monaldi Hospital, Naples, Italy
| | - Meriam Åström Aneq
- Department of Clinical Physiology, Institution of Medicine and Health Sciences, Linköping University, Linköping, Sweden
| | | | - Rajeev Saggar
- Lung Institute, Banner University Medical Center-Phoenix, University of Arizona, Phoenix, Arizona
| | - Rajan Saggar
- Lung & Heart-Lung Transplant and Pulmonary Hypertension Programs, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, California
| | | | - Eugenio Picano
- Institute of Clinical Physiology, National Research Council, Pisa, Italy
| | - Nelson B Schiller
- Cardiovascular Research Institute, Health eHeart Study, Division of Cardiology, Department of Medicine, University of California, San Francisco, San Francisco, California
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Impaired cardiac output during exercise in adults operated for ventricular septal defect in childhood: a hitherto unrecognised pathophysiological response. Cardiol Young 2017; 27:1591-1598. [PMID: 28539128 DOI: 10.1017/s1047951117000877] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
BACKGROUND Recent studies have demonstrated that surgical ventricular septal defect closure in childhood is associated with reduced functional capacity and disruption of the right ventricular force-frequency relationship during exercise. To further describe long-term cardiac function, we performed a non-invasive assessment of cardiac index during exercise in adults having undergone surgery for ventricular septal defect in early childhood. METHODS A total of 20 patients (surgical age 2.1±1.4 years, age at examination 22.1±2.2 years) and 20 healthy, matched controls (23.4±2.1 years at examination) underwent continuous supine bicycle ergometry during MRI. Their blood flow was recorded in the ascending aorta and the pulmonary trunk at increasing exercise levels. Cardiac index, retrograde flow, and vessel diameters were determined by blinded, post hoc analyses. RESULTS The patient group had normal cardiac index at rest (2.9±0.7 L/minute/m2), which was comparable with that of the controls (3.0±0.6 L/minute/m2); however, they had a lower increase in cardiac index during exercise (reaching 7.3±1.3 L/minute/m2 at submaximal exercise) compared with controls (8.2±1.2 L/minute/m2), p<0.05. Patients had a significantly higher ascending aorta retrograde flow than controls at rest and throughout exercise. In the pulmonary artery, the retrograde flow was minimal at rest in both groups, but increased significantly in patients during exercise compared with controls. CONCLUSIONS Young adults with a surgically closed ventricular septal defect have a reduced cardiac index during exercise compared with healthy, young adults. The impaired cardiac index appears to be related to an increasing retrograde flow in the pulmonary artery with progressive exertion.
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Schaan CW, Macedo ACPD, Sbruzzi G, Umpierre D, Schaan BD, Pellanda LC. Functional Capacity in Congenital Heart Disease: A Systematic Review and Meta-Analysis. Arq Bras Cardiol 2017; 109:357-367. [PMID: 28876372 PMCID: PMC5644216 DOI: 10.5935/abc.20170125] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2016] [Accepted: 03/09/2017] [Indexed: 11/20/2022] Open
Abstract
Background Children and adolescents with congenital heart disease often have alterations
in their exercise capacity that can be evaluated by various functional
testing. Objective To evaluate the functional capacity of children and adolescents with
congenital heart disease (CHD) with systematic review and meta-analyses. Methods The review included observational studies, data from the first evaluation of
randomized clinical trials or observational follow-up periods after clinical
trials which evaluated functional capacity by cardiopulmonary exercise test,
stress testing, six-minute walk test or step test, in children and
adolescents with CHD, aged between six and 18 years, and comparisons with
healthy controls in the same age group. The quantitative assessment was
performed by meta-analysis, by comparing the maximal oxygen consumption
(VO2max) of children and adolescents with CHD and respective
control groups. Results Twenty-five of 2.683 studies identified in the search met the inclusion
criteria. The VO2max measurement showed that patients with CHD
have a decrease of 9.31 ml/Kg/min (95% CI. -12.48 to -6.13; I2,
94.3%, P for heterogeneity < 0.001) compared with the control group. The
meta-analysis of the data of maximum heart rate (HR) reached during
cardiopulmonary test and stress testing, retrieved from 18 studies, showed a
HR value of -15.14 bpm (95% CI. -20.97 to -9.31; I2, 94.3%, P for
heterogeneity < 0.001) compared with the control group. Conclusion Children and adolescents with CHD have lower VO2max and HR
compared to controls.
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Affiliation(s)
| | | | | | - Daniel Umpierre
- Hospital de Clínicas de Porto Alegre, Porto Alegre, RS, Brazil
| | | | - Lucia Campos Pellanda
- Instituto de Cardiologia, Fundação Universitária de Cardiologia, Porto Alegre, RS, Brazil
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Heiberg J, Asschenfeldt B, Maagaard M, Ringgaard S. Dynamic bicycle exercise to assess cardiac output at multiple exercise levels during magnetic resonance imaging. Clin Imaging 2017; 46:102-107. [PMID: 28778011 DOI: 10.1016/j.clinimag.2017.07.010] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2017] [Revised: 07/10/2017] [Accepted: 07/17/2017] [Indexed: 11/25/2022]
Abstract
PURPOSE The aim was to establish a method for performing dynamic exercise during magnetic resonance imaging (MRI) using a slowly increasing workload protocol. METHODS An ergometer bicycle with a step-wise, exercise protocol was used. Real-time phase-contrast MRI images of the aorta were obtained at each exercise step. RESULTS In total, 40 participants completed the exercise protocol to reach a mean maximum cardiac output of 13.7±3.7l/min and a heart rate of 150±16beats/min at the highest exercise level. Less than 1% of scans were discarded due to poor quality. CONCLUSIONS Dynamic, high intensity exercise is feasible during MRI.
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Affiliation(s)
- Johan Heiberg
- Dept. of Cardiothoracic and Vascular Surgery, Aarhus University Hospital, Denmark; Dept. of Clinical Medicine, Aarhus University Hospital, Denmark.
| | - Benjamin Asschenfeldt
- Dept. of Cardiothoracic and Vascular Surgery, Aarhus University Hospital, Denmark; Dept. of Clinical Medicine, Aarhus University Hospital, Denmark
| | - Marie Maagaard
- Dept. of Cardiothoracic and Vascular Surgery, Aarhus University Hospital, Denmark; Dept. of Clinical Medicine, Aarhus University Hospital, Denmark
| | - Steffen Ringgaard
- MR Research Center, Aarhus University Hospital, Denmark; Dept. of Clinical Medicine, Aarhus University Hospital, Denmark
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Clift P, Celermajer D. Managing adult Fontan patients: where do we stand? Eur Respir Rev 2016; 25:438-450. [PMID: 27903666 PMCID: PMC9487559 DOI: 10.1183/16000617.0091-2016] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2016] [Accepted: 10/13/2016] [Indexed: 01/10/2023] Open
Abstract
The Fontan operation is performed as a palliative procedure to improve survival in infants born with a functionally univentricular circulation. The success of the operation is demonstrated by a growing adult Fontan population that exists with this unique physiology. Late follow-up has demonstrated expected and unexpected sequelae, and has shown multisystem effects of this circulation. This review discusses the challenges of managing the late complications in terms of understanding this unique physiology and the innovative therapeutic interventions that are being investigated. The challenge remains to maintain quality of life for adult survivors, as well as extending life expectancy. Innovative solutions are required to meet the challenges of the Fontan circulation faced in adult lifehttp://ow.ly/XTSm305oH8b
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Roberts PA, Cowan BR, Liu Y, Lin ACW, Nielsen PMF, Taberner AJ, Stewart RAH, Lam HI, Young AA. Real-time aortic pulse wave velocity measurement during exercise stress testing. J Cardiovasc Magn Reson 2015; 17:86. [PMID: 26438096 PMCID: PMC4594994 DOI: 10.1186/s12968-015-0191-4] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2015] [Accepted: 09/17/2015] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Pulse wave velocity (PWV), a measure of arterial stiffness, has been demonstrated to be an independent predictor of adverse cardiovascular outcomes. This can be derived non-invasively using cardiovascular magnetic resonance (CMR). Changes in PWV during exercise may reveal further information on vascular pathology. However, most known CMR methods for quantifying PWV are currently unsuitable for exercise stress testing. METHODS A velocity-sensitive real-time acquisition and evaluation (RACE) pulse sequence was adapted to provide interleaved acquisition of two locations in the descending aorta (at the level of the pulmonary artery bifurcation and above the renal arteries) at 7.8 ms temporal resolution. An automated method was used to calculate the foot-to-foot transit time of the velocity pulse wave. The RACE method was validated against a standard gated phase contrast (STD) method in flexible tube phantoms using a pulsatile flow pump. The method was applied in 50 healthy volunteers (28 males) aged 22-75 years using a MR-compatible cycle ergometer to achieve moderate work rate (38 ± 22 W, with a 31 ± 12 bpm increase in heart rate) in the supine position. Central pulse pressures were estimated using a MR-compatible brachial device. Scan-rescan reproducibility was evaluated in nine volunteers. RESULTS Phantom PWV was 22 m/s (STD) vs. 26 ± 5 m/s (RACE) for a butyl rubber tube, and 5.5 vs. 6.1 ± 0.3 m/s for a latex rubber tube. In healthy volunteers PWV increased with age at both rest (R(2) = 0.31 p < 0.001) and exercise (R(2) = 0.40, p < 0.001). PWV was significantly increased at exercise relative to rest (0.71 ± 2.2 m/s, p = 0.04). Scan-rescan reproducibility at rest was -0.21 ± 0.68 m/s (n = 9). CONCLUSIONS This study demonstrates the validity of CMR in the evaluation of PWV during exercise in healthy subjects. The results support the feasibility of using this method in evaluating of patients with systemic aortic disease.
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Affiliation(s)
- Paul A Roberts
- Auckland Bioengineering Institute, University of Auckland, Auckland, New Zealand.
| | - Brett R Cowan
- Department of Anatomy with Radiology, Faculty of Medical and Health Sciences, University of Auckland, 85 Park Road, Auckland, 1142, New Zealand.
| | - Yingmin Liu
- Department of Anatomy with Radiology, Faculty of Medical and Health Sciences, University of Auckland, 85 Park Road, Auckland, 1142, New Zealand.
| | - Aaron C W Lin
- Greenlane Cardiovascular Unit, Auckland City Hospital, Auckland, New Zealand.
| | - Poul M F Nielsen
- Auckland Bioengineering Institute, University of Auckland, Auckland, New Zealand.
- Department of Engineering Science, University of Auckland, Auckland, New Zealand.
| | - Andrew J Taberner
- Auckland Bioengineering Institute, University of Auckland, Auckland, New Zealand.
- Department of Engineering Science, University of Auckland, Auckland, New Zealand.
| | - Ralph A H Stewart
- Greenlane Cardiovascular Unit, Auckland City Hospital, Auckland, New Zealand.
| | - Hoi Ieng Lam
- Department of Anatomy with Radiology, Faculty of Medical and Health Sciences, University of Auckland, 85 Park Road, Auckland, 1142, New Zealand.
| | - Alistair A Young
- Department of Anatomy with Radiology, Faculty of Medical and Health Sciences, University of Auckland, 85 Park Road, Auckland, 1142, New Zealand.
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Effect of respiration on cardiac filling at rest and during exercise in Fontan patients: A clinical and computational modeling study. IJC HEART & VASCULATURE 2015; 9:100-108. [PMID: 28785717 PMCID: PMC5497350 DOI: 10.1016/j.ijcha.2015.08.002] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2015] [Revised: 08/03/2015] [Accepted: 08/06/2015] [Indexed: 11/24/2022]
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20
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Cifra B, Dragulescu A, Border WL, Mertens L. Stress echocardiography in paediatric cardiology. Eur Heart J Cardiovasc Imaging 2015; 16:1051-9. [DOI: 10.1093/ehjci/jev159] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/22/2015] [Accepted: 05/25/2015] [Indexed: 01/08/2023] Open
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Exercise capacity in single-ventricle patients after Fontan correlates with haemodynamic energy loss in TCPC. Heart 2014; 101:139-43. [DOI: 10.1136/heartjnl-2014-306337] [Citation(s) in RCA: 87] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
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Hemodynamic causes of exercise intolerance in Fontan patients. Int J Cardiol 2014; 175:478-83. [DOI: 10.1016/j.ijcard.2014.06.015] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/08/2014] [Revised: 06/11/2014] [Accepted: 06/20/2014] [Indexed: 11/18/2022]
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Bossers SSM, Cibis M, Gijsen FJ, Schokking M, Strengers JLM, Verhaart RF, Moelker A, Wentzel JJ, Helbing WA. Computational fluid dynamics in Fontan patients to evaluate power loss during simulated exercise. Heart 2014; 100:696-701. [PMID: 24634021 DOI: 10.1136/heartjnl-2013-304969] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
OBJECTIVE Exercise intolerance is common in total cavopulmonary connection (TCPC) patients. It has been suggested that power loss (Ploss) inside the TCPC plays a role in reduced exercise performance. Our objective is to establish the role of Ploss inside the TCPC during increased flow, simulating exercise in a patient-specific way. METHODS Cardiac MRI (CMR) was used to obtain flow rates from the caval veins during rest and increased flow, simulating exercise with dobutamine. A 3D reconstruction of the TCPC was created using CMR data. Computational fluid dynamics (CFD) simulations were performed to calculate Ploss inside the TCPC structure for rest and stress conditions. To reflect the flow distribution during exercise, a condition where inferior caval vein (IVC) flow was increased twofold compared with rest was added. 29 TCPC patients (15 intra-atrial lateral tunnel (ILT) and 14 extracardiac conduit (ECC)) were included. RESULTS Mean Ploss at rest was 1.36 ± 0.94 (ILT) and 3.20 ± 1.26 (ECC) mW/m(2) (p<0.001), 2.84 ±1.95 (ILT) and 8.41 ± 3.77 (ECC) mW/m(2) (p<0.001) during dobutamine and 5.21 ± 3.50 (ILT) and 15.28 ± 8.30 (ECC) mW/m(2) (p=0.001) with twofold IVC flow. The correlation between cardiac index and Ploss was exponential (ILT: R(2)=0.811, p<0.001; ECC: R(2)=0.690, p<0.001). CONCLUSIONS Ploss inside the TCPC structure is limited but increases with simulated exercise. This relates to the anatomy of TCPC and the surgical technique used. In all flow conditions, ILT patients have lower Ploss than ECC patients. We did not find a relationship between Ploss and exercise capacity.
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Affiliation(s)
- Sjoerd S M Bossers
- Department of Paediatrics, Division of Cardiology, Erasmus Medical Centre-Sophia Children's Hospital, , Rotterdam, The Netherlands
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Mock circulatory system of the Fontan circulation to study respiration effects on venous flow behavior. ASAIO J 2013; 59:253-60. [PMID: 23644612 DOI: 10.1097/mat.0b013e318288a2ab] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
We describe an in vitro model of the Fontan circulation with respiration to study subdiaphragmatic venous flow behavior. The venous and arterial connections of a total cavopulmonary connection (TCPC) test section were coupled with a physical lumped parameter (LP) model of the circulation. Intrathoracic and subdiaphragmatic pressure changes associated with normal breathing were applied. This system was tuned for two patients (5 years, 0.67 m2; 10 years, 1.2 m2) to physiological values. System function was verified by comparison to the analytical model on which it was based and by consistency with published clinical measurements. Overall, subdiaphragmatic venous flow was influenced by respiration. Flow within the arteries and veins increased during inspiration but decreased during expiration, with retrograde flow in the inferior venous territories. System pressures and flows showed close agreement with the analytical LP model (p < 0.05). The ratio of the flow rates occurring during inspiration to expiration were within the clinical range of values reported elsewhere. The approach used to set up and control the model was effective and provided reasonable comparisons with clinical data.
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Quantitative liver ADC measurements using diffusion-weighted MRI at 3 Tesla: evaluation of reproducibility and perfusion dependence using different techniques for respiratory compensation. MAGNETIC RESONANCE MATERIALS IN PHYSICS BIOLOGY AND MEDICINE 2013; 26:431-42. [PMID: 23483359 DOI: 10.1007/s10334-013-0375-6] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/07/2012] [Revised: 02/22/2013] [Accepted: 02/23/2013] [Indexed: 12/13/2022]
Abstract
OBJECT Diffusion weighted imaging (DWI) of the liver suffers from low signal to noise making 3 Tesla (3 T) an attractive option, but 3 T data is scarce. It was the aim to study the influence of different b values and respiratory compensation methods (RCM) on the apparent diffusion coefficient (ADC) level and on ADC reproducibility at 3 T. MATERIALS AND METHODS Ten healthy volunteers and 12 patients with malignant liver lesions underwent repeated (2-22 days) breathhold, free-breathing and respiratory triggered DWI at 3 T using b values between 0 and 1,000 s/mm(2). RESULTS The ADCs changed up to 150% in healthy livers and up to 48% in malignant lesions depending on b value combinations. Best ADC reproducibility in healthy livers were obtained with respiratory triggering (95% limits of agreement: ±0.12) and free-breathing (±0.14). In malignant lesions equivalent reproducibility was obtained with less RCM dependence. The use of a lower maximum b value (b = 500) decreased reproducibility (±0.14 to ±0.32) in both normal liver and malignant lesions. CONCLUSION Large differences in absolute ADC values and reproducibility caused by varying combinations of clinically realistic b values were demonstrated. Different RCMs caused smaller differences. Lowering maximum b value to 500 increased limits of agreement up to a factor of two. Serial ADC changes larger than approximately 15% can be detected confidently on an individual basis in both malignant lesions and normal liver parenchyma at 3 T using appropriate b values and respiratory compensation.
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Caval flow reflects Fontan hemodynamics: quantification by magnetic resonance imaging. Clin Res Cardiol 2011; 101:133-8. [DOI: 10.1007/s00392-011-0374-4] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/08/2011] [Accepted: 10/21/2011] [Indexed: 10/15/2022]
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Abstract
PURPOSE OF REVIEW Heart failure is an important problem after surgical correction of congenital heart disease. Timely recognition may be difficult. Recent developments in exercise testing and stress-imaging may change the management of patients with congenital heart disease. RECENT FINDINGS Exercise tests are commonly used in the follow-up of patients with congenital heart disease. Maximal exercise studies are not always feasible in this patient population. Variables of submaximal exercise and ventilator efficiency have shown a good correlation with variables of maximal exercise and have been suggested to relate to long-term cardiac function.For evaluation of submaximal exercise, stress imaging may reveal abnormal responses unrecognized at rest. Both physical exercise as well as pharmacological stress may be used in combination with various imaging modalities. For practical reasons, dobutamine is most widely used to generate and mimic stress and is well tolerated in low doses. Particularly in lesions affecting the right ventricle and with single ventricular physiology after the Fontan operation, magnetic resonance stress imaging has provided additional insight into the cardiac function. SUMMARY The abnormal stress responses can potentially be used for risk assessment in the follow-up of patients with congenital cardiac disease. Further studies are required to provide common protocols for stress imaging.
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Dur O, DeGroff CG, Keller BB, Pekkan K. Optimization of inflow waveform phase-difference for minimized total cavopulmonary power loss. J Biomech Eng 2010; 132:031012. [PMID: 20459200 DOI: 10.1115/1.4000954] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
The Fontan operation is a palliative surgical procedure performed on children, born with congenital heart defects that have yielded only a single functioning ventricle. The total cavo-pulmonary connection (TCPC) is a common variant of the Fontan procedure, where the superior vena cava (SVC) and inferior vena cava (IVC) are routed directly into the pulmonary arteries (PA). Due to the limited pumping energy available, optimized hemodynamics, in turn, minimized power loss, inside the TCPC pathway is required for the best optimal surgical outcomes. To complement ongoing efforts to optimize the anatomical geometric design of the surgical Fontan templates, here, we focused on the characterization of power loss changes due to the temporal variations in between SVC and IVC flow waveforms. An experimentally validated pulsatile computational fluid dynamics solver is used to quantify the effect of phase-shift between SVC and IVC inflow waveforms and amplitudes on internal energy dissipation. The unsteady hemodynamics of two standard idealized TCPC geometries are presented, incorporating patient-specific real-time PC-MRI flow waveforms of "functional" Fontan patients. The effects of respiration and pulsatility on the internal energy dissipation of the TCPC pathway are analyzed. Optimization of phase-shift between caval flows is shown to lead to lower energy dissipation up to 30% in these idealized models. For physiological patient-specific caval waveforms, the power loss is reduced significantly (up to 11%) by the optimization of all three major harmonics at the same mean pathway flow (3 L/min). Thus, the hemodynamic efficiency of single ventricle circuits is influenced strongly by the caval flow waveform quality, which is regulated through respiratory dependent physiological pathways. The proposed patient-specific waveform optimization protocol may potentially inspire new therapeutic applications to aid postoperative hemodynamics and improve the well being of the Fontan patients.
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Affiliation(s)
- Onur Dur
- Department of Biomedical Engineering, Carnegie Mellon University, Pittsburgh, PA 15219, USA
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Abstract
In patients with coronary arterial disease, stress imaging is able to demonstrate abnormalities in the motion of the ventricular walls, and abnormalities in coronary arterial perfusion not apparent at rest. It can also provide information on prognostic factors. In patients with congenitally malformed hearts, stress imaging is used to determine contractile reserve, abnormalities of mural motion, and global systolic function, but also to assess diastolic and vascular function. In most of these patients, stress is usually induced using pharmacological agents, mainly dobutamine given in varying doses. The clinical usefulness of abnormal responses to the stress induced in such patients has to be addressed in follow-up studies. The abnormal stress might serve as surrogate endpoints, predicting primary endpoints at an early stage, which are useful for stratification of risk in this population of growing patients. We review here the stress imaging studies performed to date in patients with congenitally malformed hearts, with a special emphasis on echocardiography and cardiac magnetic resonance imaging.
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Dur O, Lara M, Arnold D, Vandenberghe S, Keller BB, DeGroff C, Pekkan K. Pulsatile In Vitro Simulation of the Pediatric Univentricular Circulation for Evaluation of Cardiopulmonary Assist Scenarios. Artif Organs 2009; 33:967-76. [DOI: 10.1111/j.1525-1594.2009.00951.x] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
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Abstract
Total cavopulmonary connection (CPC) has a significant incidence of late failure due to increased systemic venous pressure and low cardiac output. Mechanical support could prevent failure by correcting hemodynamics. We established a model of inferior CPC using an axial flow pump (Thoratec HeartMate II, Thoratec Corp. Pleasanton, CA) in a group of ten 47-57 kg sheep and assessed hemodynamics and metabolism as a potential chronic treatment option for failed Fontan circulation. After pilot studies (n = 7), three animals underwent pump-supported inferior CPC to assess hemodynamic and metabolic responses. Pump inflow was connected to the inferior vena cava (IVC) and outflow to the main pulmonary artery. The IVC was ligated at the right atrium. Hemodynamic and biochemical parameters were recorded over four days. The first seven animals died from pump-related causes (graft kinking, three; pump thrombosis, one) or other causes (GI bleeding, one; suspected stroke, two). The subsequent three animals were electively euthanized on postoperative day four due to IRB requirements. Over the four day postoperative period, pump flow was 3.43 +/- 0.62 L/min and IVC pressure 4.05 +/- 3.21 mm Hg (mean +/- SD). Lactate levels remained normal. Low pressure and high-volume IVC flow was sustained by mechanical support. We will next attempt chronic pump implantation.
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