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Latus H, Hofmann L, Gummel K, Khalil M, Yerebakan C, Waschulzik B, Schranz D, Voges I, Jux C, Reich B. Exercise-dependent changes in ventricular-arterial coupling and aortopulmonary collateral flow in Fontan patients: a real-time CMR study. Eur Heart J Cardiovasc Imaging 2022; 24:88-97. [PMID: 35045176 PMCID: PMC9762934 DOI: 10.1093/ehjci/jeac001] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/27/2021] [Accepted: 01/07/2022] [Indexed: 12/24/2022] Open
Abstract
AIMS Inefficient ventricular-arterial (V-A) coupling has been described in Fontan patients and may result in adverse haemodynamics. A varying amount of aortopulmonary collateral (APC) flow is also frequently present that increases volume load of the single ventricle. The aim of the study was to assess changes in V-A coupling and APC flow during exercise CMR. METHODS AND RESULTS Eighteen Fontan patients (age 24 ± 3 years) and 14 controls (age 23 ± 4 years) underwent exercise CMR using a cycle ergometer. Ventricular volumetry and flow measurements in the ascending aorta (AAO), inferior (IVC), and superior (SVC) vena cava were assessed using real-time sequences during stepwise increases in work load. Measures of systemic arterial elastance Ea, ventricular elastance Ees, and V-A coupling (Ea/Ees) were assessed. APC flow was quantified as AAO - (SVC + IVC). Ea remained unchanged during all levels of exercise in both groups (P = 0.39 and P = 0.11). Ees increased in both groups (P = 0.001 and P < 0.001) with exercise but was lower in the Fontan group (P = 0.04). V-A coupling was impaired in Fontan patients at baseline (P = 0.04). Despite improvement during exercise (P = 0.002) V-A coupling remained impaired compared with controls (P = 0.001). Absolute APC flow in Fontan patients did not change during exercise even at maximum work load (P = 0.98). CONCLUSIONS Inefficient V-A coupling was already present at rest in Fontan patients and aggravated during exercise due to a limited increase in ventricular contractility which demonstrates the importance of a limited functional reserve of the single ventricle. APC flow remained unchanged suggesting no further increase in volume load during exercise.
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Affiliation(s)
- Heiner Latus
- Corresponding author. Tel: +49 89 1218 3011; Fax: +49 89 1218 3013. E-mail: ;
| | - Lucas Hofmann
- Pediatric Heart Center, Justus-Liebig University Hospital Giessen, Feulgenstr 10-12, 35385 Giessen, Germany
| | - Kerstin Gummel
- Pediatric Heart Center, Justus-Liebig University Hospital Giessen, Feulgenstr 10-12, 35385 Giessen, Germany
| | - Markus Khalil
- Pediatric Heart Center, Justus-Liebig University Hospital Giessen, Feulgenstr 10-12, 35385 Giessen, Germany
| | - Can Yerebakan
- Department of Cardiovascular Surgery, Children's National Hospital, Children's National Heart Institute, The George WashingtonUniversity School of Medicine and Health Sciences, 111 Michigan Ave NW, Washington, DC 20010, USA
| | - Birgit Waschulzik
- Institute for AI and Informatics Medicine, Technical University Munich, Ismaninger Str. 22, 81675 Munich, Germany
| | - Dietmar Schranz
- Pediatric Heart Center, Justus-Liebig University Hospital Giessen, Feulgenstr 10-12, 35385 Giessen, Germany
| | - Inga Voges
- Pediatric Heart Center, Justus-Liebig University Hospital Giessen, Feulgenstr 10-12, 35385 Giessen, Germany,Department of Congenital Heart Disease and Pediatric Cardiology, University Hospital Schleswig-Holstein, Arnold-Heller-Str 3, 24105 Kiel, Germany,DZHK (German Centre for Cardiovascular Research), Partner Site Hamburg/Kiel/Lübeck, Kiel, Germany
| | - Christian Jux
- Pediatric Heart Center, Justus-Liebig University Hospital Giessen, Feulgenstr 10-12, 35385 Giessen, Germany
| | - Bettina Reich
- Department of Pediatric Cardiology and Congenital Heart Disease, German Heart Centre, Technical University Munich, Lazarettstr. 36, 80636 Munich, Germany,Pediatric Heart Center, Justus-Liebig University Hospital Giessen, Feulgenstr 10-12, 35385 Giessen, Germany
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Gabbert DD, Trotz P, Kheradvar A, Jerosch-Herold M, Scheewe J, Kramer HH, Voges I, Rickers C. Abnormal torsion and helical flow patterns of the neo-aorta in hypoplastic left heart syndrome assessed with 4D-flow MRI. Cardiovasc Diagn Ther 2021; 11:1379-1388. [PMID: 35070806 PMCID: PMC8748477 DOI: 10.21037/cdt-20-770] [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: 09/08/2020] [Accepted: 12/08/2020] [Indexed: 07/22/2023]
Abstract
BACKGROUND The Norwood procedure is the first stage of correction for patients with hypoplastic left heart syndrome (HLHS) and may lead to an abnormal neoaortic anatomy. We prospectively studied the neoaorta's fluid dynamics and the abnormal twist of the neoaorta by MRI examinations of HLHS patients in Fontan circulation. This study for the first time investigates the hypothesis that the neoaorta twist is associated with increased helical flow patterns, which may lead to an increased workload for the systemic right ventricle (RV) and ultimately to RV hypertrophy. METHODS A group of forty-two HLHS patients with a median age of 4.9 (2.9-17.0) years, at NYHA I was studied along with a control group of eleven subjects with healthy hearts and a median age of 12.1 (4.0-41.6). All subjects underwent MRI of the thoracic aorta including ECG-gated 2D balanced SSFP cine for an axial slice stack and 4D-flow MRI for a sagittal volume slab covering the thoracic aorta. The twist of the neoaortic arch was quantified by the effective geometric torsion, defined as the product of curvature and geometric torsion. Fluid dynamics and geometry in the neoaorta, including the flow helicity index, were evaluated using an in-house analysis software (MeVisLab-based). Myocardial mass of the systemic ventricle at end-diastole was estimated by planimetry of the short-axis stack. RESULTS Compared to the control group, the neoaorta in the HLHS patients shows an increased twist (P=0.04) and higher peak helicity density (P=0.03). The maximum helicity density was correlated with maximum effective torsion of the ascending neoaorta (P<0.001). The degree of maximum twist correlated with the increase in RV myocardial mass (P<0.01). CONCLUSIONS This study shows that the abnormal twist of the neoaortic arch in HLHS patients is associated with abnormal helical flow patterns, which may contribute to increased RV afterload and may adversely affect the systemic RV by stimulation of myocardial hypertrophy. These findings suggest that further improvements of surgical aortic reconstruction, guided by insights from 4D-flow MRI, could lead to better neoaortic fluid dynamics in patients with HLHS.
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Affiliation(s)
- Dominik Daniel Gabbert
- Department of Congenital Heart Disease and Pediatric Cardiology, DZHK (German Center for Cardiovascular Research), partner site Hamburg/Kiel/Lübeck, University Hospital Schleswig-Holstein, Kiel, Germany
| | - Patrick Trotz
- Department of Congenital Heart Disease and Pediatric Cardiology, DZHK (German Center for Cardiovascular Research), partner site Hamburg/Kiel/Lübeck, University Hospital Schleswig-Holstein, Kiel, Germany
| | - Arash Kheradvar
- The Edwards Lifesciences Center for Advanced Cardiovascular Technology, University of California, CA, Irvine, USA
| | | | - Jens Scheewe
- Department of Congenital Heart Disease and Pediatric Cardiology, DZHK (German Center for Cardiovascular Research), partner site Hamburg/Kiel/Lübeck, University Hospital Schleswig-Holstein, Kiel, Germany
- Department of Cardiac and Vascular Surgery, University Hospital Schleswig-Holstein, Kiel, Germany
| | - Hans-Heiner Kramer
- Department of Congenital Heart Disease and Pediatric Cardiology, DZHK (German Center for Cardiovascular Research), partner site Hamburg/Kiel/Lübeck, University Hospital Schleswig-Holstein, Kiel, Germany
| | - Inga Voges
- Department of Congenital Heart Disease and Pediatric Cardiology, DZHK (German Center for Cardiovascular Research), partner site Hamburg/Kiel/Lübeck, University Hospital Schleswig-Holstein, Kiel, Germany
| | - Carsten Rickers
- Department of Congenital Heart Disease and Pediatric Cardiology, DZHK (German Center for Cardiovascular Research), partner site Hamburg/Kiel/Lübeck, University Hospital Schleswig-Holstein, Kiel, Germany
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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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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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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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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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Atrial dysfunction in Fontan patients: Does it add another piece to the puzzle? Int J Cardiol 2020; 319:67-68. [PMID: 32485193 DOI: 10.1016/j.ijcard.2020.05.045] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/09/2020] [Accepted: 05/14/2020] [Indexed: 11/20/2022]
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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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Schäfer M, Frank BS, Jacobsen R, Rausch CM, Mitchell MB, Jaggers J, Stone ML, Morgan GJ, Browne LP, Barker AJ, Hunter KS, Ivy DD, Younoszai A, Di Maria MV. Patients with Fontan circulation have abnormal aortic wave propagation patterns: A wave intensity analysis study. Int J Cardiol 2020; 322:158-167. [PMID: 32853667 DOI: 10.1016/j.ijcard.2020.08.063] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/21/2020] [Revised: 07/17/2020] [Accepted: 08/17/2020] [Indexed: 01/09/2023]
Abstract
BACKGROUND Elevated systemic afterload in patients with Fontan circulation may lead to impaired single ventricular function. Wave intensity analysis (WIA) enables evaluation of compression and expansion waves traveling through vasculature. We aimed to investigate the unfavorable wave propagation causing excessive afterload may be an important contributor to the overall single ventricle function and to the limited functional capacity in this patient population. METHODS Patients with hypoplastic left heart syndrome (HLHS) (n = 25), single left ventricle (SLV) (n = 24), and normal controls (n = 10) underwent phase-contrast MRI based WIA analysis evaluated in the ascending aorta. Forward compression wave (FCW) representing dP/dt, backward compression wave (BCW) reflecting vascular stiffness, and forward decompression wave (FDW) representing LV relaxation were recorded and indexed to each other. RESULTS FCW was lowest in HLHS patients (1098 mm5/s), and higher in the SLV group (1457 mm5/s), and controls (6457 mm5/s) (P < 0.001). BCW/FCW was increased in HLHS (0.22) and SLV (0.14) groups compared to controls (0.08) (P = 0.003). Peak VO2 correlated with FCW (R = 0.50, P = 0.015), stroke volume (R = 0.72, P < 0.001), and cardiac output (R = 0.44, P = 0.034). CONCLUSIONS Patients with HLHS and SLV have unfavorable aortic WIA patterns with increased BCW/FCW ratio indicating increased systemic afterload due to retrograde compression waves. Reduced FCW and systolic MRI indices correlated with peak VO2 suggesting that abnormal systolic wave propagation may play a role in exercise intolerance for Fontan patients.
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Affiliation(s)
- Michal Schäfer
- Heart Institute, Children's Hospital Colorado, University of Colorado - Denver, Anschutz Medical Campus, USA.
| | - Benjamin S Frank
- Heart Institute, Children's Hospital Colorado, University of Colorado - Denver, Anschutz Medical Campus, USA
| | - Roni Jacobsen
- Heart Institute, Children's Hospital Colorado, University of Colorado - Denver, Anschutz Medical Campus, USA
| | - Christopher M Rausch
- Heart Institute, Children's Hospital Colorado, University of Colorado - Denver, Anschutz Medical Campus, USA
| | - Max B Mitchell
- Division of Pediatric Cardiothoracic Surgery, Department of Surgery, University of Colorado - Denver, Anschutz Medical Campus, USA
| | - James Jaggers
- Division of Pediatric Cardiothoracic Surgery, Department of Surgery, University of Colorado - Denver, Anschutz Medical Campus, USA
| | - Matthew L Stone
- Division of Pediatric Cardiothoracic Surgery, Department of Surgery, University of Colorado - Denver, Anschutz Medical Campus, USA
| | - Gareth J Morgan
- Heart Institute, Children's Hospital Colorado, University of Colorado - Denver, Anschutz Medical Campus, USA
| | - Lorna P Browne
- Department of Radiology, Children's Hospital Colorado, University of Colorado - Denver, Anschutz Medical Campus, USA
| | - Alex J Barker
- Department of Radiology, Children's Hospital Colorado, University of Colorado - Denver, Anschutz Medical Campus, USA; Department of Bioengineering, University of Colorado - Denver, Anschutz Medical Campus, USA
| | - Kendall S Hunter
- Heart Institute, Children's Hospital Colorado, University of Colorado - Denver, Anschutz Medical Campus, USA; Department of Bioengineering, University of Colorado - Denver, Anschutz Medical Campus, USA
| | - D Dunbar Ivy
- Heart Institute, Children's Hospital Colorado, University of Colorado - Denver, Anschutz Medical Campus, USA
| | - Adel Younoszai
- Heart Institute, Children's Hospital Colorado, University of Colorado - Denver, Anschutz Medical Campus, USA
| | - Michael V Di Maria
- Heart Institute, Children's Hospital Colorado, University of Colorado - Denver, Anschutz Medical Campus, USA
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Latus H, Kruppa P, Hofmann L, Reich B, Jux C, Apitz C, Schranz D, Voges I, Khalil M, Gummel K. Impact of aortopulmonary collateral flow and single ventricle morphology on longitudinal hemodynamics in Fontan patients: A serial CMR study. Int J Cardiol 2020; 311:28-34. [DOI: 10.1016/j.ijcard.2020.01.065] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/02/2019] [Revised: 12/06/2019] [Accepted: 01/27/2020] [Indexed: 11/30/2022]
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Michel M, Dubowy KO, Zlamy M, Karall D, Adam MG, Entenmann A, Keller MA, Koch J, Odri Komazec I, Geiger R, Salvador C, Niederwanger C, Müller U, Scholl-Bürgi S, Laser KT. Targeted metabolomic analysis of serum phospholipid and acylcarnitine in the adult Fontan patient with a dominant left ventricle. Ther Adv Chronic Dis 2020; 11:2040622320916031. [PMID: 32426103 PMCID: PMC7222265 DOI: 10.1177/2040622320916031] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2019] [Accepted: 02/19/2020] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND Patients with a Fontan circulation have altered cholesterol and lipoprotein values. We analysed small organic molecules in extended phopsholipid and acylcarnitine metabolic pathways ('metabolomes') in adult Fontan patients with a dominant left ventricle, seeking differences between profiles in baseline and Fontan circulations. METHODS In an observational matched cross-sectional study, we compared phosphatidylcholine (PC), sphingomyelin (SM), and acylcarnitine metabolomes (105 analytes; AbsoluteIDQ® p180 kit (Biocrates Life Sciences AG, Innsbruck, Austria) in 20 adult Fontan patients having a dominant left ventricle with those in 20 age- and sex-matched healthy controls. RESULTS Serum levels of total PC (q-value 0.01), total SM (q-value 0.0002) were significantly lower, and total acylcarnitines (q-value 0.02) were significantly higher in patients than in controls. After normalisation of data, serum levels of 12 PC and 1 SM Fontan patients were significantly lower (q-values <0.05), and concentrations of 3 acylcarnitines were significantly higher than those in controls (q-values <0.05). CONCLUSION Metabolomic profiling can use small specimens to identify biomarker patterns that track derangement in multiple metabolic pathways. The striking alterations in the phospholipid and acylcarnitine metabolome that we found in Fontan patients may reflect altered cell signalling and metabolism as found in heart failure in biventricular patients, chronic low-level inflammation, and alteration of functional or structural properties of lymphatic or blood vessels. TRIAL REGISTRATION NUMBER ClinicalTrials.gov Identifier NCT03886935.
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Affiliation(s)
- Miriam Michel
- Department of Pediatrics III, Division of Pediatric Cardiology, Medical University of Innsbruck, Anichstraße 35, Innsbruck, 6020, Austria Center of Pediatric Cardiology and Congenital Heart Disease, Heart and Diabetes Center North Rhine-Westphalia, Ruhr-University of Bochum, Georgstraße, Bad Oeynhausen, Germany
| | - Karl-Otto Dubowy
- Center of Pediatric Cardiology and Congenital Heart Disease, Heart and Diabetes Center North Rhine-Westphalia, Ruhr-University of Bochum, Georgstraße, Bad Oeynhausen, Germany
| | - Manuela Zlamy
- Department of Pediatrics I, Division of Inherited Metabolic Disorders, Medical University of Innsbruck, Innsbruck, Austria
| | - Daniela Karall
- Department of Pediatrics I, Division of Inherited Metabolic Disorders, Medical University of Innsbruck, Innsbruck, Austria
| | | | - Andreas Entenmann
- Department of Pediatrics I, Division of Gastroenterology and Hepatology, Medical University of Innsbruck, Innsbruck, Austria
| | | | - Jakob Koch
- Institute of Human Genetics, Medical University of Innsbruck, Innsbruck, Austria
| | - Irena Odri Komazec
- Department of Pediatrics III, Division of Pediatric Cardiology, Medical University of Innsbruck, Innsbruck, Austria
| | - Ralf Geiger
- Department of Pediatrics III, Division of Pediatric Cardiology, Medical University of Innsbruck, Innsbruck, Austria
| | - Christina Salvador
- Department of Pediatrics I, Division of Inherited Metabolic Disorders, Medical University of Innsbruck, Innsbruck, Austria
| | - Christian Niederwanger
- Department of Pediatrics I, Division of Inherited Metabolic Disorders, Medical University of Innsbruck, Innsbruck, Austria
| | - Udo Müller
- Biocrates Life Sciences AG, Innsbruck, Austria
| | - Sabine Scholl-Bürgi
- Department of Pediatrics I, Division of Inherited Metabolic Disorders, Medical University of Innsbruck, Innsbruck, Austria
| | - Kai Thorsten Laser
- Center of Pediatric Cardiology and Congenital Heart Disease, Heart and Diabetes Center North Rhine-Westphalia, Ruhr-University of Bochum, Georgstraße, Bad Oeynhausen, Germany
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12
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Iacobelli R, Ricci Z, Marinari E, Haiberger R, Di Molfetta A, Toscano A, Di Chiara L. Effects of levosimendan on ventriculo-arterial coupling and cardiac efficiency in paediatric patients with single-ventricle physiology after surgical palliation: retrospective study. Interact Cardiovasc Thorac Surg 2020; 30:623-629. [PMID: 31986196 DOI: 10.1093/icvts/ivz319] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2019] [Revised: 12/12/2019] [Accepted: 12/19/2019] [Indexed: 11/14/2022] Open
Abstract
Abstract
OBJECTIVES
The use of levosimendan for paediatric patients with low cardiac output after congenital heart surgery has been recently described. We sought to evaluate ventriculo-arterial coupling (VAC) and other ventricular energetic parameters before and after 72 h from levosimendan start in infants with single-ventricle physiology and cardiac failure after palliation with Norwood or hybrid procedures.
METHODS
In this single-centre retrospective study, 9 consecutive patients affected by hypoplastic left heart syndrome-like anatomy were retrospectively analysed. Systolic elastance, diastolic elastance, arterial elastance, VAC and cardiac mechanical efficiency were calculated by measuring, through 2-dimensional echocardiography, end-systolic volume and end-diastolic volume and by recording mean arterial pressure and central venous pressure.
RESULTS
The median (range) weight and age were 2.8 (2.3–6) kg and 16.5 (6–116) days, respectively. After 72 h from levosimendan start, end-systolic volume significantly decreased (−1 ml, −3.2 to −0.1, P = 0.007), whereas mean arterial pressure and end-diastolic volume remained stable. Heart rate showed a significant decrease (−28 beats/min, −41 to 22, P = 0.008). Systolic elastance (2.9 mmHg/ml, 0.4–5.4, P = 0.008), arterial elastance (−5.9, −24 to −0.5, P = 0.038), VAC (−0.86, −1.5 to −0.16, P = 0.009) and cardiac mechanical efficiency (0.18, 0.03–0.22, P = 0.008) differences also showed significant modifications.
CONCLUSIONS
In a small case series of patients with single-ventricle physiology, levosimendan showed to improve contractility and optimize VAC, with a reduction of heart rate. Monitoring of VAC and ventricular energetics can be an interesting aspect to improve the management of heart failure in infants with univentricular anatomy.
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Affiliation(s)
- Roberta Iacobelli
- Pediatric Cardiology Unit, Department of Cardiology and Cardiac Surgery, Bambino Gesù Children’s Hospital, Rome, Italy
| | - Zaccaria Ricci
- Pediatric Cardiac Intensive Care Unit, Department of Cardiology and Cardiac Surgery, Bambino Gesù Children’s Hospital, Rome, Italy
| | - Eleonora Marinari
- Pediatric Cardiac Intensive Care Unit, Department of Cardiology and Cardiac Surgery, Bambino Gesù Children’s Hospital, Rome, Italy
| | - Roberta Haiberger
- Pediatric Cardiac Intensive Care Unit, Department of Cardiology and Cardiac Surgery, Bambino Gesù Children’s Hospital, Rome, Italy
| | - Arianna Di Molfetta
- Department of Cardiac Surgery, Policlinico Universitario A. Gemelli, Rome, Italy
| | - Alessandra Toscano
- Pediatric Cardiology Unit, Department of Cardiology and Cardiac Surgery, Bambino Gesù Children’s Hospital, Rome, Italy
| | - Luca Di Chiara
- Pediatric Cardiac Intensive Care Unit, Department of Cardiology and Cardiac Surgery, Bambino Gesù Children’s Hospital, Rome, Italy
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13
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Huntgeburth M, Germund I, Geerdink LM, Sreeram N, Udink Ten Cate FEA. Emerging clinical applications of strain imaging and three-dimensional echocardiography for the assessment of ventricular function in adult congenital heart disease. Cardiovasc Diagn Ther 2019; 9:S326-S345. [PMID: 31737540 DOI: 10.21037/cdt.2018.11.08] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Management of congenital heart disease (CHD) in adults (ACHD) remains an ongoing challenge due to the presence of residual hemodynamic lesions and development of ventricular dysfunction in a large number of patients. Echocardiographic imaging plays a central role in clinical decision-making and selection of patients who will benefit most from catheter interventions or cardiac surgery.. Recent advances in both strain imaging and three-dimensional (3D)-echocardiography have significantly contributed to a greater understanding of the complex pathophysiological mechanisms involved in CHD. The aim of this paper is to provide an overview of emerging clinical applications of speckle-tracking imaging and 3D-echocardiography in ACHD with focus on functional assessment, ventriculo-ventricular interdependency, mechanisms of electromechanical delay, and twist abnormalities in adults with tetralogy of Fallot (TOF), a systemic RV after atrial switch repair or in double discordance ventricles, and in those with a Fontan circulation.
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Affiliation(s)
- Michael Huntgeburth
- Center for Grown-ups with congenital heart disease (GUCH), Clinic III for Internal Medicine, Department of Cardiology, Heart Center, University Hospital of Cologne, Germany
| | - Ingo Germund
- Department of Pediatric Cardiology, Heart Center, University Hospital of Cologne, Germany
| | - Lianne M Geerdink
- Academic Center for Congenital Heart Disease (ACAHA), Department of Pediatric Cardiology, Amalia Children's Hospital, Radboud University Medical Center, Nijmegen.,Division of Pediatric Cardiology, Department of Pediatrics, Sophia Children's Hospital, Erasmus Medical Center, Rotterdam, The Netherlands
| | - Narayanswami Sreeram
- Department of Pediatric Cardiology, Heart Center, University Hospital of Cologne, Germany
| | - Floris E A Udink Ten Cate
- Academic Center for Congenital Heart Disease (ACAHA), Department of Pediatric Cardiology, Amalia Children's Hospital, Radboud University Medical Center, Nijmegen.,Division of Pediatric Cardiology, Department of Pediatrics, Sophia Children's Hospital, Erasmus Medical Center, Rotterdam, The Netherlands
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14
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Asada S, Yamagishi M, Itatani K, Maeda Y, Taniguchi S, Fujita S, Hongu H, Yaku H. Early outcomes and computational fluid dynamic analyses of chimney reconstruction in the Norwood procedure†. Interact Cardiovasc Thorac Surg 2019; 29:252–259. [PMID: 30879071 DOI: 10.1093/icvts/ivz040] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2018] [Revised: 02/01/2019] [Accepted: 02/03/2019] [Indexed: 11/13/2022] Open
Abstract
OBJECTIVES The ideal configuration of a reconstructed aortic arch in the Norwood procedure for hypoplastic left heart syndrome is still a matter of debate. Chimney reconstruction was developed to avoid postoperative complications and turbulent flow in the aortic arch. This study sought to clarify early outcomes of the procedure and verify its haemodynamic advantages using computational fluid dynamics (CFD). METHODS Fourteen consecutive patients with hypoplastic left heart syndrome or a variant who underwent chimney reconstruction in the Norwood procedure between January 2013 and March 2018 were enrolled. Median age and body weight at the time of operation were 2.5 months and 4.1 kg, respectively. Thirteen patients (93.9%) had been palliated with previous bilateral pulmonary artery (PA) banding. In addition, patient-specific CFD models of neoarches based on postoperative computed tomograms from 6 patients were created and the flow profiles analysed. RESULTS Survival rates at 1, 3 and 5 years were 76.6%, 67.3% and 67.3%, respectively. No patient developed left PA compression by neoaorta, neoaortic dilation or neoaortic insufficiency. Only 2 patients (14.3%) required surgical intervention for recoarctation. Fontan completion was performed on 5 patients. On CFD analysis, all reconstructed aortic arches showed low energy loss (9.16-14.4 mW/m2) and low wall shear stresses. CONCLUSIONS Chimney reconstruction was a feasible technique when homografts were not readily available. CFD analyses underscored the fact that this technique produced excellent flow profiles. Larger studies should be conducted to clarify long-term outcomes.
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Affiliation(s)
- Satoshi Asada
- Department of Pediatric Cardiovascular Surgery, Children's Medical Center, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - Masaaki Yamagishi
- Department of Pediatric Cardiovascular Surgery, Children's Medical Center, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - Keiichi Itatani
- Department of Pediatric Cardiovascular Surgery, Children's Medical Center, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - Yoshinobu Maeda
- Department of Pediatric Cardiovascular Surgery, Children's Medical Center, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - Satoshi Taniguchi
- Department of Pediatric Cardiovascular Surgery, Children's Medical Center, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - Shuhei Fujita
- Department of Pediatric Cardiovascular Surgery, Children's Medical Center, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - Hisayuki Hongu
- Department of Pediatric Cardiovascular Surgery, Children's Medical Center, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - Hitoshi Yaku
- Division of Cardiovascular Surgery, Department of Surgery, Kyoto Prefectural University of Medicine, Kyoto, Japan
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15
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Forsha D, Li L, Joseph N, Kutty S, Friedberg MK. Association of left ventricular size with regional right ventricular mechanics in Hypoplastic Left Heart Syndrome. Int J Cardiol 2019; 298:66-71. [PMID: 31402159 DOI: 10.1016/j.ijcard.2019.07.090] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/27/2019] [Revised: 07/19/2019] [Accepted: 07/30/2019] [Indexed: 10/26/2022]
Abstract
BACKGROUND In Hypoplastic Left Heart Syndrome (HLHS), RV dysfunction is associated with poor outcomes. However, the effect of varying LV size on regional RV mechanics and outcome has not been studied. METHODS Twenty newborns (0-7 days) with HLHS had pre-stage 1 and pre-stage 2 echocardiograms prospectively protocoled for strain analysis of the apical 4-chamber view. RV longitudinal strain was analyzed, and LV size was classified as diminutive (no visible LV chamber) or moderate size (visible LV chamber). Clinical outcome was reported as alive vs death or transplant (D-TP) at final clinical follow-up (pre-stage 3). Groups were compared with t-test, Fisher's Exact, and ANOVA tests as appropriate. RESULTS At pre-stage 1, infants with a diminutive LV (7/20, 35%) vs a moderately hypoplastic LV (13/20, 65%) did not have significantly different global RV strain (-18.4 ± 2.6% vs -18.8 ± 3.2%; p = 0.83). However, basal septal strain was significantly diminished in the moderately hypoplastic LV group vs the diminutive LV group (-4.4 ± 6.0% vs -14.7 ± 3.3%; p < 0.005). There was severely diminished septal strain in nearly all (11/13) of the moderately hypoplastic group. At the pre-stage II echo, global RV strain between groups remained similar (p = 0.76) as did the diminished septal strain in the moderate LV group (p = 0.86). The moderately hypoplastic LV group had worse clinical outcomes (6/13 D-TP vs 0/7 D-TP; p = 0.05). CONCLUSIONS In this small HLHS cohort, diminished septal strain leading to asymmetric RV mechanics may be associated with poor outcomes in those with larger LV/septal size.
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Affiliation(s)
- Daniel Forsha
- Division of Cardiology, Ward Family Heart Center, Children's Mercy Hospital, Kansas City, MO, United States of America.
| | - Ling Li
- Division of Pediatric Cardiology, University of Nebraska Medical Center, Children's Hospital and Medical Center, Omaha, NE, United States of America.
| | - Navya Joseph
- Division of Pediatric Cardiology, University of Nebraska Medical Center, Children's Hospital and Medical Center, Omaha, NE, United States of America.
| | - Shelby Kutty
- Division of Pediatric Cardiology, University of Nebraska Medical Center, Children's Hospital and Medical Center, Omaha, NE, United States of America.
| | - Mark K Friedberg
- Department of Cardiology, Labatt Family Heart Centre, Hospital for Sick Children, Toronto, ON, Canada; Department of Pediatrics, University of Toronto, Toronto, ON, Canada.
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16
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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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17
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Burkhart HM, Thompson JL, Mir A. The importance of arch geometry after Norwood reconstruction. J Thorac Cardiovasc Surg 2017; 154:1385-1386. [PMID: 28495069 DOI: 10.1016/j.jtcvs.2017.04.026] [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: 04/10/2017] [Accepted: 04/13/2017] [Indexed: 11/16/2022]
Affiliation(s)
- Harold M Burkhart
- Division of Cardiovascular and Thoracic Surgery, University of Oklahoma Health Sciences Center, Oklahoma City, Okla.
| | - Jess L Thompson
- Division of Cardiovascular and Thoracic Surgery, University of Oklahoma Health Sciences Center, Oklahoma City, Okla
| | - Arshid Mir
- Section of Pediatric Cardiology, University of Oklahoma Health Sciences Center, Oklahoma City, Okla
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