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Bassareo PP. Innominate Vein Turndown Procedure as Another Option for Lymphatic Abnormalities in Fontan Patients. Radiol Cardiothorac Imaging 2024; 6:e240257. [PMID: 39115408 PMCID: PMC11369645 DOI: 10.1148/ryct.240257] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/06/2024]
Affiliation(s)
- Pier Paolo Bassareo
- University College of Dublin School of Medicine, Mater Misericordiae University Hospital and Children’s Health Ireland Crumlin, Eccles Street, Dublin, Ireland D07 R2WY
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2
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Reddy SV, Sinha SP. Lymphatic Interventions in Congenital Heart Disease. Interv Cardiol Clin 2024; 13:343-354. [PMID: 38839168 DOI: 10.1016/j.iccl.2024.03.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/07/2024]
Abstract
Lymphatic disorders in congenital heart disease can be broadly classified into chest compartment, abdominal compartment, or multicompartment disorders. Heavily T2-weighted noninvasive lymphatic imaging (for anatomy) and invasive dynamic contrast magnetic resonance lymphangiography (for flow) have become the main diagnostic modalities of choice to identify the cause of lymphatic disorders. Selective lymphatic duct embolization (SLDE) has largely replaced total thoracic duct embolization as the main lymphatic therapeutic procedure. Recurrence of symptoms needing repeat interventions is more common in patients who underwent SLDE. Novel surgical and transcatheter thoracic duct decompression strategies are promising, but long-term follow-up is critical and eagerly awaited.
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Affiliation(s)
- Surendranath Veeram Reddy
- Childrens/UT Southwestern Medical Center, Heart Center, B 405, Childrens Medical Center, 1935 Medical District Drive, Dallas, TX 75235, USA
| | - Sanjay Prakash Sinha
- CHOC/CS Cardiology, UC Irvine School of Medicine, UCLA Mattel Children's Hospital.
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3
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Smood B, Katsunari T, Smith C, Dori Y, Mavroudis CD, Morton S, Davis A, Chen JM, Gaynor JW, Kilbaugh T, Maeda K. Preliminary report of a thoracic duct-to-pulmonary vein lymphovenous anastomosis in swine: A novel technique and potential treatment for lymphatic failure. Semin Pediatr Surg 2024; 33:151427. [PMID: 38823193 PMCID: PMC11265529 DOI: 10.1016/j.sempedsurg.2024.151427] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/03/2024]
Abstract
OBJECTIVE The thoracic duct is the largest lymphatic vessel in the body, and carries fluid and nutrients absorbed in abdominal organs to the central venous circulation. Thoracic duct obstruction can cause significant failure of the lymphatic circulation (i.e., protein-losing enteropathy, plastic bronchitis, etc.). Surgical anastomosis between the thoracic duct and central venous circulation has been used to treat thoracic duct obstruction but cannot provide lymphatic decompression in patients with superior vena cava obstruction or chronically elevated central venous pressures (e.g., right heart failure, single ventricle physiology, etc.). Therefore, this preclinical feasibility study sought to develop a novel and optimal surgical technique for creating a thoracic duct-to-pulmonary vein lymphovenous anastomosis (LVA) in swine that could remain patent and preserve unidirectional lymphatic fluid flow into the systemic venous circulation to provide therapeutic decompression of the lymphatic circulation even at high central venous pressures. METHODS A thoracic duct-to-pulmonary vein LVA was attempted in 10 piglets (median age 80 [IQR 80-83] days; weight 22.5 [IQR 21.4-26.8] kg). After a right thoracotomy, the thoracic duct was mobilized, transected, and anastomosed to the right inferior pulmonary vein. Animals were systemically anticoagulated on post-operative day 1. Lymphangiography was used to evaluate LVA patency up to post-operative day 7. RESULTS A thoracic duct-to-pulmonary vein LVA was successfully completed in 8/10 (80.0%) piglets, of which 6/8 (75.0%) survived to the intended study endpoint without any complication (median 6 [IQR 4-7] days). Initially, 2/10 (20.0%) LVAs were aborted intraoperatively, and 2/10 (20.0%) animals were euthanized early due to post-operative complications. However, using an optimized surgical technique, the success rate for creating a thoracic duct-to-pulmonary vein LVA in six animals was 100%, all of which survived to their intended study endpoint without any complications (median 6 [IQR 4-7] days). LVAs remained patent for up to seven days. CONCLUSION A thoracic duct-to-pulmonary vein LVA can be completed safely and remain patent for at least one week with systemic anticoagulation, which provides an important proof-of-concept that this novel intervention could effectively offload the lymphatic circulation in patients with lymphatic failure and elevated central venous pressures.
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Affiliation(s)
- Benjamin Smood
- Division of Cardiovascular Surgery, Department of Surgery, The University of Pennsylvania, Philadelphia, PA, United States; Division of Cardiothoracic Surgery, Department of Surgery, Children's Hospital of Philadelphia, Philadelphia, PA, United States.
| | - Terakawa Katsunari
- Division of Cardiothoracic Surgery, Department of Surgery, Children's Hospital of Philadelphia, Philadelphia, PA, United States
| | - Christopher Smith
- Jill and Mark Fishman Center for Lymphatic Disorders, Children's Hospital of Philadelphia, Philadelphia, PA, United States; Department of Cardiology, Children's Hospital of Philadelphia, Philadelphia, PA, United States
| | - Yoav Dori
- Jill and Mark Fishman Center for Lymphatic Disorders, Children's Hospital of Philadelphia, Philadelphia, PA, United States; Department of Cardiology, Children's Hospital of Philadelphia, Philadelphia, PA, United States
| | - Constantine D Mavroudis
- Division of Cardiovascular Surgery, Department of Surgery, The University of Pennsylvania, Philadelphia, PA, United States; Division of Cardiothoracic Surgery, Department of Surgery, Children's Hospital of Philadelphia, Philadelphia, PA, United States
| | - Sarah Morton
- Resuscitation Science Center, The Children's Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, United States
| | - Anthony Davis
- Resuscitation Science Center, The Children's Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, United States
| | - Jonathan M Chen
- Division of Cardiovascular Surgery, Department of Surgery, The University of Pennsylvania, Philadelphia, PA, United States; Division of Cardiothoracic Surgery, Department of Surgery, Children's Hospital of Philadelphia, Philadelphia, PA, United States
| | - J William Gaynor
- Division of Cardiovascular Surgery, Department of Surgery, The University of Pennsylvania, Philadelphia, PA, United States; Division of Cardiothoracic Surgery, Department of Surgery, Children's Hospital of Philadelphia, Philadelphia, PA, United States
| | - Todd Kilbaugh
- Resuscitation Science Center, The Children's Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, United States; Department of Anesthesiology, Children's Hospital of Philadelphia, Philadelphia, PA, United States
| | - Katsuhide Maeda
- Division of Cardiovascular Surgery, Department of Surgery, The University of Pennsylvania, Philadelphia, PA, United States; Division of Cardiothoracic Surgery, Department of Surgery, Children's Hospital of Philadelphia, Philadelphia, PA, United States; Jill and Mark Fishman Center for Lymphatic Disorders, Children's Hospital of Philadelphia, Philadelphia, PA, United States
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4
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Smood B, Smith C, Dori Y, Mavroudis CD, Fuller S, Gaynor JW, Maeda K. Lymphatic failure and lymphatic interventions: Knowledge gaps and future directions for a new frontier in congenital heart disease. Semin Pediatr Surg 2024; 33:151426. [PMID: 38820801 PMCID: PMC11229519 DOI: 10.1016/j.sempedsurg.2024.151426] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/02/2024]
Abstract
Lymphatic failure is a broad term that describes the lymphatic circulation's inability to adequately transport fluid and solutes out of the interstitium and into the systemic venous circulation, which can result in dysfunction and dysregulation of immune responses, dietary fat absorption, and fluid balance maintenance. Several investigations have recently elucidated the nexus between lymphatic failure and congenital heart disease, and the associated morbidity and mortality is now well-recognized. However, the precise pathophysiology and pathogenesis of lymphatic failure remains poorly understood and relatively understudied, and there are no targeted therapeutics or interventions to reliably prevent its development and progression. Thus, there is growing enthusiasm towards the development and application of novel percutaneous and surgical lymphatic interventions. Moreover, there is consensus that further investigations are needed to delineate the underlying mechanisms of lymphatic failure, which could help identify novel therapeutic targets and develop innovative procedures to improve the overall quality of life and survival of these patients. With these considerations, this review aims to provide an overview of the lymphatic circulation and its vasculature as it relates to current understandings into the pathophysiology and pathogenesis of lymphatic failure in patients with congenital heart disease, while also summarizing strategies for evaluating and managing lymphatic complications, as well as specific areas of interest for future translational and clinical research efforts.
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Affiliation(s)
- Benjamin Smood
- Division of Cardiothoracic Surgery, Department of Surgery, Children's Hospital of Philadelphia, Philadelphia, PA, 19104, United States of America; Division of Cardiovascular Surgery, Department of Surgery, The University of Pennsylvania, Philadelphia, Pennsylvania, 19104, United States of America.
| | - Christopher Smith
- Jill and Mark Fishman Center for Lymphatic Disorders, Children's Hospital of Philadelphia, Philadelphia, PA, United States; Department of Cardiology, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, 19104 United States of America
| | - Yoav Dori
- Jill and Mark Fishman Center for Lymphatic Disorders, Children's Hospital of Philadelphia, Philadelphia, PA, United States; Department of Cardiology, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, 19104 United States of America
| | - Constantine D Mavroudis
- Division of Cardiothoracic Surgery, Department of Surgery, Children's Hospital of Philadelphia, Philadelphia, PA, 19104, United States of America; Division of Cardiovascular Surgery, Department of Surgery, The University of Pennsylvania, Philadelphia, Pennsylvania, 19104, United States of America
| | - Stephanie Fuller
- Division of Cardiothoracic Surgery, Department of Surgery, Children's Hospital of Philadelphia, Philadelphia, PA, 19104, United States of America; Division of Cardiovascular Surgery, Department of Surgery, The University of Pennsylvania, Philadelphia, Pennsylvania, 19104, United States of America
| | - J William Gaynor
- Division of Cardiothoracic Surgery, Department of Surgery, Children's Hospital of Philadelphia, Philadelphia, PA, 19104, United States of America; Division of Cardiovascular Surgery, Department of Surgery, The University of Pennsylvania, Philadelphia, Pennsylvania, 19104, United States of America
| | - Katsuhide Maeda
- Division of Cardiothoracic Surgery, Department of Surgery, Children's Hospital of Philadelphia, Philadelphia, PA, 19104, United States of America; Division of Cardiovascular Surgery, Department of Surgery, The University of Pennsylvania, Philadelphia, Pennsylvania, 19104, United States of America; Jill and Mark Fishman Center for Lymphatic Disorders, Children's Hospital of Philadelphia, Philadelphia, PA, United States
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5
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Juaneda I, Kreutzer C, Jatene MB. Fifth "Jatene Lecture on Surgical Innovation": Innovation in Congenital Heart Surgery: Contributions From South America. World J Pediatr Congenit Heart Surg 2024; 15:265-269. [PMID: 38404004 DOI: 10.1177/21501351241227881] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/27/2024]
Abstract
We present the fifth "Jatene Lecture on Surgical Innovation" on Innovation in Congenital Heart Surgery, given at the Eighth Scientific Meeting of the World Society for Pediatric and Congenital Heart Surgery and Eighth World Congress of Pediatric Cardiology and Cardiac Surgery in Washington DC in 2023. We highlight what surgical innovation is and how innovation was accomplished in cardiac surgery and particularly in congenital heart surgery. A brief history of the development of congenital heart surgery across the world is summarized and we finally illustrate the South American contributions to congenital heart surgery, acknowledging the great innovations of Adib Jatene and Guillermo Kreutzer to our field.
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Affiliation(s)
- Ignacio Juaneda
- Congenital Heart Surgery, Hospital Privado Universitario de Córdoba, Cordoba, Argentina
- Congenital Heart Surgery, Hospital de Niños de Córdoba, Cordoba, Argentina
| | - Christian Kreutzer
- Congenital Heart Surgery, Hospital Privado Universitario de Córdoba, Cordoba, Argentina
- Congenital Heart Surgery, Hospital Universitario Austral, Pilar, Argentina
| | - Marcelo B Jatene
- Congenital Heart Surgery, Instituto do Coração, Hospital das Clínicas, Universidade de São Paulo, São Paulo, Brazil
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Tomasulo CE, Dori Y, Smith CL. Understanding the next circulation: lymphatics and what the future holds. Curr Opin Cardiol 2023; 38:369-374. [PMID: 37195304 DOI: 10.1097/hco.0000000000001064] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/18/2023]
Abstract
PURPOSE OF REVIEW The lymphatic system was previously considered the forgotten circulation because of an absence of adequate options for imaging and intervention. However, recent advances over the last decade have improved management strategies for patients with lymphatic disease, including chylothorax, plastic bronchitis, ascites, and protein-losing enteropathy. RECENT FINDINGS New imaging modalities have enabled detailed visualization of lymphatic vessels to allow for a better understanding of the cause of lymphatic dysfunction in a variety of patient subsets. This sparked the development of multiple transcatheter and surgery-based techniques tailored to each patient based on imaging findings. In addition, the new field of precision lymphology has added medical management options for patients with genetic syndromes, who have global lymphatic dysfunction and typically do not respond as well to the more standard lymphatic interventions. SUMMARY Recent developments in lymphatic imaging have given insight into disease processes and changed the way patients are managed. Medical management has been enhanced and new procedures have given patients more options, leading to better long-term results.
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Affiliation(s)
| | - Yoav Dori
- Division of Cardiology, Jill and Mark Fishman Center for Lymphatic Disorders, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Christopher L Smith
- Division of Cardiology, Jill and Mark Fishman Center for Lymphatic Disorders, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
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7
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Savla JJ, Kelly B, Krogh E, Smith CL, Krishnamurthy G, Glatz AC, DeWitt AG, Pinto EM, Ravishankar C, Gillespie MJ, O’Byrne ML, Escobar FA, Rome JJ, Hjortdal V, Dori Y. Occlusion Pressure of the Thoracic Duct in Fontan Patients With Lymphatic Failure: Does Dilatation Challenge Contractility? World J Pediatr Congenit Heart Surg 2022; 13:737-744. [DOI: 10.1177/21501351221119394] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background The Fontan circulation challenges the lymphatic system. Increasing production of lymphatic fluid and impeding lymphatic return, increased venous pressure may cause lymphatic dilatation and decrease lymphatic contractility. In-vitro studies have reported a lymphatic diameter-tension curve, with increasing passive stretch affecting the intrinsic contractile properties of each thoracic duct segment. We aimed to describe thoracic duct occlusion pressure and asses if thoracic duct dilation impairs contractility in individuals with a Fontan circulation and lymphatic failure. Methods Central venous pressure and thoracic duct measurements were retrospectively collected from 31 individuals with a Fontan circulation. Thoracic duct occlusion pressure was assessed during a period of external manual compression and used as an indicator of lymphatic vessel contractility. Measurements of pressure were correlated with measurements of the thoracic duct diameter in images obtained by dynamic contrast-enhanced MR lymphangiography. Results The average central venous pressure and average pressure of the thoracic duct were 17 mm Hg. During manual occlusion, the thoracic duct pressure significantly increased to 32 mm Hg. The average thoracic duct diameter was 3.3 mm. Thoracic duct diameter correlated closely with the central venous pressure. The rise in pressure following manual occlusion showed an inverse correlation with the diameter of the thoracic duct. Conclusion Higher central venous pressures are associated with increasing diameters of the thoracic duct. When challenged by manual occlusion, dilated thoracic ducts display a decreased ability to increase pressure. Dilatation and a resulting decreased contractility may partly explain the challenged lymphatic system in individuals with a Fontan circulation.
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Affiliation(s)
- Jill J. Savla
- Division of Cardiology, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Benjamin Kelly
- Department of Cardiothoracic Surgery, Aarhus University Hospital, Aarhus, Denmark
- Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
| | - Emil Krogh
- Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
| | - Christopher L. Smith
- Division of Cardiology, Children's Hospital of Philadelphia, Philadelphia, PA, USA
- The Jill and Mark Fishman Center for Lymphatic Disorders, Children's Hospital of Philadelphia, PA, USA
| | - Ganesh Krishnamurthy
- The Jill and Mark Fishman Center for Lymphatic Disorders, Children's Hospital of Philadelphia, PA, USA
- Department of Radiology, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Andrew C. Glatz
- Division of Cardiology, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Aaron G. DeWitt
- The Jill and Mark Fishman Center for Lymphatic Disorders, Children's Hospital of Philadelphia, PA, USA
- Division of Critical Care, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Erin M. Pinto
- Division of Cardiology, Children's Hospital of Philadelphia, Philadelphia, PA, USA
- The Jill and Mark Fishman Center for Lymphatic Disorders, Children's Hospital of Philadelphia, PA, USA
| | - Chitra Ravishankar
- Division of Cardiology, Children's Hospital of Philadelphia, Philadelphia, PA, USA
- The Jill and Mark Fishman Center for Lymphatic Disorders, Children's Hospital of Philadelphia, PA, USA
| | - Matthew J. Gillespie
- Division of Cardiology, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Michael L. O’Byrne
- Division of Cardiology, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Fernando A. Escobar
- The Jill and Mark Fishman Center for Lymphatic Disorders, Children's Hospital of Philadelphia, PA, USA
- Department of Radiology, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Jonathan J. Rome
- Division of Cardiology, Children's Hospital of Philadelphia, Philadelphia, PA, USA
- The Jill and Mark Fishman Center for Lymphatic Disorders, Children's Hospital of Philadelphia, PA, USA
| | - Vibeke Hjortdal
- Department of Cardiothoracic Surgery, Rigshospitalet, Aarhus, Denmark
| | - Yoav Dori
- Division of Cardiology, Children's Hospital of Philadelphia, Philadelphia, PA, USA
- The Jill and Mark Fishman Center for Lymphatic Disorders, Children's Hospital of Philadelphia, PA, USA
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8
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Alsaied T, Lubert AM, Goldberg DJ, Schumacher K, Rathod R, Katz DA, Opotowsky AR, Jenkins M, Smith C, Rychik J, Amdani S, Lanford L, Cetta F, Kreutzer C, Feingold B, Goldstein BH. Protein losing enteropathy after the Fontan operation. INTERNATIONAL JOURNAL OF CARDIOLOGY CONGENITAL HEART DISEASE 2022. [DOI: 10.1016/j.ijcchd.2022.100338] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
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RochéRodríguez M, DiNardo JA. The Lymphatic System in the Fontan Patient-Pathophysiology, Imaging, and Interventions: What the Anesthesiologist Should Know. J Cardiothorac Vasc Anesth 2021; 36:2669-2678. [PMID: 34446325 DOI: 10.1053/j.jvca.2021.07.049] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/12/2021] [Accepted: 07/28/2021] [Indexed: 01/30/2023]
Abstract
The Fontan surgery was developed as a palliative intervention for congenital heart disease (CHD) patients with single-ventricle physiology who are not candidates for a biventricular repair. Improvements in the surgery and medical management of these patients have increased survival, yet this population remains at risk for complications and end-organ dysfunction due to Fontan failure. Lymphatic vessels maintain a fluid balance within the extracellular space, participate in fat reabsorption from the small intestine, and play an important role in the body's immune response. Altered Starling forces at the capillary level, capillary leak, and lymphatic obstruction contribute to lymphatic dysfunction in patients with Fontan physiology. These lymphatic complications include edema, pleural effusions, plastic bronchitis (PB), and protein-losing enteropathy (PLE). Over the past decade, there have been innovations in lymphatic imaging. These new imaging techniques include noncontrast magnetic resonance (MR) lymphangiography, intranodal lymphangiography (IL), dynamic contrast-enhanced magnetic resonance lymphangiography (DCMRL), and liver lymphangiography. These imaging techniques help in delineating anatomy and guiding the appropriate therapeutic approach. Lymphatic interventions then may be performed to decompress the lymphatic system or to identify and occlude abnormal lymphatic vessels and drainage pathways. The anesthesiologist should have an understanding of the effects of lymphatic disorders on the Fontan circulation and apply appropriate management techniques for the associated interventions. The Fontan surgery was developed as a palliative intervention for CHD patients with single-ventricle physiology who are not candidates for a biventricular repair. The surgery creates a series systemic and pulmonary circulation with the energy necessary to provide gradient-driven pulmonary blood flow generated by the ventricle.1 In the past decades, improvements in the surgery and medical management of these patients have increased survival, with 30-year survival rates close to 85%.2 Despite these improvements, this population remains at risk for complications and end-organ dysfunction due to Fontan failure, which is characterized by elevated systemic venous pressures and low cardiac output. These complications include arrhythmias, cardiac dysfunction, ascites, liver fibrosis/cirrhosis, renal dysfunction, pulmonary failure, and lymphatic complications such as edema, pleural effusions, PB, and PLE. Complications ultimately contribute to increased risk for hospitalization, death, and need for heart transplantation.3,4 For this reason, there has been increasing interest in the role of abnormal lymphatic circulation in the genesis of Fontan failure. The authors characterize the lymphatic pathophysiology associated with Fontan physiology and review the imaging and interventional strategies used to treat these patients.
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Affiliation(s)
- Maricarmen RochéRodríguez
- Division of Cardiac Anesthesia, Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children's Hospital, Harvard Medical School, Boston, MA.
| | - James A DiNardo
- Division of Cardiac Anesthesia, Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children's Hospital, Harvard Medical School, Boston, MA
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10
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Loomba RS, Wong J, Davis M, Kane S, Heenan B, Farias JS, Villarreal EG, Flores S. Medical Interventions for Chylothorax and their Impacts on Need for Surgical Intervention and Admission Characteristics: A Multicenter, Retrospective Insight. Pediatr Cardiol 2021; 42:543-553. [PMID: 33394111 DOI: 10.1007/s00246-020-02512-x] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/15/2020] [Accepted: 11/17/2020] [Indexed: 10/22/2022]
Abstract
The incidence of chylothorax is reported from 1-9% in pediatric patients undergoing congenital heart surgery. Effective evidenced-based practice is limited for the management of post-operative chylothorax in the pediatric cardiac intensive care unit. The study characterizes the population of pediatric patients with cardiac surgery and chylothorax who eventually require pleurodesis and/or thoracic duct ligation; it also establishes objective data on the impact of various medical interventions. Data were obtained from the Pediatric Health Information System database from 2004-2015. Inclusion criteria for admissions for this study were pediatric admissions, cardiac diagnosis, cardiac surgery, and chylothorax. These data were then divided into two groups: those that did and did not require surgical intervention for chylothorax. Other data points obtained included congenital heart malformation, age, gender, length of stay, billed charges, and inpatient mortality. A total of 3503 pediatric admissions with cardiac surgery and subsequent chylothorax were included. Of these, 236 (9.4%) required surgical intervention for the chylothorax. The following cardiac diagnoses, cardiac surgeries, and comorbidities were associated with increased odds of surgical intervention: d-transposition, arterial switch, mitral valvuloplasty, acute kidney injury, need for dialysis, cardiac arrest, and extracorporeal membrane oxygenation. Statistically significant medical interventions which did have an impact were specific steroids (hydrocortisone, dexamethasone, methylprednisolone) and specific diuretics (furosemide). These were significantly associated with decreased length of stay and costs. Dexamethasone, methylprednisolone, and furosemide were associated with decreased odds for surgical intervention. These analyses offer objective data regarding the effects of interventions for chylothorax in pediatric cardiac surgery admissions. Results from this study seem to indicate that most post-operative chylothoraxes should improve with furosemide, a low-fat diet, and steroids.
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Affiliation(s)
- Rohit S Loomba
- Department of Pediatrics, Chicago Medical School, Chicago, IL, USA.,Division of Cardiology, Advocate Children's Hospital, Chicago, IL, USA
| | - Joshua Wong
- Division of Cardiology, Advocate Children's Hospital, Chicago, IL, USA
| | - Megan Davis
- Division of Cardiology, Advocate Children's Hospital, Chicago, IL, USA
| | - Sarah Kane
- Division of Cardiology, Advocate Children's Hospital, Chicago, IL, USA
| | - Brian Heenan
- Division of Cardiology, Advocate Children's Hospital, Chicago, IL, USA
| | - Juan S Farias
- Tecnologico de Monterrey, Escuela de Medicina y Ciencias de la Salud, Monterrey, Nuevo Leon, Mexico
| | - Enrique G Villarreal
- Tecnologico de Monterrey, Escuela de Medicina y Ciencias de la Salud, Monterrey, Nuevo Leon, Mexico.
| | - Saul Flores
- Section of Critical Care, Texas Children's Hospital, Houston, TX, USA
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Johnson BN, Fierro JL, Panitch HB. Pulmonary Manifestations of Congenital Heart Disease in Children. Pediatr Clin North Am 2021; 68:25-40. [PMID: 33228936 DOI: 10.1016/j.pcl.2020.09.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
This review addresses how anomalous cardiovascular anatomy imparts consequences to the airway, respiratory system mechanics, pulmonary vascular system, and lymphatic system. Abnormal formation or enlargement of great vessels can compress airways and cause large and small airway obstructions. Alterations in pulmonary blood flow associated with congenital heart disease (CHD) can cause abnormalities in pulmonary mechanics and limitation of exercise. CHD can lead to pulmonary arterial hypertension. Lymphatic abnormalities associated with CHD can cause pulmonary edema, chylothorax, or plastic bronchitis. Understanding how the cardiovascular system has an impact on pulmonary growth and function can help determine options and timing of intervention.
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Affiliation(s)
- Brandy N Johnson
- Pediatric Pulmonology, Division of Pulmonary Medicine, Children's Hospital of Philadelphia, 3501 Civic Center Boulevard, Philadelphia, PA 19104, USA
| | - Julie L Fierro
- Division of Pulmonary Medicine, The Perelman School of Medicine at the University of Pennsylvania, Children's Hospital of Philadelphia, 3501 Civic Center Boulevard, Philadelphia, PA 19104, USA
| | - Howard B Panitch
- Technology Dependence Center, Division of Pulmonary Medicine, The Perelman School of Medicine at the University of Pennsylvania, Children's Hospital of Philadelphia, 3501 Civic Center Boulevard, Philadelphia, PA 19104, USA.
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12
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Lymphatic Disorders and Management in Patients with Congenital Heart Disease. Ann Thorac Surg 2020; 113:1101-1111. [PMID: 33373590 DOI: 10.1016/j.athoracsur.2020.10.058] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/07/2020] [Revised: 09/11/2020] [Accepted: 10/05/2020] [Indexed: 11/20/2022]
Abstract
Congenital heart disease can lead to significant lymphatic complications such as chylothorax, plastic bronchitis, protein losing enteropathy and ascites. Recent improvements in lymphatic imaging and the development of new lymphatic procedures can help alleviate symptoms and improve outcomes.
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13
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Luque‐González MA, Reis RL, Kundu SC, Caballero D. Human Microcirculation‐on‐Chip Models in Cancer Research: Key Integration of Lymphatic and Blood Vasculatures. ACTA ACUST UNITED AC 2020; 4:e2000045. [DOI: 10.1002/adbi.202000045] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2020] [Revised: 03/27/2020] [Indexed: 12/19/2022]
Affiliation(s)
- Maria Angélica Luque‐González
- 3B’s Research Group, I3Bs—Research Institute on Biomaterials Biodegradables and BiomimeticsUniversity of MinhoHeadquarters of the European Institute of Excellence on Tissue Engineering and Regenerative MedicineICVS/3B’s—PT Government Associate Laboratory AvePark, Parque de Ciência e Tecnologia, Zona Industrial da Gandra 4805‐017 Barco Braga/Guimarães Portugal
| | - Rui Luis Reis
- 3B’s Research Group, I3Bs—Research Institute on Biomaterials Biodegradables and BiomimeticsUniversity of MinhoHeadquarters of the European Institute of Excellence on Tissue Engineering and Regenerative MedicineICVS/3B’s—PT Government Associate Laboratory AvePark, Parque de Ciência e Tecnologia, Zona Industrial da Gandra 4805‐017 Barco Braga/Guimarães Portugal
| | - Subhas Chandra Kundu
- 3B’s Research Group, I3Bs—Research Institute on Biomaterials Biodegradables and BiomimeticsUniversity of MinhoHeadquarters of the European Institute of Excellence on Tissue Engineering and Regenerative MedicineICVS/3B’s—PT Government Associate Laboratory AvePark, Parque de Ciência e Tecnologia, Zona Industrial da Gandra 4805‐017 Barco Braga/Guimarães Portugal
| | - David Caballero
- 3B’s Research Group, I3Bs—Research Institute on Biomaterials Biodegradables and BiomimeticsUniversity of MinhoHeadquarters of the European Institute of Excellence on Tissue Engineering and Regenerative MedicineICVS/3B’s—PT Government Associate Laboratory AvePark, Parque de Ciência e Tecnologia, Zona Industrial da Gandra 4805‐017 Barco Braga/Guimarães Portugal
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14
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Abstract
INTRODUCTION Although chylothorax is an uncommon complication following paediatric cardiothoracic surgery, it has significant associated morbidities and increased in-hospital mortality, as well as results in higher costs. A lack of prospective evidence or consensus guidelines for management of chylothorax further hinders optimal management. The aim of this survey was to characterise variations in practice in the management of chylothorax and to identify areas for future research. MATERIALS AND METHODS A descriptive, observational survey investigating conservative management practices of chylothorax was distributed internationally to health-care professionals in paediatric intensive care and cardiology units. The survey investigated five domains: the first providing general information about health-care professionals and four domains focusing on clinical practice including diet composition and duration. RESULTS In total, sixty-four health-care professionals completed the survey, representing 38 organisations from 16 countries. The respondents were dietitians (80%), physicians (19%), and nurses (1%). In Australia and New Zealand, management was most commonly directed by physicians' preference (67%) as compared to unit protocols in Europe (67%), United States of America (67%), and Other regions (55%). Dietitians in Australia/New Zealand, United Kingdom, and Ireland followed the most restrictive diet therapy recommending <5 g long chain triglyceride fat per day (p < 0.00001). The duration of diet therapy significantly varied between regions: Australia/New Zealand: 4 weeks (36%) and 6 weeks (43%); Europe: 4 weeks (25%) and 6 weeks (57%); and North America: 4 weeks (18%) and 6 weeks (75%) (p < 0.00001). CONCLUSIONS This survey highlights international variations in practice in the management of chylothorax, particularly with respect to treatment duration and dietary fat restriction. Future research should include a multi-centre randomised controlled trial to inform evidence-based practice and reduce morbidity, particularly poor growth.
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Pediatric chylothorax-lymphatic imaging enables targeted surgical treatment. Indian J Thorac Cardiovasc Surg 2019; 35:233-236. [PMID: 33061014 DOI: 10.1007/s12055-018-00779-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2018] [Revised: 11/20/2018] [Accepted: 11/23/2018] [Indexed: 10/27/2022] Open
Abstract
Chylothorax-the collection of lymphatic fluid in the pleural space-is a rare finding in otherwise healthy adolescents. Initially, clinical signs and symptoms are often non-specific and a wide range of underlying causes necessitates extensive diagnostic workup. Treatment options include dietary measures, medical treatment, and various surgical procedures. We report about a 12-year-old boy with accidental diagnosis of chylothorax. Lymphatic imaging led to visualization of a leakage of an accessory left-sided thoracic duct and thoracoscopic clipping was successfully performed. Lymphatic imaging procedures depict underlying causes of chylothorax allowing targeted therapeutic management.
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Mohanakumar S, Telinius N, Kelly B, Lauridsen H, Boedtkjer D, Pedersen M, de Leval M, Hjortdal V. Morphology and Function of the Lymphatic Vasculature in Patients With a Fontan Circulation. Circ Cardiovasc Imaging 2019; 12:e008074. [DOI: 10.1161/circimaging.118.008074] [Citation(s) in RCA: 38] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Affiliation(s)
- Sheyanth Mohanakumar
- Department of Cardiothoracic and Vascular Surgery, Aarhus University Hospital, Denmark (S.M., N.T., B.K., V.H.)
- Department of Clinical Medicine (S.M., N.T., B.K., D.B., M.P., V.H.), Aarhus University, Denmark
| | - Niklas Telinius
- Department of Cardiothoracic and Vascular Surgery, Aarhus University Hospital, Denmark (S.M., N.T., B.K., V.H.)
- Department of Clinical Medicine (S.M., N.T., B.K., D.B., M.P., V.H.), Aarhus University, Denmark
| | - Benjamin Kelly
- Department of Cardiothoracic and Vascular Surgery, Aarhus University Hospital, Denmark (S.M., N.T., B.K., V.H.)
- Department of Clinical Medicine (S.M., N.T., B.K., D.B., M.P., V.H.), Aarhus University, Denmark
| | - Henrik Lauridsen
- Comparative Medicine Lab, Department of Clinical Medicine (H.L., M.P.), Aarhus University, Denmark
| | - Donna Boedtkjer
- Department of Clinical Medicine (S.M., N.T., B.K., D.B., M.P., V.H.), Aarhus University, Denmark
- Department of Biomedicine (D.B.), Aarhus University, Denmark
| | - Michael Pedersen
- Department of Clinical Medicine (S.M., N.T., B.K., D.B., M.P., V.H.), Aarhus University, Denmark
- Comparative Medicine Lab, Department of Clinical Medicine (H.L., M.P.), Aarhus University, Denmark
| | - Marc de Leval
- The Harley Street Clinic Children’s Hospital, London, United Kingdom (M.d.L.)
| | - Vibeke Hjortdal
- Department of Cardiothoracic and Vascular Surgery, Aarhus University Hospital, Denmark (S.M., N.T., B.K., V.H.)
- Department of Clinical Medicine (S.M., N.T., B.K., D.B., M.P., V.H.), Aarhus University, Denmark
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