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Aronowitz DI, Geoffrion TR, Burstein D, White RM, McHugh-Grant S, Mavroudis CD, Nuri MAK, Maeda K, Chen JM, Mascio CE, Gaynor JW, Fuller S. Reintervention for Superior Vena Cava Obstruction After Heart Transplant. Ann Thorac Surg 2024; 117:198-204. [PMID: 35934067 DOI: 10.1016/j.athoracsur.2022.07.033] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/03/2022] [Revised: 06/14/2022] [Accepted: 07/19/2022] [Indexed: 11/01/2022]
Abstract
BACKGROUND Children undergoing orthotopic heart transplant (OHT) may require complex reconstruction of superior vena cava (SVC) anomalies. SVC anatomy and mode of reconstruction are potential risk factors for SVC obstruction. METHODS A retrospective single-center review was conducted of patients undergoing initial OHT between January 1, 1990, and July 1, 2021. Simple SVC anatomy included a single right SVC to the right atrium or bilateral SVCs with a left SVC to an intact coronary sinus, without prior superior cavopulmonary connection. Presence of anomalous SVC anatomy, superior cavopulmonary connection, or previous atrial switch operation defined complex anatomy. Reconstructive strategies included atrial anastomosis; direct SVC-to-SVC anastomosis; and augmented SVC anastomosis using innominate vein, patch, cavopulmonary connection, or interposition graft. The primary outcome was reintervention for SVC obstruction. RESULTS Of 288 patients, pretransplant diagnoses included congenital heart disease (n = 155 [54%]), cardiomyopathy (n = 125 [43%]), and other (n = 8 [3%]). Most (n = 208 [72%]) had simple SVC anatomy compared with complex SVC anatomy (80 [28%]). Reintervention for SVC obstruction occurred in 15 of 80 (19%) with complex anatomy and 1 of 208 (0.5%) with simple anatomy (P = .0001). Reintervention was more common when innominate vein or a patch was used (9/25 [36%]) compared with an interposition graft (1/7 [14%]) or direct anastomosis (6/82 [7%]; χ2 = 13.1; P = .001). Most reinterventions occurred within 30 days of OHT (14/16 [88%]). CONCLUSIONS Patients with complex SVC anatomy have a higher rate of reintervention for SVC obstruction after OHT compared with those with simple SVC anatomy. In cases of complex SVC anatomy, interposition grafts may be associated with less reintervention compared with complex reconstructions using donor tissue.
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Affiliation(s)
- Danielle I Aronowitz
- Division of Cardiothoracic Surgery, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania.
| | - Tracy R Geoffrion
- Division of Cardiothoracic Surgery, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Danielle Burstein
- Division of Cardiology, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Rachel M White
- Division of Cardiology, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Sara McHugh-Grant
- Division of Cardiothoracic Surgery, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Constantine D Mavroudis
- Division of Cardiothoracic Surgery, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Muhammad A K Nuri
- Division of Cardiothoracic Surgery, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Katsuhide Maeda
- Division of Cardiothoracic Surgery, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Jonathan M Chen
- Division of Cardiothoracic Surgery, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Christopher E Mascio
- Division of Cardiothoracic Surgery, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - J William Gaynor
- Division of Cardiothoracic Surgery, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Stephanie Fuller
- Division of Cardiothoracic Surgery, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
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Coyan GN, Gillespie MJ, Ewing SG, Maeda K. Successful dilation of a novel expandable polytetrafluoroethylene pulmonary artery band negating need for further surgery. JTCVS Tech 2023; 22:258-260. [PMID: 38152218 PMCID: PMC10750872 DOI: 10.1016/j.xjtc.2023.08.029] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2023] [Accepted: 08/17/2023] [Indexed: 12/29/2023] Open
Affiliation(s)
- Garrett N. Coyan
- Division of Cardiothoracic Surgery, Children’s Hospital of Philadelphia, Philadelphia, Pa
| | - Mathew J. Gillespie
- Division of Cardiology, Children’s Hospital of Philadelphia, Philadelphia, Pa
| | - Stanford G. Ewing
- Division of Cardiology, Children’s Hospital of Philadelphia, Philadelphia, Pa
| | - Katsuhide Maeda
- Division of Cardiothoracic Surgery, Children’s Hospital of Philadelphia, Philadelphia, Pa
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Garven E, Rodell CB, Shema K, Govender K, Cassel SE, Ferrick B, Kupsho G, Kung E, Spiller KL, Stevens R, Throckmorton AL. Tunable Blood Shunt for Neonates With Complex Congenital Heart Defects. Front Bioeng Biotechnol 2022; 9:734310. [PMID: 35096785 PMCID: PMC8794538 DOI: 10.3389/fbioe.2021.734310] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2021] [Accepted: 11/17/2021] [Indexed: 11/13/2022] Open
Abstract
Despite advancements in procedures and patient care, mortality rates for neonatal recipients of the Norwood procedure, a palliation for single ventricle congenital malformations, remain high due to the use of a fixed-diameter blood shunt. In this study, a new geometrically tunable blood shunt was investigated to address limitations of the current treatment paradigm (e.g., Modified Blalock-Taussig Shunt) by allowing for controlled modulation of blood flow through the shunt to accommodate physiological changes due to the patient’s growth. First, mathematical and computational cardiovascular models were established to investigate the hemodynamic requirements of growing neonatal patients with shunts and to inform design criteria for shunt diameter changes. Then, two stages of prototyping were performed to design, build and test responsive hydrogel systems that facilitate tuning of the shunt diameter by adjusting the hydrogel’s degree of crosslinking. We examined two mechanisms to drive crosslinking: infusion of chemical crosslinking agents and near-UV photoinitiation. The growth model showed that 15–18% increases in shunt diameter were required to accommodate growing patients’ increasing blood flow; similarly, the computational models demonstrated that blood flow magnitudes were in agreement with previous reports. These target levels of diameter increases were achieved experimentally with model hydrogel systems. We also verified that the photocrosslinkable hydrogel, composed of methacrylated dextran, was contact-nonhemolytic. These results demonstrate proof-of-concept feasibility and reflect the first steps in the development of this novel blood shunt. A tunable shunt design offers a new methodology to rebalance blood flow in this vulnerable patient population during growth and development.
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Affiliation(s)
- Ellen Garven
- BioCirc Research Laboratory, School of Biomedical Engineering, Science, and Health Systems, Drexel University, Philadelphia, PA, United States
| | - Christopher B. Rodell
- Tissue Instructive Materials Laboratory, School of Biomedical Engineering, Science, and Health Systems, Drexel University, Philadelphia, PA, United States
| | - Kristen Shema
- BioCirc Research Laboratory, School of Biomedical Engineering, Science, and Health Systems, Drexel University, Philadelphia, PA, United States
- Biomaterials and Regenerative Medicine Laboratory, School of Biomedical Engineering, Science, and Health Systems, Drexel University, Philadelphia, PA, United States
| | - Krianthan Govender
- BioCirc Research Laboratory, School of Biomedical Engineering, Science, and Health Systems, Drexel University, Philadelphia, PA, United States
- Biomaterials and Regenerative Medicine Laboratory, School of Biomedical Engineering, Science, and Health Systems, Drexel University, Philadelphia, PA, United States
| | - Samantha E. Cassel
- BioCirc Research Laboratory, School of Biomedical Engineering, Science, and Health Systems, Drexel University, Philadelphia, PA, United States
- Biomaterials and Regenerative Medicine Laboratory, School of Biomedical Engineering, Science, and Health Systems, Drexel University, Philadelphia, PA, United States
| | - Bryan Ferrick
- BioCirc Research Laboratory, School of Biomedical Engineering, Science, and Health Systems, Drexel University, Philadelphia, PA, United States
- Biomaterials and Regenerative Medicine Laboratory, School of Biomedical Engineering, Science, and Health Systems, Drexel University, Philadelphia, PA, United States
| | - Gabriella Kupsho
- BioCirc Research Laboratory, School of Biomedical Engineering, Science, and Health Systems, Drexel University, Philadelphia, PA, United States
| | - Ethan Kung
- Department of Mechanical Engineering and Bioengineering, Clemson University, Clemson, SC, United States
| | - Kara L. Spiller
- Biomaterials and Regenerative Medicine Laboratory, School of Biomedical Engineering, Science, and Health Systems, Drexel University, Philadelphia, PA, United States
| | - Randy Stevens
- Pediatrics, College of Medicine, Drexel University, Philadelphia, PA, United States
- Heart Center for Children, St. Christopher’s Hospital for Children, Philadelphia, PA, United States
| | - Amy L. Throckmorton
- BioCirc Research Laboratory, School of Biomedical Engineering, Science, and Health Systems, Drexel University, Philadelphia, PA, United States
- *Correspondence: Amy L. Throckmorton,
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Bellanti E, Calaciura RE, Andriani I, Saitta M, Agati S. Case Report: "Smart Palliation" and "Clepsydra Shape": A new approach in complex congenital heart disease. Front Pediatr 2022; 10:1073412. [PMID: 36683796 PMCID: PMC9852872 DOI: 10.3389/fped.2022.1073412] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/18/2022] [Accepted: 12/07/2022] [Indexed: 01/07/2023] Open
Abstract
A limiting factor in using vascular conduits in the pediatric/newborn population is their inability to grow. Many complex congenital heart diseases require palliative surgery, but using rigid and nonexpandable conduits does not allow the structures to grow and anticipates the need for redo surgery. In newborns, a way to increase the palliation time according to the patient's growth is desirable. In recent years, expandable shunts (exGraft™ PECA) have been developed. According to recent material studies, a shunt could increase diameter after endovascular balloon dilatation. In this case report, we describe the first case of endovascular Blalock-Thomas-Taussig shunt (mBT) shunt expansion in a Tetralogy of Fallot / atrial-ventricular Septal Defect complete (TOFAVSDc) patient with trisomy 21 who went to palliative treatment for tracheomalacia (noncardiac lesion association), severe pulmonary arteries hypoplasia, and low weight. This case introduces the "Smart Palliation concept" in the clinical scenario of selected growing patients where the lifetime of the Blalock-Thomas-Taussig (BT) shunt, anatomic substrates, and complexity of clinical status may require an additional palliation time. The limitation of endovascular conduit expansion is the fragility of the anastomosis site. The anastomosis site is a lesser strength structure of the conduit, and dilatation could develop procedure complications. For this reason, in this paper, we introduced our project design: a new technique (Clepsydra Shape) that consists, before surgical implantation, of pre-expansion of the proximal and distal anastomotic parts of the shunt to obtain an increase of 30% in size of both anastomotic sides, preventing stress- and stretch-related lesion of future balloon dilatation.
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Affiliation(s)
- Ermanno Bellanti
- Department of Congenital Heart Surgery and Pediatric Cardiology Mediterranean Congenital Heart Center, " Bambino Gesù"-San Vincenzo Hospital, Taormina, Italy
| | - Rita E Calaciura
- Department of Congenital Heart Surgery and Pediatric Cardiology Mediterranean Congenital Heart Center, " Bambino Gesù"-San Vincenzo Hospital, Taormina, Italy
| | - Ines Andriani
- Department of Congenital Heart Surgery and Pediatric Cardiology Mediterranean Congenital Heart Center, " Bambino Gesù"-San Vincenzo Hospital, Taormina, Italy
| | - Michele Saitta
- Department of Congenital Heart Surgery and Pediatric Cardiology Mediterranean Congenital Heart Center, " Bambino Gesù"-San Vincenzo Hospital, Taormina, Italy
| | - Salvatore Agati
- Department of Congenital Heart Surgery and Pediatric Cardiology Mediterranean Congenital Heart Center, " Bambino Gesù"-San Vincenzo Hospital, Taormina, Italy
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