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Culp C, Andrews J, Sun KW, Hunter K, Cherry A, Podgoreanu M, Nicoara A. Right Ventricle-Pulmonary Artery Coupling in Patients Undergoing Cardiac Interventions. Curr Cardiol Rep 2024; 26:521-537. [PMID: 38581563 DOI: 10.1007/s11886-024-02052-3] [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] [Accepted: 03/25/2024] [Indexed: 04/08/2024]
Abstract
PURPOSE OF REVIEW This review aims to summarize the fundamentals of RV-PA coupling, its non-invasive means of measurement, and contemporary understanding of RV-PA coupling in cardiac surgery, cardiac interventions, and congenital heart disease. RECENT FINDINGS The need for more accessible clinical means of evaluation of RV-PA coupling has driven researchers to investigate surrogates using cardiac MRI, echocardiography, and right-sided pressure measurements in patients undergoing cardiac surgery/interventions, as well as patients with congenital heart disease. Recent research has aimed to validate these alternative means against the gold standard, as well as establish cut-off values predictive of morbidity and/or mortality. This emerging evidence lays the groundwork for identifying appropriate RV-PA coupling surrogates and integrating them into perioperative clinical practice.
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Affiliation(s)
- Crosby Culp
- Department of Anesthesiology, Duke University, 2301 Erwin Road, Box # 3094, Durham, NC, 27710, USA.
| | - Jon Andrews
- Department of Anesthesiology, Duke University, 2301 Erwin Road, Box # 3094, Durham, NC, 27710, USA
| | - Katherine Wang Sun
- Department of Anesthesiology, Duke University, 2301 Erwin Road, Box # 3094, Durham, NC, 27710, USA
| | - Kendall Hunter
- Department of Bioengineering, University of Colorado, Aurora, CO, USA
| | - Anne Cherry
- Department of Anesthesiology, Duke University, 2301 Erwin Road, Box # 3094, Durham, NC, 27710, USA
| | - Mihai Podgoreanu
- Department of Anesthesiology, Duke University, 2301 Erwin Road, Box # 3094, Durham, NC, 27710, USA
| | - Alina Nicoara
- Department of Anesthesiology, Duke University, 2301 Erwin Road, Box # 3094, Durham, NC, 27710, USA
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Yamasaki T, Umezu K, Toba S, Ishikawa R, Bessho S, Ito H, Shomura Y, Ohashi H, Sawada H, Mitani Y, Shimpo H, Takao M. Bilateral pulmonary artery banding facilitates the systemic ventricular outflow tract growth for biventricular and univentricular repair candidates of complex arch anomaly. Heart Vessels 2024:10.1007/s00380-024-02412-7. [PMID: 38733397 DOI: 10.1007/s00380-024-02412-7] [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: 12/17/2023] [Accepted: 05/01/2024] [Indexed: 05/13/2024]
Abstract
Various surgical approaches address complex heart disease with arch anomalies. Bilateral pulmonary artery banding (bPAB) is a strategy for critically ill patients with complex arch anomalies. Some reports argued the potential effect of bPAB on the growth of the left ventricular outflow tract (LVOT) during inter-stage after bPAB. This study aimed to analyze the LVOT growth for biventricular repair candidates with arch anomaly and systemic ventricular outflow tract (SVOT) for univentricular repair candidates with arch anomaly. This retrospective study analyzed 17 patients undergoing initial bPAB followed by arch repair. The Z-scores of LVOT and SVOT were compared between pre-bPAB and pre-arch repair. Patient characteristics, transthoracic echocardiogram data, and PAB circumferences were reviewed. The diameter of the minimum LVOT for biventricular repair (BVR) candidates, the pulmonary valve (neo-aortic valve, neo-AoV) and the pulmonary trunk (the neo-ascending aorta, neo-AAo) for univentricular repair (UVR) candidates, and the degree of aortic or neo-aortic insufficiency in each candidate was statistically analyzed. 17 patients were divided into the UVR candidates (group U) with 9 patients and the BVR candidates (group B) with 8 patients. In group B, the median value of the Z-score of the minimum LVOT increased from -3.2 (range: - 4.1 ~ - 1.0) at pre-PAB to -2.8 (range: - 3.6 ~ - 0.3) at pre-arch repair with a significant difference (p = 0.012). In group U, the median value of the Z-score of the neo-AoV increased from 0.5 (range: - 1.0 ~ 1.7) at pre-bPAB to 1.2 (range: 0.2 ~ 1.9) at pre-arch repair with a significant difference (p < 0.01). The median value of the Z-score of the neo-AAo was also increased from 3.1 (range: 1.5 ~ 4.6) to 4.3 (range: 3.1 ~ 5.9) with a significant difference (p = 0.028). The growth of the LVOT for BVR candidates and SVOT for UVR candidates during the inter-stage between bPAB and arch repair was observed. These results suggest the potential advantage of bPAB in surgical strategies. Further research is needed to validate these findings and refine surgical approaches.
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Affiliation(s)
- Takato Yamasaki
- Department of Thoracic and Cardiovascular Surgery, Mie University Graduate School of Medicine, 2-174 Edobashi, Tsu, Mie, 514-8507, Japan.
| | - Kentaro Umezu
- Department of Thoracic and Cardiovascular Surgery, Mie University Graduate School of Medicine, 2-174 Edobashi, Tsu, Mie, 514-8507, Japan.
| | - Shuhei Toba
- Department of Thoracic and Cardiovascular Surgery, Mie University Graduate School of Medicine, 2-174 Edobashi, Tsu, Mie, 514-8507, Japan
| | - Renta Ishikawa
- Department of Thoracic and Cardiovascular Surgery, Mie University Graduate School of Medicine, 2-174 Edobashi, Tsu, Mie, 514-8507, Japan
| | - Saki Bessho
- Department of Thoracic and Cardiovascular Surgery, Mie University Graduate School of Medicine, 2-174 Edobashi, Tsu, Mie, 514-8507, Japan
| | - Hisato Ito
- Department of Thoracic and Cardiovascular Surgery, Mie University Graduate School of Medicine, 2-174 Edobashi, Tsu, Mie, 514-8507, Japan
| | - Yu Shomura
- Department of Thoracic and Cardiovascular Surgery, Mie University Graduate School of Medicine, 2-174 Edobashi, Tsu, Mie, 514-8507, Japan
| | - Hiroyuki Ohashi
- Department of Pediatrics, Mie University Graduate School of Medicine, 2-174 Edobashi, Tsu, Mie, 514-8507, Japan
| | - Hirofumi Sawada
- Department of Pediatrics, Mie University Graduate School of Medicine, 2-174 Edobashi, Tsu, Mie, 514-8507, Japan
| | - Yoshihide Mitani
- Department of Pediatrics, Mie University Graduate School of Medicine, 2-174 Edobashi, Tsu, Mie, 514-8507, Japan
| | - Hideto Shimpo
- Mie Prefectural General Medical Center, 5450-132 Hinaga, Yokkaichi, Mie, 510-8561, Japan
| | - Motoshi Takao
- Department of Thoracic and Cardiovascular Surgery, Mie University Graduate School of Medicine, 2-174 Edobashi, Tsu, Mie, 514-8507, Japan
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Hiremath G, Batlivala S, Callahan R, Thatte N, Rockefeller T, Nawaytou H, Reddy SV, Hussain T, Chabiniok R, Butts R, Vettukattil J, Aregullin EO, Aldweib N, Burkhoff D, Brener MI. Clinical Applications of Pressure-Volume Assessment in Congenital Heart Disease. JOURNAL OF THE SOCIETY FOR CARDIOVASCULAR ANGIOGRAPHY & INTERVENTIONS 2023; 2:100599. [PMID: 39130717 PMCID: PMC11307813 DOI: 10.1016/j.jscai.2023.100599] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 10/10/2022] [Revised: 01/02/2023] [Accepted: 01/31/2023] [Indexed: 08/13/2024]
Abstract
Ventricular pressure-volume (PV) loops offer unique insights into cardiovascular mechanics. PV loops can be instrumental in improving our understanding of various congenital heart diseases, including single ventricular physiology, heart failure, and pulmonary hypertension, as well as guiding therapeutic interventions. This review focuses on the theoretical and practical foundations for the acquisition and interpretation of PV loops in congenital heart disease and discusses their clinical applications.
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Affiliation(s)
- Gurumurthy Hiremath
- Division of Pediatric Cardiology, Department of Pediatrics, Masonic Children’s Hospital, University of Minnesota, Minneapolis, Minnesota
| | - Sarosh Batlivala
- Division of Pediatric Cardiology, The Heart Institute, Cincinnati Children’s Hospital Medical Center, University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - Ryan Callahan
- Department of Pediatrics, Children’s Hospital of Philadelphia, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Nikhil Thatte
- Department of Cardiology, Boston Children’s Hospital, Harvard Medical School, Boston, Massachusetts
| | - Toby Rockefeller
- Interventional Pediatric Cardiology, University of Missouri-Kansas City School of Medicine, Children’s Mercy, Kansas City, Missouri
| | - Hythem Nawaytou
- Department of Pediatrics, UCSF Benioff Children’s Hospital and the University of California, San Francisco, California
| | | | - Tarique Hussain
- Pediatric Cardiology, Children’s Medical Center, Dallas, Texas
| | | | - Ryan Butts
- Pediatric Cardiology, Children’s Medical Center, Dallas, Texas
| | - Joseph Vettukattil
- Congenital Heart Center, Spectrum Health Helen DeVos Children’s Hospital, Grand Rapids, Michigan
| | - E. Oliver Aregullin
- Congenital Heart Center, Spectrum Health Helen DeVos Children’s Hospital, Grand Rapids, Michigan
| | - Nael Aldweib
- Division of Cardiovascular Medicine, Oregon Health Sciences University, Portland, Oregon
| | - Daniel Burkhoff
- Division of Cardiology, Columbia University Irving Medical Center/NewYork-Presbyterian Hospital, New York, New York
| | - Michael I. Brener
- Division of Cardiology, Columbia University Irving Medical Center/NewYork-Presbyterian Hospital, New York, New York
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4
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de Vecchi A, Faraci A, Fernandes JF, Marlevi D, Bellsham-Revell H, Hussain T, Laji N, Ruijsink B, Wong J, Razavi R, Anderson D, Salih C, Pushparajah K, Nordsletten D, Lamata P. Unlocking the Non-invasive Assessment of Conduit and Reservoir Function in the Aorta. J Cardiovasc Transl Res 2022; 15:1075-1085. [PMID: 35199256 PMCID: PMC9622527 DOI: 10.1007/s12265-022-10221-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/18/2021] [Accepted: 02/14/2022] [Indexed: 11/06/2022]
Abstract
Aortic surgeries in congenital conditions, such as hypoplastic left heart syndrome (HLHS), aim to restore and maintain the conduit and reservoir functions of the aorta. We proposed a method to assess these two functions based on 4D flow MRI, and we applied it to study the aorta in pre-Fontan HLHS. Ten pre-Fontan HLHS patients and six age-matched controls were studied to derive the advective pressure difference and viscous dissipation for conduit function, and pulse wave velocity and elastic modulus for reservoir function. The reconstructed neo-aorta in HLHS subjects achieved a good conduit function at a cost of an impaired reservoir function (69.7% increase of elastic modulus). The native descending HLHS aorta displayed enhanced reservoir (elastic modulus being 18.4% smaller) but impaired conduit function (three-fold increase in peak advection). A non-invasive and comprehensive assessment of aortic conduit and reservoir functions is feasible and has potentially clinical relevance in congenital vascular conditions.
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Affiliation(s)
- Adelaide de Vecchi
- School of Biomedical Engineering and Imaging Sciences, King's College London, 5th Floor Becket House, Lambeth Palace Road, London, SE1 7EU, UK
| | - Alessandro Faraci
- School of Biomedical Engineering and Imaging Sciences, King's College London, 5th Floor Becket House, Lambeth Palace Road, London, SE1 7EU, UK
| | - Joao Filipe Fernandes
- School of Biomedical Engineering and Imaging Sciences, King's College London, 5th Floor Becket House, Lambeth Palace Road, London, SE1 7EU, UK
| | - David Marlevi
- Massachusetts Institute of Technology, Cambridge, MA, USA
| | - Hannah Bellsham-Revell
- Department of Congenital Heart Disease, Evelina London Children's Hospital, Guy's & St Thomas' Hospitals, London, SE1 7EH, UK
| | - Tarique Hussain
- Pediatric Cardiology, UT Southwestern, Children's Medical Center Dallas, 1935 Medical District Dr, Dallas, TX, 75235, USA
| | - Nidhin Laji
- School of Biomedical Engineering and Imaging Sciences, King's College London, 5th Floor Becket House, Lambeth Palace Road, London, SE1 7EU, UK
| | - Bram Ruijsink
- School of Biomedical Engineering and Imaging Sciences, King's College London, 5th Floor Becket House, Lambeth Palace Road, London, SE1 7EU, UK
| | - James Wong
- School of Biomedical Engineering and Imaging Sciences, King's College London, 5th Floor Becket House, Lambeth Palace Road, London, SE1 7EU, UK
| | - Reza Razavi
- School of Biomedical Engineering and Imaging Sciences, King's College London, 5th Floor Becket House, Lambeth Palace Road, London, SE1 7EU, UK
| | - David Anderson
- Department of Congenital Heart Disease, Evelina London Children's Hospital, Guy's & St Thomas' Hospitals, London, SE1 7EH, UK
| | - Caner Salih
- Department of Congenital Heart Disease, Evelina London Children's Hospital, Guy's & St Thomas' Hospitals, London, SE1 7EH, UK
| | - Kuberan Pushparajah
- School of Biomedical Engineering and Imaging Sciences, King's College London, 5th Floor Becket House, Lambeth Palace Road, London, SE1 7EU, UK
| | - David Nordsletten
- School of Biomedical Engineering and Imaging Sciences, King's College London, 5th Floor Becket House, Lambeth Palace Road, London, SE1 7EU, UK.,Department of Biomedical Engineering and Cardiac Surgery, University of Michigan, Ann Arbor, MI, USA
| | - Pablo Lamata
- School of Biomedical Engineering and Imaging Sciences, King's College London, 5th Floor Becket House, Lambeth Palace Road, London, SE1 7EU, UK.
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Mennander AA. Commentary: Preventive treatment of right-sided heart failure before adulthood? J Thorac Cardiovasc Surg 2021; 164:e511-e512. [PMID: 34799094 DOI: 10.1016/j.jtcvs.2021.11.001] [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: 11/01/2021] [Revised: 11/01/2021] [Accepted: 11/01/2021] [Indexed: 11/17/2022]
Affiliation(s)
- Ari A Mennander
- Tampere University Heart Hospital and Tampere University, Tampere, Finland.
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Rickers C, Wegner P, Silberbach M, Madriago E, Gabbert DD, Kheradvar A, Voges I, Scheewe J, Attmann T, Jerosch-Herold M, Kramer HH. Myocardial Perfusion in Hypoplastic Left Heart Syndrome. Circ Cardiovasc Imaging 2021; 14:e012468. [PMID: 34610753 DOI: 10.1161/circimaging.121.012468] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND The status of the systemic right ventricular coronary microcirculation in hypoplastic left heart syndrome (HLHS) is largely unknown. It is presumed that the systemic right ventricle's coronary microcirculation exhibits unique pathophysiological characteristics of HLHS in Fontan circulation. The present study sought to quantify myocardial blood flow by cardiac magnetic resonance imaging and evaluate the determinants of microvascular coronary dysfunction and myocardial ischemia in HLHS. METHODS One hundred nineteen HLHS patients (median age, 4.80 years) and 34 healthy volunteers (median age, 5.50 years) underwent follow-up cardiac magnetic resonance imaging ≈1.8 years after total cavopulmonary connection. Right ventricle volumes and function, myocardial perfusion, diffuse fibrosis, and late gadolinium enhancement were assessed in 4 anatomic HLHS subtypes. Myocardial blood flow (MBF) was quantified at rest and during adenosine-induced hyperemia. Coronary conductance was estimated from MBF at rest and catheter-based measurements of mean aortic pressure (n=99). RESULTS Hyperemic MBF in the systemic ventricle was lower in HLHS compared with controls (1.89±0.57 versus 2.70±0.84 mL/g per min; P<0.001), while MBF at rest normalized by the rate-pressure product, was similar (1.25±0.36 versus 1.19±0.33; P=0.446). Independent risk factors for a reduced hyperemic MBF were an HLHS subtype with mitral stenosis and aortic atresia (P=0.017), late gadolinium enhancement (P=0.042), right ventricular diastolic dysfunction (P=0.005), and increasing age at total cavopulmonary connection (P=0.022). The coronary conductance correlated negatively with systemic blood oxygen saturation (r, -0.29; P=0.02). The frequency of late gadolinium enhancement increased with age at total cavopulmonary connection (P=0.014). CONCLUSIONS The coronary microcirculation of the systemic ventricle in young HLHS patients shows significant differences compared with controls. These hypothesis-generating findings on HLHS-specific risk factors for microvascular dysfunction suggest a potential benefit from early relief of frank cyanosis by total cavopulmonary connection.
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Affiliation(s)
- Carsten Rickers
- University Heart Center, Adult Congenital Heart Disease Unit, University Hospital Hamburg-Eppendorf, Hamburg, Germany (C.R.)
| | - Philip Wegner
- Department of Congenital Heart Disease and Pediatric Cardiology (P.W., D.D.G., I.V., H.-H.K.) University Hospital Schleswig-Holstein, Kiel, Germany
| | - Michael Silberbach
- Department of Pediatric Cardiology, Doernbecher Children's Hospital, Oregon Health and Science University, Portland (M.S., E.M.)
| | - Erin Madriago
- Department of Pediatric Cardiology, Doernbecher Children's Hospital, Oregon Health and Science University, Portland (M.S., E.M.)
| | - Dominik Daniel Gabbert
- Department of Congenital Heart Disease and Pediatric Cardiology (P.W., D.D.G., I.V., H.-H.K.) University Hospital Schleswig-Holstein, Kiel, Germany
| | - Arash Kheradvar
- Edwards Lifesciences Center for Advanced Cardiovascular Technology, University of California Irvine (A.K.)
| | - Inga Voges
- Department of Congenital Heart Disease and Pediatric Cardiology (P.W., D.D.G., I.V., H.-H.K.) University Hospital Schleswig-Holstein, Kiel, Germany
| | - Jens Scheewe
- Department of Cardiovascular Surgery (J.S., T.A.), University Hospital Schleswig-Holstein, Kiel, Germany
| | - Tim Attmann
- Department of Cardiovascular Surgery (J.S., T.A.), University Hospital Schleswig-Holstein, Kiel, Germany
| | - Michael Jerosch-Herold
- Department of Radiology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA (M.J.-H.)
| | - Hans-Heiner Kramer
- Department of Congenital Heart Disease and Pediatric Cardiology (P.W., D.D.G., I.V., H.-H.K.) University Hospital Schleswig-Holstein, Kiel, Germany
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Becker K, Uebing A, Hansen JH. Pulmonary vascular disease in Fontan circulation-is there a rationale for pulmonary vasodilator therapies? Cardiovasc Diagn Ther 2021; 11:1111-1121. [PMID: 34527537 DOI: 10.21037/cdt-20-431] [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: 04/12/2020] [Accepted: 06/29/2020] [Indexed: 12/21/2022]
Abstract
The Fontan circulation is a palliative concept for patients with univentricular hearts. The central veins are connected directly to the pulmonary arteries (cavo-pulmonary connection) to separate the pulmonary and the systemic circulation. There is no sub-pulmonary ventricle that generates pressure to drive blood through the pulmonary arteries. Pulmonary blood flow is determined by central venous pressure (CVP) and pulmonary vascular resistance (PVR). The capability of the Fontan circulation to compensate for alterations in PVR is limited, as CVP can only be increased within narrow ranges without adverse clinical consequences. Consequently, systemic ventricular preload and cardiac output are dependent on a healthy lung with low PVR. Failure of the Fontan circulation is relatively common. In addition to ventricular dysfunction, maladaptive pulmonary vascular remodeling resulting in increased pulmonary resistance may play a key role. The pathophysiology of the maladaptive vascular processes remains largely unclear and diagnosis of an increased PVR is challenging in Fontan circulation as accurate measurement of pulmonary arterial blood flow is difficult. In the absence of a sub-pulmonary ventricle, pulmonary artery pressure will almost never reach the threshold conventionally used to define pulmonary arterial hypertension. There is a need for markers of pulmonary vascular disease complementary to invasive hemodynamic data in Fontan patients. In order to treat or prevent failure of the Fontan circulation, pathophysiological considerations support the use of pulmonary vasodilators to augment pulmonary blood flow and systemic ventricular preload and lower CVP. However, to date the available trial data have neither yielded enough evidence to support routine use of pulmonary vasodilators in every Fontan patient nor have they been helpful in defining subgroups of patients that might benefit from such therapies. This review discusses potential pathomechanisms of pulmonary vascular disease; it summarizes the current knowledge of the effects and efficacy of pulmonary vasodilator therapy in Fontan patients and tries to outline areas of potential future research on the diagnosis and treatment of pulmonary vascular disease and Fontan failure.
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Affiliation(s)
- Kolja Becker
- Department of Congenital Heart Disease and Pediatric Cardiology, University Hospital of Schleswig-Holstein, Campus Kiel, Kiel, Germany
| | - Anselm Uebing
- Department of Congenital Heart Disease and Pediatric Cardiology, University Hospital of Schleswig-Holstein, Campus Kiel, Kiel, Germany.,DZHK (German Center for Cardiovascular Research), Partner Site Hamburg/Kiel/Lübeck, Germany
| | - Jan Hinnerk Hansen
- Department of Congenital Heart Disease and Pediatric Cardiology, University Hospital of Schleswig-Holstein, Campus Kiel, Kiel, Germany.,DZHK (German Center for Cardiovascular Research), Partner Site Hamburg/Kiel/Lübeck, Germany
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8
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Stone ML, Schäfer M, DiMaria MV, von Alvensleben JC, Campbell DN, Jaggers J, Mitchell MB. Diastolic inflow is associated with inefficient ventricular flow dynamics in Fontan patients. J Thorac Cardiovasc Surg 2021; 163:1195-1207. [DOI: 10.1016/j.jtcvs.2021.06.064] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/06/2021] [Revised: 06/17/2021] [Accepted: 06/17/2021] [Indexed: 12/17/2022]
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9
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Danton MHD. Right ventricular remodelling in hypoplastic left heart syndrome following Fontan completion. Eur J Cardiothorac Surg 2021; 61:43-44. [PMID: 34109371 DOI: 10.1093/ejcts/ezab267] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Affiliation(s)
- Mark H D Danton
- Department of Paediatric Cardiac Surgery, Royal Hospital for Children, Glasgow, Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, Scotland, UK
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10
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Hornung A, Vollmer D, Wiegand G, Apitz C, Latus H, Hofbeck M, Sieverding L. A Comprehensive Functional Analysis in Patients after Atrial Switch Surgery. Thorac Cardiovasc Surg 2021; 69:e32-e40. [PMID: 33851400 PMCID: PMC8045928 DOI: 10.1055/s-0041-1726307] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/02/2022]
Abstract
Background Long-term course after atrial switch operation is determined by
increasing right ventricular (RV) insufficiency. The aim of our study was to investigate
subtle functional parameters by invasive measurements with conductance technique and
noninvasive examinations with cardiac magnetic resonance imaging (CMR). Methods We used invasive (pressure–volume loops under baseline conditions and
dobutamine) and noninvasive techniques (CMR with feature tracking [FT] method) to evaluate
RV function. All patients had cardiopulmonary exercise testing (CPET). Results From 2011 to 2013, 16 patients aged 28.2 ± 7.3 (22–50) years after atrial
switch surgery (87.5% Senning and 12.5% Mustard) were enrolled in this prospective study.
All patients were in New York Heart Association (NYHA) class I to II and presented mean
peak oxygen consumption of 30.1 ± 5.7 (22.7–45.5) mL/kg/min. CMR-derived end-diastolic
volume was 110 ± 22 (78–156) mL/m 2 and RV ejection fraction 41 ± 8% (25–52%).
CMR-FT revealed lower global systolic longitudinal, radial, and circumferential strain for
the systemic RV compared with the subpulmonary left ventricle. End-systolic elastance
(Ees) was overall reduced (compared with data from the literature) and showed significant
increase under dobutamine (0.80 ± 0.44 to 1.89 ± 0.72 mm Hg/mL, p ≤ 0.001), whereas
end-diastolic elastance (Eed) was not significantly influenced (0.11 ± 0.70 to
0.13 ± 0.15 mm Hg/mL, p = 0.454). We found no relevant relationship between
load-independent conductance indices and strain or CPET parameters. Conductance analysis
revealed significant mechanical dyssynchrony, higher during diastole (mean 30 ± 4%
baseline, 24 ± 6% dobutamine) than during systole (mean 17 ± 6% baseline, 19 ± 7%
dobutamine). Conclusions Functional assessment of a deteriorating systemic RV remains
demanding. Conductance indices as well as the CMR-derived strain parameters showed overall
reduced values, but a significant relationship was not present (including CPET). Our
conductance analysis revealed intraventricular and predominantly diastolic RV
dyssynchrony.
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Affiliation(s)
- Andreas Hornung
- Department Pediatric Cardiology, Pulmonology and Intensive Care, University Children's Hospital Tuebingen, Tuebingen, Germany
| | - Daniela Vollmer
- Department Pediatric Cardiology, Pulmonology and Intensive Care, University Children's Hospital Tuebingen, Tuebingen, Germany
| | - Gesa Wiegand
- Department Pediatric Cardiology, Pulmonology and Intensive Care, University Children's Hospital Tuebingen, Tuebingen, Germany
| | - Christian Apitz
- Department Pediatric Cardiology, University Children's Hospital Ulm, Ulm, Germany
| | - Heiner Latus
- Department Pediatric Cardiology and Congenital Heart Disease, German Heart Center, Munich, Germany
| | - Michael Hofbeck
- Department Pediatric Cardiology, Pulmonology and Intensive Care, University Children's Hospital Tuebingen, Tuebingen, Germany
| | - Ludger Sieverding
- Department Pediatric Cardiology, Pulmonology and Intensive Care, University Children's Hospital Tuebingen, Tuebingen, Germany
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11
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Linden K, Winkler C, Breuer J, Herberg U. Assessment of pressure-volume relations in univentricular hearts: Comparison of obtainment by real-time 3D echocardiography and mini pressure-wire with conductance technology. PLoS One 2021; 16:e0246031. [PMID: 33524066 PMCID: PMC7850469 DOI: 10.1371/journal.pone.0246031] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2020] [Accepted: 01/12/2021] [Indexed: 11/18/2022] Open
Abstract
Objectives The gold standard to obtain pressure-volume relations (PVR) of the heart, the conductance technology (PVRCond), is rarely used in children. PVR can also be obtained by 3D-echocardiography volume data combined with simultaneously measured pressure data by a mini pressure-wire (PVR3DE). We sought to investigate the feasibility of both methods in patients with univentricular hearts and to compare them, including hemodynamic changes. Methods We studied 19 patients (age 2–29 years). PVR3DE and PVRCond were assessed under baseline conditions and stimulation with dobutamine. Results Obtaining PVR3DE was successful in all patients. Obtaining PVRCond was possible in 15 patients during baseline (79%) and in 12 patients under dobutamine (63%). Both methods showed that end-systolic elastance (Ees) and arterial elastance (Ea) increased under dobutamine and that Tau showed a statistically significant decrease. Intraclass correlation (95% confidence interval) showed moderate to good agreement between methods: Ees: 0.873 (0.711–0.945), Ea: 0.709 (0.336–0.873), Tau: 0.867 (0.697–0.942). Bland-Altman analyses showed an acceptable bias with wider limits of agreement: Ees: 1.63 mmHg/ml (-3.83–7.08 mmHg/ml), Ea: 0.53 mmHg/ml (-5.23–6.28 mmHg/ml), Tau: -0,76 ms (-10.73–9.21 ms). Conclusion Changes of PVR-specific parameters under dobutamine stimulation were reflected in the same way by both methods. However, the absolute values for these parameters could vary between methods and, therefore, methods are not interchangeable. Obtaining PVR3DE in a single ventricle was easier, faster and more successful than PVRCond. PVR3DE provides a promising and needed alternative to the conductance technology for the assessment of cardiac function in univentricular hearts.
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Affiliation(s)
- Katharina Linden
- Department of Pediatric Cardiology, Children’s Hospital, University Hospital Bonn, Bonn, Germany
- * E-mail:
| | - Christian Winkler
- Department of Pediatric Cardiology, Children’s Hospital, University Hospital Bonn, Bonn, Germany
| | - Johannes Breuer
- Department of Pediatric Cardiology, Children’s Hospital, University Hospital Bonn, Bonn, Germany
| | - Ulrike Herberg
- Department of Pediatric Cardiology, Children’s Hospital, University Hospital Bonn, Bonn, Germany
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12
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Tsuda T, Kernizan D, Del Grippo E, Thacker D, Kharouf R, Srivastava S. Echocardiographic assessment of ventricular function: Conventional and advanced technologies and their clinical applications. PROGRESS IN PEDIATRIC CARDIOLOGY 2020. [DOI: 10.1016/j.ppedcard.2020.101269] [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: 11/27/2022]
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13
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Abstract
A bicuspid aortic valve and/or coarctation of the aorta (COA) are often associated with dilatation of the ascending aorta and para-coarctation. Congenital heart diseases (CHD), such as truncus arteriosus, transposition of the great arteries (TGA), tetralogy of Fallot (TOF), hypoplastic left heart syndrome (HLHS), single ventricle with pulmonary stenosis/atresia and the Fontan procedure, are also associated with aortic root dilatation, aneurysm and rarely, dissection, which can be fatal and require aortic valve and root surgery. A significant subset of adults with complex CHD exhibit progressive dilatation of the aortic root even after repair due to aortic medial degeneration. Medial degeneration in the ascending aorta is prevalent among the above CHD. In Marfan syndrome, bicuspid aortic valve and COA, medial degeneration is more extensive and severe than in another complex CHD. Accordingly, the incidence of ascending aortic dilatation, dissection and rupture is higher in the former. This aortic medial degeneration in CHD may either be intrinsic or secondary to the increased volume overload of the aortic root due to right-to-left shunting, or a combination of both. The association of aortic pathophysiological abnormalities, aortic dilatation and aorto-ventricular interaction is clinically referred to as "aortopathy". The major purpose of medical treatment for aortopathy is to reduce the structural changes within the aortic wall and slow down the progression of aortic dilatation to reduce the risk of cardiovascular events. Several medications have been studied, including β-blockers, angiotensin II type I (AT1) receptor blockers (ARBs) and Ca-antagonists. However, the results, except for Marfan syndrome, are limited. In aortopathy, concomitant aortic valve and aortic root repair/replacement is required. The Bentall operation comprises root replacement with an aortic tube graft and mechanical valve, and has been widely applied. On the other hand, valve-sparing operations have been developed in order to preserve the aortic valve.
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Affiliation(s)
- Koichiro Niwa
- Department of Cardiology, Cardiovascular Center, St Luke's International Hospital, Tokyo, Japan
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14
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Di Molfetta A, Iacobelli R, Guccione P, Di Chiara L, Rocchi M, Cobianchi Belisari F, Campanale M, Gagliardi MG, Filippelli S, Ferrari G, Amodeo A. Evolution of Ventricular Energetics in the Different Stages of Palliation of Hypoplastic Left Heart Syndrome: A Retrospective Clinical Study. Pediatr Cardiol 2017; 38:1613-1619. [PMID: 28831530 DOI: 10.1007/s00246-017-1704-8] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/05/2017] [Accepted: 07/28/2017] [Indexed: 11/27/2022]
Abstract
Hyperplastic left heart syndrome (HLHS) patients are palliated by creating a Fontan-type circulation passing from different surgical stages. The aim of this work is to describe the evolution of ventricular energetics parameters in HLHS patients during the different stages of palliation including the hybrid, the Norwood, the bidirectional Glenn (BDG), and the Fontan procedures. We conducted a retrospective clinical study enrolling all HLHS patients surgically treated with hybrid procedure and/or Norwood and/or BDG and/or Fontan operation from 2011 to 2016 collecting echocardiographic and hemodynamic data. Measured data were used to calculate energetic variables such as ventricular elastances, external and internal work, ventriculo-arterial coupling and cardiac mechanical efficiency. From 2010 to 2016, a total of 29 HLHS patients undergoing cardiac catheterization after hybrid (n = 7) or Norwood (n = 6) or Glenn (n = 8) or Fontan (n = 8) procedure were retrospectively enrolled. Ventricular volumes were significantly higher in the Norwood circulation than in the hybrid circulation (p = 0.03) with a progressive decrement from the first stage to the Fontan completion. Ventricular elastances were lower in the Norwood circulation than in the hybrid circulation and progressively increased passing from the first stage to the Fontan completion. The arterial elastance and Rtot increased in the Fontan circulation. The ventricular work progressively increased. Finally, the ventricular efficiency improves passing from the first to the last stage of palliation. The use of ventricular energetic parameters could lead to a more complete evaluation of such complex patients to better understand their adaptation to different pathophysiological conditions.
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Affiliation(s)
- A Di Molfetta
- Department of Pediatric Cardiology and Cardiac Surgery, Pediatric Hospital Bambino Gesù, Piazza Sant'Onofrio, 4, 00165, Rome, RM, Italy.
| | - R Iacobelli
- Department of Pediatric Cardiology and Cardiac Surgery, Pediatric Hospital Bambino Gesù, Piazza Sant'Onofrio, 4, 00165, Rome, RM, Italy
| | - P Guccione
- Department of Pediatric Cardiology and Cardiac Surgery, Pediatric Hospital Bambino Gesù, Piazza Sant'Onofrio, 4, 00165, Rome, RM, Italy
| | - L Di Chiara
- Department of Pediatric Cardiology and Cardiac Surgery, Pediatric Hospital Bambino Gesù, Piazza Sant'Onofrio, 4, 00165, Rome, RM, Italy
| | - M Rocchi
- Faculty of Biomedical Engineer, Rome University Campus Bio-medico, Via Álvaro del Portillo, 21, Rome, RM, Italy
| | - F Cobianchi Belisari
- Department of Cardiology, Catholic University of Rome, Largo A. Gemelli, 1, 20123, Milan, MI, Italy
| | - M Campanale
- Department of Pediatric Cardiology and Cardiac Surgery, Pediatric Hospital Bambino Gesù, Piazza Sant'Onofrio, 4, 00165, Rome, RM, Italy
| | - M G Gagliardi
- Department of Pediatric Cardiology and Cardiac Surgery, Pediatric Hospital Bambino Gesù, Piazza Sant'Onofrio, 4, 00165, Rome, RM, Italy
| | - S Filippelli
- Department of Pediatric Cardiology and Cardiac Surgery, Pediatric Hospital Bambino Gesù, Piazza Sant'Onofrio, 4, 00165, Rome, RM, Italy
| | - G Ferrari
- Nalecz Institute of Technology, IBBE-PAS, Warsaw, Poland
| | - A Amodeo
- Department of Pediatric Cardiology and Cardiac Surgery, Pediatric Hospital Bambino Gesù, Piazza Sant'Onofrio, 4, 00165, Rome, RM, Italy
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15
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Hays BS, Baker M, Laib A, Tan W, Udholm S, Goldstein BH, Sanders SP, Opotowsky AR, Veldtman GR. Histopathological abnormalities in the central arteries and veins of Fontan subjects. Heart 2017; 104:324-331. [PMID: 28970278 DOI: 10.1136/heartjnl-2017-311838] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/08/2017] [Revised: 07/07/2017] [Accepted: 07/23/2017] [Indexed: 11/04/2022] Open
Abstract
OBJECTIVE Fontan circulations have obligatory venous hypertension, depressed cardiac output and abnormal arterial elastance. Ventriculovascular coupling is known to be abnormal, but the underlying mechanisms are poorly defined. We aim to describe the histopathological features of vascular remodelling encountered in the central arteries and veins in the Fontan circulation as a possible underlying pathological representation of abnormal ventriculovascular coupling. METHODS Postmortemvasculature (inferior vena cava (IVC), superior vena cava (SVC), pulmonary artery (PA), pulmonary vein (PV) and aorta) of 13 patients with a Fontan circulation (mean age 29.9 years, range 9.0-59.8 years) and 2 biventricular controls (ages 17.9 and 30.2 years) was examined. RESULTS IVC and SVC: Eccentric and variable intimal fibromuscular proliferation occurred in 11 Fontan subjects. There was variable loss of medial smooth muscle bundles with reciprocal replacement with dense collagenous tissue.PA: Similar intimal fibromuscular proliferation was seen; however, these intimal changes were accompanied by medial thinning rather than expansion, medial myxoid degeneration and elastic alteration.PV: The PVs demonstrated intimal fibroproliferation and disorganisation of the muscular media.Aorta: The aortic lamina intima was thickened, with associated fibromuscular proliferation and elasticisation. There was also moderate lymphocytic inflammation in the aortic wall. CONCLUSIONS Vascular architectural remodelling is common in Fontan patients. The central veins demonstrate profound changes of eccentric intimal expansion and smooth muscle replacement with collagen. The pulmonary demonstrated abnormal intimal proliferation, and aortic remodelling was characterised by intima lamina thickening and a moderate degree of aortic wall inflammation.
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Affiliation(s)
- Brandon S Hays
- Heart Institute, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA.,Cardiology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
| | - Michael Baker
- Cardiology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA.,Division of Pathology, Cincinnati Children's Hospital Medical Centre, Cincinnati, Ohio, USA
| | - Annie Laib
- Cardiology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA.,Division of Pathology, Cincinnati Children's Hospital Medical Centre, Cincinnati, Ohio, USA
| | - Wei Tan
- University of Colorado at Boulder, Boulder, Colorado, USA
| | - Sebastian Udholm
- Heart Institute, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
| | - Bryan H Goldstein
- Heart Institute, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA.,Cardiology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
| | | | | | - Gruschen R Veldtman
- Adolescent and Adult Congenital Heart Disease Program, Cincinnati Children's Hospital Medical Centre, Ohio, Cincinnati, USA
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16
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Veldtman GR, Opotowsky AR, Wittekind SG, Rychik J, Penny DJ, Fogel M, Marino BS, Gewillig M. Cardiovascular adaptation to the Fontan circulation. CONGENIT HEART DIS 2017; 12:699-710. [DOI: 10.1111/chd.12526] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/30/2017] [Accepted: 07/17/2017] [Indexed: 11/28/2022]
Affiliation(s)
- Gruschen R. Veldtman
- Adolescent and Adult Congenital Program; Heart Institute, Cincinnati Children's Hospital Medical Centre; Cincinnati Ohio, USA
| | | | - Samuel G. Wittekind
- Adolescent and Adult Congenital Program; Heart Institute, Cincinnati Children's Hospital Medical Centre; Cincinnati Ohio, USA
| | - Jack Rychik
- The Cardiac Center at The Children's Hospital of Philadelphia, Professor of Pediatrics, Perelman School of Medicine at the University of Pennsylvania; Philadelphia Pennsylvania, USA
| | - Daniel J. Penny
- Department of Cardiology; Texas Children's Hospital and Department of Pediatrics, Baylor College of Medicine; Houston Texas, USA
| | - Mark Fogel
- The Cardiac Center at The Children's Hospital of Philadelphia, Professor of Pediatrics, Perelman School of Medicine at the University of Pennsylvania; Philadelphia Pennsylvania, USA
| | - Bradley S. Marino
- Ann & Robert H. Lurie Children's Hospital of Chicago; Chicago Illinois, USA
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17
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Haller C, Chetan D, Saedi A, Parker R, Van Arsdell GS, Honjo O. Geometry and growth of the reconstructed aorta in patients with hypoplastic left heart syndrome and variants. J Thorac Cardiovasc Surg 2017; 153:1479-1487.e1. [DOI: 10.1016/j.jtcvs.2017.02.011] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/06/2016] [Revised: 01/12/2017] [Accepted: 02/04/2017] [Indexed: 10/20/2022]
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18
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Logoteta J, Ruppel C, Hansen J, Fischer G, Becker K, Kramer HH, Uebing A. Ventricular function and ventriculo-arterial coupling after palliation of hypoplastic left heart syndrome: A comparative study with Fontan patients with LV morphology. Int J Cardiol 2017; 227:691-697. [DOI: 10.1016/j.ijcard.2016.10.076] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/20/2016] [Accepted: 10/28/2016] [Indexed: 11/25/2022]
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19
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Haller C, Chetan D, Saedi A, Parker R, Van Arsdell GS, Caldarone CA, Honjo O. Geometry of the Aortic Arch After Initial Hybrid or Norwood Palliation. Ann Thorac Surg 2016; 102:2077-2086. [DOI: 10.1016/j.athoracsur.2016.05.008] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/03/2016] [Revised: 03/20/2016] [Accepted: 05/02/2016] [Indexed: 10/21/2022]
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20
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Kim JW, Bang JY, Park CS, Gwak M, Shin WJ, Hwang GS. Usefulness of the maximum rate of pressure rise in the central and peripheral arteries after weaning from cardiopulmonary bypass in pediatric congenital heart surgery: A retrospective analysis. Medicine (Baltimore) 2016; 95:e5405. [PMID: 27930515 PMCID: PMC5265987 DOI: 10.1097/md.0000000000005405] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/08/2023] Open
Abstract
The maximum rate of pressure rise (dP/dtmax) in radial artery has been proposed as a noninvasive surrogate of aortic dp/dtmax, reflecting left ventricular (LV) contractility in children. The aim of this study was to investigate relationship between aortic and radial dp/dtmax at weaning from cardiopulmonary bypass (CPB) and usefulness of these indices for estimating postoperative outcomes in pediatric congenital heart surgery.Aortic and radial arterial pressure waveforms were analyzed simultaneously during weaning from CPB in 29 congenital heart surgery. The maximum first derivatives of aortic and radial arterial waveforms were calculated and averaged from 3 consecutive respiratory cycles. We obtained the maximum vasoactive inotropic score during the first 36 postoperative hours, LV ejection fraction, and fractional shortening on transthoracic echocardiography performed within postoperative day 7.A significant difference between aortic and radial dP/dtmax was observed (mean difference 356 mm Hg/s, 44% of averages), and radial dP/dtmax was weakly correlated with aortic dP/dtmax (r =0.373, P = 0.047). Aortic dP/dtmax was significantly associated with the maximum vasoactive inotropic score (P < 0.001), postoperative LV ejection fraction (P = 0.018), and fractional shortening (P = 0.015); however, radial dP/dtmax was not. On Receiver operating characteristic analysis, aortic dP/dtmax had a greater area under the curve than radial dP/dtmax in predicting higher vasoactive inotropic score (0.827 vs 0.673).Immediately after CPB in pediatric congenital heart surgery, radial dP/dtmax may not replace aortic dP/dtmax because of a discrepancy between central and peripheral arterial waveforms. In this critical period, aortic dP/dtmax can be useful to estimate postoperative ventricular function rather than peripherally derived dP/dtmax.
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Affiliation(s)
- Jung-Won Kim
- Department of Anesthesiology and Pain Medicine, Catholic Kwandong University International St. Mary's Hospital, Incheon
| | - Ji-Yeon Bang
- Department of Anesthesiology and Pain Medicine
- Laboratory for Cardiovascular Dynamics, Asan Medical Center, University of Ulsan College of Medicine
| | - Chun Soo Park
- Division of Pediatric Cardiac Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | | | - Won-Jung Shin
- Department of Anesthesiology and Pain Medicine
- Laboratory for Cardiovascular Dynamics, Asan Medical Center, University of Ulsan College of Medicine
| | - Gyu-Sam Hwang
- Department of Anesthesiology and Pain Medicine
- Laboratory for Cardiovascular Dynamics, Asan Medical Center, University of Ulsan College of Medicine
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21
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Michel M, Logoteta J, Entenmann A, Hansen JH, Voges I, Kramer HH, Petko C. Decline of Systolic and Diastolic 2D Strain Rate During Follow-Up of HLHS Patients After Fontan Palliation. Pediatr Cardiol 2016; 37:1250-7. [PMID: 27255292 DOI: 10.1007/s00246-016-1424-5] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/05/2016] [Accepted: 05/24/2016] [Indexed: 11/29/2022]
Abstract
Accurate assessment of ventricular function is particularly important in children with hypoplastic left heart syndrome (HLHS) after completion of the total cavopulmonary connection (TCPC). For this purpose, two-dimensional speckle tracking (2DST) is a promising technique as it does not depend on the angle of insonation or the geometry of the ventricle. The objective of this study was to assess changes in systolic and diastolic right ventricular (RV) function within a 5-year follow-up period of HLHS patients after TCPC using conventional and 2DST echocardiography. RV fractional area change (RVFAC), tricuspid annular plane systolic excursion (TAPSE), E/A, E/e' and 2DST parameters [global longitudinal peak systolic strain (GS) and strain rate (GSRs), global strain rate in early (GSRe) and late (GSRa) diastole] of 40 HLHS patients were compared at 1.6 and at 5.1 years after TCPC. RVFAC, E/A, E/e' and GS did not change, whereas TAPSE (13.7 ± 3.2 vs. 10.5 ± 2.4 mm/m(2), p < 0.001), GSRs (-1.56 ± 0.28 vs. -1.35 ± 0.31 1/s, p < 0.001), GSRe (2.22 ± 0.49 vs. 1.96 ± 0.44 1/s, p = 0.004) and GSRa (1.19 ± 0.39 vs. 0.92 ± 0.39 1/s, p < 0.001) decreased significantly. Systolic and diastolic RV function parameters of HLHS patients decreased from 1.6 to 5.1 years after TCPC in our patients. Changes in global strain rate parameters may be signaling early RV dysfunction that is not detectable by traditional echocardiography. Further study is needed to verify this and to determine whether these changes are clinically relevant.
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Affiliation(s)
- Miriam Michel
- Department for Congenital Heart Disease and Paediatric Cardiology, University Hospital of Schleswig-Holstein, Campus Kiel, Arnold-Heller-Str. 3, 24105, Kiel, Germany.
| | - Jana Logoteta
- Department for Congenital Heart Disease and Paediatric Cardiology, University Hospital of Schleswig-Holstein, Campus Kiel, Arnold-Heller-Str. 3, 24105, Kiel, Germany
| | - Andreas Entenmann
- Department for Congenital Heart Disease and Paediatric Cardiology, University Hospital of Schleswig-Holstein, Campus Kiel, Arnold-Heller-Str. 3, 24105, Kiel, Germany
| | - Jan Hinnerk Hansen
- Department for Congenital Heart Disease and Paediatric Cardiology, University Hospital of Schleswig-Holstein, Campus Kiel, Arnold-Heller-Str. 3, 24105, Kiel, Germany
| | - Inga Voges
- Department for Congenital Heart Disease and Paediatric Cardiology, University Hospital of Schleswig-Holstein, Campus Kiel, Arnold-Heller-Str. 3, 24105, Kiel, Germany
| | - Hans-Heiner Kramer
- Department for Congenital Heart Disease and Paediatric Cardiology, University Hospital of Schleswig-Holstein, Campus Kiel, Arnold-Heller-Str. 3, 24105, Kiel, Germany
| | - Colin Petko
- Department of Pediatric, Fetal and Congenital Cardiology, Hawaii Permanente Medical Group, Kaiser Permanente Moanalua Medical Center, Honolulu, HI, USA
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22
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Goldstein BH, Urbina EM, Khoury PR, Gao Z, Amos MA, Mays WA, Redington AN, Marino BS. Endothelial Function and Arterial Stiffness Relate to Functional Outcomes in Adolescent and Young Adult Fontan Survivors. J Am Heart Assoc 2016; 5:JAHA.116.004258. [PMID: 27664807 PMCID: PMC5079057 DOI: 10.1161/jaha.116.004258] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Abstract
Background Fontan survivors demonstrate diminished vascular function and functional outcomes, but the relationships between these measures have not been established. Methods and Results We performed a cross‐sectional study of 60 Fontan survivors (52% male) with a mean age of 13.9±4.1 years and mean Fontan duration of 9.9±4.2 years. Multimodality assessment of endothelial function (reactive hyperemia index and flow‐mediated dilation) and arterial stiffness (augmentation index and baseline pulse amplitude) was performed with peripheral arterial tonometry and brachial flow‐mediated dilation. Aerobic capacity was determined using cardiopulmonary exercise testing; mean peak and percentage of predicted oxygen consumption (VO2) were 27.8±7.6 mL/kg per minute and 71.0±21.2%, respectively. Quality of life and physical activity were assessed using the Pediatric Quality of Life Inventory (PedsQL) and the Physical Activity Questionnaire. Vascular measures served as predictor variables, whereas functional measures served as outcome variables. In all cases, worse vascular measures were associated with worse functional measures. Flow‐mediated dilation–derived reactive hyperemia index (P<0.05) was positively associated with VO2 at anaerobic threshold. Peripheral arterial tonometry–derived baseline pulse amplitude (P<0.05) was negatively associated with the ratio of minute ventilation to carbon dioxide at anaerobic threshold. Flow‐mediated dilation–derived reactive hyperemia index and peripheral arterial tonometry–derived augmentation index (P<0.05) were positively and negatively associated, respectively, with peak VO2. Maximum flow‐mediated dilation (P<0.05) was positively associated with Physical Activity Questionnaire score. Peripheral arterial tonometry–derived augmentation index and baseline pulse amplitude (P<0.05) were negatively associated with parent‐reported PedsQL total and physical heath summary scores. Conclusions Increased arterial stiffness and decreased endothelial function are associated with lower aerobic capacity, physical activity, and quality of life in adolescent and young adult Fontan survivors. Understanding the cause–effect relationship between vascular function and functional outcomes is an important next step.
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Affiliation(s)
- Bryan H Goldstein
- The Heart Institute, Cincinnati Children's Hospital Medical Center, Cincinnati, OH
| | - Elaine M Urbina
- The Heart Institute, Cincinnati Children's Hospital Medical Center, Cincinnati, OH
| | - Philip R Khoury
- The Heart Institute, Cincinnati Children's Hospital Medical Center, Cincinnati, OH
| | - Zhiqian Gao
- The Heart Institute, Cincinnati Children's Hospital Medical Center, Cincinnati, OH
| | - Michelle A Amos
- The Heart Institute, Cincinnati Children's Hospital Medical Center, Cincinnati, OH
| | - Wayne A Mays
- The Heart Institute, Cincinnati Children's Hospital Medical Center, Cincinnati, OH
| | - Andrew N Redington
- The Heart Institute, Cincinnati Children's Hospital Medical Center, Cincinnati, OH
| | - Bradley S Marino
- Division of Cardiology, Northwestern University Feinberg School of Medicine and Lurie Children's Hospital, Chicago, IL
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23
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Clinical-Physiological Considerations in Patients Undergoing Staged Palliation for a Functionally Single Ventricle. Pediatr Crit Care Med 2016; 17:S347-55. [PMID: 27490622 DOI: 10.1097/pcc.0000000000000821] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES The objectives of this review are to discuss the pathophysiology of the circulation with a functionally univentricular heart, with a focus on the unique physiologic characteristics, which provide the underpinnings for the management of these complex patients. DATA SOURCE MEDLINE and PubMed. CONCLUSIONS The circulation of the patient with a functionally univentricular heart displays unique physiologic characteristics, which are quite different from those of the normal biventricular circulation. There are profound differences within the heart itself in terms of ventricular function, interventricular interactions, and myocardial architecture, which are likely to have significant implications for the efficiency of ventricular ejection and metabolism. The coupling between the systemic ventricle and the aorta also displays unique features. The 3D orientation of the Fontan anastomosis itself can profoundly impact cardiac output, although the "portal" pulmonary arterial bed is a crucial determinant of overall cardiovascular function. As a result, disease-specific approaches to improve cardiovascular function are required at all stages during the care of these complex patients.
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24
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Latus H, Gerstner B, Kerst G, Moysich A, Gummel K, Apitz C, Bauer J, Schranz D. Effect of Inhaled Nitric Oxide on Blood Flow Dynamics in Patients After the Fontan Procedure Using Cardiovascular Magnetic Resonance Flow Measurements. Pediatr Cardiol 2016; 37:504-11. [PMID: 26547436 DOI: 10.1007/s00246-015-1307-1] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/29/2015] [Accepted: 11/02/2015] [Indexed: 10/22/2022]
Abstract
Invasive hemodynamic studies have shown that nitric oxide (NO), a selective pulmonary vasodilator, can lower pulmonary vascular resistance in Fontan patients. Because oximetry-derived flow quantification may be unreliable, we sought to detect changes in blood flow within the Fontan circulation after inhalation of NO using cardiovascular magnetic resonance (CMR). Thirty-three patients (mean age 12.8 ± 7.0 years) after the Fontan procedure underwent CMR as part of their routine clinical assessment. Standard two-dimensional blood flow measurements were performed in the Fontan tunnel, superior vena cava (SVC) and ascending aorta (AAO) before and after inhalation of 40 ppm NO for 8-10 min. Systemic-to-pulmonary collateral (SPC) flow was calculated as AAO - (SVC + tunnel). Heart rate (82 ± 18 to 81 ± 18 bpm; p = 0.31) and transcutaneous oxygen saturations (93 ± 4 to 94 ± 3 %; p = 0.13) did not change under NO inhalation. AAO flow (3.23 ± 0.72 to 3.12 ± 0.79 l/min/m(2); p = 0.08) decreased, tunnel flow (1.58 ± 0.40 to 1.65 ± 0.46 l/min/m(2); p = 0.032) increased, and SVC flow (1.01 ± 0.39 to 1.02 ± 0.40 l/min/m(2); p = 0.50) remained unchanged resulting in higher total caval flow (Qs) (2.59 ± 0.58 to 2.67 ± 0.68 l/min/m(2); p = 0.038). SPC flow decreased significantly from 0.64 ± 0.52 to 0.45 ± 0.51 l/min/m(2) (p = 0.002) and resulted in a significant decrement of the Qp/Qs ratio (1.23 ± 0.23 to 1.15 ± 0.23; p = 0.001). Inhalation of NO in Fontan patients results in significant changes in pulmonary and systemic blood flow. The reduction in SPC flow is accompanied by a net increase in effective systemic blood flow suggesting beneficial effects of pulmonary vasodilators on cardiac output, tissue perfusion and exercise capacity.
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Affiliation(s)
- Heiner Latus
- Pediatric Heart Center, Justus-Liebig-University of Giessen, Feulgenstr. 12, 35392, Giessen, Germany.
| | - Bettina Gerstner
- Pediatric Heart Center, Justus-Liebig-University of Giessen, Feulgenstr. 12, 35392, Giessen, Germany
| | - Gunter Kerst
- Pediatric Heart Center, Justus-Liebig-University of Giessen, Feulgenstr. 12, 35392, Giessen, Germany
| | - Axel Moysich
- Pediatric Heart Center, Justus-Liebig-University of Giessen, Feulgenstr. 12, 35392, Giessen, Germany
| | - Kerstin Gummel
- Pediatric Heart Center, Justus-Liebig-University of Giessen, Feulgenstr. 12, 35392, Giessen, Germany
| | - Christian Apitz
- Pediatric Heart Center, Justus-Liebig-University of Giessen, Feulgenstr. 12, 35392, Giessen, Germany
| | - Juergen Bauer
- Pediatric Heart Center, Justus-Liebig-University of Giessen, Feulgenstr. 12, 35392, Giessen, Germany
| | - Dietmar Schranz
- Pediatric Heart Center, Justus-Liebig-University of Giessen, Feulgenstr. 12, 35392, Giessen, Germany
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Averin K, Hirsch R, Seckeler MD, Whiteside W, Beekman RH, Goldstein BH. Diagnosis of occult diastolic dysfunction late after the Fontan procedure using a rapid volume expansion technique. Heart 2016; 102:1109-14. [DOI: 10.1136/heartjnl-2015-309042] [Citation(s) in RCA: 36] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/20/2015] [Accepted: 02/04/2016] [Indexed: 11/04/2022] Open
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26
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Ventriculoarterial coupling in palliated hypoplastic left heart syndrome: Noninvasive assessment of the effects of surgical arch reconstruction and shunt type. J Thorac Cardiovasc Surg 2014; 148:1526-33. [DOI: 10.1016/j.jtcvs.2014.02.012] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/12/2013] [Revised: 01/21/2014] [Accepted: 02/03/2014] [Indexed: 11/23/2022]
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Schlangen J, Petko C, Hansen JH, Michel M, Hart C, Uebing A, Fischer G, Becker K, Kramer HH. Two-dimensional global longitudinal strain rate is a preload independent index of systemic right ventricular contractility in hypoplastic left heart syndrome patients after Fontan operation. Circ Cardiovasc Imaging 2014; 7:880-6. [PMID: 25270741 DOI: 10.1161/circimaging.114.002110] [Citation(s) in RCA: 52] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Assessment of systemic right ventricular (RV) function in patients with hypoplastic left heart syndrome is important during long-term follow-up after Fontan repair. Traditional echocardiographic parameters to evaluate systolic ventricular function are affected by loading conditions. The only generally accepted load-independent parameter of systolic function, end systolic elastance (Ees), requires invasive catheterization. Therefore, we sought to determine if parameters obtained by 2-dimensional speckle tracking (2DST) were affected by acute changes in preload and correlated with catheterization-derived indices of RV contractility in hypoplastic left heart syndrome patients after Fontan palliation. METHODS AND RESULTS Fifty-two patients with hypoplastic left heart syndrome (median age, 6.6; range 2.9-22.2 years) were prospectively enrolled to have echocardiography and conductance catheter studies performed simultaneously. We compared traditional echo, 2-dimensional speckle tracking and catheterization-derived parameters during different states of preload at baseline and during dobutamine infusion. Global longitudinal strain (S) showed a tendency to decrease with preload reduction, whereas global longitudinal strain rate (SR) did not change (S: -17.7 ± 3.4% versus -16.9 ± 3.8%, P=0.08; SR: -1.30 ± 0.29 versus -1.34 ± 0.34 s(-1), P=0.3). S did not change with dobutamine infusion (-17.7 ± 3.4% versus -18.4 ± 3.9%, P=0.24), whereas SR increased significantly (-1.30 ± 0.29 versus -2.26 ± 0.49 s(-1), P<0.001). RV Ees correlated with SR (rs= -0.47, P<0.001), but not with S (rs=0.07, P=0.5) or other echocardiographic parameters. CONCLUSIONS In contrast to S, SR was not affected by preload and correlated with Ees of the systemic RV. SR may be a useful noninvasive surrogate of RV contractility and suitable for follow-up of patients with hypoplastic left heart syndrome after Fontan palliation.
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Affiliation(s)
- Jana Schlangen
- From the Department for Congenital Heart Disease and Paediatric Cardiology, University Hospital of Schleswig-Holstein, Campus Kiel, Kiel, Germany (J.S., C.P., J.H.H., M.M., C.H., G.F., K.B., H.-H.K.); Department of Pediatric, Fetal and Congenital Cardiology, Hawaii Permanente Medical Group, Kaiser Permanente Moanalua Medical Center, Honolulu, HI (C.P.); and Adult Congenital Heart Disease Centre and National Centre for Pulmonary Hypertension, Royal Brompton and Harefield NHS Foundation Trust, London, United Kingdom (A.U.).
| | - Colin Petko
- From the Department for Congenital Heart Disease and Paediatric Cardiology, University Hospital of Schleswig-Holstein, Campus Kiel, Kiel, Germany (J.S., C.P., J.H.H., M.M., C.H., G.F., K.B., H.-H.K.); Department of Pediatric, Fetal and Congenital Cardiology, Hawaii Permanente Medical Group, Kaiser Permanente Moanalua Medical Center, Honolulu, HI (C.P.); and Adult Congenital Heart Disease Centre and National Centre for Pulmonary Hypertension, Royal Brompton and Harefield NHS Foundation Trust, London, United Kingdom (A.U.)
| | - Jan H Hansen
- From the Department for Congenital Heart Disease and Paediatric Cardiology, University Hospital of Schleswig-Holstein, Campus Kiel, Kiel, Germany (J.S., C.P., J.H.H., M.M., C.H., G.F., K.B., H.-H.K.); Department of Pediatric, Fetal and Congenital Cardiology, Hawaii Permanente Medical Group, Kaiser Permanente Moanalua Medical Center, Honolulu, HI (C.P.); and Adult Congenital Heart Disease Centre and National Centre for Pulmonary Hypertension, Royal Brompton and Harefield NHS Foundation Trust, London, United Kingdom (A.U.)
| | - Miriam Michel
- From the Department for Congenital Heart Disease and Paediatric Cardiology, University Hospital of Schleswig-Holstein, Campus Kiel, Kiel, Germany (J.S., C.P., J.H.H., M.M., C.H., G.F., K.B., H.-H.K.); Department of Pediatric, Fetal and Congenital Cardiology, Hawaii Permanente Medical Group, Kaiser Permanente Moanalua Medical Center, Honolulu, HI (C.P.); and Adult Congenital Heart Disease Centre and National Centre for Pulmonary Hypertension, Royal Brompton and Harefield NHS Foundation Trust, London, United Kingdom (A.U.)
| | - Christopher Hart
- From the Department for Congenital Heart Disease and Paediatric Cardiology, University Hospital of Schleswig-Holstein, Campus Kiel, Kiel, Germany (J.S., C.P., J.H.H., M.M., C.H., G.F., K.B., H.-H.K.); Department of Pediatric, Fetal and Congenital Cardiology, Hawaii Permanente Medical Group, Kaiser Permanente Moanalua Medical Center, Honolulu, HI (C.P.); and Adult Congenital Heart Disease Centre and National Centre for Pulmonary Hypertension, Royal Brompton and Harefield NHS Foundation Trust, London, United Kingdom (A.U.)
| | - Anselm Uebing
- From the Department for Congenital Heart Disease and Paediatric Cardiology, University Hospital of Schleswig-Holstein, Campus Kiel, Kiel, Germany (J.S., C.P., J.H.H., M.M., C.H., G.F., K.B., H.-H.K.); Department of Pediatric, Fetal and Congenital Cardiology, Hawaii Permanente Medical Group, Kaiser Permanente Moanalua Medical Center, Honolulu, HI (C.P.); and Adult Congenital Heart Disease Centre and National Centre for Pulmonary Hypertension, Royal Brompton and Harefield NHS Foundation Trust, London, United Kingdom (A.U.)
| | - Gunther Fischer
- From the Department for Congenital Heart Disease and Paediatric Cardiology, University Hospital of Schleswig-Holstein, Campus Kiel, Kiel, Germany (J.S., C.P., J.H.H., M.M., C.H., G.F., K.B., H.-H.K.); Department of Pediatric, Fetal and Congenital Cardiology, Hawaii Permanente Medical Group, Kaiser Permanente Moanalua Medical Center, Honolulu, HI (C.P.); and Adult Congenital Heart Disease Centre and National Centre for Pulmonary Hypertension, Royal Brompton and Harefield NHS Foundation Trust, London, United Kingdom (A.U.)
| | - Kolja Becker
- From the Department for Congenital Heart Disease and Paediatric Cardiology, University Hospital of Schleswig-Holstein, Campus Kiel, Kiel, Germany (J.S., C.P., J.H.H., M.M., C.H., G.F., K.B., H.-H.K.); Department of Pediatric, Fetal and Congenital Cardiology, Hawaii Permanente Medical Group, Kaiser Permanente Moanalua Medical Center, Honolulu, HI (C.P.); and Adult Congenital Heart Disease Centre and National Centre for Pulmonary Hypertension, Royal Brompton and Harefield NHS Foundation Trust, London, United Kingdom (A.U.)
| | - Hans-Heiner Kramer
- From the Department for Congenital Heart Disease and Paediatric Cardiology, University Hospital of Schleswig-Holstein, Campus Kiel, Kiel, Germany (J.S., C.P., J.H.H., M.M., C.H., G.F., K.B., H.-H.K.); Department of Pediatric, Fetal and Congenital Cardiology, Hawaii Permanente Medical Group, Kaiser Permanente Moanalua Medical Center, Honolulu, HI (C.P.); and Adult Congenital Heart Disease Centre and National Centre for Pulmonary Hypertension, Royal Brompton and Harefield NHS Foundation Trust, London, United Kingdom (A.U.)
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