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Bucholz EM, Morton SU, Madriago E, Roberts AE, Ronai C. The Evolving Role of Genetic Evaluation in the Prenatal Diagnosis and Management of Congenital Heart Disease. J Cardiovasc Dev Dis 2024; 11:170. [PMID: 38921669 PMCID: PMC11203735 DOI: 10.3390/jcdd11060170] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2024] [Revised: 05/16/2024] [Accepted: 05/26/2024] [Indexed: 06/27/2024] Open
Abstract
Congenital heart disease (CHD) is increasingly diagnosed prenatally and the ability to screen and diagnose the genetic factors involved in CHD have greatly improved. The presence of a genetic abnormality in the setting of prenatally diagnosed CHD impacts prenatal counseling and ensures that families and providers have as much information as possible surrounding perinatal management and what to expect in the future. This review will discuss the genetic evaluation that can occur prior to birth, what different genetic testing methods are available, and what to think about in the setting of various CHD diagnoses.
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Affiliation(s)
- Emily M. Bucholz
- Section of Cardiology, Department of Pediatrics, University of Colorado Denver, Denver, CO 80204, USA
| | - Sarah U. Morton
- Division of Newborn Medicine, Department of Pediatrics, Boston Children’s Hospital, Harvard Medical School, Boston, MA 02115, USA
| | - Erin Madriago
- Department of Pediatrics, Oregon Health and Science University, Portland, OR 97239, USA
| | - Amy E. Roberts
- Department of Cardiology, Boston Children’s Hospital, Department of Pediatrics, Harvard Medical School, Boston, MA 02115, USA
| | - Christina Ronai
- Department of Cardiology, Boston Children’s Hospital, Department of Pediatrics, Harvard Medical School, Boston, MA 02115, USA
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Pidaparti M, Geddes GC, Durbin MD. Clinical Genetic and Genomic Testing in Congenital Heart Disease and Cardiomyopathy. J Clin Med 2024; 13:2544. [PMID: 38731073 PMCID: PMC11084871 DOI: 10.3390/jcm13092544] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2024] [Revised: 04/20/2024] [Accepted: 04/21/2024] [Indexed: 05/13/2024] Open
Abstract
Congenital heart disease (CHD) and cardiomyopathies are the leading cause of morbidity and mortality worldwide. These conditions are often caused by genetic factors, and recent research has shown that genetic and genomic testing can provide valuable information for patient care. By identifying genetic causes, healthcare providers can screen for other related health conditions, offer early interventions, estimate prognosis, select appropriate treatments, and assess the risk for family members. Genetic and genomic testing is now the standard of care in patients with CHD and cardiomyopathy. However, rapid advances in technology and greater availability of testing options have led to changes in recommendations for the most appropriate testing method. Several recent studies have investigated the utility of genetic testing in this changing landscape. This review summarizes the literature surrounding the clinical utility of genetic evaluation in patients with CHD and cardiomyopathy.
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Affiliation(s)
- Mahati Pidaparti
- Division of Neonatal-Perinatal Medicine, Department of Pediatrics, Indiana University School of Medicine, Indianapolis, IN 46202, USA;
| | - Gabrielle C. Geddes
- Department of Medical and Molecular Genetics, Indiana University School of Medicine, Indianapolis, IN 46202, USA;
| | - Matthew D. Durbin
- Division of Neonatal-Perinatal Medicine, Department of Pediatrics, Indiana University School of Medicine, Indianapolis, IN 46202, USA;
- Herman B Wells Center for Pediatric Research, 1044 W. Walnut, Indianapolis, IN 46202, USA
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3
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Mohiuddin TA, Raol N, Tey CS, Horný M, Zhang C, Sharp WG, Chanani N, Patzer RE. Quantifying the Healthcare Burden of Pediatric Feeding Disorder after Congenital Heart Surgery. J Pediatr 2023; 261:113593. [PMID: 37399917 DOI: 10.1016/j.jpeds.2023.113593] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/10/2023] [Revised: 05/27/2023] [Accepted: 06/26/2023] [Indexed: 07/05/2023]
Abstract
OBJECTIVE To determine the healthcare costs and use burden of pediatric feeding disorder after congenital heart surgery. STUDY DESIGN A retrospective, population-based cohort study using claims data (2009-2018) was performed. Participants include patients aged 0-18 years who had undergone congenital heart surgery and were included in the insurance database ≥1 year after surgery. The main exposure variable was the presence of a pediatric feeding disorder, defined as a need for a feeding tube at discharge or diagnosis of dysphagia or feeding-related difficulty within the study timeframe. Main outcomes include overall and feeding-related medical care use, defined as readmissions and outpatient use, and feeding-related cost of care within 1 year of surgery. RESULTS A total of 10 849 pediatric patients were identified, with 3347 (30.9%) presenting with pediatric feeding disorder within 1 year of surgery. Patients with pediatric feeding disorder spent a median of 12 days (IQR, 6-33 days) in the hospital, compared with 5 days (IQR, 3-8 days) in patients without (P < .001). Rate ratios for overall readmissions, feeding-related readmissions, feeding-related outpatient use, and cost of care over the first year after surgery were significantly increased at 2.9 (95% CI, 2.5-3.4), 5.1 (95% CI, 4.6-5.7), 7.7 (95% CI, 6.5-9.1), and 2.2 (95% CI, 2.0-2.3) among patients with pediatric feeding disorder as compared with those without. CONCLUSIONS Pediatric feeding disorder after congenital heart surgery is associated with a significant healthcare burden. Multidisciplinary care for and research on this health condition is needed to identify optimal management strategies to reduce this burden and improve outcomes.
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Affiliation(s)
- Tahmina A Mohiuddin
- Medical Scholars Program, Augusta University/University of Georgia Medical Partnership, Athens, GA
| | - Nikhila Raol
- Department of Otolaryngology, Emory School of Medicine, Atlanta, GA; Department of Pediatrics, Emory School of Medicine, Atlanta, GA; Childrens Healthcare of Atlanta, Atlanta, GA; Division of Pediatric Otolaryngology, Children's Healthcare of Atlanta, Atlanta, GA.
| | - Ching S Tey
- Department of Pediatrics, Emory School of Medicine, Atlanta, GA
| | - Michal Horný
- Department of Radiology and Imaging Sciences, Emory School of Medicine, Atlanta, GA; Department of Epidemiology, Emory Rollins School of Public Health, Atlanta, GA
| | - Chao Zhang
- Department of Pediatrics, Emory School of Medicine, Atlanta, GA
| | - William G Sharp
- Department of Pediatrics, Emory School of Medicine, Atlanta, GA; Childrens Healthcare of Atlanta, Atlanta, GA; Children's Feeding Program, Children's Healthcare of Atlanta, Atlanta, GA
| | - Nikhil Chanani
- Department of Pediatrics, Emory School of Medicine, Atlanta, GA; Childrens Healthcare of Atlanta, Atlanta, GA; Sibley Heart Center, Alpharetta, GA; Division of Pediatric Cardiology, Children's Healthcare of Atlanta, Atlanta, GA
| | - Rachel E Patzer
- Department of Epidemiology, Emory Rollins School of Public Health, Atlanta, GA
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Durbin MD, Fairman K, Helvaty LR, Huang M, Li M, Abreu D, Geddes GC, Helm BM, Landis BJ, McEntire A, Mitchell DK, Ware SM. Genetic Testing Guidelines Impact Care in Newborns with Congenital Heart Defects. J Pediatr 2023; 260:113495. [PMID: 37211210 PMCID: PMC10660555 DOI: 10.1016/j.jpeds.2023.113495] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/30/2022] [Revised: 05/11/2023] [Accepted: 05/14/2023] [Indexed: 05/23/2023]
Abstract
OBJECTIVE To evaluate genetic evaluation practices in newborns with the most common birth defect, congenital heart defects (CHD), we determined the prevalence and the yield of genetic evaluation across time and across patient subtypes, before and after implementation of institutional genetic testing guidelines. STUDY DESIGN This was a retrospective, cross-sectional study of 664 hospitalized newborns with CHD using multivariate analyses of genetic evaluation practices across time and patient subtypes. RESULTS Genetic testing guidelines for hospitalized newborns with CHD were implemented in 2014, and subsequently genetic testing increased (40% in 2013 and 75% in 2018, OR 5.02, 95% CI 2.84-8.88, P < .001) as did medical geneticists' involvement (24% in 2013 and 64% in 2018, P < .001). In 2018, there was an increased use of chromosomal microarray (P < .001), gene panels (P = .016), and exome sequencing (P = .001). The testing yield was high (42%) and consistent across years and patient subtypes analyzed. Increased testing prevalence (P < .001) concomitant with consistent testing yield (P = .139) added an estimated 10 additional genetic diagnoses per year, reflecting a 29% increase. CONCLUSIONS In patients with CHD, yield of genetic testing was high. After implementing guidelines, genetic testing increased significantly and shifted to newer sequence-based methods. Increased use of genetic testing identified more patients with clinically important results with potential to impact patient care.
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Affiliation(s)
- Matthew D Durbin
- Division of Neonatal-Perinatal Medicine, Department of Pediatrics, Riley Hospital for Children, Indiana University School of Medicine, Indianapolis, IN
| | - Korre Fairman
- Division of Neonatal-Perinatal Medicine, Department of Pediatrics, Washington University School of Medicine, St. Louis, MO
| | - Lindsey R Helvaty
- Department of Pediatrics, Indiana University School of Medicine, Indianapolis, IN
| | - Manyan Huang
- Department of Epidemiology and Biostatistics, Indiana University Bloomington School of Public Health, Bloomington, IN
| | - Ming Li
- Department of Epidemiology and Biostatistics, Indiana University Bloomington School of Public Health, Bloomington, IN
| | - Daniel Abreu
- Indiana University School of Medicine, Indianapolis, IN
| | - Gabrielle C Geddes
- Department of Medical and Molecular Genetics, Indiana University School of Medicine, Indianapolis, IN
| | - Benjamin M Helm
- Department of Medical and Molecular Genetics, Indiana University School of Medicine, Indianapolis, IN
| | - Benjamin J Landis
- Department of Medical and Molecular Genetics, Indiana University School of Medicine, Indianapolis, IN; Division of Pediatric Cardiology, Department of Pediatrics, Riley Hospital for Children, Indiana University School of Medicine, Indianapolis, IN
| | - Alexis McEntire
- Department of Medical and Molecular Genetics, Indiana University School of Medicine, Indianapolis, IN
| | - Dana K Mitchell
- Department of Pediatrics, Indiana University School of Medicine, Indianapolis, IN
| | - Stephanie M Ware
- Department of Pediatrics, Indiana University School of Medicine, Indianapolis, IN; Department of Medical and Molecular Genetics, Indiana University School of Medicine, Indianapolis, IN.
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Hăşmăşanu MG, Procopciuc LM, Matyas M, Zonda GI, Zaharie GC. Genetic Polymorphisms of Vascular Endothelial Growth Factor in Neonatal Pathologies: A Systematic Search and Narrative Synthesis of the Literature. CHILDREN (BASEL, SWITZERLAND) 2023; 10:children10040744. [PMID: 37189993 DOI: 10.3390/children10040744] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/28/2023] [Revised: 04/11/2023] [Accepted: 04/18/2023] [Indexed: 05/17/2023]
Abstract
(1) Background: Vascular endothelial growth factor (VEGF) is essential in vasculo- and angiogenesis due to its role in endothelial cell proliferation and migration. As a vascular proliferative factor, VEGF is one of the hallmarks of cancer and, in adult populations, the relationship between genetic polymorphism and neoplasm was widely investigated. For the neonatal population, only a few studies attempted to uncover the link between the genetic polymorphism of VEGF and neonatal pathology, especially related to late-onset complications. Our objective is to evaluate the literature surrounding VEGF genetic polymorphisms and the morbidity of the neonatal period. (2) Methods: A systematic search was initially conducted in December 2022. The PubMed platform was used to explore MEDLINE (1946 to 2022) and PubMed Central (2000 to 2022) by applying the search string ((VEGF polymorphism*) and newborn*). (3) Results: The PubMed search yielded 62 documents. A narrative synthesis of the findings was undertaken considering our predetermined subheadings (infants with low birth weight or preterm birth, heart pathologies, lung diseases, eye conditions, cerebral pathologies, and digestive pathologies). (4) Conclusion: The VEGF polymorphisms seem to be associated with neonatal pathology. The involvement of VEGF and VEGF polymorphism has been demonstrated for retinopathy of prematurity.
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Affiliation(s)
- Monica G Hăşmăşanu
- Department of Neonatology, Iuliu Haţieganu University of Medicine and Pharmacy, 400006 Cluj-Napoca, Romania
| | - Lucia M Procopciuc
- Department of Medical Biochemistry, Iuliu Haţieganu University of Medicine and Pharmacy, 400349 Cluj-Napoca, Romania
| | - Melinda Matyas
- Department of Neonatology, Iuliu Haţieganu University of Medicine and Pharmacy, 400006 Cluj-Napoca, Romania
| | - Gabriela I Zonda
- Department of Mother and Child Care, "Grigore T. Popa" University of Medicine and Pharmacy Iasi, 700115 Iași, Romania
| | - Gabriela C Zaharie
- Department of Neonatology, Iuliu Haţieganu University of Medicine and Pharmacy, 400006 Cluj-Napoca, Romania
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Vanreusel I, Vermeulen D, Goovaerts I, Stoop T, Ectors B, Cornelis J, Hens W, de Bliek E, Heuten H, Van Craenenbroeck EM, Van Berendoncks A, Segers VFM, Briedé JJ. Circulating Reactive Oxygen Species in Adults with Congenital Heart Disease. Antioxidants (Basel) 2022; 11:antiox11122369. [PMID: 36552576 PMCID: PMC9774177 DOI: 10.3390/antiox11122369] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2022] [Revised: 11/24/2022] [Accepted: 11/25/2022] [Indexed: 12/05/2022] Open
Abstract
Oxidative stress is an important pathophysiological mechanism in the development of numerous cardiovascular disorders, but few studies have examined the levels of oxidative stress in adults with congenital heart disease (CHD). The objective of this study was to investigate oxidative stress levels in adults with CHD and the association with inflammation, exercise capacity and endothelial function. To this end, 36 adults with different types of CHD and 36 age- and gender-matched healthy controls were enrolled. Blood cell counts, hs-CRP, NT-proBNP, fasting glucose, cholesterol levels, iron saturation and folic acid concentrations were determined in venous blood samples. Levels of superoxide anion radical in whole blood were determined using electron paramagnetic resonance spectroscopy in combination with the spin probe CMH. Physical activity was assessed with the IPAQ-SF questionnaire. Vascular function assessment (EndoPAT) and cardiopulmonary exercise testing were performed in the patient group. Superoxide anion radical levels were not statistically significantly different between adults with CHD and the matched controls. Moreover, oxidative stress did not correlate with inflammation, or with endothelial function or cardiorespiratory fitness in CHD; however, a significant negative correlation with iron saturation was observed. Overall, whole blood superoxide anion radical levels in adults with CHD were not elevated, but iron levels seem to play a more important role in oxidative stress mechanisms in CHD than in healthy controls. More research will be needed to improve our understanding of the underlying pathophysiology of CHD.
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Affiliation(s)
- Inne Vanreusel
- Department of Cardiology, Antwerp University Hospital, 2650 Edegem, Belgium
- Research Group Cardiovascular Diseases, GENCOR, University of Antwerp, 2000 Antwerp, Belgium
- Correspondence: ; Tel.: +32-3-821-38-47
| | - Dorien Vermeulen
- Department of Cardiology, Antwerp University Hospital, 2650 Edegem, Belgium
| | - Inge Goovaerts
- Department of Cardiology, Antwerp University Hospital, 2650 Edegem, Belgium
| | - Tibor Stoop
- Department of Cardiology, Antwerp University Hospital, 2650 Edegem, Belgium
| | - Bert Ectors
- Department of Cardiology, Antwerp University Hospital, 2650 Edegem, Belgium
| | - Jacky Cornelis
- Department of Cardiology, Antwerp University Hospital, 2650 Edegem, Belgium
| | - Wendy Hens
- Department of Cardiology, Antwerp University Hospital, 2650 Edegem, Belgium
- Cardiac Rehabilitation Centre, Antwerp University Hospital, 2650 Edegem, Belgium
- Department of Rehabilitation Sciences and Physiotherapy, Faculty of Medicine and Health Sciences, MOVANT Research Group, University of Antwerp, 2000 Antwerp, Belgium
| | - Erwin de Bliek
- Department of Cardiology, Antwerp University Hospital, 2650 Edegem, Belgium
- Research Group Cardiovascular Diseases, GENCOR, University of Antwerp, 2000 Antwerp, Belgium
- Cardiac Rehabilitation Centre, Antwerp University Hospital, 2650 Edegem, Belgium
| | - Hilde Heuten
- Department of Cardiology, Antwerp University Hospital, 2650 Edegem, Belgium
- Research Group Cardiovascular Diseases, GENCOR, University of Antwerp, 2000 Antwerp, Belgium
| | - Emeline M. Van Craenenbroeck
- Department of Cardiology, Antwerp University Hospital, 2650 Edegem, Belgium
- Research Group Cardiovascular Diseases, GENCOR, University of Antwerp, 2000 Antwerp, Belgium
| | - An Van Berendoncks
- Department of Cardiology, Antwerp University Hospital, 2650 Edegem, Belgium
- Research Group Cardiovascular Diseases, GENCOR, University of Antwerp, 2000 Antwerp, Belgium
| | - Vincent F. M. Segers
- Department of Cardiology, Antwerp University Hospital, 2650 Edegem, Belgium
- Research Group Cardiovascular Diseases, GENCOR, University of Antwerp, 2000 Antwerp, Belgium
| | - Jacob J. Briedé
- Department of Toxicogenomics, School of Oncology and Developmental Biology (GROW), Maastricht University, 6211 MD Maastricht, The Netherlands
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Kikano S, Kannankeril PJ. Precision Medicine in Pediatric Cardiology. Pediatr Ann 2022; 51:e390-e395. [PMID: 36215086 DOI: 10.3928/19382359-20220803-05] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Precision medicine is a developing strategy for individualized treatment of a wide range of diseases. Congenital heart disease is the most common of all congenital defects and carries a high degree of variability in outcomes because of unidentified causes. Advances have identified individual genetic and environmental factors that have helped understand variations in morbidity and mortality in pediatric cardiology. A focus on genomics and pharmacogenetics has also been key to risk prediction and improvement in drug safety and efficacy in the pediatric population. With the rapidly evolving understanding of these individual factors, there also come challenges in implementation of personalized medicine into our health care model. This review outlines the key features of precision medicine in pediatric cardiology and highlights the clinical effects of these findings in patients with congenital heart disease. [Pediatr Ann. 2022;51(10):e390-e395.].
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Abstract
BACKGROUND Vocal cord palsy is one of the recognised complications of complex cardiac surgery in the paediatric population. While there is an abundance of literature highlighting the presence of this complication, there is a scarcity of research focusing on the pathophysiology, presentation, diagnosis, and treatment options available for children affected by vocal cord palsy. MATERIALS AND METHODS Electronic searches were conducted using the search terms: "Vocal Cord Palsy," "VCP," "Vocal Cord Injury," "Paediatric Heart Surgery," "Congenital Heart Surgery," "Pediatric Heart Surgery," "Vocal Fold Movement Impairment," "VFMI," "Vocal Fold Palsy," "PDA Ligation." The inclusion criteria were any articles discussing the outcomes of vocal cord palsy following paediatric cardiac surgery. RESULTS The two main populations affected by vocal cord palsy are children undergoing aortic arch surgery or those undergoing PDA ligation. There is paucity of prospective follow-up studies; it is therefore difficult to reliably assess the current approaches and the long-term implications of management options. CONCLUSION Vocal cord palsy can be a devastating complication following cardiac surgery, which if left untreated, could potentially result in debilitation of quality of life and in severe circumstances could even lead to death. Currently, there is not enough high-quality evidence in the literature to aid recognition, diagnosis, and management leaving clinicians to extrapolate evidence from adult studies to make clinical judgements. Future research with a focus on the paediatric perspective is necessary in providing evidence for good standards of care.
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Genetic variant burden and adverse outcomes in pediatric cardiomyopathy. Pediatr Res 2021; 89:1470-1476. [PMID: 32746448 PMCID: PMC8256333 DOI: 10.1038/s41390-020-1101-5] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/30/2020] [Revised: 07/07/2020] [Accepted: 07/22/2020] [Indexed: 11/08/2022]
Abstract
BACKGROUND Previous genetic research in pediatric cardiomyopathy (CM) has focused on pathogenic variants for diagnostic purposes, with limited data evaluating genotype-outcome correlations. We explored whether greater genetic variant burden (pathogenic or variants of unknown significance, VUS) correlates with worse outcomes. METHODS Children with dilated CM (DCM) and hypertrophic CM (HCM) who underwent multigene testing between 2010 and 2018 were included. Composite endpoint was freedom from major adverse cardiac event (MACE). RESULTS Three hundred and thirty-eight subjects were included [49% DCM, median age 5.7 (interquartile range (IQR) 0.2-13.4) years, 51% HCM, median age 3.0 (IQR 0.1-12.5) years]. Pathogenic variants alone were not associated with MACE in either cohort (DCM p = 0.44; HCM p = 0.46). In DCM, VUS alone [odds ratio (OR) 4.0, 95% confidence interval (CI) 1.9-8.3] and in addition to pathogenic variants (OR 5.2, 95% CI 1.7-15.9) was associated with MACE. The presence of VUS alone or in addition to pathogenic variants were not associated with MACE in HCM (p = 0.22 and p = 0.33, respectively). CONCLUSION Increased genetic variant burden (pathogenic variants and VUS) is associated with worse clinical outcomes in DCM but not HCM. Genomic variants that influence DCM onset may be distinct from those driving disease progression, highlighting the potential value of universal genetic testing to improve risk stratification. IMPACT In pediatric CM, inconsistent findings historically have been shown between genotype and phenotype severity when only pathogenic variants have been considered. Increased genetic variant burden (including both pathogenic variants and VUS) is associated with worse clinical outcomes in DCM but not HCM. Genomic variants that influence CM onset may be distinct from those variants that drive disease progression and influence outcomes in phenotype-positive individuals. Incorporation of both pathogenic variants and VUS may improve risk stratification models in pediatric CM.
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Abstract
BACKGROUND Feeding difficulty is a known complication of congenital heart surgery. Despite this, there is a relative sparsity in the available data regarding risk factors, incidence, associated symptoms, and outcomes. METHODS In this retrospective chart review, patients aged 0-18 years who underwent congenital heart surgery at a single institution between January and December, 2017 were reviewed. Patients with feeding difficulties before surgery, multiple surgeries, and potentially abnormal recurrent laryngeal nerve anatomy were excluded. Data collected included patient demographics, feeding outcomes, post-operative symptoms, flexible nasolaryngoscopy findings, and rates of readmission within a 1-year follow-up period. Multivariable regression analyses were performed to evaluate the risk of an alternative feeding plan at discharge and length of stay. RESULTS Three-hundred and twenty-six patients met the inclusion criteria for this study. Seventy-two (22.09%) were discharged with a feeding tube and 70 (97.22%) of this subgroup were younger than 12 months at the time of surgery. Variables that increased the risk of being discharged with a feeding tube included patient age, The Society of Thoracic Surgeons-European Association for Cardio-Thoracic Surgery score, procedure group, aspiration, and reflux. Speech-language pathology was the most frequently utilised consulting service for patients discharged with feeding tubes (90.28%) while other services were not frequently consulted. The median length of stay was increased from 4 to 10 days for patients who required an enteral feeding tube at discharge. DISCUSSION Multidisciplinary management protocol and interventions should be developed and standardised to improve feeding outcomes following congenital heart surgery.
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Kim RW. Is There Any Clinical Utility to Genetic Testing for Patients With Congenital Heart Disease? Semin Thorac Cardiovasc Surg Pediatr Card Surg Annu 2021; 24:26-29. [PMID: 34116779 DOI: 10.1053/j.pcsu.2021.04.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2021] [Revised: 04/11/2021] [Accepted: 04/19/2021] [Indexed: 11/11/2022]
Abstract
Genetic diagnosis is becoming increasingly sophisticated, with the ability to identify even fine differences in patients with a wide variety of congenital heart lesions. Although we have an incomplete understanding of the clinical consequences of most genetic findings, some categories of mutations can have important implications for disease recurrence and prognosis. Consideration of the biology underlying a genetic deficiency, when known, can be useful in the clinical management of some patients.
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Affiliation(s)
- Richard W Kim
- Pediatric and Congenital Cardiac Surgery, Guerin Congenital Heart Program, Smidt Heart Institute, Cedars- Sinai Medical Center, Los Angeles, California.
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12
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Russell MW, Moldenhauer JS, Rychik J, Burnham NB, Zullo E, Parry SI, Simmons RA, Elovitz MA, Nicolson SC, Linn RL, Johnson MP, Yu S, Sampson MG, Hakonarson H, Gaynor JW. Damaging Variants in Proangiogenic Genes Impair Growth in Fetuses with Cardiac Defects. J Pediatr 2019; 213:103-109. [PMID: 31227283 PMCID: PMC6765419 DOI: 10.1016/j.jpeds.2019.05.013] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/15/2019] [Revised: 04/30/2019] [Accepted: 05/09/2019] [Indexed: 02/08/2023]
Abstract
OBJECTIVE To determine the impact of damaging genetic variation in proangiogenic pathways on placental function, complications of pregnancy, fetal growth, and clinical outcomes in pregnancies with fetal congenital heart defect. STUDY DESIGN Families delivering a baby with a congenital heart defect requiring surgical repair in infancy were recruited. The placenta and neonate were weighed and measured. Hemodynamic variables were recorded from a third trimester (36.4 ± 1.7 weeks) fetal echocardiogram. Exome sequencing was performed on the probands (N = 133) and consented parents (114 parent-child trios, and 15 parent-child duos) and the GeneVetter analysis tool used to identify damaging coding sequence variants in 163 genes associated with the positive regulation of angiogenesis (PRA) (GO:0045766). RESULTS In total, 117 damaging variants were identified in PRA genes in 133 congenital heart defect probands with 73 subjects having at least 1 variant. Presence of a damaging PRA variant was associated with increased umbilical artery pulsatility index (mean 1.11 with variant vs 1.00 without; P = .01). The presence of a damaging PRA variant was also associated with lower neonatal length and head circumference for age z score at birth (mean -0.44 and -0.47 with variant vs 0.23 and -0.05 without; P = .01 and .04, respectively). During median 3.1 years (IQR 2.0-4.1 years) of follow-up, deaths occurred in 2 of 60 (3.3%) subjects with no PRA variant and in 9 of 73 (12.3%) subjects with 1 or more PRA variants (P = .06). CONCLUSIONS Damaging variants in proangiogenic genes may impact placental function and are associated with impaired fetal growth in pregnancies involving a fetus with congenital heart defect.
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Affiliation(s)
- Mark W Russell
- Division of Pediatric Cardiology, Department of Pediatrics, University of Michigan Medical School, Ann Arbor, MI.
| | - Julie S Moldenhauer
- Center for Fetal Diagnosis and Therapy, The Children's Hospital of Philadelphia, Philadelphia, PA
| | - Jack Rychik
- Division of Pediatric Cardiology, The Children's Hospital of Philadelphia, Philadelphia, PA
| | - Nancy B Burnham
- Division of Cardiothoracic Surgery, The Children's Hospital of Philadelphia, Philadelphia, PA
| | - Erin Zullo
- Division of Cardiothoracic Surgery, The Children's Hospital of Philadelphia, Philadelphia, PA
| | - Samuel I Parry
- Division of Maternal Fetal Medicine, Perelman School of Medicine, The University of Pennsylvania, Philadelphia, PA
| | - Rebecca A Simmons
- Division of Neonatology, The Children's Hospital of Philadelphia, Philadelphia, PA
| | - Michal A Elovitz
- Division of Maternal Fetal Medicine, Perelman School of Medicine, The University of Pennsylvania, Philadelphia, PA
| | - Susan C Nicolson
- Division of Cardiothoracic Anesthesiology, The Children's Hospital of Philadelphia, Philadelphia, PA
| | - Rebecca L Linn
- Division of Anatomic Pathology, The Children's Hospital of Philadelphia, Philadelphia, PA
| | - Mark P Johnson
- Center for Fetal Diagnosis and Therapy, The Children's Hospital of Philadelphia, Philadelphia, PA
| | - Sunkyung Yu
- Division of Pediatric Cardiology, Department of Pediatrics, University of Michigan Medical School, Ann Arbor, MI
| | - Matthew G Sampson
- Division of Pediatric Nephrology, Department of Pediatrics, and Center for Computational Medicine and Bioinformatics, University of Michigan Medical School, Ann Arbor, MI
| | - Hakon Hakonarson
- The Center for Applied Genomics, The Children's Hospital of Philadelphia and the Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - J William Gaynor
- Division of Cardiothoracic Surgery, The Children's Hospital of Philadelphia, Philadelphia, PA
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Pasquali SK, Gaies M, Banerjee M, Zhang W, Donohue J, Russell M, Gaynor JW. The Quest for Precision Medicine: Unmeasured Patient Factors and Mortality After Congenital Heart Surgery. Ann Thorac Surg 2019; 108:1889-1894. [PMID: 31398358 DOI: 10.1016/j.athoracsur.2019.06.031] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/25/2019] [Revised: 05/16/2019] [Accepted: 06/03/2019] [Indexed: 12/31/2022]
Abstract
BACKGROUND Emerging data across many fields suggest that unique patient characteristics can impact disease manifestation and response to therapy, supporting "precision medicine" approaches and more individualized and targeted therapeutic strategies. In children undergoing congenital heart surgery, current risk models primarily focus on the population level, and their utility in understanding precise characteristics that place individual patients at risk for poor outcome remains unclear. METHODS We analyzed index surgeries in the Pediatric Cardiac Critical Care Consortium (PC4) registry (August 2014 to May 2016) and utilized a previously constructed model containing patient factors typically included in in-hospital mortality risk models (age, weight, prematurity, chromosomal anomalies/syndromes, preoperative factors, The Society of Thoracic Surgeons-European Association for Cardio-Thoracic Surgery score). Partitioned variances based on a hierarchical generalized linear model were used to estimate the proportion of variation in mortality explained by these factors. RESULTS A total of 8406 operations (22 hospitals) were included. We found that only 30% of the total between-patient variation in mortality in our cohort was explained by the patient factors included in our model. Age, The Society of Thoracic Surgeons-European Association for Cardio-Thoracic Surgery score, and preoperative mechanical ventilation explained the greatest proportion of variation. Of the variation that remained unexplained, 95% was attributable to unmeasured patient factors. In stratified analyses, these results were consistent across patient subgroups. CONCLUSIONS Patient factors typically included in congenital heart surgery risk models explain only a small portion of total variation in mortality. A better understanding of other underrecognized factors is critical in further defining risk profiles and in developing more individualized and tailored therapeutic strategies.
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Affiliation(s)
- Sara K Pasquali
- Division of Cardiology, Department of Pediatrics and Communicable Diseases, University of Michigan C.S. Mott Children's Hospital, Ann Arbor, Michigan.
| | - Michael Gaies
- Division of Cardiology, Department of Pediatrics and Communicable Diseases, University of Michigan C.S. Mott Children's Hospital, Ann Arbor, Michigan
| | - Mousumi Banerjee
- Department of Biostatistics, University of Michigan, Ann Arbor, Michigan
| | - Wenying Zhang
- Division of Cardiology, Department of Pediatrics and Communicable Diseases, University of Michigan C.S. Mott Children's Hospital, Ann Arbor, Michigan
| | - Janet Donohue
- Division of Cardiology, Department of Pediatrics and Communicable Diseases, University of Michigan C.S. Mott Children's Hospital, Ann Arbor, Michigan
| | - Mark Russell
- Division of Cardiology, Department of Pediatrics and Communicable Diseases, University of Michigan C.S. Mott Children's Hospital, Ann Arbor, Michigan
| | - J William Gaynor
- Department of Surgery, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
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14
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Orzell S, Joseph R, Ongkasuwan J, Bedwell J, Shin J, Raol N. Outcomes of Vocal Fold Motion Impairment and Dysphagia after Pediatric Cardiothoracic Surgery: A Systematic Review. Otolaryngol Head Neck Surg 2019; 161:754-763. [DOI: 10.1177/0194599819858594] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
Objective The objective of this study was to systematically review the literature regarding vocal fold motion impairment (VFMI), respiratory outcomes, and swallowing outcomes in children following congenital heart surgery (CHS). Data Sources PubMed, Embase, Medline, and CINAHL databases. Review Methods Data sources were searched from inception to November 30, 2018. Studies that described recovery of VFMI and swallowing function following CHS were included, and a qualitative analysis was performed. Results A total of 1371 studies were identified, of which 8 met inclusion criteria for VFMI and 5 met inclusion criteria for swallowing outcomes. Studies including patients who underwent isolate patent ductus arteriosus ligation were excluded. VFMI was present in 8% to 59% of subjects, and rates of recovery ranged from 9% to 96% at 6 months to 6 years of follow-up. Inability to maintain an oral diet occurred in 14% to 100% of subjects with VFMI and 11% to 61% without VFMI following surgery. Tolerance of an oral diet without tube feeding was present in 66% to 75% of subjects with VFMI and 88% to 100% without VFMI at 24 days to 3.2 years of follow-up. Limited data suggest that time to extubation is longer in VFMI subjects, but overall hospital length of stay and mortality may not be affected by VFMI status. Conclusions Data evaluating dysphagia and VFMI after CHS are limited. Most studies suggest significant improvement in swallowing function, while rate of recovery of VFMI is variable. Future prospective studies with standardized screening and follow-up are needed to better elucidate outcomes to help develop algorithms for identification and management of VFMI after CHS.
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Affiliation(s)
- Susannah Orzell
- Department of Otolaryngology, SUNY Upstate Medical Center, Syracuse, New York, USA
| | - Rahul Joseph
- School of Medicine Emory University, Atlanta, Georgia, USA
| | - Julina Ongkasuwan
- Department of Otolaryngology, Baylor College of Medicine, Houston, Texas, USA
| | - Joshua Bedwell
- Department of Otolaryngology, Baylor College of Medicine, Houston, Texas, USA
| | - Jennifer Shin
- Department of Otolaryngology, Harvard Medical School, Boston, Massachusetts, USA
| | - Nikhila Raol
- Department of Otolaryngology–Head and Neck Surgery, School of Medicine, Emory University, Atlanta, Georgia, USA
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15
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Impact of genetic studies on comprehension and treatment of congenital heart disease. PROGRESS IN PEDIATRIC CARDIOLOGY 2018. [DOI: 10.1016/j.ppedcard.2018.10.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
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16
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Russell MW, Chung WK, Kaltman JR, Miller TA. Advances in the Understanding of the Genetic Determinants of Congenital Heart Disease and Their Impact on Clinical Outcomes. J Am Heart Assoc 2018; 7:e006906. [PMID: 29523523 PMCID: PMC5907537 DOI: 10.1161/jaha.117.006906] [Citation(s) in RCA: 68] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Affiliation(s)
- Mark W Russell
- Division of Pediatric Cardiology, University of Michigan, Ann Arbor, MI
| | - Wendy K Chung
- Departments of Pediatrics and Medicine, Columbia University, New York, NY
| | - Jonathan R Kaltman
- Division of Cardiovascular Sciences, National Heart, Lung, and Blood Institute, Bethesda, MD
| | - Thomas A Miller
- Department of Pediatrics, University of Utah, Salt Lake City, UT
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17
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A vascular endothelial growth factor A genetic variant is associated with improved ventricular function and transplant-free survival after surgery for non-syndromic CHD. Cardiol Young 2018; 28:39-45. [PMID: 28927471 DOI: 10.1017/s1047951117001391] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
BACKGROUND We have previously shown that the minor alleles of vascular endothelial growth factor A (VEGFA) single-nucleotide polymorphism rs833069 and superoxide dismutase 2 (SOD2) single-nucleotide polymorphism rs2758331 are both associated with improved transplant-free survival after surgery for CHD in infants, but the underlying mechanisms are unknown. We hypothesised that one or both of these minor alleles are associated with better systemic ventricular function, resulting in improved survival. METHODS This study is a follow-up analysis of 422 non-syndromic CHD patients who underwent neonatal cardiac surgery with cardiopulmonary bypass. Echocardiographic reports were reviewed. Systemic ventricular function was subjectively categorised as normal, or as mildly, moderately, or severely depressed. The change in function was calculated as the change from the preoperative study to the last available study. Stepwise linear regression, adjusting for covariates, was performed for the outcome of change in ventricular function. Model comparison was performed using Akaike's information criterion. Only variables that improved the model prediction of change in systemic ventricular function were retained in the final model. RESULTS Genetic and echocardiographic data were available for 335/422 subjects (79%). Of them, 33 (9.9%) developed worse systemic ventricular function during a mean follow-up period of 13.5 years. After covariate adjustment, the presence of the VEGFA minor allele was associated with preserved ventricular function (p=0.011). CONCLUSIONS These data support the hypothesis that the mechanism by which the VEGFA single-nucleotide polymorphism rs833069 minor allele improves survival may be the preservation of ventricular function. Further studies are needed to validate this genotype-phenotype association and to determine whether this mechanism is related to increased vascular endothelial growth factor production.
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18
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Kim DS, Li YK, Kim JH, Bergquist CS, Gerdes M, Bernbaum JC, Burnham N, McDonald-McGinn DM, Zackai EH, Nicolson SC, Spray TL, Nickerson DA, Hakonarson H, Jarvik GP, Gaynor JW. Autosomal dominant mannose-binding lectin deficiency is associated with worse neurodevelopmental outcomes after cardiac surgery in infants. J Thorac Cardiovasc Surg 2017; 155:1139-1147.e2. [PMID: 29452463 DOI: 10.1016/j.jtcvs.2017.08.035] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/24/2017] [Revised: 07/01/2017] [Accepted: 08/03/2017] [Indexed: 11/19/2022]
Abstract
OBJECTIVES The MBL2 gene is the major genetic determinant of mannose-binding lectin (MBL)-an acute phase reactant. Low MBL levels have been associated with adverse outcomes in preterm infants. The MBL2Gly54Asp missense variant causes autosomal dominant MBL deficiency. We tested the hypothesis that MBL2Gly54Asp is associated with worse neurodevelopmental outcomes after cardiac surgery in neonates. METHODS This is an analysis of a previously described cohort of patients with nonsyndromic congenital heart disease who underwent cardiac surgery with cardiopulmonary bypass before age 6 months (n = 295). Four-year neurodevelopment was assessed in 3 domains: Full-Scale Intellectual Quotient, the Visual Motor Integration development test, and the Child Behavior Checklist to assess behavior problems. The Child Behavior Checklist measured total behavior problems, pervasive developmental problems, and internalizing/externalizing problems. A multivariable linear regression model, adjusting for confounders, was fit. RESULTS MBL2Gly54Asp was associated with a significantly increased covariate-adjusted pervasive developmental problem score (β = 3.98; P = .0025). Sensitivity analyses of the interaction between age at first surgery and MBL genotype suggested effect modification for the patients with MBL2Gly54Asp (Pinteraction = .039), with the poorest neurodevelopment outcomes occurring in children who had surgery earlier in life. CONCLUSIONS We report the novel finding that carriers of MBL2Gly54Asp causing autosomal dominant MBL deficiency have increased childhood pervasive developmental problems after cardiac surgery, independent of other covariates. Sensitivity analyses suggest that this effect may be larger in children who underwent surgery at earlier ages. These data support the role of nonsyndromic genetic variation in determining postsurgical neurodevelopment-related outcomes in children with congenital heart disease.
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MESH Headings
- Age Factors
- Cardiac Surgical Procedures/adverse effects
- Checklist
- Child Behavior
- Child Development
- Child Development Disorders, Pervasive/diagnosis
- Child Development Disorders, Pervasive/etiology
- Child Development Disorders, Pervasive/physiopathology
- Child Development Disorders, Pervasive/psychology
- Child, Preschool
- Female
- Gene-Environment Interaction
- Genetic Predisposition to Disease
- Heart Defects, Congenital/complications
- Heart Defects, Congenital/diagnostic imaging
- Heart Defects, Congenital/surgery
- Humans
- Infant
- Infant, Newborn
- Male
- Mannose-Binding Lectin/deficiency
- Mannose-Binding Lectin/genetics
- Metabolism, Inborn Errors/complications
- Metabolism, Inborn Errors/diagnosis
- Metabolism, Inborn Errors/genetics
- Metabolism, Inborn Errors/physiopathology
- Motor Skills
- Mutation, Missense
- Nervous System/growth & development
- Neurologic Examination
- Phenotype
- Risk Assessment
- Risk Factors
- Time Factors
- Treatment Outcome
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Affiliation(s)
- Daniel Seung Kim
- Division of Medical Genetics, Department of Medicine, University of Washington, Seattle, Wash; Department of Genome Sciences, University of Washington, Seattle, Wash; Department of Biostatistics, University of Michigan, Ann Arbor, Mich
| | - Yatong K Li
- Department of Biostatistics, University of Michigan, Ann Arbor, Mich
| | - Jerry H Kim
- Department of Anesthesiology and Pain Medicine, University of Washington, Seattle, Wash
| | - Curtis S Bergquist
- Section of Thoracic Surgery, Department of Surgery, University of Michigan, Ann Arbor, Mich
| | - Marsha Gerdes
- Department of Pediatrics, The Children's Hospital of Philadelphia and the Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pa
| | - Judy C Bernbaum
- Department of Pediatrics, The Children's Hospital of Philadelphia and the Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pa
| | - Nancy Burnham
- Division of Cardiothoracic Surgery, The Children's Hospital of Philadelphia and the Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pa
| | - Donna M McDonald-McGinn
- Division of Genetics, The Children's Hospital of Philadelphia and the Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pa
| | - Elaine H Zackai
- Division of Genetics, The Children's Hospital of Philadelphia and the Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pa
| | - Susan C Nicolson
- Division of Cardiothoracic Anesthesiology, The Children's Hospital of Philadelphia and the Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pa
| | - Thomas L Spray
- Division of Cardiothoracic Surgery, The Children's Hospital of Philadelphia and the Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pa
| | | | - Hakon Hakonarson
- Center for Applied Genomics, The Children's Hospital of Philadelphia and the Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pa
| | - Gail P Jarvik
- Division of Medical Genetics, Department of Medicine, University of Washington, Seattle, Wash; Department of Genome Sciences, University of Washington, Seattle, Wash
| | - J William Gaynor
- Division of Cardiothoracic Surgery, The Children's Hospital of Philadelphia and the Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pa.
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19
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Blue GM, Kirk EP, Giannoulatou E, Sholler GF, Dunwoodie SL, Harvey RP, Winlaw DS. Advances in the Genetics of Congenital Heart Disease: A Clinician's Guide. J Am Coll Cardiol 2017; 69:859-870. [PMID: 28209227 DOI: 10.1016/j.jacc.2016.11.060] [Citation(s) in RCA: 88] [Impact Index Per Article: 12.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/26/2016] [Revised: 11/15/2016] [Accepted: 11/17/2016] [Indexed: 11/18/2022]
Abstract
Our understanding of the genetics of congenital heart disease (CHD) is rapidly expanding; however, many questions, particularly those relating to sporadic forms of disease, remain unanswered. Massively parallel sequencing technology has made significant contributions to the field, both from a diagnostic perspective for patients and, importantly, also from the perspective of disease mechanism. The importance of de novo variation in sporadic disease is a recent highlight, and the genetic link between heart and brain development has been established. Furthermore, evidence of an underlying burden of genetic variation contributing to sporadic and familial forms of CHD has been identified. Although we are still unable to identify the cause of CHD for most patients, recent findings have provided us with a much clearer understanding of the types of variants and their individual contributions and collectively mark an important milestone in our understanding of both familial and sporadic forms of disease.
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Affiliation(s)
- Gillian M Blue
- Kids Heart Research, The Children's Hospital at Westmead, Sydney, Australia; Heart Centre for Children, The Children's Hospital at Westmead, Sydney, Australia; Sydney Medical School, University of Sydney, Australia
| | - Edwin P Kirk
- Department of Medical Genetics, Sydney Children's Hospital, Sydney, Australia; School of Women's and Children's Health, Faculty of Medicine, University of New South Wales, Sydney, Australia
| | - Eleni Giannoulatou
- Victor Chang Cardiac Research Institute, Darlinghurst, Sydney, Australia; St Vincent's Clinical School, Faculty of Medicine, University of New South Wales, Sydney, Australia; School of Biotechnology and Biomolecular Sciences, University of New South Wales, Sydney
| | - Gary F Sholler
- Kids Heart Research, The Children's Hospital at Westmead, Sydney, Australia; Heart Centre for Children, The Children's Hospital at Westmead, Sydney, Australia; Sydney Medical School, University of Sydney, Australia
| | - Sally L Dunwoodie
- Victor Chang Cardiac Research Institute, Darlinghurst, Sydney, Australia; St Vincent's Clinical School, Faculty of Medicine, University of New South Wales, Sydney, Australia; School of Biotechnology and Biomolecular Sciences, University of New South Wales, Sydney
| | - Richard P Harvey
- Victor Chang Cardiac Research Institute, Darlinghurst, Sydney, Australia; St Vincent's Clinical School, Faculty of Medicine, University of New South Wales, Sydney, Australia; School of Biotechnology and Biomolecular Sciences, University of New South Wales, Sydney
| | - David S Winlaw
- Kids Heart Research, The Children's Hospital at Westmead, Sydney, Australia; Heart Centre for Children, The Children's Hospital at Westmead, Sydney, Australia; Sydney Medical School, University of Sydney, Australia.
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20
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Ramroop R, Manase G, Lu D, Manase D, Chen S, Kim R, Lee T, Mahle WT, McHugh K, Mitchell M, Tristani-Firouzi M, Wechsler SB, Wilder NS, Zak V, Lafreniere-Roula M, Newburger JW, Gaynor JW, Russell MW, Mital S. Adrenergic receptor genotypes influence postoperative outcomes in infants in the Single-Ventricle Reconstruction Trial. J Thorac Cardiovasc Surg 2017; 154:1703-1710.e3. [PMID: 28734628 DOI: 10.1016/j.jtcvs.2017.06.041] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/04/2016] [Revised: 06/06/2017] [Accepted: 06/20/2017] [Indexed: 12/18/2022]
Abstract
OBJECTIVES Adrenergic receptor (ADR) genotypes have been associated with adverse outcomes in heart failure. Our objective was to evaluate the association of ADR genotypes with post-Norwood outcomes in infants with hypoplastic left heart syndrome (HLHS). METHODS Infants with HLHS participating in the Pediatric Heart Network Single-Ventricle Reconstruction Trial underwent genotyping for 4 single-nucleotide polymorphisms in 3 ADR genes: ADRB1_231A/G, ADRB1_1165G/C, ADRB2_5318C/G, and ADRA2A_2790C/T. The association of genotype with freedom from serious adverse events (SAEs) (death, transplant, extracorporeal membrane oxygenation, cardiopulmonary resuscitation, acute shunt failure, unplanned reoperations, or necrotizing enterocolitis) during 14 months' follow-up was assessed with Cox regression and the association with post-Norwood complications was assessed with Poisson regression. Models were adjusted for clinical and surgical factors. RESULTS The study included 351 eligible patients (62% male; 83% white). The mean age at Norwood procedure was 5.6 ± 3.6 days. A total of 152 patients had SAEs during 14-month follow-up including 84 deaths and 10 transplants. ADRA2A_2790CC genotype had lower SAE-free survival compared with CT/TT genotypes during follow-up (Log rank test, P = .02), and this association was independent of clinical and surgical risk factors (adjusted Cox regression, hazard ratio 1.54 [95% confidence interval 1.04, 2.30] P = .033). Post-Norwood complication rate did not differ by genotype. CONCLUSIONS Infants with HLHS harboring ADR genotypes that are associated with greater catecholamine release or sensitivity had lower event-free survival after staged palliation. Excess catecholamine activation may adversely affect cardiovascular adaptation after the Norwood procedure. Future studies should explore whether targeting adrenergic activation in those harboring risk genotypes can improve outcomes. (ClinicalTrials.gov number NCT00115934).
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Affiliation(s)
- Ronand Ramroop
- Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
| | - George Manase
- Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
| | - Danny Lu
- Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
| | - Dorin Manase
- Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
| | - Shan Chen
- New England Research Institute, Watertown, Mass
| | - Richard Kim
- Children's Hospital of Los Angeles, Los Angeles, Calif
| | - Teresa Lee
- Columbia University Medical Center, New York, NY
| | | | | | | | | | | | | | - Victor Zak
- New England Research Institute, Watertown, Mass
| | | | | | | | | | - Seema Mital
- Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada.
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21
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Oster ME, Watkins S, Hill KD, Knight JH, Meyer RE. Academic Outcomes in Children With Congenital Heart Defects: A Population-Based Cohort Study. Circ Cardiovasc Qual Outcomes 2017; 10:CIRCOUTCOMES.116.003074. [PMID: 28228450 DOI: 10.1161/circoutcomes.116.003074] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/10/2016] [Accepted: 01/13/2017] [Indexed: 02/04/2023]
Abstract
BACKGROUND Most studies evaluating neurocognitive outcomes in children with congenital heart defects (CHD) have focused on high-risk patients or used specialized, resource-intensive testing. To determine the association of CHD with academic outcomes and compare outcomes according to the severity of CHD, we linked state educational records with a birth defects registry and birth certificates. METHODS AND RESULTS We performed a retrospective cohort study using data from the North Carolina Birth Defects Monitoring Program, North Carolina Department of Public Instruction, and North Carolina Department of Health and Human Services vital records. We performed logistic regression, adjusting for maternal education, race/ethnicity, enrollment in public pre-Kindergarten, and gestational age, to determine the association of CHD with not meeting standards on reading and math end-of-grade examinations in third grade in 2006 to 2012. Of 5624 subjects with CHD and 10 832 with no structural birth defects, 2807 (50%) and 6355 (59%) were linked, respectively. Children with CHD had 1.24× the odds of not meeting standards in either reading or math (95% confidence interval, 1.12-1.37), with 44.6% of children with CHD not meeting standards in at least one of these areas compared with 37.5% without CHD. Although children with both critical and noncritical CHD had poorer outcomes, those with critical CHD were significantly more likely to receive exceptional services compared with the noncritical group (adjusted odds ratio, 1.46; 95% confidence interval, 1.15-1.86). CONCLUSIONS Children with all types of CHD have poorer academic outcomes compared with their peers. Evaluation for exceptional services should be considered in children with any type of CHD.
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Affiliation(s)
- Matthew E Oster
- From the Department of Pediatrics, Emory University School of Medicine, Atlanta, GA (M.E.O); Department of Cardiology, Children's Healthcare of Atlanta, GA (M.E.O.); Department of Epidemiology, Emory University Rollins School of Public Health, Atlanta, GA (M.E.O., J.H.K.); Department of Physical Therapy, Methodist University, Fayetteville, NC (S.W.); Department of Pediatrics, Duke University Medical Center and the Duke Clinical Research Institute, Durham, NC (K.D.H.); and Birth Defects Monitoring Branch, State Center for Health Statistics, North Carolina Division of Public Health, Raleigh (R.E.M.).
| | - Stephanie Watkins
- From the Department of Pediatrics, Emory University School of Medicine, Atlanta, GA (M.E.O); Department of Cardiology, Children's Healthcare of Atlanta, GA (M.E.O.); Department of Epidemiology, Emory University Rollins School of Public Health, Atlanta, GA (M.E.O., J.H.K.); Department of Physical Therapy, Methodist University, Fayetteville, NC (S.W.); Department of Pediatrics, Duke University Medical Center and the Duke Clinical Research Institute, Durham, NC (K.D.H.); and Birth Defects Monitoring Branch, State Center for Health Statistics, North Carolina Division of Public Health, Raleigh (R.E.M.)
| | - Kevin D Hill
- From the Department of Pediatrics, Emory University School of Medicine, Atlanta, GA (M.E.O); Department of Cardiology, Children's Healthcare of Atlanta, GA (M.E.O.); Department of Epidemiology, Emory University Rollins School of Public Health, Atlanta, GA (M.E.O., J.H.K.); Department of Physical Therapy, Methodist University, Fayetteville, NC (S.W.); Department of Pediatrics, Duke University Medical Center and the Duke Clinical Research Institute, Durham, NC (K.D.H.); and Birth Defects Monitoring Branch, State Center for Health Statistics, North Carolina Division of Public Health, Raleigh (R.E.M.)
| | - Jessica H Knight
- From the Department of Pediatrics, Emory University School of Medicine, Atlanta, GA (M.E.O); Department of Cardiology, Children's Healthcare of Atlanta, GA (M.E.O.); Department of Epidemiology, Emory University Rollins School of Public Health, Atlanta, GA (M.E.O., J.H.K.); Department of Physical Therapy, Methodist University, Fayetteville, NC (S.W.); Department of Pediatrics, Duke University Medical Center and the Duke Clinical Research Institute, Durham, NC (K.D.H.); and Birth Defects Monitoring Branch, State Center for Health Statistics, North Carolina Division of Public Health, Raleigh (R.E.M.)
| | - Robert E Meyer
- From the Department of Pediatrics, Emory University School of Medicine, Atlanta, GA (M.E.O); Department of Cardiology, Children's Healthcare of Atlanta, GA (M.E.O.); Department of Epidemiology, Emory University Rollins School of Public Health, Atlanta, GA (M.E.O., J.H.K.); Department of Physical Therapy, Methodist University, Fayetteville, NC (S.W.); Department of Pediatrics, Duke University Medical Center and the Duke Clinical Research Institute, Durham, NC (K.D.H.); and Birth Defects Monitoring Branch, State Center for Health Statistics, North Carolina Division of Public Health, Raleigh (R.E.M.)
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22
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Spray TL, Gaynor JW. A Word of Caution in Public Reporting. Semin Thorac Cardiovasc Surg Pediatr Card Surg Annu 2017; 20:49-55. [PMID: 28007065 DOI: 10.1053/j.pcsu.2016.09.014] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2016] [Accepted: 09/28/2016] [Indexed: 06/06/2023]
Abstract
Public reporting in its current form will lead to confusion amongst physicians, administrators, families, and the media. It is unclear that we are giving the families information they really need. At the current time there is no evidence that public reporting really leads to improved outcomes. Rather, it may lead to risk aversion and limit access to care. This is a problem not just for congenital heart surgery but for the entire field of medicine and the care that we provide to our patients. We must be very careful that we don't create a system where we are afraid to take on a patient with increased risk of mortality because it may affect our overall ranking.
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Affiliation(s)
- Thomas L Spray
- The Children's Hospital of Philadelphia, Philadelphia, PA.
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23
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Abstract
OBJECTIVES The objectives of this review are to discuss the scope of neurologic injuries in newborns with congenital heart disease, the mechanisms of injury, including prenatal, pre-, intra-, and postoperative factors, neurodevelopmental outcomes, and therapeutic strategies for the timely intervention and prevention of neurologic injury. DATA SOURCE MEDLINE and PubMed. CONCLUSION At the current time, important research is underway to 1) better understand the developing brain in the fetus with complex congenital heart disease, 2) to identify modifiable risk factors in the operating room and ICU to maximize long-term neurodevelopmental outcomes, and 3) develop strategies to improve family psychosocial health, childhood development, and health-related quality of life following hospital discharge. Crucial in this effort is the identification of an early postoperative surrogate variable with good predictive validity for long-term outcomes. If an appropriate surrogate variable for long-term outcomes can be identified, and measured relatively early after surgical intervention for complex congenital heart disease, reliable clinical trials can be undertaken to improve upon current outcomes.
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Chaix MA, Andelfinger G, Khairy P. Genetic testing in congenital heart disease: A clinical approach. World J Cardiol 2016; 8:180-191. [PMID: 26981213 PMCID: PMC4766268 DOI: 10.4330/wjc.v8.i2.180] [Citation(s) in RCA: 35] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/08/2015] [Revised: 10/16/2015] [Accepted: 12/11/2015] [Indexed: 02/06/2023] Open
Abstract
Congenital heart disease (CHD) is the most common type of birth defect. Traditionally, a polygenic model defined by the interaction of multiple genes and environmental factors was hypothesized to account for different forms of CHD. It is now understood that the contribution of genetics to CHD extends beyond a single unified paradigm. For example, monogenic models and chromosomal abnormalities have been associated with various syndromic and non-syndromic forms of CHD. In such instances, genetic investigation and testing may potentially play an important role in clinical care. A family tree with a detailed phenotypic description serves as the initial screening tool to identify potentially inherited defects and to guide further genetic investigation. The selection of a genetic test is contingent upon the particular diagnostic hypothesis generated by clinical examination. Genetic investigation in CHD may carry the potential to improve prognosis by yielding valuable information with regards to personalized medical care, confidence in the clinical diagnosis, and/or targeted patient follow-up. Moreover, genetic assessment may serve as a tool to predict recurrence risk, define the pattern of inheritance within a family, and evaluate the need for further family screening. In some circumstances, prenatal or preimplantation genetic screening could identify fetuses or embryos at high risk for CHD. Although genetics may appear to constitute a highly specialized sector of cardiology, basic knowledge regarding inheritance patterns, recurrence risks, and available screening and diagnostic tools, including their strengths and limitations, could assist the treating physician in providing sound counsel.
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Kim DS, Kim JH, Burt AA, Crosslin DR, Burnham N, Kim CE, McDonald-McGinn DM, Zackai EH, Nicolson SC, Spray TL, Stanaway IB, Nickerson DA, Heagerty PJ, Hakonarson H, Gaynor JW, Jarvik GP. Burden of potentially pathologic copy number variants is higher in children with isolated congenital heart disease and significantly impairs covariate-adjusted transplant-free survival. J Thorac Cardiovasc Surg 2015; 151:1147-51.e4. [PMID: 26704054 DOI: 10.1016/j.jtcvs.2015.09.136] [Citation(s) in RCA: 55] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/20/2015] [Revised: 08/14/2015] [Accepted: 09/14/2015] [Indexed: 12/23/2022]
Abstract
OBJECTIVES Copy number variants (CNVs) are duplications or deletions of genomic regions. Large CNVs are potentially pathogenic and are overrepresented in children with congenital heart disease (CHD). We sought to determine the frequency of large CNVs in children with isolated CHD, and to evaluate the relationship of these potentially pathogenic CNVs with transplant-free survival. METHODS These cases are derived from a prospective cohort of patients with nonsyndromic CHD (n = 422) identified before first surgery. Healthy pediatric controls (n = 500) were obtained from the electronic Medical Records and Genetic Epidemiology Network, and CNV frequency was contrasted for CHD cases and controls. CNVs were determined algorithmically; subsequently screened for >95% overlap between 2 methods, size (>300 kb), quality score, overlap with a gene, and novelty (absent from databases of known, benign CNVs); and separately validated by quantitative polymerase chain reaction. Survival likelihoods for cases were calculated using Cox proportional hazards modeling to evaluate the joint effect of CNV burden and known confounders on transplant-free survival. RESULTS Children with nonsyndromic CHD had a higher burden of potentially pathogenic CNVs compared with pediatric controls (12.1% vs 5.0%; P = .00016). Presence of a CNV was associated with significantly decreased transplant-free survival after surgery (hazard ratio, 3.42; 95% confidence interval, 1.66-7.09; P = .00090) with confounder adjustment. CONCLUSIONS We confirm that children with isolated CHD have a greater burden of rare/large CNVs. We report a novel finding that these CNVs are associated with an adjusted 2.55-fold increased risk of death or transplant. These data suggest that CNV burden is an important modifier of survival after surgery for CHD.
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Affiliation(s)
- Daniel Seung Kim
- Division of Medical Genetics, Department of Medicine, University of Washington, Seattle, Wash; Department of Genome Sciences, University of Washington, Seattle, Wash; Department of Biostatistics, University of Washington, Seattle, Wash
| | - Jerry H Kim
- Department of Anesthesiology and Pain Medicine, University of Washington, Seattle, Wash
| | - Amber A Burt
- Division of Medical Genetics, Department of Medicine, University of Washington, Seattle, Wash
| | - David R Crosslin
- Division of Medical Genetics, Department of Medicine, University of Washington, Seattle, Wash; Department of Genome Sciences, University of Washington, Seattle, Wash
| | - Nancy Burnham
- Division of Cardiothoracic Surgery, The Children's Hospital of Philadelphia, Philadelphia, Pa
| | - Cecilia E Kim
- Center for Applied Genomics, The Children's Hospital of Philadelphia, Philadelphia, Pa
| | | | - Elaine H Zackai
- Division of Genetics, The Children's Hospital of Philadelphia, Philadelphia, Pa
| | - Susan C Nicolson
- Division of Cardiothoracic Anesthesiology, The Children's Hospital of Philadelphia, Philadelphia, Pa
| | - Thomas L Spray
- Division of Cardiothoracic Surgery, The Children's Hospital of Philadelphia, Philadelphia, Pa
| | - Ian B Stanaway
- Department of Genome Sciences, University of Washington, Seattle, Wash
| | | | | | - Hakon Hakonarson
- Center for Applied Genomics, The Children's Hospital of Philadelphia, Philadelphia, Pa
| | - J William Gaynor
- Division of Cardiothoracic Surgery, The Children's Hospital of Philadelphia, Philadelphia, Pa
| | - Gail P Jarvik
- Division of Medical Genetics, Department of Medicine, University of Washington, Seattle, Wash; Department of Genome Sciences, University of Washington, Seattle, Wash.
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Lee TM, Bacha EA. Copy number variants in congenital heart disease: A new risk factor impacting outcomes? J Thorac Cardiovasc Surg 2015; 151:1152-3. [PMID: 26515872 DOI: 10.1016/j.jtcvs.2015.10.002] [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: 09/29/2015] [Accepted: 10/01/2015] [Indexed: 10/22/2022]
Affiliation(s)
- Teresa M Lee
- Division of Pediatric Cardiology, Department of Pediatrics, Columbia University Medical Center, New York, NY.
| | - Emile A Bacha
- Pediatric Cardiac Surgery, Division of Cardiac, Thoracic and Vascular Surgery, Department of Surgery, Columbia University Medical Center, New York, NY
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Alfares FA, Hynes CF, Ansari G, Chounoune R, Ramadan M, Shaughnessy C, Reilly BK, Zurakowski D, Jonas RA, Nath DS. Outcomes of recurrent laryngeal nerve injury following congenital heart surgery: A contemporary experience. J Saudi Heart Assoc 2015; 28:1-6. [PMID: 26778899 PMCID: PMC4685232 DOI: 10.1016/j.jsha.2015.05.002] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2015] [Revised: 03/29/2015] [Accepted: 05/05/2015] [Indexed: 12/04/2022] Open
Abstract
Objective Injury to the recurrent laryngeal nerve can lead to significant morbidity during congenital cardiac surgery. The objective is to expand on the limited understanding of the severity and recovery of this iatrogenic condition. Design A six-year retrospective review of all congenital heart operations at a single institution from January 1, 2008 to December 31, 2013 was performed. All patients with documented vocal cord paralysis on laryngoscopic examination comprised the study cohort. Evaluation of time to vocal cord recovery and need for further surgical intervention was the primary focus. Results The incidence of post-operative vocal cord paralysis was 1.1% (32 out of 3036 patients; 95% confidence interval: 0.7–1.5%). The majority were left-sided injuries (71%). Overall rate of recovery was 61% with a median time of 10 months in those who recovered, and a total follow up of 46 months. Due to feeding complications, 45% of patients required gastrostomy tube after the injury, and these patients were found to have longer duration of post-operative days of intubation (median 10 vs. 5 days, p = 0.03), ICU length of stay (50 vs. 8 days, p = 0.002), and hospital length of stay (92 vs. 41 days, p = 0.01). No pre-operative variables were identified as predictive of recovery or need for gastrostomy placement. Conclusion Recurrent laryngeal nerve injury is a serious complication of congenital heart surgery that impacts post-operative morbidity, in some cases leading to a need for further intervention, in particular, gastrostomy tube placement. A prospective, multi-center study is needed to fully evaluate factors that influence severity and time to recovery.
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Affiliation(s)
- Fahad A Alfares
- Division of Cardiovascular Surgery, Children's National Health System, Washington, DC, United States
| | - Conor F Hynes
- Division of Cardiovascular Surgery, Children's National Health System, Washington, DC, United States
| | - Ghedak Ansari
- Division of Cardiovascular Surgery, Children's National Health System, Washington, DC, United States
| | - Reginald Chounoune
- Division of Cardiovascular Surgery, Children's National Health System, Washington, DC, United States
| | - Manelle Ramadan
- Division of Cardiovascular Surgery, Children's National Health System, Washington, DC, United States
| | - Conner Shaughnessy
- Division of Cardiovascular Surgery, Children's National Health System, Washington, DC, United States
| | - Brian K Reilly
- Department of Otolaryngology, Children's National Health System, Washington, DC, United States
| | - David Zurakowski
- Departments of Anesthesia and Surgery, Boston Children's Hospital, Harvard Medical School, Boston, MA, United States
| | - Richard A Jonas
- Division of Cardiovascular Surgery, Children's National Health System, Washington, DC, United States
| | - Dilip S Nath
- Division of Cardiovascular Surgery, Children's National Health System, Washington, DC, United States
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