1
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Kerstein JS, Valencia E, Collins S, Ferraro AM, Harrild DM, Gauvreau K, Callahan R, Mullen MP. Transcatheter Ductus Arteriosus Stenting for Acute Pediatric Pulmonary Arterial Hypertension is Associated with Improved Right Ventricular Echocardiography Strain. Pediatr Cardiol 2024; 45:1573-1580. [PMID: 37442851 DOI: 10.1007/s00246-023-03233-7] [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: 05/15/2023] [Accepted: 07/05/2023] [Indexed: 07/15/2023]
Abstract
BACKGROUND Interventional therapies for severe pulmonary arterial hypertension (PAH) can provide right ventricular (RV) decompression and preserve cardiac output. Transcatheter stent placement in a residual ductus arteriosus (PDA) is one potentially effective option in critically ill infants and young children with PAH. We sought to assess recovery of RV function by echocardiographic strain in infants and young children following PDA stenting for acute PAH. METHODS Retrospective review of patients < 2 years old who underwent PDA stenting for acute PAH. Clinical data were abstracted from the electronic medical record. RV strain (both total and free wall components) was assessed from echocardiographic images at baseline and 3, 6, and 12 months post-intervention, as well as at last echocardiogram. RESULTS Nine patients underwent attempted ductal stenting for PAH. The median age at intervention was 38 days and median weight 3.7 kg. One-third (3of 9) of patients had PAH associated with a congenital diaphragmatic hernia. PDA stents were successfully deployed in eight patients. Mean RV total strain was - 14.9 ± 5.6% at baseline and improved to - 23.8 ± 2.2% at 6 months post-procedure (p < 0.001). Mean free wall RV strain was - 19.5 ± 5.4% at baseline and improved to - 27.7 ± 4.1% at 6 months (p = 0.002). Five patients survived to discharge, and four patients survived 1 year post-discharge. CONCLUSION PDA stenting for severe, acute PAH can improve RV function as assessed by strain echocardiography. The quantitative improvement is more prominent in the first 6 months post-procedure and stabilizes thereafter.
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Affiliation(s)
- Jason S Kerstein
- Department of Cardiology, Boston Children's Hospital, 300 Longwood Avenue, Boston, MA, 02115, USA.
- Harvard Medical School, Boston, MA, USA.
| | - Eleonore Valencia
- Department of Cardiology, Boston Children's Hospital, 300 Longwood Avenue, Boston, MA, 02115, USA
- Harvard Medical School, Boston, MA, USA
| | - Shane Collins
- Department of Cardiology, Boston Children's Hospital, 300 Longwood Avenue, Boston, MA, 02115, USA
| | - Alessandra M Ferraro
- Department of Cardiology, Boston Children's Hospital, 300 Longwood Avenue, Boston, MA, 02115, USA
| | - David M Harrild
- Department of Cardiology, Boston Children's Hospital, 300 Longwood Avenue, Boston, MA, 02115, USA
- Harvard Medical School, Boston, MA, USA
| | - Kimberlee Gauvreau
- Department of Cardiology, Boston Children's Hospital, 300 Longwood Avenue, Boston, MA, 02115, USA
- Harvard Medical School, Boston, MA, USA
| | - Ryan Callahan
- Department of Cardiology, Boston Children's Hospital, 300 Longwood Avenue, Boston, MA, 02115, USA
- Harvard Medical School, Boston, MA, USA
- Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Mary P Mullen
- Department of Cardiology, Boston Children's Hospital, 300 Longwood Avenue, Boston, MA, 02115, USA
- Harvard Medical School, Boston, MA, USA
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2
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Ivy D, Rosenzweig EB, Abman SH, Beghetti M, Bonnet D, Douwes JM, Manes A, Berger RMF. Embracing the challenges of neonatal and paediatric pulmonary hypertension. Eur Respir J 2024:2401345. [PMID: 39209483 DOI: 10.1183/13993003.01345-2024] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2024] [Accepted: 07/11/2024] [Indexed: 09/04/2024]
Abstract
Paediatric pulmonary arterial hypertension (PAH) shares common features with adult disease, but is associated with several additional disorders and challenges that require unique approaches. This article discusses recent advances, ongoing challenges and distinct approaches for caring for infants and children with PAH, as presented by the paediatric task force of the 7th World Symposium on Pulmonary Hypertension. We provide updates on diagnosing, classifying, risk-stratifying and treating paediatric pulmonary hypertension (PH) and identify critical knowledge gaps. An updated risk stratification tool and treatment algorithm is provided, now also including strategies for patients with associated cardiopulmonary conditions. Treatment of paediatric PH continues to be hindered by the lack of randomised controlled clinical trials. The challenging management of children failing targeted PAH therapy is discussed, including balloon atrial septostomy, lung transplantation and pulmonary-to-systemic shunt (Potts). A novel strategy using a multimodal approach for the management of PAH associated with congenital heart diseases with borderline pulmonary vascular resistance is included. Advances in diagnosing neonatal PH, especially signs and interpretation of PH by echocardiography, are highlighted. A team approach to the rapidly changing physiology of neonatal PH is emphasised. Challenges in drug approval are discussed, particularly the challenges of designing accurate paediatric clinical trials with age-appropriate end-points and adequate enrolment.
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Affiliation(s)
- Dunbar Ivy
- Pediatric Cardiology, University of Colorado School of Medicine, and Children's Hospital Colorado, Aurora, CO, USA
| | - Erika B Rosenzweig
- Department of Pediatrics, Maria Fareri Children's Hospital at WMC Health and New York Medical College of Touro University, Valhalla, NY, USA
| | - Steven H Abman
- Department of Pediatrics, University of Colorado School of Medicine, and Children's Hospital Colorado, Aurora, CO, USA
| | - Maurice Beghetti
- Paediatric Cardiology Unit, Department of Paediatrics, Gynecology and Obstetrics, Geneva University Hospital, University of Geneva, Geneva, Switzerland
| | - Damien Bonnet
- Centre de Référence Malformations Cardiaques Congénitales Complexes, M3C, Necker Hospital for Sick Children, Assistance Publique des Hôpitaux de Paris, Paediatric Cardiology, Paris, France
| | - Johannes Menno Douwes
- Center for Congenital Heart Diseases, Paediatric Cardiology, Beatrix Children's Hospital, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Alessandra Manes
- Cardiology Unit IRCCS, S. Orsola University Hospital, Bologna, Italy
| | - Rolf M F Berger
- Center for Congenital Heart Diseases, Paediatric and Congenital Cardiology, Beatrix Children's Hospital, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
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3
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Price K, Ryan JR, El-Said H. Stenting of the Patent Ductus Arteriosus. Interv Cardiol Clin 2024; 13:421-430. [PMID: 38839174 DOI: 10.1016/j.iccl.2024.02.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/07/2024]
Abstract
Since PDA stenting was first attempted in the early 1990s, significant technical advancements have improved outcomes and some centers have even transitioned to exclusive PDA stenting for all infants with duct-dependent pulmonary circulation. In addition to its use in infants with duct-dependent pulmonary circulation, PDA stenting has also been adapted as a percutaneous palliative option for suprasystemic pulmonary arterial hypertension and as a component of the hybrid procedure. In this article, the authors aim to review indications and outcomes for PDA stenting, describe the procedure, and discuss future directions.
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Affiliation(s)
- Katherine Price
- Department of Pediatrics, Cincinnati Children's Hospital Medical Center, 3333 Burnett Avenue, Cincinnati, OH, USA
| | - Justin R Ryan
- Webster Foundation 3D Innovations Lab, Rady Children's Hospital, 3020 Children's way, San Diego, CA 92123, USA
| | - Howaida El-Said
- Department of Pediatric Cardiology, Rady Children's Hospital, 3020 Children's way, San Diego, CA 92123, USA.
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4
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Tsoi SM, Nawaytou H, Almeneisi H, Steurer M, Zhao Y, Fineman JR, Keller RL. Prostaglandin-E1 infusion in persistent pulmonary hypertension of the newborn. Pediatr Pulmonol 2024; 59:379-388. [PMID: 37975485 PMCID: PMC10872594 DOI: 10.1002/ppul.26759] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/15/2023] [Revised: 10/13/2023] [Accepted: 11/05/2023] [Indexed: 11/19/2023]
Abstract
BACKGROUND Neonates with persistent pulmonary hypertension of the newborn (PPHN) can present with hypoxia and right ventricular dysfunction with resultant inadequate oxygen delivery and end-organ damage. This study describes the use of prostaglandin-E1 (PGE) for ductal patency to preserve right ventricular systolic function and limit afterload in newborns with PPHN. METHODS This is a retrospective cohort study that follows the hemodynamics, markers of end-organ perfusion, length of therapeutics, and echocardiographic variables of 57 newborns who used prostglandin-E1 in the setting of PPHN. RESULTS Tachycardia, lactic acidosis, and supplemental oxygen use improved following PGE initiation. Fractional area change (FAC), to assess right ventricular systolic function, and pulmonary arterial acceleration time indexed to right ventricular ejection time (PAAT/RVET), to assess right ventricular afterload, also improved over three time points relative to PGE use (before, during, and after). CONCLUSIONS Overall, we described the safety and utility of PGE in newborns with severe PPHN for stabilization while allowing natural disease progression.
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Affiliation(s)
- Stephanie M Tsoi
- Department of Pediatrics, Division of Critical Care Medicine, University of California San Francisco, San Francisco, California, USA
| | - Hythem Nawaytou
- Department of Pediatrics, Division of Cardiology, University of California San Francisco, San Francisco, California, USA
| | - Hassan Almeneisi
- Department of Pediatrics, Division of Cardiology, University of California San Francisco, San Francisco, California, USA
| | - Martina Steurer
- Department of Pediatrics, Division of Critical Care Medicine, University of California San Francisco, San Francisco, California, USA
- Department of Pediatrics, Division of Neonatology, University of California San Francisco, San Francisco, California, USA
- Department of Epidemiology and Biostatistics, University of California San Francisco, San Francisco, California, USA
| | - Yili Zhao
- Department of Pediatrics, Division of Cardiology, University of California San Francisco, San Francisco, California, USA
| | - Jeffrey R Fineman
- Department of Pediatrics, Division of Critical Care Medicine, University of California San Francisco, San Francisco, California, USA
- Cardiovascular Research Institute, University of California San Francisco, San Francisco, California, USA
| | - Roberta L Keller
- Department of Pediatrics, Division of Neonatology, University of California San Francisco, San Francisco, California, USA
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5
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do Valle LR, Martins CN, Lopes RM, Fantini FA, Vrandecic EC, Amaral F. Reversed Potts Shunt as a Palliative Option for EndStage Idiopathic Pulmonary Arterial Hypertension in Childhood. Braz J Cardiovasc Surg 2023; 38:e20220034. [PMID: 37801477 PMCID: PMC10550217 DOI: 10.21470/1678-9741-2022-0034] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2022] [Accepted: 07/13/2022] [Indexed: 10/08/2023] Open
Affiliation(s)
| | | | | | | | | | - Fernando Amaral
- Hospital das Clínicas da Faculdade de Medicina de
Ribeirão Preto, Universidade de São Paulo, Ribeirão Preto,
São Paulo, Brazil
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6
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Interventionelle Behandlungsverfahren der pulmonalen Hypertension im Kindesalter. Monatsschr Kinderheilkd 2022. [DOI: 10.1007/s00112-022-01583-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/14/2022]
Abstract
ZusammenfassungDie pulmonale Hypertension (PH) ist eine progressive Gefäßerkrankung und führt über eine Widerstands- und/oder Druckerhöhung im kleinen Kreislauf zu einem fortschreitenden Rechtsherzversagen. Auch wenn mithilfe aktueller medikamentöser Therapien eine deutliche Verbesserung der Lebensqualität und des Überlebens der Betroffenen erreicht werden konnte, bleibt die PH eine zumeist nichtheilbare Erkrankung, die im fortgeschrittenen Stadium eine Lungentransplantation notwendig macht. Interventionelle Verfahren, wie die Anlage eines interatrialen Shunts (z. B. durch atriale Septostomie oder den Atrial Flow Regulator) oder eines Reversed Potts Shunt, verbessern die RV-Funktion und die ventrikuläre Interaktion durch Schaffung einer prä- oder posttrikuspidalen „Eisenmenger-Physiologie“ und stellen eine Überbrückung oder sogar Alternative zur Lungentransplantation dar. Bei Patienten mit segmentaler PH oder chronisch thrombembolischer pulmonaler Hypertension (CTEPH) stellt die Ballonangioplastie eine bereits etablierte Intervention zur Verbesserung der pulmonalen Perfusion und damit rechtsventrikulären (RV-)Funktion dar. Dagegen ist die pulmonalarterielle Denervation ein neuartiges Verfahren, mit dem Ziel, die neurohumorale Dysregulation bei PH positiv zu beeinflussen. Der individuelle Einsatz solcher Interventionen, additiv zu den bereits etablierten medikamentösen Therapien, erweitert die Behandlungsmöglichkeiten und kann die Prognose betroffener Patienten noch weiter verbessern.
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7
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Mendel B, Christianto C, Angellia P, Holiyono I, Prakoso R, Siagian SN. Reversed Potts Shunt Outcome in Suprasystemic Pulmonary Arterial Hypertension: A Systematic Review and Meta-Analysis. Curr Cardiol Rev 2022; 18:e090522204486. [PMID: 35538823 PMCID: PMC9893152 DOI: 10.2174/1573403x18666220509203335] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/21/2022] [Revised: 02/14/2022] [Accepted: 03/15/2022] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND Reversed Potts shunt has been a prospective approach to treat suprasystemic pulmonary hypertension, particularly when medication treatment fails to reduce right ventricular afterload. OBJECTIVE This meta-analysis aims to review the clinical, laboratory, and hemodynamic parameters after a reversed Potts shunt in suprasystemic pulmonary hypertension patients. METHODS Six electronic databases were searched from the date of inception to August 2021, where the obtained studies were evaluated according to the PRISMA statement. The effects of shunt creation were evaluated by comparing preprocedural to postprocedural or follow-up parameters, expressed as a mean difference of 99% confidence interval. Quality assessment was conducted using the STROBE statement. RESULTS Seven studies suited the inclusion criteria which were included in this article. A reduction in upper and lower limb oxygen saturation [Upper limb: St. Mean difference -0.55, 99% CI -1.25 to 0.15; P=0.04; I2=6%. Lower limb: St. Mean difference -4.45, 99% CI -7.37 to -1.52; P<0.00001; I2=65%]. Reversed Potts shunt was shown to improve WHO functional class, 6-minute walk distance, NTpro-BNP level, and hemodynamic parameters including tricuspid annular plane systolic excursion, interventricular septal curvature, and end-diastolic right ventricle/left ventricle ratio. CONCLUSION Reversed Potts shunt cannot be said to be relatively safe, although it allows improvement in the clinical and functional status in patients with suprasystemic PAH. Reversed Potts shunt procedure may be the last resort for drug-resistant pulmonary hypertension as it is considered a high-risk procedure performed on patients with extremely poor conditions.
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Affiliation(s)
- Brian Mendel
- Pediatric Cardiology and Congenital Heart Defect Division, Department of Cardiology and Vascular Medicine, National Cardiovascular Center Harapan Kita, Universitas Indonesia, Jakarta, Indonesia
| | | | | | - Indra Holiyono
- Faculty of Medicine, Universitas Indonesia, Jakarta, Indonesia
| | - Radityo Prakoso
- Pediatric Cardiology and Congenital Heart Defect Division, Department of Cardiology and Vascular Medicine, National Cardiovascular Center Harapan Kita, Universitas Indonesia, Jakarta, Indonesia
| | - Sisca Natalia Siagian
- Pediatric Cardiology and Congenital Heart Defect Division, Department of Cardiology and Vascular Medicine, National Cardiovascular Center Harapan Kita, Universitas Indonesia, Jakarta, Indonesia
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8
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Schranz D, Akintuerk H, Esmaeili A, Latus H, Apitz C. Heart failure therapy based on interventricular mechanics and cardio-vascular communications. Cardiovasc Diagn Ther 2021; 11:1080-1088. [PMID: 34527534 DOI: 10.21037/cdt-20-347] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2020] [Accepted: 04/15/2020] [Indexed: 01/10/2023]
Abstract
The heart should not be divided in right and left, whether in health nor in disease. However, the morphological and functional differences between the right and left ventricle should be known and the impact of the ventricle's position considered. Further, the parameters beyond heart rate, contractility, pre- and afterload guaranteeing a sufficient systemic cardiac output have to be integrated in therapeutic measures; preferentially the influence of interventricular mechanics. Despite of recent developments of specific drug therapies, heart failure is associated with a high rate of morbidity and mortality in children. During the progression of heart failure, pulmonary vascular disease is the consequence or the reason for further failing. Clinical symptoms are associated with congestion and low cardiac output at rest or exercise. Improved understanding of the pathophysiological mechanisms particularly of ventricular failure has resulted in the development of innovative therapies that target atrial/ventricular/arterial interactions. Recent advances in interventional and surgical approaches provide promising new strategies to deal with right and left ventricular deterioration. These techniques may delay listing for heart and (heart-) lung transplantation or even make redundant in individual cases. The beneficial effects of these ventricular interaction strategies are mainly based on the mechanics of the interventricular septum and improvement of systolic and diastolic ventricular performance.
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Affiliation(s)
- Dietmar Schranz
- Pediatric Heart Center, Justus-Liebig University, Giessen, Germany.,Pediatric Cardiology, University Clinic Frankfurt, Frankfurt, Germany
| | - Hakan Akintuerk
- Pediatric Heart Center, Justus-Liebig University, Giessen, Germany
| | - Anoosh Esmaeili
- Pediatric Cardiology, University Clinic Frankfurt, Frankfurt, Germany
| | - Heiner Latus
- Pediatric Cardiology, German Heart Center, Munich, Germany
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9
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Schranz D. Reverse Potts Shunt for Pulmonary Hypertension: Back to a "Fetal" Circulation in Part? J Am Coll Cardiol 2021; 78:478-480. [PMID: 34325837 DOI: 10.1016/j.jacc.2021.05.038] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/05/2021] [Revised: 05/10/2021] [Accepted: 05/11/2021] [Indexed: 11/30/2022]
Affiliation(s)
- Dietmar Schranz
- Pediatric Heart Center Giessen & Frankfurt, Johann-Wolfgang-Goethe University Clinic, Frankfurt, Germany.
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10
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Lancaster TS, Shahanavaz S, Balzer DT, Sweet SC, Grady RM, Eghtesady P. Midterm outcomes of the Potts shunt for pediatric pulmonary hypertension, with comparison to lung transplant. J Thorac Cardiovasc Surg 2021; 161:1139-1148. [DOI: 10.1016/j.jtcvs.2020.10.163] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/08/2020] [Revised: 10/16/2020] [Accepted: 10/26/2020] [Indexed: 10/22/2022]
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Bobhate P, Mohanty SR, Tailor K, Kadam S, Karande T, Bhavsar K, Katanna HB, Rao S, Kulkarni S. Potts shunt as an effective palliation for patients with end stage pulmonary arterial hypertension. Indian Heart J 2021; 73:196-204. [PMID: 33865518 PMCID: PMC8065372 DOI: 10.1016/j.ihj.2021.01.007] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2020] [Revised: 11/24/2020] [Accepted: 01/02/2021] [Indexed: 11/29/2022] Open
Abstract
BACKGROUND Potts shunt has been suggested as an effective palliative therapy for patients with pulmonary artery hypertension (PAH) not associated with congenital heart disease. MATERIALS AND METHODS This is a prospective single-center study performed to assess outcomes of Potts shunt in patients with PAH who are in functional class III or IV. RESULTS 52 patients in functional class III/IV with pulmonary arterial hypertension without significant intra or extracardiac shunt on maximal medical therapy were evaluated and counseled for undergoing Potts shunt/patent ductus arteriosus (PDA) stenting. 16/52 patients (13 females) consented for the procedure; 14 patients underwent surgical creation of Potts, and 2 underwent transcatheter stenting of PDA, which physiologically acted like a Potts shunt. Standard medical therapy was continued in patients who did not consent for the procedure. 12/16 patients survived the procedure. Patients who did not survive the procedure were older, with severe right ventricular systolic dysfunction, and functional class IV. Patients who survived the procedure were followed up in the pulmonary hypertension clinic. The Median follow-up was 17 months (1-40 months). 11/13 patients discharged after the operation showed sustained clinical, echocardiographic, and biochemical improvement, which reduced need for pulmonary vasodilator therapy in 10/13 patients. There was one death in the follow-up period 16 months post-surgery due to lower respiratory tract infection. CONCLUSION Potts shunt is feasible in patients with PAH without significant intra or extracardiac shunts. It can be done safely with an acceptable success rate. Patient selection, preoperative stabilization, and meticulous postoperative management are essential. It should be performed at the earliest sign of clinical, echocardiographic, or laboratory deterioation for optimal outcomes. Long-term follow-up is required to see a sustained improvement in functional class and the need for a lung transplant in the future.
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Affiliation(s)
- Prashant Bobhate
- Children's' Heart Center, Second Floor, Kokilaben Dhirubai Ambani Hospital and Research Center, Rao Achyut Rao PAtwardhan Marg, Four Bunglows, Andheri West, Mumbai, Maharashtra, 400053, India.
| | - Smruti Ranjan Mohanty
- Children's' Heart Center, Second Floor, Kokilaben Dhirubai Ambani Hospital and Research Center, Rao Achyut Rao PAtwardhan Marg, Four Bunglows, Andheri West, Mumbai, Maharashtra, 400053, India
| | - Kamlesh Tailor
- Children's' Heart Center, Second Floor, Kokilaben Dhirubai Ambani Hospital and Research Center, Rao Achyut Rao PAtwardhan Marg, Four Bunglows, Andheri West, Mumbai, Maharashtra, 400053, India
| | - Shankar Kadam
- Children's' Heart Center, Second Floor, Kokilaben Dhirubai Ambani Hospital and Research Center, Rao Achyut Rao PAtwardhan Marg, Four Bunglows, Andheri West, Mumbai, Maharashtra, 400053, India
| | - Tanuja Karande
- Children's' Heart Center, Second Floor, Kokilaben Dhirubai Ambani Hospital and Research Center, Rao Achyut Rao PAtwardhan Marg, Four Bunglows, Andheri West, Mumbai, Maharashtra, 400053, India
| | - Keyoor Bhavsar
- Children's' Heart Center, Second Floor, Kokilaben Dhirubai Ambani Hospital and Research Center, Rao Achyut Rao PAtwardhan Marg, Four Bunglows, Andheri West, Mumbai, Maharashtra, 400053, India
| | - Hari Bipin Katanna
- Children's' Heart Center, Second Floor, Kokilaben Dhirubai Ambani Hospital and Research Center, Rao Achyut Rao PAtwardhan Marg, Four Bunglows, Andheri West, Mumbai, Maharashtra, 400053, India
| | - Suresh Rao
- Children's' Heart Center, Second Floor, Kokilaben Dhirubai Ambani Hospital and Research Center, Rao Achyut Rao PAtwardhan Marg, Four Bunglows, Andheri West, Mumbai, Maharashtra, 400053, India
| | - Snehal Kulkarni
- Children's' Heart Center, Second Floor, Kokilaben Dhirubai Ambani Hospital and Research Center, Rao Achyut Rao PAtwardhan Marg, Four Bunglows, Andheri West, Mumbai, Maharashtra, 400053, India
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12
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Capel A, Lévy M, Szezepanski I, Malekzadeh-Milani S, Vouhé P, Bonnet D. Potts anastomosis in children with severe pulmonary arterial hypertension and atrial septal defect. ESC Heart Fail 2020; 8:326-332. [PMID: 33216469 PMCID: PMC7835613 DOI: 10.1002/ehf2.13074] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2020] [Revised: 10/01/2020] [Accepted: 10/05/2020] [Indexed: 11/26/2022] Open
Abstract
Aims Potts shunt has been proposed as a bridge or alternative to lung transplantation for children with severe and drug‐refractory suprasystemic pulmonary arterial hypertension (PAH). We describe the management of the atrial shunt when a Potts shunt is planned in refractory PAH. Methods and results We report a case series of children in whom a Potts shunt was done for severe PAH associated with an atrial septal defect to illustrate the different clinical and haemodynamic scenarios. Five children (2 to 13 years) underwent a Potts shunt: three surgical, one percutaneous Potts shunt, and one percutaneous stenting of a restrictive arterial duct. All had associated atrial septal defect. Those who had generalized cyanosis before the procedure had a complicated postoperative course and required longer ventilatory and inotropic support, except the one who had atrial septal defect closure before the Potts shunt. One of the three cyanotic patients died. Two patients with left‐to‐right shunt before the Potts shunt had an uncomplicated postoperative course. Conclusions Shunt physiology is only partially predictable after the Potts shunt in children with PAH and atrial septal defect. Abrupt drop in left ventricle preload while the right ventricle is decompressed can potentially be prevented by atrial septal defect closure prior to the Potts shunt.
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Affiliation(s)
- Alice Capel
- M3C-Necker, Hôpital Universitaire Necker-Enfants Malades, APHP, 149, Rue de Sèvres, Paris, 75015, France.,Université de Paris, Paris, France
| | - Marilyne Lévy
- M3C-Necker, Hôpital Universitaire Necker-Enfants Malades, APHP, 149, Rue de Sèvres, Paris, 75015, France.,Université de Paris, Paris, France
| | - Isabelle Szezepanski
- M3C-Necker, Hôpital Universitaire Necker-Enfants Malades, APHP, 149, Rue de Sèvres, Paris, 75015, France.,Université de Paris, Paris, France
| | - Sophie Malekzadeh-Milani
- M3C-Necker, Hôpital Universitaire Necker-Enfants Malades, APHP, 149, Rue de Sèvres, Paris, 75015, France.,Université de Paris, Paris, France
| | - Pascal Vouhé
- M3C-Necker, Hôpital Universitaire Necker-Enfants Malades, APHP, 149, Rue de Sèvres, Paris, 75015, France.,Université de Paris, Paris, France
| | - Damien Bonnet
- M3C-Necker, Hôpital Universitaire Necker-Enfants Malades, APHP, 149, Rue de Sèvres, Paris, 75015, France.,Université de Paris, Paris, France
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Albinni S, Marx M, Lang IM. Focused Update on Pulmonary Hypertension in Children-Selected Topics of Interest for the Adult Cardiologist. MEDICINA (KAUNAS, LITHUANIA) 2020; 56:E420. [PMID: 32825190 PMCID: PMC7559541 DOI: 10.3390/medicina56090420] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/06/2020] [Revised: 08/13/2020] [Accepted: 08/16/2020] [Indexed: 11/16/2022]
Abstract
Pulmonary hypertensive vascular disease (PHVD), and pulmonary hypertension (PH), which is a broader term, are severe conditions associated with high morbidity and mortality at all ages. Treatment guidelines in childhood are widely adopted from adult data and experience, though big differences may exist regarding aetiology, concomitant conditions and presentation. Over the past few years, paediatric aspects have been incorporated into the common guidelines, which currently address both children and adults with pulmonary hypertension (PH). There are multiple facets of PH in the context of cardiac conditions in childhood. Apart from Eisenmenger syndrome (ES), the broad spectrum of congenital heart disease (CHD) comprises PH in failing Fontan physiology, as well as segmental PH. In this review we provide current data and novel aspects on the pathophysiological background and individual management concepts of these conditions. Moreover, we focus on paediatric left heart failure with PH and its challenging issues, including end stage treatment options, such as mechanical support and paediatric transplantation. PH in the context of rare congenital disorders, such as Scimitar Syndrome and sickle cell disease is discussed. Based on current data, we provide an overview on multiple underlying mechanisms of PH involved in these conditions, and different management strategies in children and adulthood. In addition, we summarize the paediatric aspects and the pros and cons of the recently updated definitions of PH. This review provides deeper insights into some challenging conditions of paediatric PH in order to improve current knowledge and care for children and young adults.
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Affiliation(s)
- Sulaima Albinni
- Paediatric Heart Centre Vienna, Department of Paediatrics and Adolescent Medicine, Medical University of Vienna, 1090 Wien, Austria;
| | - Manfred Marx
- Paediatric Heart Centre Vienna, Department of Paediatrics and Adolescent Medicine, Medical University of Vienna, 1090 Wien, Austria;
| | - Irene M. Lang
- AKH-Vienna, Department of Cardiology, Medical University of Vienna, 1090 Wien, Austria;
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Neuhäuser CA, Kreymborg KG, Müller C, Khalil M, Jux C, Galambos C, Schranz D. Successful Management of an Infant with Atypical Presentation of Alveolar Capillary Dysplasia with Misalignment of the Pulmonary Veins. J Pediatr Intensive Care 2020; 10:228-231. [PMID: 34395042 DOI: 10.1055/s-0040-1713437] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2020] [Accepted: 05/10/2020] [Indexed: 10/24/2022] Open
Abstract
A newborn infant patient presented with persistent pulmonary hypertension. For right ventricular decompression, the ductus arteriosus was kept open by prostaglandin E 1 infusion and was stented at the age of 4 weeks during heart catheterization. The child was weaned from mechanical ventilation, since pulmonary functions were adequate. A small atrial septal defect was identified and closed in cardiac catheterization laboratory to decrease preductal hypoxemia. Diagnostic workup led to the diagnosis of alveolar capillary dysplasia with misalignment of the pulmonary veins. Suprasystemic pulmonary arterial hypertension with persisting nitric oxide dependency remained the leading symptoms. The child underwent bilateral lung transplantation at the age of 28 months. He is well at the age of 44 months.
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Affiliation(s)
- Christoph Armin Neuhäuser
- Department of Pediatric Cardiology, Pediatric Heart Center, University Children's Hospital, Justus Liebig University, Giessen, Germany
| | - Karsten Grosse Kreymborg
- Department of Pediatric Cardiology, Pediatric Heart Center, University Children's Hospital, Justus Liebig University, Giessen, Germany
| | - Carsten Müller
- Department of Pediatric Pneumology and Neonatology, University Children's Hospital, Hannover Medical School, Hannover, Germany
| | - Markus Khalil
- Department of Pediatric Cardiology, Pediatric Heart Center, University Children's Hospital, Justus Liebig University, Giessen, Germany
| | - Christian Jux
- Department of Pediatric Cardiology, Pediatric Heart Center, University Children's Hospital, Justus Liebig University, Giessen, Germany
| | - Csaba Galambos
- Department of Pathology and Laboratory Medicine, Children's Hospital Colorado, University of Colorado School of Medicine, Aurora, Colorado, United States
| | - Dietmar Schranz
- Department of Pediatric Cardiology, Pediatric Heart Center, University Children's Hospital, Justus Liebig University, Giessen, Germany
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Valdeomillos E, Jalal Z, Boudjemline Y, Thambo JB. Transcatheter ductus arteriosus stenting in paediatric cardiology: Indications, results and perspectives. Arch Cardiovasc Dis 2019; 113:129-141. [PMID: 31753586 DOI: 10.1016/j.acvd.2019.10.004] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/03/2019] [Revised: 09/27/2019] [Accepted: 10/02/2019] [Indexed: 12/17/2022]
Abstract
Stenting the arterial duct emerged in the early 1990s as an alternative to a variety of surgical interventions in neonates with a duct-dependent pulmonary or systemic circulation complex defect. Furthermore, palliative ductal stenting has been applied in older children with severe suprasystemic pulmonary arterial hypertension, as an alternative to surgical shunts, such as Potts anastomosis. Early results of this technique were discouraging, but by learning from the failures of the past, ductal stenting has become a reliable palliative therapy. In this review, we aim to describe the historical evolution of ductal stenting, its different clinical applications and outcomes, and future perspectives for this strategy in congenital cardiac catheterization.
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Affiliation(s)
- Estibaliz Valdeomillos
- Department of Paediatric and Adult Congenital Cardiology, Bordeaux University Hospital (CHU), avenue Magellan, 33600 Pessac, France; IHU Liryc, Electrophysiology and Heart Modelling Institute, fondation Bordeaux université, 33600 Pessac, France; U1045, Inserm, centre de recherche cardio-thoracique de Bordeaux, 33000 Bordeaux, France.
| | - Zakaria Jalal
- Department of Paediatric and Adult Congenital Cardiology, Bordeaux University Hospital (CHU), avenue Magellan, 33600 Pessac, France; IHU Liryc, Electrophysiology and Heart Modelling Institute, fondation Bordeaux université, 33600 Pessac, France; U1045, Inserm, centre de recherche cardio-thoracique de Bordeaux, 33000 Bordeaux, France
| | | | - Jean-Benoit Thambo
- Department of Paediatric and Adult Congenital Cardiology, Bordeaux University Hospital (CHU), avenue Magellan, 33600 Pessac, France; IHU Liryc, Electrophysiology and Heart Modelling Institute, fondation Bordeaux université, 33600 Pessac, France; U1045, Inserm, centre de recherche cardio-thoracique de Bordeaux, 33000 Bordeaux, France
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- Department of Paediatric and Adult Congenital Cardiology, Bordeaux University Hospital (CHU), avenue Magellan, 33600 Pessac, France; IHU Liryc, Electrophysiology and Heart Modelling Institute, fondation Bordeaux université, 33600 Pessac, France; U1045, Inserm, centre de recherche cardio-thoracique de Bordeaux, 33000 Bordeaux, France; Heart Center, Sidra Medicine, Doha, Qatar
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16
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Khalil M, Jux C, Rueblinger L, Behrje J, Esmaeili A, Schranz D. Acute therapy of newborns with critical congenital heart disease. Transl Pediatr 2019; 8:114-126. [PMID: 31161078 PMCID: PMC6514285 DOI: 10.21037/tp.2019.04.06] [Citation(s) in RCA: 26] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
Critical congenital heart disease (cCHD) is the most common reason for acute cardiac failure in the neonatal period. cCHD, defined by systemic low cardiac output (LCO) and requiring surgery or catheter-based intervention in the first year of life, has an incidence of approximately 15% of CHD and is responsible for up to 25% fatalities of newborn infants. Clinical deterioration develops in most cases due to rapid closure of the ductus arteriosus (DA). Early diagnosis and immediate treatment determinate beneficial outcome. Critical CHD can be classified in duct-dependent systemic flow, duct-dependent pulmonary flow and transposition of the great arteries. The latter two manifest themselves in oxygen resistant cyanosis, whereas CHD with duct-dependent systemic flow may present itself with cardiogenic shock, which can be difficult to differentiate from other causes of shock such as sepsis. Besides prostaglandin therapy for reopening the arterial duct, a balanced parallel pulmonary and systemic circulation should be a therapeutic goal. In CHD with duct-dependent systemic flow a decrease of pulmonary resistance should be avoided; therefore inadequate oxygen therapy, hyperventilation and alkalosis due to excessive treatment of acidosis, should be averted. Volume therapy should be performed carefully. In CHD with duct-dependent pulmonary flow, pulmonary resistance can be decreased, in case of poor pulmonary flow systemic resistance should be increased, mild alkalosis is recommended. Intense volume therapy is in most cases necessary, except if a restrictive atrial communication is present. In addition to intensive care measures, an arsenal of catheter- and surgery-based procedures need to be hold available as back-up for emergency procedures. Transcatheter interventions are nowadays decisive. Atrial-septostomy was the first and still the most utilized high-urgency procedure; DA-stenting is used in prostaglandin-refractory duct stenosis. In the presence of critical aortic valve stenosis, palliation consists of balloon valvuloplasty. In critical aortic coarctation with myocardial failure and no response to prostaglandin, palliative balloon angioplasty may be the method of choice as bridging for corrective surgery.
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Affiliation(s)
- Markus Khalil
- Pediatric Heart Center of Hessen, Justus Liebig University, Giessen, Germany
| | - Christian Jux
- Pediatric Heart Center of Hessen, Justus Liebig University, Giessen, Germany
| | - Lucie Rueblinger
- Pediatric Heart Center of Hessen, Justus Liebig University, Giessen, Germany
| | - Johanna Behrje
- Pediatric Heart Center of Hessen, Justus Liebig University, Giessen, Germany
| | - Anoosh Esmaeili
- Pediatric Heart Center of Hessen, Goethe University, Frankfurt am Main, Germany
| | - Dietmar Schranz
- Pediatric Heart Center of Hessen, Justus Liebig University, Giessen, Germany.,Pediatric Heart Center of Hessen, Goethe University, Frankfurt am Main, Germany
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17
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Fulminant cytomegalovirus myocarditis in an infant with concomitant large atrial and ventricular septal defects: medical intervention strategy for functional cardiac regeneration. Cardiol Young 2019; 29:277-279. [PMID: 30572976 DOI: 10.1017/s1047951118002160] [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] [Indexed: 11/06/2022]
Abstract
A cytomegalovirus-associated heart failure in a young infant with atrial and ventricular septal defects is reported in this case report. The patient recovered by an anti-congestive and anti-viral therapy with an extra percutaneous transcatheter treatment strategy. In the context of bi-ventricular predominant right heart failure associated with supra-systemic pulmonary hypertension, the already closed arterial duct was re-opened and stented to unload the right ventricle and thereby augment the systemic blood flow. Either the left-to-right shunting atrial septal defect or bi-directional shunting ventricular septal defect was involved in the disease process and was not able to avoid global heart failure. After clinical improvement, the stented duct was shunted left-to-right and was occluded with an ADO-II-AS. During the same procedure the atrial septal defect was closed with an Amplatzer-ASD occluder, while the peri-membranous ventricular septal defect was closed with an ADO-II occluder 2 months later.
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Delhaas T, Koeken Y, Latus H, Apitz C, Schranz D. Potts Shunt to Be Preferred Above Atrial Septostomy in Pediatric Pulmonary Arterial Hypertension Patients: A Modeling Study. Front Physiol 2018; 9:1252. [PMID: 30246808 PMCID: PMC6139355 DOI: 10.3389/fphys.2018.01252] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2018] [Accepted: 08/20/2018] [Indexed: 12/13/2022] Open
Abstract
Aims: To quantitatively evaluate the basic pathophysiological process involved in the creation of Eisenmenger syndrome in pediatric pulmonary arterial hypertension (PAH) patients by either atrial septostomy (AS) or Potts shunt (PS) as well as to predict the effects of AS or PS in future PAH patients. Methods: The multi-scale lumped parameter CircAdapt model of the cardiovascular system was used to investigate the effects of AS and PS on cardiovascular hemodynamics and mechanics, as well as on oxygen saturation in moderate to severe PAH. The reference simulation, with cardiac output set to 2.1 l/min and mean systemic pressure to 61 mmHg, was used to create a compensated moderate PAH simulation with mPAP 50 mmHg. Thereupon we created a range of decompensated PAH simulations in which mPAP was stepwise increased from 50 to 80 mmHg. Then we simulated for each level of mPAP the acute effects of either PS or AS with connection diameters ranging between 0–16 mm. Results: For any mPAP level, the effect on shunt flow size is much larger for the PS than for AS. Whereas right ventricular pump work in PS is mainly dependent on mPAP, in AS it depends on both mPAP and the size of the defect. The effects on total cardiac pump work were similar for PS and AS. As expected, PS resulted in a drastic decrease of lower body oxygen saturation, whereas in AS both the upper and lower body oxygen saturation decreased, though not as drastically as in PS. Conclusion: Our simulations support the opinion that a PS can transfer suprasystemic PAH to an Eisenmenger physiology associated with a right-to-left shunt at the arterial level. Contrary to the current opinion that PS in PAH will decompress and unload the right ventricle, we show that while a PS does lead to a decrease in mPAP toward mean systemic arterial pressure, it does not unload the right ventricle because it mainly diverts flow from the pulmonary arterial system toward the lower body systemic arteries.
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Affiliation(s)
- Tammo Delhaas
- Department of Biomedical Engineering, CARIM School for Cardiovascular Diseases, Maastricht University, Maastricht, Netherlands
| | - Yvette Koeken
- Department of Biomedical Engineering, CARIM School for Cardiovascular Diseases, Maastricht University, Maastricht, Netherlands
| | - Heiner Latus
- Department of Paediatric Cardiology and Congenital Heart Defects, German Heart Centre, Munich, Germany
| | - Christian Apitz
- Division of Pediatric Cardiology, University Children's Hospital Ulm, Ulm, Germany
| | - Dietmar Schranz
- Pediatric Heart Center, Justus Liebig University Giessen, Giessen, Germany
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19
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Hoeper MM, Apitz C, Grünig E, Halank M, Ewert R, Kaemmerer H, Kabitz HJ, Kähler C, Klose H, Leuchte H, Ulrich S, Olsson KM, Distler O, Rosenkranz S, Ghofrani HA. Targeted therapy of pulmonary arterial hypertension: Updated recommendations from the Cologne Consensus Conference 2018. Int J Cardiol 2018; 272S:37-45. [PMID: 30190158 DOI: 10.1016/j.ijcard.2018.08.082] [Citation(s) in RCA: 47] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/09/2018] [Accepted: 08/24/2018] [Indexed: 01/09/2023]
Abstract
In the summer of 2016, delegates from the German Respiratory Society, the German Society of Cardiology and the German Society of Pediatric Cardiology met in Cologne, Germany, to define consensus-based practice recommendations for the management of patients with pulmonary arterial hypertension (PAH). These recommendations were built on the 2015 European Pulmonary Hypertension guidelines and included new evidence, where available. The treatment algorithm for PAH was modified based on the observation that there are now many patients diagnosed with IPAH who are at an advanced age and have significant cardiopulmonary comorbidities. For patients newly diagnosed with classic forms of PAH, i.e. younger patients without significant cardiopulmonary comorbidities, the consensus-based recommendation was to use initial combination therapy as the standard approach. The use of monotherapies was no longer considered appropriate in such patients. The choice of treatment strategies should be based on the risk assessment as proposed in the European guidelines. In patients presenting with a low or intermediate risk, oral combination therapy with endothelin receptor antagonists and phosphodiesterase-5 inhibitors or soluble guanylate cyclase stimulators, respectively, should be used. In high-risk patients, triple combination therapy including a subcutaneous or intravenous prostacyclin analogue should be considered. For patients who suffer from PAH and significant cardiopulmonary comorbidities, initial monotherapy is recommended and the use of combination therapies should be considered on an individual basis. The latter recommendations are based on the scarcity of evidence supporting the use of combination therapy and the higher risk of drug-related adverse events in such patients.
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Affiliation(s)
- Marius M Hoeper
- Department of Pneumology, Hannover Medical School, Hanover, Germany; German Centre for Lung Research (DZL), Germany.
| | - Christian Apitz
- Department of Pediatric Cardiology, University Hospital for Pediatric and Adolescent Medicine, Ulm, Germany
| | - Ekkehard Grünig
- German Centre for Lung Research (DZL), Germany; Centre for Pulmonary Hypertension, Chest Clinic at Heidelberg University Hospital, Germany
| | - Michael Halank
- Medical Department I, Carl Gustav Carus University Hospital at the TU Dresden, Dresden, Germany
| | - Ralf Ewert
- University Medicine Greifswald, Department and Outpatient Department for Internal Medicine, Pneumology/Infectiology, Greifswald, Germany
| | - Harald Kaemmerer
- Department of Pediatric Cardiology and Congenital Heart Defects, German Heart Centre Munich, Hospital at the Technical University of Munich, Germany
| | - Hans-Joachim Kabitz
- Medical Department II, Pneumology, Cardiology and Internal Intensive Medicine, Constance Hospital, Germany
| | - Christian Kähler
- Department of Pneumology, Critical Care and Allergology, Lung Centre South-West, Wangen im Allgäu, Germany
| | - Hans Klose
- Centre for Pulmonary Hypertension Hamburg, Pneumology Department, Hamburg-Eppendorf University Hospital, Germany
| | - Hanno Leuchte
- Neuwittelsbach, Hospital of the Compassionate Sisters and Academic Teaching Hospital at the LMU, Munich, Germany
| | - Silvia Ulrich
- Clinic for Pneumology, Zurich University Hospital, Switzerland
| | - Karen M Olsson
- Department of Pneumology, Hannover Medical School, Hanover, Germany; German Centre for Lung Research (DZL), Germany
| | - Oliver Distler
- Clinic for Rheumatology, Zurich University Hospital, Switzerland
| | - Stephan Rosenkranz
- Department of Internal Medicine III, Cardiovascular Research Centre (CCRC), Heart Centre of the University of Cologne, Germany
| | - H Ardeschir Ghofrani
- German Centre for Lung Research (DZL), Germany; Universities of Giessen and Marburg Lung Center (UGMLC), Gießen, Germany; Department for Pneumology, Kerckhoff Hospital Bad Nauheim, Germany; Department of Medicine, Imperial College, London, UK
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21
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Interventional Therapies in Pulmonary Hypertension. ACTA ACUST UNITED AC 2018; 71:565-574. [PMID: 29545075 DOI: 10.1016/j.rec.2018.02.002] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2017] [Accepted: 01/13/2018] [Indexed: 01/20/2023]
Abstract
Despite advances in drug therapy, pulmonary hypertension-particularly arterial hypertension (PAH)-remains a fatal disease. Untreatable right heart failure (RHF) from PAH eventually ensues and remains a significant cause of death in these patients. Lowering pulmonary input impedance with different PAH-specific drugs is the obvious therapeutic target in RHF due to chronically increased afterload. However, potential clinical gain can also be expected from attempts to unload the right heart and increase systemic output. Atrial septostomy, Potts anastomosis, and pulmonary artery denervation are interventional procedures serving this purpose. Percutaneous balloon pulmonary angioplasty, another interventional therapy, has re-emerged in the last few years as a clear alternative for the management of patients with distal, inoperable, chronic thromboembolic pulmonary hypertension. The current review discusses the physiological background, experimental evidence, and potential clinical and hemodynamic benefits of all these interventional therapies regarding their use in the setting of RHF due to severe pulmonary hypertension.
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22
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Single center experience with the Potts shunt in severe pulmonary arterial hypertension. PROGRESS IN PEDIATRIC CARDIOLOGY 2018. [DOI: 10.1016/j.ppedcard.2017.12.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
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23
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Therapie der pulmonalen Hypertension im Kontext angeborener Herzfehler. Monatsschr Kinderheilkd 2017. [DOI: 10.1007/s00112-017-0362-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
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Gorbachevsky SV, Shmalts AA, Barishnikova IY, Zaets SB. Potts shunt in children with pulmonary arterial hypertension: institutional experience. Interact Cardiovasc Thorac Surg 2017; 25:595-599. [DOI: 10.1093/icvts/ivx209] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2016] [Accepted: 04/14/2017] [Indexed: 11/13/2022] Open
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25
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Schranz D, Akintuerk H, Voelkel NF. 'End-stage' heart failure therapy: potential lessons from congenital heart disease: from pulmonary artery banding and interatrial communication to parallel circulation. Heart 2016; 103:262-267. [PMID: 28011759 PMCID: PMC5293839 DOI: 10.1136/heartjnl-2015-309110] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/31/2016] [Revised: 09/28/2016] [Accepted: 09/29/2016] [Indexed: 12/28/2022] Open
Abstract
The final therapy of 'end-stage heart failure' is orthotopic heart, lung or heart-lung transplantation. However, these options are not available for many patients worldwide. Therefore, novel therapeutical strategies are needed. Based on pathophysiological insights regarding (1) the long-term impact of an obstructive pulmonary outflow tract in neonates with congenitally corrected transposition of the great arteries, (2) the importance of a restrictive versus a non-restrictive atrial septum in neonates born with a borderline left ventricle and (3) the significance of both, a patent foramen ovale and/or open ductus arteriosus for survival of newborns with persistent pulmonary hypertension, the current review introduces some therapeutical strategies that may be applicable to selected patients with heart failure. These strategies include (1) reversible pulmonary artery banding in left ventricular-dilated cardiomyopathy with preserved right ventricular function, (2) the creation of restrictive interatrial communication to treat diastolic (systolic) heart failure, (3) atrioseptostomy or reverse Potts shunt in pulmonary arterial hypertension and (4) return to a fetal, parallel circulation by combining atrioseptostomy and reversed Potts shunt with or without placement of a bilateral pulmonary artery banding. While still being experimental, it is hoped that the procedures presented in the current overview will inspire future novel therapeutic strategies that may be applicable to selected patients with heart failure.
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Affiliation(s)
- Dietmar Schranz
- Pediatric Heart Center, Justus Liebig University Giessen, Virginia Commonwealth University, School of Pharmacy, Richmond, Virginia, USA
| | - Hakan Akintuerk
- Pediatric Heart Center, Justus Liebig University Giessen, Virginia Commonwealth University, School of Pharmacy, Richmond, Virginia, USA
| | - Norbert F Voelkel
- Pediatric Heart Center, Justus Liebig University Giessen, Virginia Commonwealth University, School of Pharmacy, Richmond, Virginia, USA
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26
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Hansmann G, Apitz C. Treatment of children with pulmonary hypertension. Expert consensus statement on the diagnosis and treatment of paediatric pulmonary hypertension. The European Paediatric Pulmonary Vascular Disease Network, endorsed by ISHLT and DGPK. Heart 2016; 102 Suppl 2:ii67-85. [PMID: 27053700 DOI: 10.1136/heartjnl-2015-309103] [Citation(s) in RCA: 48] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/29/2015] [Accepted: 01/18/2016] [Indexed: 11/04/2022] Open
Abstract
Treatment of children and adults with pulmonary hypertension (PH) with or without cardiac dysfunction has improved in the last two decades. The so-called pulmonary arterial hypertension (PAH)-specific medications currently approved for therapy of adults with PAH target three major pathways (endothelin, nitric oxide, prostacyclin). Moreover, some PH centres may use off-label drugs for compassionate use. Pulmonary hypertensive vascular disease (PHVD) in children is complex, and selection of appropriate therapies remains difficult. In addition, paediatric PAH/PHVD therapy is vastly based on experience and trial data from adult rather than paediatric studies; however, the first randomised paediatric PAH trials have been conducted recently. We present consensus recommendations for the treatment of children with PH. Class of recommendation and level of evidence were assigned based on paediatric data only or on adult studies that included >10% children. After a systematic literature search and analysis of the published data, we developed treatment strategies and algorithms that can guide goal-oriented PH therapy. We discuss early combination therapy (double, triple) in patients with PAH in functional class II-IV and in those with inadequate response to the initial pharmacotherapy. In those children with progressive, severe PAH and inadequate response, advances in drug development, and interventional and surgical approaches provide promising new strategies to avoid, reverse or ameliorate right heart failure and left ventricular compression. In particular, first follow-up data indicate that Potts shunt (left pulmonary artery to descending aorta anastomosis) may be an alternative destination therapy, or bridge to bilateral lung transplantation, in end-stage paediatric PAH.
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Affiliation(s)
- Georg Hansmann
- Department of Paediatric Cardiology and Critical Care, Hannover Medical School, Hannover, Germany
| | - Christian Apitz
- Division of Paediatric Cardiology, Children's University Hospital Ulm, Ulm, Germany
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28
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Sizarov A, Raimondi F, Bonnet D, Boudjemline Y. Vascular anatomy in children with pulmonary hypertension regarding the transcatheter Potts shunt. Heart 2016; 102:1735-1741. [DOI: 10.1136/heartjnl-2016-309352] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/26/2016] [Accepted: 05/17/2016] [Indexed: 11/03/2022] Open
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29
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Koestenberger M, Friedberg MK, Nestaas E, Michel-Behnke I, Hansmann G. Transthoracic echocardiography in the evaluation of pediatric pulmonary hypertension and ventricular dysfunction. Pulm Circ 2016; 6:15-29. [PMID: 27162612 PMCID: PMC4860554 DOI: 10.1086/685051] [Citation(s) in RCA: 51] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
Transthoracic echocardiography (TTE) is the most accessible noninvasive diagnostic procedure for the initial assessment of pediatric pulmonary hypertension (PH). This review focuses on principles and use of TTE to determine morphologic and functional parameters that are also useful for follow-up investigations in pediatric PH patients. A basic echocardiographic study of a patient with PH commonly includes the hemodynamic calculation of the systolic pulmonary artery pressure (PAP), the mean and diastolic PAP, the pulmonary artery acceleration time, and the presence of a pericardial effusion. A more detailed TTE investigation of the right ventricle (RV) includes assessment of its size and function. RV function can be evaluated by RV longitudinal systolic performance (e.g., tricuspid annular plane systolic excursion), the tricuspid regurgitation velocity/right ventricular outflow tract velocity time integral ratio, the fractional area change, tissue Doppler imaging-derived parameters, strain measurements, the systolic-to-diastolic duration ratio, the myocardial performance (Tei) index, the RV/left ventricle (LV) diameter ratio, the LV eccentricity index, determination of an enlarged right atrium and RV size, and RV volume determination by 3-dimensional echocardiography. Here, we discuss the potential use and limitations of TTE techniques in children with PH and/or ventricular dysfunction. We suggest a protocol for TTE assessment of PH and myocardial function that helps to identify PH patients and their response to pharmacotherapy. The outlined protocol focuses on the detailed assessment of the hypertensive RV; RV-LV crosstalk must be analyzed separately in the evaluation of different pathologies that account for pediatric PH.
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Affiliation(s)
- Martin Koestenberger
- Division of Pediatric Cardiology, Department of Pediatrics, Medical University Graz, Graz, Austria
| | - Mark K Friedberg
- Labatt Family Heart Center, Hospital for Sick Children and University of Toronto, Toronto, Ontario, Canada
| | - Eirik Nestaas
- Center for Cardiological Innovation, Department of Cardiology, Oslo University Hospital Rikshospitalet, Oslo, Norway; and Department of Paediatrics, Vestfold Hospital Trust, Vestfold, Norway
| | - Ina Michel-Behnke
- Division of Pediatric Cardiology, Pediatric Heart Center Vienna, Department of Pediatrics and Adolescent Medicine, Medical University of Vienna, Vienna, Austria
| | - Georg Hansmann
- Department of Pediatric Cardiology and Critical Care, Hannover Medical School, Hannover, Germany
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Miranda CD, Kenny D. Bilateral ductal stenting in a neonate with right isolated pulmonary artery of ductal origin and differential pulmonary vascular resistances. Catheter Cardiovasc Interv 2015; 87:1130-1134. [PMID: 26602495 DOI: 10.1002/ccd.26282] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/14/2015] [Accepted: 10/03/2015] [Indexed: 11/11/2022]
Abstract
We report our experience with stenting a right ductus arteriosus in a neonate with ductal origin of the right pulmonary artery (PA), who subsequently developed severe pulmonary hypertension in the left PA requiring decompression of the right ventricle with stenting of the left ductus. © 2015 Wiley Periodicals, Inc.
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Affiliation(s)
| | - Damien Kenny
- Rush University Medical Center, Chicago, Illinois
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Schranz D, Kerst G, Menges T, Akintürk H, van Alversleben I, Ostermayer S, Apitz C, Moysich A. Transcatheter creation of a reverse Potts shunt in a patient with severe pulmonary arterial hypertension associated with Moyamoya syndrome. EUROINTERVENTION 2015; 11:121. [DOI: 10.4244/eijv11i1a21] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
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Amir G. In search of ideal surgical palliation for drug refractory pulmonary hypertension. Eur J Cardiothorac Surg 2014; 47:e110-2. [PMID: 25535207 DOI: 10.1093/ejcts/ezu482] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Affiliation(s)
- Gabriel Amir
- Department of Pediatric Cardiac Surgery, Schneider Children's Medical Center of Israel, Petch Tikva, Israel
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Baruteau AE, Belli E, Boudjemline Y, Laux D, Lévy M, Simonneau G, Carotti A, Humbert M, Bonnet D. Palliative Potts shunt for the treatment of children with drug-refractory pulmonary arterial hypertension: updated data from the first 24 patients. Eur J Cardiothorac Surg 2014; 47:e105-10. [DOI: 10.1093/ejcts/ezu445] [Citation(s) in RCA: 102] [Impact Index Per Article: 10.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
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Latus H, Yerebakan C, Schranz D, Akintuerk H. Right ventricular failure from severe pulmonary hypertension after surgery for shone complex: Back to fetal physiology with reducting, atrioseptectomy, and bilateral pulmonary arterial banding. J Thorac Cardiovasc Surg 2014; 148:e226-8. [DOI: 10.1016/j.jtcvs.2014.07.042] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/25/2014] [Revised: 06/16/2014] [Accepted: 07/07/2014] [Indexed: 10/25/2022]
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