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Abdulkarim M, Loomba RS, Zaidi SJ, Li Y, Wilson M, Roberson D, Farias JS, Flores S, Villarreal EG, Husayni T. Echocardiographic Strain to Predict Need for Transplant or Mortality in Fontan Patients with Hypoplastic Left Heart Syndrome. Pediatr Cardiol 2024; 45:1475-1484. [PMID: 37204486 DOI: 10.1007/s00246-023-03187-w] [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: 11/10/2022] [Accepted: 05/14/2023] [Indexed: 05/20/2023]
Abstract
Despite recent advances, hypoplastic left heart syndrome (HLHS) patients subsequent to the Fontan still have significant morbidity and mortality. Some require heart transplant due to systemic ventricular dysfunction. Limited data exist on timing for transplant referral. This study aims to correlate systemic ventricular strain by echocardiography to transplant-free survival. HLHS patients who had Fontan palliation at our institution were included. Patients were divided into: 1) Required transplant or experienced mortality (composite end point); 2) Did not require transplant or survived. For those who experienced the composite endpoint, the last echocardiogram prior to the composite outcome was used, while for those who did not experience the composite endpoint the last echocardiogram obtained was used. Several qualitative and quantitative parameters were analyzed with focus on strain parameters. Ninety-five patients with HLHS Fontan palliation were identified. Sixty-six had adequate images and eight (12%) experienced transplant or mortality. These patients had greater myocardial performance index by flow Doppler (0.72 versus 0.53, p = 0.01), higher systolic/diastolic duration ratio (1.51 versus 1.13, p = 0.02), lower fractional area change (17.65 versus 33.99, p < 0.01), lower global longitudinal strain (GLS) (-8.63 versus - 17.99, p < 0.01), lower global longitudinal strain rate (GLSR) (- 0.51 versus - 0.93, p < 0.01), lower global circumferential strain (GCS) (-6.68 versus -18.25, p < 0.01), and lower (GCSR) global circumferential strain rate (-0.45 versus -1.01, p < 0.01). ROC analysis demonstrated predictive value for GLS - 7.6 (71% sensitive, 97% specific, AUC 81%), GLSR -0.58 (71% sensitive, 88% specific, AUC 82%), GCS - 10.0 (86% sensitive, 91% specific, AUC 82%), and GCSR -0.85 (100% sensitive, 71% specific, AUC 90%). GLS and GCS can help predict transplant-free survival in patients with hypoplastic left heart syndrome having undergone Fontan palliation. Higher strain values (closer to zero) may be a helpful tool in determining when transplant evaluation is warranted in these patients.
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Affiliation(s)
- Mubeena Abdulkarim
- Advocate Children's Heart Institute, Advocate Children's Hospital, Oak Lawn, IL, USA
- Department of Pediatric Cardiology, Nicklaus Children's Hospital, Miami, FL, USA
| | - Rohit S Loomba
- Advocate Children's Heart Institute, Advocate Children's Hospital, Oak Lawn, IL, USA
| | - S Javed Zaidi
- Advocate Children's Heart Institute, Advocate Children's Hospital, Oak Lawn, IL, USA
- Department of Pediatric Cardiology, Carle BroMenn Medical Center, Normal, IL, USA
| | - Yi Li
- Advocate Children's Heart Institute, Advocate Children's Hospital, Oak Lawn, IL, USA
| | - Melissa Wilson
- Advocate Children's Heart Institute, Advocate Children's Hospital, Oak Lawn, IL, USA
| | - David Roberson
- Advocate Children's Heart Institute, Advocate Children's Hospital, Oak Lawn, IL, USA
| | | | - Saul Flores
- Division of Critical Care, Texas Children's Hospital, Baylor College of Medicine, Houston, TX, USA
| | - Enrique G Villarreal
- Tecnologico de Monterrey, Escuela de Medicina Y Ciencias de La Salud, Monterrey, Nuevo Leon, Mexico.
| | - Tarek Husayni
- Advocate Children's Heart Institute, Advocate Children's Hospital, Oak Lawn, IL, USA
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2
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Houska N, Albertz M, Frank B, Ing RJ. 2024 Guidelines for Performing a Comprehensive Pediatric Transthoracic Echocardiogram: Recommendations From the American Society of Echocardiography. J Cardiothorac Vasc Anesth 2024; 38:1627-1629. [PMID: 38834446 DOI: 10.1053/j.jvca.2024.03.035] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/20/2024] [Accepted: 03/24/2024] [Indexed: 06/06/2024]
Affiliation(s)
- Nicholas Houska
- Department of Anesthesiology, University of Colorado School of Medicine, Children's Hospital Colorado, Anschutz Medical Campus, Aurora, CO
| | - Megan Albertz
- Department of Anesthesiology, University of Colorado School of Medicine, Children's Hospital Colorado, Anschutz Medical Campus, Aurora, CO
| | - Benjamin Frank
- Department of Pediatric Cardiology, University of Colorado School of Medicine, Children's Hospital Colorado, Anschutz Medical Campus, Aurora, CO
| | - Richard J Ing
- Department of Anesthesiology, University of Colorado School of Medicine, Children's Hospital Colorado, Anschutz Medical Campus, Aurora, CO.
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Amdani S, Conway J, George K, Martinez HR, Asante-Korang A, Goldberg CS, Davies RR, Miyamoto SD, Hsu DT. Evaluation and Management of Chronic Heart Failure in Children and Adolescents With Congenital Heart Disease: A Scientific Statement From the American Heart Association. Circulation 2024; 150:e33-e50. [PMID: 38808502 DOI: 10.1161/cir.0000000000001245] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/30/2024]
Abstract
With continued medical and surgical advancements, most children and adolescents with congenital heart disease are expected to survive to adulthood. Chronic heart failure is increasingly being recognized as a major contributor to ongoing morbidity and mortality in this population as it ages, and treatment strategies to prevent and treat heart failure in the pediatric population are needed. In addition to primary myocardial dysfunction, anatomical and pathophysiological abnormalities specific to various congenital heart disease lesions contribute to the development of heart failure and affect potential strategies commonly used to treat adult patients with heart failure. This scientific statement highlights the significant knowledge gaps in understanding the epidemiology, pathophysiology, staging, and outcomes of chronic heart failure in children and adolescents with congenital heart disease not amenable to catheter-based or surgical interventions. Efforts to harmonize the definitions, staging, follow-up, and approach to heart failure in children with congenital heart disease are critical to enable the conduct of rigorous scientific studies to advance our understanding of the actual burden of heart failure in this population and to allow the development of evidence-based heart failure therapies that can improve outcomes for this high-risk cohort.
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Wang AP, Husain N, Penk J, Laternser C, Magnetta D, Watanabe K, Hauck A. Prognostic Value of RV Function Analysis During the Interstage Period in Patients with Hypoplastic Left Heart Syndrome. Pediatr Cardiol 2024; 45:1120-1128. [PMID: 38519623 DOI: 10.1007/s00246-024-03463-3] [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: 12/10/2023] [Accepted: 02/26/2024] [Indexed: 03/25/2024]
Abstract
Cardiac dysfunction is associated with mortality in children with hypoplastic left heart syndrome (HLHS). We evaluated the ability of qualitative and quantitative RV functional parameters to predict outcomes in HLHS patients. In this retrospective, single-center study, echocardiograms from 3 timepoints (pre-stage 1 palliation, 4-8 weeks post-stage 1 palliation, and pre-Glenn) were analyzed in infants with HLHS. Patients were stratified into two groups based on outcome of transplant-free survival post-Glenn (survivors) versus mortality or transplantation prior to Fontan (non-survivors). Images were retrospectively reviewed to obtain RV global longitudinal strain (RVGLS), RV-free wall strain (RVFWS), fractional area change (FAC), tricuspid annular systolic plane excursion (TAPSE), tissue motion annular displacement of the tricuspid valve (TMAD-TV) and qualitative systolic function assessment during the predetermined timepoints. An equal variance t-test and chi-square were used to determine significant differences and ROC curve analysis was performed to derive optimal cutoff values to predict mortality/transplant. A total of 47 patients met inclusion criteria, of which, 21 patients met composite endpoint. There were no significant differences in any RV functional parameter during the pre- or post-stage 1 palliation timepoints. The absolute values of RVFWS, RVGLS, and TMAD-TV were significantly greater in survivors than non-survivors during the pre-Glenn timepoint. A pre-Glenn RVGLS > -15.6 (AUC 0.79), RVFWS > -18.6 (AUC 0.75), and TMAD-TV < 12.6% (AUC 0.82) were sensitive and specific for predicting death or need for transplantation prior to Fontan completion. RVGLS, RVFWS, and TMAD-TV may help identify higher-risk HLHS patients during the interstage period.
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Affiliation(s)
- Alan P Wang
- Division of Pediatric Cardiology, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL, USA.
| | - Nazia Husain
- Division of Pediatric Cardiology, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL, USA
| | - Jamie Penk
- Division of Pediatric Cardiology, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL, USA
| | - Christina Laternser
- Division of Pediatric Cardiology, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL, USA
| | - Defne Magnetta
- Division of Pediatric Cardiology, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL, USA
| | - Kae Watanabe
- Lillie Frank Abercrombie Division of Pediatric Cardiology, Department of Pediatrics, Texas Children's Hospital, Baylor College of Medicine, Houston, TX, USA
| | - Amanda Hauck
- Division of Pediatric Cardiology, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL, USA
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5
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Ittleman B, Lowenstein S, Edwards LA, Caris E, Bhat A, Conwell J, Lewin M, Arya B. Fetal Echocardiographic Evaluation of Tricuspid Valve and Right Ventricular Function Including Global Longitudinal Strain in Hypoplastic Left Heart Syndrome and Association with Postnatal Outcomes. Pediatr Cardiol 2024:10.1007/s00246-024-03453-5. [PMID: 38647657 DOI: 10.1007/s00246-024-03453-5] [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: 10/28/2023] [Accepted: 02/12/2024] [Indexed: 04/25/2024]
Abstract
Despite significant advancements in the care of patients with hypoplastic left heart syndrome (HLHS) morbidity and mortality remain high. Postnatal right ventricular dysfunction and tricuspid regurgitation (TR) are associated with worse outcomes in HLHS. We aim to determine if right ventricle functional parameters and TR on fetal echocardiogram are associated with postnatal outcomes in HLHS patients. Retrospective review was performed on all fetuses with HLHS from 2014 to 2022 at our institution. Initial and follow up fetal echocardiogram measurements of right ventricular myocardial performance index (MPI), fractional area change (FAC) and global longitudinal strain (GLS) were retrospectively measured. The presence and severity of TR was recorded from the fetal echocardiogram reports. Postnatal outcomes including transplant-free survival, hospital length of stay > 30 days after initial palliation and need for bidirectional Glenn at < 4 months were reviewed. Forty-three subjects met inclusion criteria. Mean gestational age at presentation was 26.1 ± 5.9 weeks. Nine subjects died and 3 required heart transplantation. Initial fetal echocardiogram MPI was significantly lower (better) (0.36 ± 0.06 vs 0.44 ± 0.11; p = < 0.001) and FAC was significantly higher (better) (45 ± 6% vs 40 ± 8%; p = 0.035) in transplant-free survivors. Fetal right ventricular GLS and presence of mild TR were not associated with postnatal outcome. In fetuses with HLHS, abnormal MPI and right ventricular FAC are associated with decreased transplant-free survival. There was no observed association between GLS and postnatal outcomes. To our knowledge this is the first study examining fetal right ventricular function and GLS in HLHS patients and its link to postnatal outcomes.
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Affiliation(s)
- Benjamin Ittleman
- Arkansas Children's Hospital, University of Arkansas Medical Sciences, Little Rock, AR, USA.
| | | | - Lindsay A Edwards
- Department of Pediatrics, Division of Cardiology, Duke University School of Medicine, Durham, NC, USA
| | - Elizabeth Caris
- University of Pittsburgh School of Medicine, University of Pittsburgh Medical Center Children's Hospital of Pittsburgh, Pittsburgh, PA, USA
| | - Aarti Bhat
- Seattle Children's Hospital, University of Washington School of Medicine, Seattle, WA, USA
| | - Jeffrey Conwell
- Seattle Children's Hospital, University of Washington School of Medicine, Seattle, WA, USA
| | - Mark Lewin
- Seattle Children's Hospital, University of Washington School of Medicine, Seattle, WA, USA
| | - Bhawna Arya
- Seattle Children's Hospital, University of Washington School of Medicine, Seattle, WA, USA
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Madan N, Aly D, Kathol M, Buddhavarapu A, Rieth T, Sherman A, Forsha D. Relationship Between Obesity and Global Longitudinal Strain in the Pediatric Single Ventricle Fontan Population Across Ventricular Morphologies. J Am Heart Assoc 2024; 13:e028616. [PMID: 38240220 PMCID: PMC11056151 DOI: 10.1161/jaha.122.028616] [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: 11/01/2022] [Accepted: 11/27/2023] [Indexed: 02/07/2024]
Abstract
BACKGROUND Obesity is associated with diminished myocardial function as measured by strain echocardiography in children and young adults with normal cardiac anatomy. Data are lacking about the effect of obesity on myocardial strain in patients with a single ventricle. In this study, the relationship between body mass index (BMI) and single ventricle myocardial strain in the Fontan population was assessed. METHODS AND RESULTS Thirty-eight abnormal BMI Fontan cases (21 overweight and 17 obese) and 30 normal BMI Fontan controls matched based on single ventricular morphology, age, and sex were included in the study. Ventricular morphology was categorized as single right ventricle, single left ventricle, or biventricular. Single ventricle global longitudinal peak systolic strain (GLS) and other echocardiographic measurements were performed and compared between groups, with a P≤0.05 defined as significant. The abnormal BMI group demonstrated diminished GLS (-15.7±3.6% versus -17.2±3.2%, [P=0.03]) and elevated systolic blood pressure (P=0.04) compared with the normal BMI group. On subgroup analysis of those with single right ventricle morphology, the abnormal BMI group demonstrated diminished GLS compared with controls. There was no significant difference in GLS between the abnormal BMI and control groups in the single left ventricle and biventricular subgroups. Analyzed by ventricular morphology, no other variables were statistically different in the abnormal BMI group including systolic blood pressure. Inter-reader reproducibility for GLS and strain rate were excellent for both measures. CONCLUSIONS Obesity has an adverse relationship with myocardial strain in the young Fontan population, with the most maladaptive response seen in the single right ventricle.
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Affiliation(s)
- Nitin Madan
- Ward Family Heart Center, Children’s Mercy Kansas CityKansas CityMOUSA
- University of Missouri‐Kansas CityKansas CityMOUSA
| | - Doaa Aly
- Ward Family Heart Center, Children’s Mercy Kansas CityKansas CityMOUSA
- University of Missouri‐Kansas CityKansas CityMOUSA
| | - Melanie Kathol
- Ward Family Heart Center, Children’s Mercy Kansas CityKansas CityMOUSA
| | | | - Thomas Rieth
- University of Missouri‐Kansas CityKansas CityMOUSA
| | - Ashley Sherman
- Health Services and Outcomes Research, Children’s Mercy Kansas CityKansas CityMOUSA
| | - Daniel Forsha
- Ward Family Heart Center, Children’s Mercy Kansas CityKansas CityMOUSA
- University of Missouri‐Kansas CityKansas CityMOUSA
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Lopez L, Saurers DL, Barker PCA, Cohen MS, Colan SD, Dwyer J, Forsha D, Friedberg MK, Lai WW, Printz BF, Sachdeva R, Soni-Patel NR, Truong DT, Young LT, Altman CA. Guidelines for Performing a Comprehensive Pediatric Transthoracic Echocardiogram: Recommendations From the American Society of Echocardiography. J Am Soc Echocardiogr 2024; 37:119-170. [PMID: 38309834 DOI: 10.1016/j.echo.2023.11.015] [Citation(s) in RCA: 9] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2024]
Abstract
Echocardiography is a fundamental component of pediatric cardiology, and appropriate indications have been established for its use in the setting of suspected, congenital, or acquired heart disease in children. Since the publication of guidelines for pediatric transthoracic echocardiography in 2006 and 2010, advances in knowledge and technology have expanded the scope of practice beyond the use of traditional modalities such as two-dimensional, M-mode, and Doppler echocardiography to evaluate the cardiac segmental structures and their function. Adjunct modalities such as contrast, three-dimensional, and speckle-tracking echocardiography are now used routinely at many pediatric centers. Guidelines and recommendations for the use of traditional and newer adjunct modalities in children are described in detail in this document. In addition, suggested protocols related to standard operations, infection control, sedation, and quality assurance and improvement are included to provide an organizational structure for centers performing pediatric transthoracic echocardiograms.
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Affiliation(s)
- Leo Lopez
- Department of Pediatrics Cardiology, Stanford University School of Medicine and Lucile Packard Children's Hospital Stanford, Palo Alto, California.
| | - Daniel L Saurers
- Department of Pediatrics, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Piers C A Barker
- Duke Children's Hospital & Health Center, Duke University, Durham, North Carolina
| | - Meryl S Cohen
- Cardiac Center and Division of Cardiology, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Steven D Colan
- Department of Cardiology, Boston Children's Hospital, Boston, Massachusetts
| | - Jeanine Dwyer
- Pediatric Heart Institute, Children's Hospital Colorado, Aurora, Colorado
| | - Daniel Forsha
- Ward Family Heart Center, Children's Mercy Kansas City Hospital, Kansas City, Missouri
| | - Mark K Friedberg
- Labatt Family Heart Centre, Division of Cardiology, The Hospital for Sick Children and University of Toronto, Toronto, Ontario, Canada
| | - Wyman W Lai
- Division of Pediatric Cardiology, University of California School of Medicine, Irvine, California; Department of Pediatrics, Children's Hospital of Orange County, Orange, California
| | - Beth F Printz
- Rady Children's Hospital San Diego and University of California, San Diego, San Diego, California
| | - Ritu Sachdeva
- Department of Pediatrics, Emory University School of Medicine and Children's Healthcare of Atlanta, Atlanta, Georgia
| | - Neha R Soni-Patel
- Pediatric & Adult Congenital Heart Center, Cleveland Clinic Children's Hospital, Cleveland, Ohio
| | - Dongngan T Truong
- University of Utah and Division of Pediatric Cardiology, Primary Children's Hospital, Salt Lake City, Utah
| | - Luciana T Young
- Seattle Children's Hospital and Pediatric Cardiology, University of Washington School of Medicine, Seattle, Washington
| | - Carolyn A Altman
- Baylor College of Medicine and Texas Children's Heart Center, Texas Children's Hospital, Houston, Texas
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Buddhavarapu A, Chauhan D, Erickson LA, Elliott MD, Warren M, Forsha DE. The Evolution of Longitudinal Strain Across Various Univentricular Morphologies Prior to Superior Cavopulmonary Anastomosis. J Am Soc Echocardiogr 2023; 36:1100-1109. [PMID: 37141928 DOI: 10.1016/j.echo.2023.04.018] [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: 06/01/2022] [Revised: 04/22/2023] [Accepted: 04/25/2023] [Indexed: 05/06/2023]
Abstract
BACKGROUND Infants with single-ventricle physiology have increased morbidity, mortality, and ventricular dysfunction in the pre-superior cavopulmonary anastomosis (pre-SCPA) period. Echocardiography-derived longitudinal strain (LS) is emerging as a reliable marker of single-ventricle performance. We aim to assess evolution of LS during the pre-SCPA period across univentricular morphologies and explore associations of LS with modifiable and nonmodifiable factors. METHODS Ninety-four term infants (36 females) with univentricular physiology who were discharged home prior to stage 2 palliation were serially analyzed for LS (single apical view) and other echo measures at initial hospital discharge and the last pre-SCPA encounter. Ventricular myocardium was tracked for strain along the septum and respective lateral wall for single right ventricular (RV) and left ventricular (LV) groups, and along both right and left lateral walls in functionally univentricular hearts with biventricular (BiV) morphology. Clinical data were obtained from the medical record. RESULTS Longitudinal strain improved in the total cohort during the pre-SCPA period (16.48% ± 3.31% to 17.57% ± 3.81%, P = .003). Longitudinal strain improved between encounters in the single LV (P = .04) and BiV groups (P = .02). However, LS failed to improve in the RV group (P = .7) with lower LS at both visits compared with the other groups. The RV group, mostly composed of hypoplastic left heart syndrome patients-87% of cases-had a higher incidence of arrhythmias (57%) and unplanned reinterventions (60%), most of which were arch reinterventions. A subanalysis based on arch reintervention showed that LS improves between encounters in the single LV group needing arch reintervention (P = .05) compared with the single RV group needing arch reintervention (P = .89). Lower LS was independently associated with unplanned reinterventions at both encounters (P = .008 and .02). CONCLUSIONS Single-ventricle LS evolves differently across ventricular morphologies during the pre-SCPA period and is related to the need for unplanned cardiac reinterventions. Lower LS is noted in the single RV group, who mostly have hypoplastic left heart syndrome.
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Affiliation(s)
- Amulya Buddhavarapu
- Department of Pediatric Cardiology, Ward Family Heart Center, Children's Mercy Hospital, University of Missouri at Kansas City, Kansas City, Missouri
| | - Dhaval Chauhan
- Department of Pediatric Cardiology, Ward Family Heart Center, Children's Mercy Hospital, University of Missouri at Kansas City, Kansas City, Missouri
| | - Lori A Erickson
- Department of Strategic Planning and Innovation, Children's Mercy Hospital, Kansas City, Missouri
| | - Melissa D Elliott
- Department of Pediatric Cardiology, Ward Family Heart Center, Children's Mercy Hospital, University of Missouri at Kansas City, Kansas City, Missouri
| | - Matthew Warren
- Department of Pediatric Cardiology, Children's Memorial Hermann Hospital, University of Texas Health Science Center at Houston, Houston, Texas
| | - Daniel E Forsha
- Department of Pediatric Cardiology, Ward Family Heart Center, Children's Mercy Hospital, University of Missouri at Kansas City, Kansas City, Missouri.
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Moscatelli S, Borrelli N, Sabatino J, Leo I, Avesani M, Montanaro C, Di Salvo G. Role of Cardiovascular Imaging in the Follow-Up of Patients with Fontan Circulation. CHILDREN (BASEL, SWITZERLAND) 2022; 9:children9121875. [PMID: 36553321 PMCID: PMC9777137 DOI: 10.3390/children9121875] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 11/04/2022] [Revised: 11/27/2022] [Accepted: 11/28/2022] [Indexed: 12/02/2022]
Abstract
Since its first description in 1971, the Fontan procedure and its modifications have led to a substantial improvement in the survival rates of patients with a variety of types of complex Congenital Heart Disease (CHD) characterised by the presence of a single, dominant ventricle. However, despite the significant improvement of the prognosis over the years, Fontan patients are still exposed to several cardiovascular and systemic complications. It is, therefore, important to fully understand the pitfalls hidden behind a Fontan anatomy and the potential predictors of ventricular failure. Cardiovascular imaging plays a key role in this context, allowing for the early identification of complications with important prognostic implications. Echocardiography remains the first-line imaging modality for serial evaluation of Fontan patients. However, there is a growing role of cardiovascular magnetic resonance and cardiac computed tomography from pre-operative assessment to longitudinal follow-up. The aim of this paper will be to provide a comprehensive overview of the role, strengths, and weaknesses of each imaging modality in the assessment of congenital cardiac conditions palliated with the Fontan procedure.
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Affiliation(s)
- Sara Moscatelli
- Paediatric Cardiology Department, Royal Brompton Hospital Harefield NHS Foundation Trust, London SW3 5NP, UK
| | - Nunzia Borrelli
- Adult Congenital Heart Disease Unit, A.O. dei Colli, Monaldi Hospital, 80131 Naples, Italy
| | - Jolanda Sabatino
- Division of Paediatric Cardiology, Department of Women and Children’s Health, University Hospital Padua, 35128 Padua, Italy
- Paediatric Research Institute (IRP), Città Della Speranza, 35127 Padua, Italy
| | - Isabella Leo
- Department of Medical and Surgical Sciences, Magna Grecia University, 88100 Catanzaro, Italy
- Cardiac Magnetic Resonance Department, Royal Brompton Hospital Harefield NHS Foundation Trust, London SW3 5NP, UK
| | - Martina Avesani
- Division of Paediatric Cardiology, Department of Women and Children’s Health, University Hospital Padua, 35128 Padua, Italy
| | - Claudia Montanaro
- Adult Congenital Department, Royal Brompton Hospital & Harefield NHS Foundation Trust, London SW3 5NP, UK
| | - Giovanni Di Salvo
- Division of Paediatric Cardiology, Department of Women and Children’s Health, University Hospital Padua, 35128 Padua, Italy
- Paediatric Research Institute (IRP), Città Della Speranza, 35127 Padua, Italy
- Correspondence:
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10
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Colquitt JL, McFarland CA, Loar RW, Liu A, Pignatelli RH, Ou Z, Minich LL, Wilkinson JC. Relation of Right Atrial Strain to Mortality in Infants With Single Right Ventricles. Am J Cardiol 2022; 177:137-143. [PMID: 35710588 DOI: 10.1016/j.amjcard.2022.04.054] [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: 02/14/2022] [Revised: 04/28/2022] [Accepted: 04/29/2022] [Indexed: 11/01/2022]
Abstract
We explored associations of surveillance testing in infants with single right ventricle (sRV) physiology with clinical outcomes. This prospective, single-center study included patients with sRV who had initial palliative surgery (September 2019 to December 2020). Echocardiograms and B-type naturetic peptide (BNP) obtained as a pair within 24 hours as part of clinical care were included. The primary outcome was death/heart transplant. Secondary outcomes included interstage duration of milrinone use, hospital length of stay, and no digoxin use. sRV functional assessment (subjective grade, fractional area change, tricuspid annular plane systolic excursion, global longitudinal strain, right atrial strain [RAS]) was performed offline. Associations between echocardiography, BNP, and clinical outcomes were determined. Of 26 subjects (47 encounters), 20 had hypoplastic left heart syndrome (77%). Median age at data collection was 50 days (interquartile range 26 to 90). In most encounters (73%), sRV function was subjectively normal. Median BNP was 332 pg/ml (interquartile range 160 to 1,085). A total of 5 patients (19%) met the primary outcome and had lower RAS (14.1 vs 21.3, p = 0.038), but all other parameters were similar to transplant-free survivors. RAS (16.1%, 0.83) had the highest area under curve, followed by global longitudinal strain (-14.4%, 0.77). Higher RAS was associated with fewer days on milrinone (coefficient -1.37, 95% confidence interval [CI] -2.54 to -0.20, p = 0.02) and higher odds of digoxin use (odds ratio 1.09, 95% CI 1.01 to 1.18, p = 0.047). Higher BNP was only associated with a lower odds of digoxin use (odds ratio 0.69, 95% CI 0.5 to 0.96, p = 0.03). In conclusion, RAS is a potentially important imaging marker in infants with sRV and merits further investigation in larger studies.
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Affiliation(s)
- John L Colquitt
- Division of Pediatric Cardiology, Department of Pediatrics, University of Utah and Primary Children's Hospital, Salt Lake City, Utah.
| | - Carol A McFarland
- Division of Pediatric Cardiology, Department of Pediatrics, University of Utah and Primary Children's Hospital, Salt Lake City, Utah
| | - Robert W Loar
- Pediatric Cardiology, Cook Children's Medical Center, Fort Worth, Texas
| | - Asela Liu
- Division of Pediatric Cardiology, Department of Pediatrics, Baylor College of Medicine and Texas Children's Hospital, Houston, Texas
| | - Ricardo H Pignatelli
- Division of Pediatric Cardiology, Department of Pediatrics, Baylor College of Medicine and Texas Children's Hospital, Houston, Texas
| | - Zhining Ou
- Division of Epidemiology, Department of Internal Medicine, University of Utah, Salt Lake City, Utah
| | - L LuAnn Minich
- Division of Pediatric Cardiology, Department of Pediatrics, University of Utah and Primary Children's Hospital, Salt Lake City, Utah
| | - J Chris Wilkinson
- Division of Pediatric Cardiology, Department of Pediatrics, Baylor College of Medicine and Texas Children's Hospital, Houston, Texas
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11
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Evaluation of Right Ventricular Function and Myocardial Microstructure in Fetal Hypoplastic Left Heart Syndrome. J Clin Med 2022; 11:jcm11154456. [PMID: 35956075 PMCID: PMC9369849 DOI: 10.3390/jcm11154456] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2022] [Revised: 07/15/2022] [Accepted: 07/22/2022] [Indexed: 02/05/2023] Open
Abstract
Right ventricular (RV) function is one of the critical factors affecting the prognosis of fetuses with hypoplastic left heart syndrome (HLHS). Our study objectives included assessment of cardiac function and comprehensive measurement of cardiac microstructure. We retrospectively studied 42 fetuses diagnosed as HLHS by echocardiography. Myocardial deformation of the right ventricular wall was calculated automatically in offline software. Postmortem cardiac imaging for three control fetal hearts and four HLHS specimens was performed by a 9.4T DTI scanner. Myocardial deformation parameters of the RV (including strain, strain rate, and velocity) were significantly lower in HLHS fetuses (all p < 0.01). FA values increased (0.18 ± 0.01 vs. 0.21 ± 0.02; p < 0.01) in HLHS fetuses, but MD reduced (1.3 ± 0.15 vs. 0.88 ± 0.13; p < 0.001). The HLHS fetuses’ RV lateral base wall (−7.31 ± 51.91 vs. −6.85 ± 31.34; p = 0.25), middle wall (1.71 ± 50.92 vs. −9.38 ± 28.18; p < 0.001), and apical wall (−6.19 ± 46.61 vs. −11.16 ± 29.86, p < 0.001) had HA gradient ascent but HA gradient descent in the anteroseptal wall (p < 0.001) and inferoseptal wall (p < 0.001). RV basal lateral wall HA degrees were correlated with RVGLS (R2 = 0.97, p = 0.02). MD values were positively correlated with RVGLS (R2 = 0.93, p = 0.04). Our study found morphological and functional changes of the RV in HLHS fetuses, and cardiac function was related to the orientation patterns of myocardial fibers. It may provide insight into understanding the underlying mechanisms of impaired RV performance in HLHS.
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Mah K, Mertens L. Echocardiographic Assessment of Right Ventricular Function in Paediatric Heart Disease: A Practical Clinical Approach. CJC PEDIATRIC AND CONGENITAL HEART DISEASE 2022; 1:136-157. [PMID: 37970496 PMCID: PMC10642122 DOI: 10.1016/j.cjcpc.2022.05.002] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/02/2022] [Accepted: 05/05/2022] [Indexed: 11/17/2023]
Abstract
As the right ventricle (RV) plays an integral role in different paediatric heart diseases, the accurate assessment of RV size and function is essential in the diagnosis, management, and prognostication of congenital and acquired cardiac lesions. Yet, echocardiographic evaluation of the RV is challenging because of its complex and variable morphology, its different physiology compared with the left ventricle, and its capability to adapt to different loading conditions associated with congenital and acquired heart diseases within certain ranges. Reliable echocardiographic detection of RV systolic and diastolic dysfunction remains challenging while important for patient management. This review provides an updated, practical approach to assessing RV function in structurally normal hearts and in children with common congenital heart defects and in those with pulmonary hypertension. We also review the impact of tricuspid valve function on RV functional parameters. There is no single functional RV parameter that uniquely describes RV function; instead a combination of different parameters is recommended in clinical practice. Qualitative and quantitative analysis of RV function will be reviewed including more recent techniques such as speckle tracking and 3D echocardiography.
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Affiliation(s)
- Kandice Mah
- Division of Cardiology, BC Children’s Hospital, University of British Columbia, Vancouver, British Columbia, Canada
| | - Luc Mertens
- Department of Paediatrics, Labatt Family Heart Centre, the Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
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13
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Wald R, Mertens L. Hypoplastic Left Heart Syndrome Across the Lifespan: Clinical Considerations for Care of the Fetus, Child, and Adult. Can J Cardiol 2022; 38:930-945. [PMID: 35568266 DOI: 10.1016/j.cjca.2022.04.028] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2022] [Revised: 04/22/2022] [Accepted: 04/24/2022] [Indexed: 12/14/2022] Open
Abstract
Hypoplastic left heart syndrome (HLHS) is the most common anatomic lesion in children born with single ventricle physiology and is characterized by the presence of a dominant right ventricle and a hypoplastic left ventricle along with small left-sided heart structures. Diagnostic subgroups of HLHS reflect the extent of inflow and outflow obstruction at the aortic and mitral valves, specifically stenosis or atresia. If left unpalliated, HLHS is a uniformly fatal lesion in infancy. Following introduction of the Norwood operation, early survival has steadily improved over the past four decades, mirroring advances in operative and peri-operative management as well as reflecting refinements in patient surveillance and interstage clinical care. Notably, survival following staged palliation has increased from 0% to a 5-year survival of 60-65% for children in some centres. Despite the prevalence of HLHS in childhood with relatively favourable surgical outcomes in contemporary series, this cohort is only now reaching early adult life and longer-term outcomes have yet to be elucidated. In this article we focus on contemporary clinical management strategies for patients with HLHS across the lifespan, from fetal to adult life. Nomenclature and diagnostic considerations are discussed and current literature pertaining to putative genetic etiologies is reviewed. The spectrum of fetal and pediatric interventional strategies, both percutaneous and surgical, are described. Clinical, patient-reported and neurodevelopmental outcomes of HLHS are delineated. Finally, note is made of current areas of clinical uncertainty and suggested directions for future research are highlighted.
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Affiliation(s)
- Rachel Wald
- Labatt Family Heart Centre, Division of Cardiology, Hospital for Sick Children, Department of Pediatrics, University of Toronto, Toronto, Ontario, Canada; Peter Munk Cardiac Centre, Division of Cardiology, University Health Network, Department of Medicine,University of Toronto, Toronto, Ontario, Canada
| | - Luc Mertens
- Labatt Family Heart Centre, Division of Cardiology, Hospital for Sick Children, Department of Pediatrics, University of Toronto, Toronto, Ontario, Canada; Peter Munk Cardiac Centre, Division of Cardiology, University Health Network, Department of Medicine,University of Toronto, Toronto, Ontario, Canada
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Global longitudinal strain analysis of the singe right ventricle: leveling the playing field. J Am Soc Echocardiogr 2022; 35:657-663. [PMID: 35271990 DOI: 10.1016/j.echo.2022.03.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/18/2021] [Revised: 01/04/2022] [Accepted: 03/01/2022] [Indexed: 11/23/2022]
Abstract
BACKGROUND All available echocardiographic methods to assess single, systemic right ventricle (sRV) systolic function have limitations. Subjective grading is prone to bias and varies among readers. Quantitative methods that require significant manual input, such as fractional area change (FAC), are often not reproducible. The aim of this study is to determine whether global longitudinal strain (GLS) is more reproducible than FAC and subjective grading in sRV patients among individual readers and across different levels of experience. METHODS Clinically indicated echocardiograms for 40 patients with functional systemic right ventricles were assessed by 5 readers with varying reading experience: one sonographer, one cardiology fellow, and three attending cardiologists at different career stages. All readers were blinded to patient data and other reader responses. Each reader reviewed the same images for subjective grade (scale 1-8, normal to severely depressed), RV end-diastolic and end-systolic area measurements, and longitudinal strain analysis. A repeat analysis was performed under identical conditions after at least 2 weeks on all 40 patients. Inter- and intra-reader reproducibility was assessed with intraclass correlation coefficient (ICC). Correlations between responses were assessed with Spearman's correlation coefficient. RESULTS The subjective method had fair to good reproducibility (ICC 0.7, interquartile range (IQR) 0.60,0.72) while the FAC method was poor (ICC 0.46, IQR 0.39,0.51) between readers. Reproducibility for GLS was excellent (ICC 0.88, IQR 0.88,0.89). Intra-reader reproducibility was excellent by subjective grading (ICC 0.85, IQR 0.73,0.88), poor by FAC (ICC = 0.63, IQR 0.35,0.66) and excellent by GLS (ICC 0.93, IQR 0.88,0.96). Attending-level readers were more consistent with their subjective grading, while all readers were excellent with GLS. CONCLUSION GLS is more reproducible than conventional methods at assessing sRV systolic function between readers with different levels of experience. For most readers it was more consistent than their own subjective grade of RV function. Laboratories staffed by multiple readers are likely to be more consistent in grading systemic RV systolic function using GLS.
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15
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Classic pattern dyssynchrony is associated with outcome in patients with Fontan circulation. J Am Soc Echocardiogr 2022; 35:513-522. [DOI: 10.1016/j.echo.2022.01.012] [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: 07/06/2021] [Revised: 01/08/2022] [Accepted: 01/21/2022] [Indexed: 11/24/2022]
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16
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Faerber JA, Huang J, Zhang X, Song L, DeCost G, Mascio CE, Ravishankar C, O'Byrne ML, Naim MY, Kawut SM, Goldmuntz E, Mercer-Rosa L. Identifying Risk Factors for Complicated Post-operative Course in Tetralogy of Fallot Using a Machine Learning Approach. Front Cardiovasc Med 2021; 8:685855. [PMID: 34368247 PMCID: PMC8339319 DOI: 10.3389/fcvm.2021.685855] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2021] [Accepted: 06/21/2021] [Indexed: 11/15/2022] Open
Abstract
Introduction: Tetralogy of Fallot (TOF) repair is associated with excellent operative survival. However, a subset of patients experiences post-operative complications, which can significantly alter the early and late post-operative course. We utilized a machine learning approach to identify risk factors for post-operative complications after TOF repair. Methods: We conducted a single-center prospective cohort study of children <2 years of age with TOF undergoing surgical repair. The outcome was occurrence of post-operative cardiac complications, measured between TOF repair and hospital discharge or death. Predictors included patient, operative, and echocardiographic variables, including pre-operative right ventricular strain and fractional area change as measures of right ventricular function. Gradient-boosted quantile regression models (GBM) determined predictors of post-operative complications. Cross-validated GBMs were implemented with and without a filtering stage non-parametric regression model to select a subset of clinically meaningful predictors. Sensitivity analysis with gradient-boosted Poisson regression models was used to examine if the same predictors were identified in the subset of patients with at least one complication. Results: Of the 162 subjects enrolled between March 2012 and May 2018, 43 (26.5%) had at least one post-operative cardiac complication. The most frequent complications were arrhythmia requiring treatment (N = 22, 13.6%), cardiac catheterization (N = 17, 10.5%), and extracorporeal membrane oxygenation (ECMO) (N = 11, 6.8%). Fifty-six variables were used in the machine learning analysis, of which there were 21 predictors that were already identified from the first-stage regression. Duration of cardiopulmonary bypass (CPB) was the highest ranked predictor in all models. Other predictors included gestational age, pre-operative right ventricular (RV) global longitudinal strain, pulmonary valve Z-score, and immediate post-operative arterial oxygen level. Sensitivity analysis identified similar predictors, confirming the robustness of these findings across models. Conclusions: Cardiac complications after TOF repair are prevalent in a quarter of patients. A prolonged surgery remains an important predictor of post-operative complications; however, other perioperative factors are likewise important, including pre-operative right ventricular remodeling. This study identifies potential opportunities to optimize the surgical repair for TOF to diminish post-operative complications and secure improved clinical outcomes. Efforts toward optimizing pre-operative ventricular remodeling might mitigate post-operative complications and help reduce future morbidity.
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Affiliation(s)
- Jennifer A Faerber
- Data Science and Biostatistics Unit, Department of Biomedical and Health Informatics, Children's Hospital of Philadelphia, Philadelphia, PA, United States
| | - Jing Huang
- Department of Biostatistics, Epidemiology & Informatics, University of Pennsylvania, Philadelphia, PA, United States.,Department of Pediatrics, Children's Hospital of Philadelphia, Philadelphia, PA, United States
| | - Xuemei Zhang
- Data Science and Biostatistics Unit, Department of Biomedical and Health Informatics, Children's Hospital of Philadelphia, Philadelphia, PA, United States
| | - Lihai Song
- Data Science and Biostatistics Unit, Department of Biomedical and Health Informatics, Children's Hospital of Philadelphia, Philadelphia, PA, United States
| | - Grace DeCost
- School of Public Health, Brown University, Providence, RI, United States
| | - Christopher E Mascio
- Division of Cardiothoracic Surgery, Department of Surgery, Children's Hospital of Philadelphia, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, United States
| | - Chitra Ravishankar
- Division of Cardiology, Department of Pediatrics, Children's Hospital of Philadelphia, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, United States
| | - Michael L O'Byrne
- Data Science and Biostatistics Unit, Department of Biomedical and Health Informatics, Children's Hospital of Philadelphia, Philadelphia, PA, United States.,Division of Cardiology, Department of Pediatrics, Children's Hospital of Philadelphia, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, United States.,Leonard Davis Institute and Center for Cardiovascular Outcomes, Quality, and Evaluative Research, University of Pennsylvania, Philadelphia, PA, United States
| | - Maryam Y Naim
- Departments of Anesthesiology, Critical Care Medicine and Pediatrics, Children's Hospital of Philadelphia, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, United States
| | - Steven M Kawut
- Departments of Medicine and Epidemiology, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, United States
| | - Elizabeth Goldmuntz
- Division of Cardiology, Department of Pediatrics, Children's Hospital of Philadelphia, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, United States
| | - Laura Mercer-Rosa
- Division of Cardiology, Department of Pediatrics, Children's Hospital of Philadelphia, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, United States
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Michielon G, DiSalvo G, Fraisse A, Carvalho JS, Krupickova S, Slavik Z, Bartsota M, Daubeney P, Bautista C, Desai A, Burmester M, Macrae D. In-hospital interstage improves interstage survival after the Norwood stage 1 operation. Eur J Cardiothorac Surg 2021; 57:1113-1121. [PMID: 32236554 DOI: 10.1093/ejcts/ezaa074] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/15/2019] [Revised: 12/18/2019] [Accepted: 12/22/2019] [Indexed: 11/13/2022] Open
Abstract
OBJECTIVES The interstage mortality rate after a Norwood stage 1 operation remains 12-20% in current series. In-hospital interstage facilitates escalation of care, possibly improving outcome. METHODS A retrospective study was designed for hypoplastic left heart syndrome (HLHS) and HLHS variants, offering an in-hospital stay after the Norwood operation until the completion of stage 2. Daily and weekly examinations were conducted systematically, including two-dimensional and speckle-tracking echocardiography. Primary end points included aggregate survival until the completion of stage 2 and interstage freedom from escalation of care. Moreover, we calculated the sensitivity and specificity of speckle-tracking echocardiographic myocardial deformation in predicting death/transplant after the Norwood procedure. RESULTS Between 2015 and 2019, 33 neonates with HLHS (24) or HLHS variants (9) underwent Norwood stage 1 (31) or hybrid palliation followed by a comprehensive stage 2 operation (2). Stage 1 Norwood-Sano was preferred in 18 (54.5%) neonates; the classic Norwood with Blalock-Taussig shunt was performed in 13 (39.4%) neonates. The Norwood stage 1 30-day mortality rate was 6.2%. The in-hospital interstage strategy was implemented after Norwood stage 1 with a 3.4% interstage mortality rate. The aggregate Norwood stage 1 and interstage Kaplan-Meier survival rate was 90.6 ± 5.2%. Escalation of care was necessary for 5 (17.2%) patients at 2.5 ± 1.2 months during the interstage for compromising atrial arrhythmias (2), Sano-shunt stenosis (1) and pneumonia requiring a high-frequency oscillator (2); there were no deaths. A bidirectional Glenn (25) or a comprehensive-Norwood stage 2 (2) was completed in 27 patients at 4.7 ± 1.2 months with a 92.6% survival rate. The overall Kaplan-Meier survival rate is 80.9 ± 7.0% at 4.3 years (mean 25.3 ± 15.7 months). An 8.7% Δ longitudinal strain 30 days after Norwood stage 1 had 100% sensitivity and 81% specificity for death/transplant. CONCLUSIONS In-hospital interstage facilitates escalation of care, which seems efficacious in reducing interstage Norwood deaths. A significant reduction of longitudinal strain after Norwood stage 1 is a strong predictor of poor outcome.
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Affiliation(s)
- Guido Michielon
- Department of Congenital Heart Surgery, Royal Brompton Hospital, Imperial College, London, UK
| | - Giovanni DiSalvo
- Department of Paediatric Cardiology, Royal Brompton Hospital, Imperial College, London, UK
| | - Alain Fraisse
- Department of Paediatric Cardiology, Royal Brompton Hospital, Imperial College, London, UK
| | - Julene S Carvalho
- Department of Paediatric Cardiology, Royal Brompton Hospital, Imperial College, London, UK
| | - Sylvia Krupickova
- Department of Paediatric Cardiology, Royal Brompton Hospital, Imperial College, London, UK
| | - Zdenek Slavik
- Department of Paediatric Cardiology, Royal Brompton Hospital, Imperial College, London, UK
| | - Margarita Bartsota
- Department of Paediatric Cardiology, Royal Brompton Hospital, Imperial College, London, UK
| | - Pierce Daubeney
- Department of Paediatric Cardiology, Royal Brompton Hospital, Imperial College, London, UK
| | - Carles Bautista
- Department of Paediatric Cardiology, Royal Brompton Hospital, Imperial College, London, UK
| | - Ajay Desai
- Department of Paediatric Intensive Care, Royal Brompton Hospital, Imperial College, London, UK
| | - Margarita Burmester
- Department of Paediatric Intensive Care, Royal Brompton Hospital, Imperial College, London, UK
| | - Duncan Macrae
- Department of Paediatric Intensive Care, Royal Brompton Hospital, Imperial College, London, UK
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Abdullah M, Kaushal S. Commentary: Cell Therapy for HLHS: Does Correlation Imply Causation? Semin Thorac Cardiovasc Surg 2021; 33:804-805. [PMID: 33600962 DOI: 10.1053/j.semtcvs.2021.01.030] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2020] [Accepted: 01/05/2021] [Indexed: 11/11/2022]
Affiliation(s)
- Mohamed Abdullah
- Division of Cardiac Surgery, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois
| | - Sunjay Kaushal
- Division of Cardiac Surgery, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois.
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19
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Aly D, Ramlogan S, France R, Schmidt S, Hinzman J, Sherman A, Goudar SP, Forsha D. Intervendor Agreement for Right Ventricular Global Longitudinal Strain in Children. J Am Soc Echocardiogr 2021; 34:786-793. [PMID: 33561494 DOI: 10.1016/j.echo.2021.02.002] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/10/2020] [Revised: 02/01/2021] [Accepted: 02/02/2021] [Indexed: 12/14/2022]
Abstract
BACKGROUND Right ventricular global longitudinal strain (RVGLS) has emerged as an important technique for clinical evaluation of (RV) function. The routine application of RVGLS in pediatrics remains limited by a lack of data on agreement between vendors. The aim of this study was to investigate intervendor agreement for RVGLS between the two commonly used analysis vendors in pediatrics, hypothesizing that RVGLS has good intervendor agreement, although it is likely lower than intravendor agreement (inter- and intraobserver reproducibility). METHODS Seventy infants and children with normal cardiac anatomy and varying ventricular function were included after prospectively obtaining RV-focused four-chamber apical images on the GE Vivid E95. Images were analyzed for RVGLS at acquired frame rates in EchoPAC (GE) and TomTec (TT) and in the compressed Digital Imaging and Communications in Medicine format in TT. Intraclass correlation coefficients and Bland-Altman plots were used to test intervendor agreement and intravendor reproducibility. RESULTS RVGLS measurements were equally feasible using TT and EchoPAC analysis (92%). There was good to excellent agreement for RVGLS between TT and EchoPAC analysis, with a relatively higher intraclass correlation coefficient between GE and TT at the acquired frame rate (0.85) than between GE and TT at the compressed frame rate (0.75) and significantly higher agreement in patients with abnormal RV function (0.7-0.9) than those with normal function (0.4-0.6). Intra- andinterobserver reproducibility for RVGLS was excellent (intraclass correlation coefficient = 0.74-0.96). Heart rate ≥ 100 beats/min and acquisition frame rate/heart rate ≤ 0.7 were associated with diminished agreement, especially when compressed data were involved. CONCLUSIONS RVGLS analyzed using EchoPAC and TT show good agreement, especially when analyzed at acquisition frame rates and in the setting of abnormal RV function. Otherwise, RVGLS should ideally be analyzed using the same vendor, and intervendor comparisons should be undertaken with caution, particularly if data are in a compressed format.
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Affiliation(s)
- Doaa Aly
- Ward Family Heart Center, Children's Mercy Hospital, Kansas City, Missouri
| | - Sandhya Ramlogan
- Children's Heart Center, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois
| | - Rita France
- Ward Family Heart Center, Children's Mercy Hospital, Kansas City, Missouri
| | - Stephanie Schmidt
- Ward Family Heart Center, Children's Mercy Hospital, Kansas City, Missouri
| | - Julie Hinzman
- Ward Family Heart Center, Children's Mercy Hospital, Kansas City, Missouri
| | - Ashley Sherman
- Division of Biostatistics, Children's Mercy Hospital, Kansas City, Missouri
| | - Suma P Goudar
- Children's National Heart Institute, Washington, District of Columbia
| | - Daniel Forsha
- Ward Family Heart Center, Children's Mercy Hospital, Kansas City, Missouri.
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20
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Colquitt JL, Wilkinson JC, Liu AM, Pignatelli RH, Loar RW. Single systemic right ventricle longitudinal strain: Intravendor reproducibility and intervendor agreement in children. Echocardiography 2021; 38:402-409. [PMID: 33523543 DOI: 10.1111/echo.14985] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2020] [Accepted: 01/11/2021] [Indexed: 11/28/2022] Open
Abstract
PURPOSE Strain derived from speckle-tracking echocardiography is emerging as a useful tool in the assessment of single ventricle function. The purpose of this study is to compare layer-specific longitudinal strain values in children with single, systemic right ventricles (sRV) using two commercially available software platforms (GE EchoPAC (EP) and TomTec (TT)). METHODS Two readers analyzed two-dimensional longitudinal strain on EP (v 202) and TT (v 2.21.25) in 40 pediatric sRV patients. Intravendor reproducibility and intervendor agreement between layer-specific measurements were assessed by intraclass correlation coefficient and Bland-Altman analysis. Absolute difference (AbΔ) and relative mean errors (RME) were calculated. Subgroup comparisons (stratified by age, heart rate (HR), and frames per second (FPS): HR ratio) were made. RESULTS Median age was 4.4 years. 32 (80%) patients had hypoplastic left heart syndrome; 19 (48%) were post-Fontan. Intravendor reproducibility was excellent with high ICC (0.86-0.97). AbΔ between readers was small (1.2%-1.5%) with interobserver RME slightly higher for TT (11%-12% vs 8%-9% for EP). Layer-specific intervendor agreement was poor (ICC 0.45-0.62). Default layer comparisons (EP mid vs TT endo) showed good agreement (ICC 0.72-0.77) and less variability (AbΔ 2%, RME 15%) than layer-to-layer. There were no differences in ICC for groups dichotomized by age, HR, or FPS:HR ratio. sRV strain values are more negative when using EP. CONCLUSION Intravendor reproducibility for sRV peak longitudinal strain in children is excellent with acceptable variability between experienced users. Intervendor, layer-specific strain agreement is poor. Vendor default layer strain values show better agreement but are not interchangeable.
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Affiliation(s)
- John L Colquitt
- Pediatric Cardiology, Baylor College of Medicine/Texas Children's Hospital, Houston, TX, USA
| | - J Chris Wilkinson
- Pediatric Cardiology, Baylor College of Medicine/Texas Children's Hospital, Houston, TX, USA
| | - Asela M Liu
- Pediatric Cardiology, Baylor College of Medicine/Texas Children's Hospital, Houston, TX, USA
| | - Ricardo H Pignatelli
- Pediatric Cardiology, Baylor College of Medicine/Texas Children's Hospital, Houston, TX, USA
| | - Robert W Loar
- Pediatric Cardiology, Cook Children's Medical Center, Fort Worth, TX, USA
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21
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Mah K, Serrano Lomelin J, Colen T, Tham EB, Lin L, Eckersley L, Smallhorn JF, Becher H, Mertens L, Khoo NS. Right Ventricular Remodeling in Hypoplastic Left Heart Syndrome is Minimally Impacted by Cardiopulmonary Bypass: A Comparison of Norwood vs. Hybrid. Pediatr Cardiol 2021; 42:294-301. [PMID: 33040260 DOI: 10.1007/s00246-020-02482-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/06/2020] [Accepted: 09/29/2020] [Indexed: 10/23/2022]
Abstract
Right ventricular (RV) remodeling in hypoplastic left heart syndrome (HLHS) begins prenatally and continues through staged palliations. However, it is unclear if the most marked observed remodeling post-Norwood is secondary to cardiopulmonary bypass (CPB) exposure or if it is an adaptation intrinsic to the systemic RV. This study aims to determine the impact of CPB on RV remodeling in HLHS. Echocardiograms of HLHS survivors undergoing stage 1 Norwood (n = 26) or Hybrid (n = 20) were analyzed at pre- and post-stage 1, pre- and post-bidirectional cavo-pulmonary anastomosis (BCPA), and pre-Fontan. RV fractional area change (FAC), vector velocity imaging for longitudinal & derived circumferential deformation (global radial shortening (GRS) = peak radial displacement/end-diastolic diameter), and deformation ratio (longitudinal/ circumferential) were assessed. Both groups had similar age, clinical status and functional parameters pre-stage 1. No difference in RV size and sphericity at any stage between groups. RVFAC was normal (> 35%) throughout for both groups. Both Norwood and Hybrid patients had increased GRS (p = 0.0001) post-stage 1 and corresponding unchanged longitudinal strain, resulting in decreased deformation ratio (greater relative RV circumferential contraction), p = 0.0001. Deformation ratio remained decreased in both groups in subsequent stages. Irrespective of timing of the first CPB exposure, both Norwood and Hybrid patients underwent similar RV remodeling, with relative increase in circumferential to longitudinal contraction soon after stage 1 palliation. The observed RV remodeling in HLHS survivors were minimally impacted by CPB.
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Affiliation(s)
- Kandice Mah
- Division of Pediatric Cardiology, Stollery Children's Hospital, 8440 112 St NW, unit 4C2.36, Edmonton, AB, T6G2B7, Canada
| | - Jesus Serrano Lomelin
- Division of Pediatric Cardiology, Stollery Children's Hospital, 8440 112 St NW, unit 4C2.36, Edmonton, AB, T6G2B7, Canada
| | - Timothy Colen
- Division of Pediatric Cardiology, Stollery Children's Hospital, 8440 112 St NW, unit 4C2.36, Edmonton, AB, T6G2B7, Canada
| | - Edythe B Tham
- Division of Pediatric Cardiology, Stollery Children's Hospital, 8440 112 St NW, unit 4C2.36, Edmonton, AB, T6G2B7, Canada
| | - Lily Lin
- Division of Pediatric Cardiology, Stollery Children's Hospital, 8440 112 St NW, unit 4C2.36, Edmonton, AB, T6G2B7, Canada
| | - Luke Eckersley
- Division of Pediatric Cardiology, Stollery Children's Hospital, 8440 112 St NW, unit 4C2.36, Edmonton, AB, T6G2B7, Canada
| | - Jeffrey F Smallhorn
- Division of Pediatric Cardiology, Stollery Children's Hospital, 8440 112 St NW, unit 4C2.36, Edmonton, AB, T6G2B7, Canada
| | - Harald Becher
- Mazankowski Alberta Heart Institute, Alberta Health Services, 11220 83 Ave NW, Edmonton, AB, T6G 2B7, Canada
| | - Luc Mertens
- Labatt Family Heart Centre, The Hospital for Sick Children, 555 University Ave, Toronto, ON, M5G1X8, Canada
| | - Nee Scze Khoo
- Division of Pediatric Cardiology, Stollery Children's Hospital, 8440 112 St NW, unit 4C2.36, Edmonton, AB, T6G2B7, Canada.
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22
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Borrelli N, Di Salvo G, Sabatino J, Ibrahim A, Avesani M, Sirico D, Josen M, Penco M, Fraisse A, Michielon G. Serial changes in longitudinal strain are associated with outcome in children with hypoplastic left heart syndrome. Int J Cardiol 2020; 317:56-62. [DOI: 10.1016/j.ijcard.2020.03.085] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/18/2020] [Accepted: 03/30/2020] [Indexed: 11/25/2022]
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Alphonso N, Angelini A, Barron DJ, Bellsham-Revell H, Blom NA, Brown K, Davis D, Duncan D, Fedrigo M, Galletti L, Hehir D, Herberg U, Jacobs JP, Januszewska K, Karl TR, Malec E, Maruszewski B, Montgomerie J, Pizzaro C, Schranz D, Shillingford AJ, Simpson JM. Guidelines for the management of neonates and infants with hypoplastic left heart syndrome: The European Association for Cardio-Thoracic Surgery (EACTS) and the Association for European Paediatric and Congenital Cardiology (AEPC) Hypoplastic Left Heart Syndrome Guidelines Task Force. Eur J Cardiothorac Surg 2020; 58:416-499. [DOI: 10.1093/ejcts/ezaa188] [Citation(s) in RCA: 24] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Affiliation(s)
- Nelson Alphonso
- Queensland Pediatric Cardiac Service, Queensland Children’s Hospital, University of Queensland, Brisbane, QLD, Australia
| | - Annalisa Angelini
- Department of Cardiac, Thoracic Vascular Sciences and Public health, University of Padua Medical School, Padua, Italy
| | - David J Barron
- Department of Cardiovascular Surgery, Hospital for Sick Children, University of Toronto, Toronto, ON, Canada
| | | | - Nico A Blom
- Division of Pediatric Cardiology, Department of Pediatrics, Leiden University Medical Center, Leiden, Netherlands
| | - Katherine Brown
- Paediatric Intensive Care, Heart and Lung Division, Great Ormond Street Hospital NHS Foundation Trust, London, UK
| | - Deborah Davis
- Department of Anesthesiology, Thomas Jefferson University, Philadelphia, PA, USA
- Nemours Cardiac Center, A.I. Du Pont Hospital for Children, Wilmington, DE, USA
| | - Daniel Duncan
- Nemours Cardiac Center, A.I. Du Pont Hospital for Children, Wilmington, DE, USA
| | - Marny Fedrigo
- Department of Cardiac, Thoracic Vascular Sciences and Public Health, University of Padua Medical School, Padua, Italy
| | - Lorenzo Galletti
- Unit of Pediatric Cardiac Surgery, Bambino Gesù Children's Hospital, Rome, Italy
| | - David Hehir
- Division of Cardiology, Children’s Hospital of Philadelphia, Philadelphia, PA, USA
| | - Ulrike Herberg
- Department of Pediatric Cardiology, University Hospital Bonn, Bonn, Germany
| | | | - Katarzyna Januszewska
- Division of Pediatric Cardiac Surgery, University Hospital Muenster, Westphalian-Wilhelm’s-University, Muenster, Germany
| | | | - Edward Malec
- Division of Pediatric Cardiac Surgery, University Hospital Muenster, Westphalian-Wilhelm’s-University, Muenster, Germany
| | - Bohdan Maruszewski
- Department for Pediatric Cardiothoracic Surgery, Children's Memorial Health Institute, Warsaw, Poland
| | - James Montgomerie
- Department of Anesthesia, Birmingham Children’s Hospital, Birmingham, UK
| | - Christian Pizzaro
- Nemours Cardiac Center, A.I. Du Pont Hospital for Children, Wilmington, DE, USA
- Department of Surgery, Thomas Jefferson University, Philadelphia, PA, USA
| | - Dietmar Schranz
- Pediatric Heart Center, Justus-Liebig University, Giessen, Germany
| | - Amanda J Shillingford
- Division of Cardiology, Children's Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
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Reproducibility and Intervendor Agreement of Left Ventricular Global Systolic Strain in Children Using a Layer-Specific Analysis. J Am Soc Echocardiogr 2019; 33:110-119. [PMID: 31668503 DOI: 10.1016/j.echo.2019.08.004] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/01/2019] [Revised: 07/31/2019] [Accepted: 08/01/2019] [Indexed: 11/23/2022]
Abstract
BACKGROUND Speckle-tracking strain analysis provides additive data to the assessment of pediatric and congenital heart disease; however, the variety of strain analysis software platforms by different vendors and the lack of data on intervendor strain agreement in children have limited its utility. The purpose of this study is to evaluate the intervendor agreement of strain on two commonly used analysis platforms in pediatrics by layer of myocardium and data compression. METHODS This prospective study analyzed two-dimensional speckle-tracking strain on two software platforms in 53 children with normal cardiac segmental anatomy and varying function. Three standard apical views and one parasternal short-axis view were exported at their acquired frame rates to workstations with GE EchoPAC and TomTec software and then also to TomTec at compressed frame rates. Both software platforms had been updated with European Association of Cardiovascular Imaging/American Society of Echocardiography Task Force recommendations for left ventricular (LV) global strain. Intravendor and intervendor agreement between layer-specific comparisons were assessed using Bland-Altman analysis (limits of agreement and bias) and intraclass correlation coefficients. RESULTS This study included subjects with normal LV function (n = 38) and cardiomyopathy (n = 15) with an age range of 1 month to 18 years. Intertechnique agreement by default vendor myocardial layer (GE mid-TomTec endocardial layer) was robust for both global longitudinal (GLS) and circumferential strain (GCS; higher for GLS than GCS). Intravendor (inter- and interreader) agreement was slightly higher than intervendor. Only small differences in intraclass correlation coefficients were present between various myocardial layers and acquired versus compressed TomTec data with narrow limits of agreement and small bias except in certain subgroup comparisons. CONCLUSIONS Comparison of LV GLS and GCS between two commonly used software platforms after European Association of Cardiovascular Imaging/American Society of Echocardiography Industry Task Force recommendations demonstrated good to excellent agreement in pediatrics, regardless of the layer of analysis or the image format, although some degree of variability remains between vendor platforms. Overall, GLS agreement was more robust than GCS, and this difference is exaggerated in specific subanalyses. These data suggest that comparisons of strain values obtained on these two vendors will be reasonable, but caution should be used when the indication is the detection of small differences between serial echocardiograms.
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Abstract
PURPOSE OF REVIEW We aim to review select literature pertaining to congenital heart disease (CHD)-induced right ventricular (RV) function and failure. RECENT FINDINGS We review recent findings pertaining to children and adults with repaired tetralogy of Fallot (rTOF), systemic RV and hypoplastic left heart syndrome (HLHS). We emphasize pathophysiological mechanisms contributing to RV dysfunction in these conditions, the risk factors for adverse outcomes and the continuing challenges in treating these patients. We discuss how recent pathology findings, as well as developments in imaging and computer modeling have broadened our understanding of the pathophysiology of these conditions. We further review developments in the molecular and cellular basis of RV failure; and in particular, the RV molecular response to stress in repaired tetralogy of Fallot (rTOF). We highlight some of the genetic complexities in HLHS and how these may influence the long-term outcomes in these patients. SUMMARY Recent literature has led to new understandings in the pathology, pathophysiology, risk factors for adverse outcomes, molecular and genetic basis for RV dysfunction and failure in CHD. Although these findings provide new therapeutic targets, the treatment of RV failure at this time remains limited.
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Forsha D, Li L, Joseph N, Kutty S, Friedberg MK. Association of left ventricular size with regional right ventricular mechanics in Hypoplastic Left Heart Syndrome. Int J Cardiol 2019; 298:66-71. [PMID: 31402159 DOI: 10.1016/j.ijcard.2019.07.090] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/27/2019] [Revised: 07/19/2019] [Accepted: 07/30/2019] [Indexed: 10/26/2022]
Abstract
BACKGROUND In Hypoplastic Left Heart Syndrome (HLHS), RV dysfunction is associated with poor outcomes. However, the effect of varying LV size on regional RV mechanics and outcome has not been studied. METHODS Twenty newborns (0-7 days) with HLHS had pre-stage 1 and pre-stage 2 echocardiograms prospectively protocoled for strain analysis of the apical 4-chamber view. RV longitudinal strain was analyzed, and LV size was classified as diminutive (no visible LV chamber) or moderate size (visible LV chamber). Clinical outcome was reported as alive vs death or transplant (D-TP) at final clinical follow-up (pre-stage 3). Groups were compared with t-test, Fisher's Exact, and ANOVA tests as appropriate. RESULTS At pre-stage 1, infants with a diminutive LV (7/20, 35%) vs a moderately hypoplastic LV (13/20, 65%) did not have significantly different global RV strain (-18.4 ± 2.6% vs -18.8 ± 3.2%; p = 0.83). However, basal septal strain was significantly diminished in the moderately hypoplastic LV group vs the diminutive LV group (-4.4 ± 6.0% vs -14.7 ± 3.3%; p < 0.005). There was severely diminished septal strain in nearly all (11/13) of the moderately hypoplastic group. At the pre-stage II echo, global RV strain between groups remained similar (p = 0.76) as did the diminished septal strain in the moderate LV group (p = 0.86). The moderately hypoplastic LV group had worse clinical outcomes (6/13 D-TP vs 0/7 D-TP; p = 0.05). CONCLUSIONS In this small HLHS cohort, diminished septal strain leading to asymmetric RV mechanics may be associated with poor outcomes in those with larger LV/septal size.
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Affiliation(s)
- Daniel Forsha
- Division of Cardiology, Ward Family Heart Center, Children's Mercy Hospital, Kansas City, MO, United States of America.
| | - Ling Li
- Division of Pediatric Cardiology, University of Nebraska Medical Center, Children's Hospital and Medical Center, Omaha, NE, United States of America.
| | - Navya Joseph
- Division of Pediatric Cardiology, University of Nebraska Medical Center, Children's Hospital and Medical Center, Omaha, NE, United States of America.
| | - Shelby Kutty
- Division of Pediatric Cardiology, University of Nebraska Medical Center, Children's Hospital and Medical Center, Omaha, NE, United States of America.
| | - Mark K Friedberg
- Department of Cardiology, Labatt Family Heart Centre, Hospital for Sick Children, Toronto, ON, Canada; Department of Pediatrics, University of Toronto, Toronto, ON, Canada.
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27
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Colquitt JL, Loar RW, Morris SA, Feagin DK, Sami S, Pignatelli RH. Serial Strain Analysis Identifies Hypoplastic Left Heart Syndrome Infants at Risk for Cardiac Morbidity and Mortality: A Pilot Study. J Am Soc Echocardiogr 2019; 32:643-650. [PMID: 30803862 DOI: 10.1016/j.echo.2019.01.006] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/14/2018] [Indexed: 11/28/2022]
Abstract
BACKGROUND Validated, objective measures of right ventricular (RV) function assessment in hypoplastic left heart syndrome (HLHS) are needed. In other populations, speckle-tracking echocardiography-derived strain is a sensitive measure that outperforms conventional parameters of RV function. We hypothesized that speckle-tracking echocardiography-derived measures of RV function would be worse in patients with HLHS who have a poor cardiac outcome. METHODS Prospective serial echocardiography was performed in 35 infants with HLHS during the first 6 months of life. Patients not undergoing staged palliation or with other variants of single RV were excluded. Traditional RV measurements and strain analysis were performed from standard apical and basal views. The primary outcome of cardiac death, heart transplantation, or persistent ≥ moderate RV dysfunction was examined using Cox regression analysis, and receiver operating characteristic curve analyses were performed to derive cutoff values. RESULTS At median follow-up of 10.9 months (interquartile range 5.6, 15.2), eight patients reached the outcome and demonstrated worse RV strain measures compared with those without the outcome. A post-Norwood global longitudinal strain (GLS) of > -16% (area under the curve [AUC] = 0.76; P = .04) and pre-Glenn GLS > -13% (AUC, 0.98; P ≤ .01) were highly sensitive and specific for poor outcome. Other thresholds included post-Norwood GLS rate (GLSr) > -1.15 %/s (AUC, 0.78; P = .03), pre-Glenn GLSr = -0.85%/sec (AUC, 0.89; P < .01), post-Glenn circumferential strain rate > -0.85%/sec (AUC, 0.92; P < .01), and GLSr > -0.85%/sec (AUC, 0.84; P = .02). CONCLUSIONS Strain analysis may help identify at-risk HLHS infants. In this pilot study, interstage strain indices were worse in infants with HLHS who had a poor cardiac outcome.
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Affiliation(s)
- John L Colquitt
- Texas Children's Hospital, Baylor College of Medicine, Houston, Texas.
| | - Robert W Loar
- Texas Children's Hospital, Baylor College of Medicine, Houston, Texas
| | - Shaine A Morris
- Texas Children's Hospital, Baylor College of Medicine, Houston, Texas
| | - Douglas K Feagin
- Texas Children's Hospital, Baylor College of Medicine, Houston, Texas
| | - Sarah Sami
- Texas Children's Hospital, Baylor College of Medicine, Houston, Texas
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