1
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Ning L, Zanella S, Tomov ML, Amoli MS, Jin L, Hwang B, Saadeh M, Chen H, Neelakantan S, Dasi LP, Avazmohammadi R, Mahmoudi M, Bauser‐Heaton HD, Serpooshan V. Targeted Rapamycin Delivery via Magnetic Nanoparticles to Address Stenosis in a 3D Bioprinted in Vitro Model of Pulmonary Veins. ADVANCED SCIENCE (WEINHEIM, BADEN-WURTTEMBERG, GERMANY) 2024; 11:e2400476. [PMID: 38696618 PMCID: PMC11234432 DOI: 10.1002/advs.202400476] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/12/2024] [Revised: 04/09/2024] [Indexed: 05/04/2024]
Abstract
Vascular cell overgrowth and lumen size reduction in pulmonary vein stenosis (PVS) can result in elevated PV pressure, pulmonary hypertension, cardiac failure, and death. Administration of chemotherapies such as rapamycin have shown promise by inhibiting the vascular cell proliferation; yet clinical success is limited due to complications such as restenosis and off-target effects. The lack of in vitro models to recapitulate the complex pathophysiology of PVS has hindered the identification of disease mechanisms and therapies. This study integrated 3D bioprinting, functional nanoparticles, and perfusion bioreactors to develop a novel in vitro model of PVS. Bioprinted bifurcated PV constructs are seeded with endothelial cells (ECs) and perfused, demonstrating the formation of a uniform and viable endothelium. Computational modeling identified the bifurcation point at high risk of EC overgrowth. Application of an external magnetic field enabled targeting of the rapamycin-loaded superparamagnetic iron oxide nanoparticles at the bifurcation site, leading to a significant reduction in EC proliferation with no adverse side effects. These results establish a 3D bioprinted in vitro model to study PV homeostasis and diseases, offering the potential for increased throughput, tunability, and patient specificity, to test new or more effective therapies for PVS and other vascular diseases.
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Affiliation(s)
- Liqun Ning
- Wallace H. Coulter Department of Biomedical EngineeringEmory University School of Medicine and Georgia Institute of TechnologyAtlantaGA30322USA
- Department of Mechanical EngineeringCleveland State UniversityClevelandOH44115USA
| | - Stefano Zanella
- Wallace H. Coulter Department of Biomedical EngineeringEmory University School of Medicine and Georgia Institute of TechnologyAtlantaGA30322USA
| | - Martin L. Tomov
- Wallace H. Coulter Department of Biomedical EngineeringEmory University School of Medicine and Georgia Institute of TechnologyAtlantaGA30322USA
| | - Mehdi Salar Amoli
- Wallace H. Coulter Department of Biomedical EngineeringEmory University School of Medicine and Georgia Institute of TechnologyAtlantaGA30322USA
| | - Linqi Jin
- Wallace H. Coulter Department of Biomedical EngineeringEmory University School of Medicine and Georgia Institute of TechnologyAtlantaGA30322USA
| | - Boeun Hwang
- Wallace H. Coulter Department of Biomedical EngineeringEmory University School of Medicine and Georgia Institute of TechnologyAtlantaGA30322USA
| | - Maher Saadeh
- Wallace H. Coulter Department of Biomedical EngineeringEmory University School of Medicine and Georgia Institute of TechnologyAtlantaGA30322USA
| | - Huang Chen
- Wallace H. Coulter Department of Biomedical EngineeringEmory University School of Medicine and Georgia Institute of TechnologyAtlantaGA30322USA
| | - Sunder Neelakantan
- Department of Biomedical EngineeringTexas A&M UniversityCollege StationTX77843USA
| | - Lakshmi Prasad Dasi
- Wallace H. Coulter Department of Biomedical EngineeringEmory University School of Medicine and Georgia Institute of TechnologyAtlantaGA30322USA
| | - Reza Avazmohammadi
- Department of Biomedical EngineeringTexas A&M UniversityCollege StationTX77843USA
- J. Mike Walker ’66 Department of Mechanical EngineeringTexas A&M UniversityCollege StationTX77840USA
| | - Morteza Mahmoudi
- Department of Radiology and Precision Health ProgramMichigan State UniversityEast LandingMI48824USA
| | - Holly D. Bauser‐Heaton
- Wallace H. Coulter Department of Biomedical EngineeringEmory University School of Medicine and Georgia Institute of TechnologyAtlantaGA30322USA
- Department of PediatricsEmory University School of MedicineAtlantaGA30322USA
- Children's Healthcare of AtlantaAtlantaGA30322USA
- Sibley Heart Center at Children's Healthcare of AtlantaAtlantaGA30322USA
| | - Vahid Serpooshan
- Wallace H. Coulter Department of Biomedical EngineeringEmory University School of Medicine and Georgia Institute of TechnologyAtlantaGA30322USA
- Department of PediatricsEmory University School of MedicineAtlantaGA30322USA
- Children's Healthcare of AtlantaAtlantaGA30322USA
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2
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Hsien S, Krishnan U, Petit CJ. Interventions for Pulmonary Vein Stenosis. Interv Cardiol Clin 2024; 13:431-438. [PMID: 38839175 DOI: 10.1016/j.iccl.2024.03.003] [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
Pulmonary vein stenosis (PVS) is a rare and unique disease of infants and young children. PVS is attended by high morbidity and mortality, and for many decades, effective therapy eluded the practitioner. However, in the most recent era, interventional techniques when employed in combination with systemic (primary) therapy have had a remarkable impact on outcomes in these at-risk children. Despite apparent complete relief of PVS in a discrete region of a pulmonary vein, stenosis reliably recurs and progresses. In this review, we discuss the current state-of-the-art interventional techniques, through the lens of our collective experiences and practices.
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Affiliation(s)
- Sophia Hsien
- Division of Pediatric Cardiology, New York Presbyterian Morgan Stanley Children's Hospital, Columbia University Medical Center, New York, NY, USA
| | - Usha Krishnan
- Division of Pediatric Cardiology, New York Presbyterian Morgan Stanley Children's Hospital, Columbia University Medical Center, New York, NY, USA
| | - Christopher J Petit
- Division of Pediatric Cardiology, New York Presbyterian Morgan Stanley Children's Hospital, Columbia University Medical Center, New York, NY, USA.
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3
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Maia PD, Abman SH, Mandell E. Bronchopulmonary Dysplasia-Associated Pulmonary Hypertension: Basing Care on Physiology. Neoreviews 2024; 25:e415-e433. [PMID: 38945971 DOI: 10.1542/neo.25-7-e415] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2023] [Revised: 12/31/2023] [Accepted: 01/13/2024] [Indexed: 07/02/2024]
Abstract
Bronchopulmonary dysplasia (BPD) is the heterogeneous chronic lung developmental disease of prematurity, which is often accompanied by multisystem comorbidities. Pulmonary vascular disease and pulmonary hypertension (PH) contribute significantly to the pathogenesis and pathophysiology of BPD and dramatically influence the outcomes of preterm infants with BPD. When caring for those patients, clinicians should consider the multitude of phenotypic presentations that fall under the "BPD-PH umbrella," reflecting the need for matching therapies to specific physiologies to improve short- and long-term outcomes. Individualized management based on the patient's prenatal and postnatal risk factors, clinical course, and cardiopulmonary phenotype needs to be identified and prioritized to provide optimal care for infants with BPD-PH.
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Affiliation(s)
- Paula Dias Maia
- Section of Neonatology, Department of Pediatrics, University of Colorado Anschutz School of Medicine and Children's Hospital Colorado, Aurora, CO
- Pediatric Heart Lung Center, Department of Pediatrics, University of Colorado Anschutz School of Medicine and Children's Hospital Colorado, Aurora, CO
| | - Steven H Abman
- Pediatric Heart Lung Center, Department of Pediatrics, University of Colorado Anschutz School of Medicine and Children's Hospital Colorado, Aurora, CO
- Section of Pulmonary Medicine, Department of Pediatrics, University of Colorado Anschutz School of Medicine and Children's Hospital Colorado, Aurora, CO
| | - Erica Mandell
- Section of Neonatology, Department of Pediatrics, University of Colorado Anschutz School of Medicine and Children's Hospital Colorado, Aurora, CO
- Pediatric Heart Lung Center, Department of Pediatrics, University of Colorado Anschutz School of Medicine and Children's Hospital Colorado, Aurora, CO
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4
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Zampi JD, Sower CT, Lancaster TS, Sood V, Romano JC. Hybrid Interventions in Congenital Heart Disease: A Review of Current Practice and Rationale for Use. Ann Thorac Surg 2024:S0003-4975(24)00184-X. [PMID: 38462049 DOI: 10.1016/j.athoracsur.2024.03.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/29/2023] [Revised: 02/14/2024] [Accepted: 03/04/2024] [Indexed: 03/12/2024]
Abstract
BACKGROUND Hybrid interventions have become a common option in the management for a variety of patients with congenital heart disease. In this review, we discuss the data that have driven decision making about hybrid interventions to date. METHODS The existing literature on various hybrid approaches was reviewed and summarized. In addition, the key tenants to creating a successful hybrid program within a congenital heart center are elucidated. RESULTS Hybrid strategies for single-ventricle patients, pulmonary atresia with intact ventricular septum, branch pulmonary artery stenosis, and muscular ventricular septal defect closure have important benefits and limitations compared with traditional approaches. CONCLUSION A growing body of evidence supports the use of hybrid interventions in congenital heart disease. But important questions remain regarding improved survival and other long-term outcomes, such as neurocognition, that might impact widespread adoption as a primary treatment strategy.
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Affiliation(s)
- Jeffrey D Zampi
- Division of Pediatric Cardiology, Department of Pediatrics, University of Michigan, Ann Arbor, Michigan.
| | - C Todd Sower
- Division of Pediatric Cardiology, Department of Pediatrics, University of Michigan, Ann Arbor, Michigan
| | - Timothy S Lancaster
- Section of Pediatric Cardiovascular Surgery, Department of Surgery, University of Michigan, Ann Arbor, Michigan
| | - Vikram Sood
- Section of Pediatric Cardiovascular Surgery, Department of Surgery, University of Michigan, Ann Arbor, Michigan
| | - Jennifer C Romano
- Section of Pediatric Cardiovascular Surgery, Department of Surgery, University of Michigan, Ann Arbor, Michigan
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5
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Vanderlaan RD. Improving Outcomes in Pulmonary Vein Stenosis: Novel Pursuits and Paradigm Shifts. Semin Thorac Cardiovasc Surg Pediatr Card Surg Annu 2024; 27:92-99. [PMID: 38522879 DOI: 10.1053/j.pcsu.2024.01.003] [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] [Received: 10/25/2023] [Revised: 01/03/2024] [Accepted: 01/12/2024] [Indexed: 03/26/2024]
Abstract
Pulmonary vein stenosis (PVS) remains a clinical challenge, with progressive restenosis being common. In the past five years, we have seen an exponential increase in both clinical and scientific publication related to PVS. Central to progress in PVS clinical care is the paradigm shift towards collaborative, multidisciplinary care that utilizes a multimodality approach to treatment. This manuscript will discuss recent conceptual gains in PVS treatment and research while highlighting important outstanding questions and barriers.
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Affiliation(s)
- Rachel D Vanderlaan
- Division of Cardiovascular Surgery, Hospital for Sick Children, Toronto, Ontario, Canada.
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6
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Hong HJ, Kwon HW, Kwak JG, Lee SY, Lee YS. An extreme case of cor triatriatum mimicking hypoplastic left heart syndrome and combined pulmonary vein stenosis. Cardiol Young 2024; 34:205-208. [PMID: 38018154 DOI: 10.1017/s1047951123003724] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2023]
Abstract
A 65-day-old girl presented to the emergency room with lethargy, requiring emergency venoarterial extracorporeal membrane oxygenation for refractory cardiogenic shock. Initially, hypoplastic left heart syndrome was suspected. However, cor triatriatum with a pinpoint opening on the membrane was diagnosed based on a detailed echocardiographic examination. After membrane resection, the left heart size was restored. However, follow-up echocardiography performed 4 months later showed occlusion of both upper pulmonary veins and stenosis in both lower pulmonary veins. Hybrid balloon angioplasty was performed in all pulmonary veins, and stents were inserted into the right upper and lower pulmonary veins. Despite repeated balloon angioplasty, all pulmonary vein stenosis progressed over 6 months and the patient expired while waiting for a heart-lung transplant. Even after successful repair of cor triatriatum, short-term close follow-up is required for detecting the development of pulmonary vein stenosis.
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Affiliation(s)
- Hee Ju Hong
- Department of Thoracic and Cardiovascular Surgery, Seoul National University Hospital, Seoul, South Korea
| | - Hye Won Kwon
- Department of Thoracic and Cardiovascular Surgery, Seoul National University Hospital, Seoul, South Korea
| | - Jae Gun Kwak
- Department of Thoracic and Cardiovascular Surgery, Seoul National University Hospital, Seoul, South Korea
| | - Sang Yun Lee
- Department of Pediatrics, Seoul National University Hospital, Seoul, South Korea
| | - Yoon Seong Lee
- Department of Radiology, Seoul National University Hospital, Seoul, South Korea
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7
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Sugitani Y, Muneuchi J, Watanabe M. Home-inhaled nitric oxide in a child with pulmonary arterial hypertension associated with post-operative pulmonary venous obstruction. Cardiol Young 2023; 33:2673-2675. [PMID: 37846473 DOI: 10.1017/s1047951123003591] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/18/2023]
Abstract
Home-inhaled nitric oxide therapy was effective and feasible in the patients with intractable pulmonary arterial hypertension. We present the case of a child with severe pulmonary arterial hypertension associated with post-operative pulmonary venous obstruction who was treated with home-inhaled nitric oxide therapy.
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Affiliation(s)
- Yuichiro Sugitani
- Department of Pediatrics, Kyushu Hospital, Japan Community Healthcare Organization, Kitakyushu, Japan
| | - Jun Muneuchi
- Department of Pediatrics, Kyushu Hospital, Japan Community Healthcare Organization, Kitakyushu, Japan
| | - Mamie Watanabe
- Department of Pediatrics, Kyushu Hospital, Japan Community Healthcare Organization, Kitakyushu, Japan
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8
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Critchfield DR, Chamberlain RC, Turek JW, Fleming GA. Hybrid approach to pulmonary vein stenting after Fontan palliation. Catheter Cardiovasc Interv 2023; 102:1095-1100. [PMID: 37681395 DOI: 10.1002/ccd.30831] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/08/2023] [Revised: 08/11/2023] [Accepted: 08/24/2023] [Indexed: 09/09/2023]
Abstract
Pulmonary vein stenosis is poorly tolerated in patients who have undergone Fontan palliation and typically requires surgical or transcatheter intervention. Percutaneous transcatheter approaches to intervention can be technically difficult due to challenging anatomy. A hybrid per-atrial transcatheter approach for stenting pulmonary veins provides a direct approach to the pulmonary veins and has the potential to improve safety and efficacy of this complex intervention. We describe our experience with hybrid per-atrial pulmonary vein stenting in three patients with pulmonary vein stenosis following Fontan palliation.
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Affiliation(s)
- Daniel R Critchfield
- Department of Pediatrics, Duke University Medical Center, Durham, North Carolina, USA
| | - Reid C Chamberlain
- Department of Pediatrics, Duke University Medical Center, Durham, North Carolina, USA
| | - Joseph W Turek
- Department of Surgery, Duke University Medical Center, Durham, North Carolina, USA
| | - Gregory A Fleming
- Department of Pediatrics, Duke University Medical Center, Durham, North Carolina, USA
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9
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Zhang Z, Qiu T, Zhou J, Gong X, Yang K, Zhang X, Lan Y, Yang C, Zhou Z, Ji Y. Toxic effects of sirolimus and everolimus on the development and behavior of zebrafish embryos. Biomed Pharmacother 2023; 166:115397. [PMID: 37659200 DOI: 10.1016/j.biopha.2023.115397] [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] [Received: 07/18/2023] [Revised: 08/22/2023] [Accepted: 08/26/2023] [Indexed: 09/04/2023] Open
Abstract
Sirolimus and everolimus have been widely used in children. These mammalian target of rapamycin (mTOR) inhibitors have shown excellent efficacy not only in organ transplant patients as immunosuppressive agents but also in patients with some other diseases. However, whether mTOR inhibitors can affect the growth and development of children is of great concern. In this study, using zebrafish models, we discovered that sirolimus and everolimus could slow the development of zebrafish, affecting indicators such as survival, hatching, deformities, body length, and movement. In addition to these basic indicators, sirolimus and everolimus had certain slowing effects on the growth and development of the nervous system, blood vessels, and the immune system. These effects were dose dependent. When the drug concentration reached or exceeded 0.5 μM, the impacts of sirolimus and everolimus were very significant. More interestingly, the impact was transient. Over time, the various manifestations of experimental embryos gradually approached those of control embryos. We also compared the effects of sirolimus and everolimus on zebrafish, and we revealed that there was no significant difference between these drugs in terms of their effects. In summary, the dose of sirolimus and everolimus in children should be strictly controlled, and the drug concentration should be monitored over time. Otherwise, drug overdosing may have a certain impact on the growth and development of children.
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Affiliation(s)
- Zixin Zhang
- Division of Oncology, Department of Pediatric Surgery, West China Hospital of Sichuan University, Chengdu 610041, China
| | - Tong Qiu
- Division of Oncology, Department of Pediatric Surgery, West China Hospital of Sichuan University, Chengdu 610041, China
| | - Jiangyuan Zhou
- Division of Oncology, Department of Pediatric Surgery, West China Hospital of Sichuan University, Chengdu 610041, China
| | - Xue Gong
- Division of Oncology, Department of Pediatric Surgery, West China Hospital of Sichuan University, Chengdu 610041, China
| | - Kaiying Yang
- Division of Oncology, Department of Pediatric Surgery, West China Hospital of Sichuan University, Chengdu 610041, China; Department of Pediatric Surgery, Guangzhou Women and Children's Medical Center, National Children's Medical Center for South Central Region, Guangzhou Medical University, Guangzhou 510623, China
| | - Xuepeng Zhang
- Division of Oncology, Department of Pediatric Surgery, West China Hospital of Sichuan University, Chengdu 610041, China
| | - Yuru Lan
- Division of Oncology, Department of Pediatric Surgery, West China Hospital of Sichuan University, Chengdu 610041, China
| | - Congxia Yang
- Division of Oncology, Department of Pediatric Surgery, West China Hospital of Sichuan University, Chengdu 610041, China
| | - Zilong Zhou
- Division of Oncology, Department of Pediatric Surgery, West China Hospital of Sichuan University, Chengdu 610041, China
| | - Yi Ji
- Division of Oncology, Department of Pediatric Surgery, West China Hospital of Sichuan University, Chengdu 610041, China.
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10
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Mirza H, Mandell EW, Kinsella JP, McNamara PJ, Abman SH. Pulmonary Vascular Phenotypes of Prematurity: The Path to Precision Medicine. J Pediatr 2023; 259:113444. [PMID: 37105409 PMCID: PMC10524716 DOI: 10.1016/j.jpeds.2023.113444] [Citation(s) in RCA: 10] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/05/2022] [Revised: 03/07/2023] [Accepted: 04/05/2023] [Indexed: 04/29/2023]
Abstract
Pulmonary hypertension (PH) is associated with significant morbidities and high mortality in preterm infants, yet mechanisms contributing to the pathogenesis of PH, the impact of early pulmonary vascular disease (PVD) on the risk for BPD, the role for PH-targeted drug therapies, and long-term pulmonary vascular sequelae remain poorly understood. PVD is not a homogeneous disease, rather, PVD in the setting of prematurity includes various phenotypes as based on underlying pathophysiology, the severity of associated PH, the timing of disease onset, its contribution to hemodynamic and respiratory status, late outcomes, and other features. As with term newborns, severe hypoxemia with acute respiratory failure (HRF) in preterm infants can be due to marked elevation of pulmonary artery pressure with extrapulmonary shunt, traditionally referred to as persistent pulmonary hypertension of the newborn (PPHN). Transient and less severe levels of PH can also be observed during the early transition after birth without evidence of severe HRF, representing physiologic PH or delayed pulmonary vascular transition in preterm infants. Importantly, echocardiographic evidence of early PH has been strongly associated with the subsequent development of bronchopulmonary dysplasia (BPD), late PH, and chronic respiratory disease during infancy and early childhood. Late PH beyond the first postnatal months in preterm in neonates with established BPD is further associated with poor outcomes, especially as related to BPD severity. In addition, echocardiographic signs of PVD can further persist throughout childhood and may lead to chronic PH of variable severity and cardiac maldevelopment in prematurely born young adults. This review discusses the importance of characterizing diverse pulmonary vascular phenotypes in preterm infants to better guide clinical care and research, and to enhance the development of more precise therapeutic strategies to optimize early and late outcomes of preterm infants.
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Affiliation(s)
- Hussnain Mirza
- Section of Neonatology, Department of Pediatrics, Advent Health for Children/UCF College of Medicine, Orlando, FL
| | - Erica W Mandell
- Pediatric Heart Lung Center and Section of Neonatology, University of Colorado Anschutz School of Medicine and Children's Hospital Colorado, Aurora, CO
| | - John P Kinsella
- Pediatric Heart Lung Center and Section of Neonatology, University of Colorado Anschutz School of Medicine and Children's Hospital Colorado, Aurora, CO
| | - Patrick J McNamara
- Division of Neonatology, Department of Pediatrics, University of Iowa School of Medicine, Iowa City, IA
| | - Steven H Abman
- Pediatric Heart Lung Center and Section of Pulmonary Medicine, Department of Pediatrics, University of Colorado Anschutz School of Medicine and Children's Hospital Colorado, Aurora, CO.
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11
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Simard T, Sarma D, Miranda WR, Jain CC, Anderson JH, Collins JD, El Sabbagh A, Jhand A, Peikert T, Reeder GS, Munger TM, Packer DL, Holmes DR. Pathogenesis, Evaluation, and Management of Pulmonary Vein Stenosis: JACC Review Topic of the Week. J Am Coll Cardiol 2023; 81:2361-2373. [PMID: 37316116 DOI: 10.1016/j.jacc.2023.04.016] [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: 03/23/2023] [Accepted: 04/06/2023] [Indexed: 06/16/2023]
Abstract
Pulmonary vein stenosis (PVS) can arise from several etiologies, including congenital, acquired, and iatrogenic sources. PVS presents insidiously, leading to significant delays in diagnosis. A high index of suspicion and dedicated noninvasive evaluation are key to diagnosis. Once diagnosed, both noninvasive and invasive evaluation may afford further insights into the relative contribution of PVS to symptoms. Treatment of underlying reversible pathologies coupled with transcatheter balloon angioplasty and stenting for persistent severe stenoses are established approaches. Ongoing refinements in diagnostic modalities, interventional approaches, postintervention monitoring, and medical therapies hold promise to further improve patient outcomes.
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Affiliation(s)
- Trevor Simard
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota, USA. https://twitter.com/tjsimard
| | - Dhruv Sarma
- Department of Internal Medicine, Mayo Clinic, Rochester, Minnesota, USA. https://twitter.com/SarmaDhruv
| | - William R Miranda
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - C Charles Jain
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Jason H Anderson
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | | | - Abdallah El Sabbagh
- Department of Cardiovascular Medicine, Mayo Clinic, Jacksonville, Florida, USA
| | - Aravdeep Jhand
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Tobias Peikert
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Guy S Reeder
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Thomas M Munger
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Douglas L Packer
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - David R Holmes
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota, USA.
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12
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Li D, Qiu L, Hong H, Chen H, Zhao P, Xiao Y, Zhang H, Sun Q, Ye L. A neonatal rat model of pulmonary vein stenosis. Cell Biosci 2023; 13:112. [PMID: 37337290 DOI: 10.1186/s13578-023-01058-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2023] [Accepted: 05/23/2023] [Indexed: 06/21/2023] Open
Abstract
OBJECTIVES Pulmonary vein stenosis (PVS), one of the most challenging clinical problems in congenital heart disease, leads to secondary pulmonary arterial hypertension (PAH) and right ventricular (RV) hypertrophy. Due to the lack of a rodent model, the mechanisms underlying PVS and its associated secondary effects are largely unknown, and treatments are minimally successful. This study developed a neonatal rat PVS model with the aim of increasing our understanding of the mechanisms and developing possible treatments for PVS. METHODS PVS was created at postnatal day 1 (P1) by banding pulmonary veins that receive blood from the right anterior and mid lobes. The condition was confirmed using echocardiography, computed tomography (CT), gross anatomic examination, hematoxylin and eosin (H&E) staining, fibrosis staining, and immunofluorescence. Lung and RV remodeling under the condition of PVS were evaluated using H&E staining, fibrosis staining, and immunofluorescence. RESULTS At P21, echocardiography revealed a change in wave form and a decrease in pulmonary artery acceleration time-indicators of PAH-at the transpulmonary valve site in the PVS group. CT at P21 showed a decrease in pulmonary vein diameter in the PVS group. At P30 in the PVS group, gross anatomic examination showed pulmonary congestion, H&E staining showed wall thickening and lumen narrowing in the upstream pulmonary veins, and immunofluorescence showed an increase in the smooth muscle layers in the upstream pulmonary veins. In addition, at P30 in the PVS group, lung remodeling was evidenced by hyperemia, thickening of pulmonary small vessel walls and smooth muscle layers, and reduction of the number of alveoli. RV remodeling was evidenced by an increase in RV free wall thickness. CONCLUSIONS A neonatal rat model of PVS was successfully established, showing secondary lung and RV remodeling. This model may serve as a useful platform for understanding the mechanisms and treatments for PVS.
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Affiliation(s)
- Debao Li
- Department of Thoracic and Cardiovascular Surgery, School of Medicine, Shanghai Children's Medical Center, Shanghai Jiao Tong University, 1678 Dongfang Road, Shanghai, 200127, China
| | - Lisheng Qiu
- Department of Thoracic and Cardiovascular Surgery, School of Medicine, Shanghai Children's Medical Center, Shanghai Jiao Tong University, 1678 Dongfang Road, Shanghai, 200127, China
| | - Haifa Hong
- Department of Thoracic and Cardiovascular Surgery, School of Medicine, Shanghai Children's Hospital, Shanghai Jiao Tong University, Shanghai, China
| | - Hao Chen
- Department of Thoracic and Cardiovascular Surgery, School of Medicine, Shanghai Children's Medical Center, Shanghai Jiao Tong University, 1678 Dongfang Road, Shanghai, 200127, China
| | - Peibin Zhao
- Institute of Cardiovascular Development and Translational Medicine, Children's Heart Center, The Second Affiliated Hospital and Yuying Children's Hospital, Wenzhou Medical University, Wenzhou, 325027, China
| | - Yingying Xiao
- Department of Thoracic and Cardiovascular Surgery, School of Medicine, Shanghai Children's Hospital, Shanghai Jiao Tong University, Shanghai, China
| | - Hao Zhang
- Institute of Cardiovascular Development and Translational Medicine, Children's Heart Center, The Second Affiliated Hospital and Yuying Children's Hospital, Wenzhou Medical University, Wenzhou, 325027, China.
- Shanghai Institute for Pediatric Congenital Heart Disease, Shanghai Children's Medical Center, Shanghai Jiao Tong University School of Medicine, 1678 Dongfang Road, Shanghai, 200127, China.
| | - Qi Sun
- Department of Thoracic and Cardiovascular Surgery, School of Medicine, Shanghai Children's Medical Center, Shanghai Jiao Tong University, 1678 Dongfang Road, Shanghai, 200127, China.
| | - Lincai Ye
- Department of Thoracic and Cardiovascular Surgery, School of Medicine, Shanghai Children's Medical Center, Shanghai Jiao Tong University, 1678 Dongfang Road, Shanghai, 200127, China.
- Department of Thoracic and Cardiovascular Surgery, School of Medicine, Shanghai Children's Hospital, Shanghai Jiao Tong University, Shanghai, China.
- Shanghai Institute for Pediatric Congenital Heart Disease, Shanghai Children's Medical Center, Shanghai Jiao Tong University School of Medicine, 1678 Dongfang Road, Shanghai, 200127, China.
- Institute of Pediatric Translational Medicine, School of Medicine, Shanghai Children's Medical Center, Shanghai Jiao Tong University, Shanghai, China.
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13
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Liu J, Duan X, Yin J, Yang H, He R, Zhao S. Effective long-term sirolimus treatment in hypoxemia mainly due to intrapulmonary right-to-left shunt in a patient with multiple vascular anomalies. Orphanet J Rare Dis 2023; 18:124. [PMID: 37226169 DOI: 10.1186/s13023-023-02732-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2022] [Accepted: 05/14/2023] [Indexed: 05/26/2023] Open
Abstract
Pulmonary arteriovenous malformations (PAVMs), particularly where feeding artery/arteries to PAVMs ≥ 3 mm can be treated with embolization. The treatment for hypoxemia resulting from multiple small or diffuse PAVMs remains unclear.We report a girl aged 5 years and 10 months presented with cyanosis and decreased activity after exercise (83-85% of pulse oxygen saturation, SpO2). She had 1 skin lesion on her face and 1 suspected hemangioma on her left upper extremity at birth and that gradually disappeared spontaneously. Physical examination revealed clubbed fingers, and abundant vascular networks on her back. Contrast-enhanced lung CT (slice thickness:1.25 mm) with vascular three-dimensional reconstruction and abdominal CT revealed increased bronchovascular bundles, increased diameter of the pulmonary artery and ascending aorta, and intrahepatic portosystemic venous shunts due to patent ductus venosus. Echocardiography revealed increased diameter of aortic and pulmonary artery. Transthoracic contrast echocardiography was highly positive (bubble appearing in the left ventricle after 5 cardiac cycles). Abdominal doppler ultrasound revealed hepatic-portal venous shunt. Magnetic resonance imaging, artery and vein of the brain revealed multiple malformations of venous sinuses. The patient received sirolimus for 2 years and 4 months. Her condition improved significantly. SpO2 gradually increased to 98%. Her finger clubbing gradually normalized.Our report implicates sirolimus might be a potential treatment option in persistent hypoxemia mainly due to intrapulmonary right-to-left shunt even small multiple or diffusive PAVMs in pediatric patients with multiple cutaneous and visceral vascular anomalies.
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Affiliation(s)
- Jinrong Liu
- Department of Respiratory Medicine, National Clinical Research Center of Respiratory Disease, Beijing Children's Hospital, National Center for Children's Health, Capital Medical University, Beijing, China
| | - Xiaomin Duan
- Imaging Center, Beijing Children's Hospital, National Center for Children's Health, Capital Medical University, Beijing, China
| | - Jie Yin
- Imaging Center, Beijing Children's Hospital, National Center for Children's Health, Capital Medical University, Beijing, China
| | - Haiming Yang
- Department of Respiratory Medicine, National Clinical Research Center of Respiratory Disease, Beijing Children's Hospital, National Center for Children's Health, Capital Medical University, Beijing, China
| | - Ruxuan He
- Department of Respiratory Medicine, National Clinical Research Center of Respiratory Disease, Beijing Children's Hospital, National Center for Children's Health, Capital Medical University, Beijing, China
| | - Shunying Zhao
- Department of Respiratory Medicine, National Clinical Research Center of Respiratory Disease, Beijing Children's Hospital, National Center for Children's Health, Capital Medical University, Beijing, China.
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14
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Predictors of Serious Adverse Events and High-Level Cardiorespiratory Support in Patients Undergoing Transcatheter Pulmonary Vein Interventions. Pediatr Cardiol 2023; 44:806-815. [PMID: 36869157 DOI: 10.1007/s00246-023-03129-6] [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: 01/12/2023] [Accepted: 02/10/2023] [Indexed: 03/05/2023]
Abstract
Patients with pulmonary vein stenosis (PVS) often require frequent transcatheter pulmonary vein (PV) interventions for management of restenosis. Predictors of serious adverse events (AEs) and need for high-level cardiorespiratory support (mechanical ventilation, vasoactive support, and/or extracorporeal membrane oxygenation) 48 h after transcatheter PV interventions have not been reported. This is a single-center retrospective cohort analysis of patients with PVS who underwent transcatheter PV interventions from 3/1/2014 to 12/31/2021. Univariate and multivariable analyses were performed using generalized estimating equations to account for within-patient correlation. 240 patients underwent 841 catheterizations involving PV interventions (median 2 catheterizations per patient [1,3]). At least one serious AE was reported in 100 (12%) cases, the most common of which were pulmonary hemorrhage (n = 20) and arrhythmia (n = 17). There were 14 severe/catastrophic AEs (1.7% of cases) including three strokes and one patient death. On multivariable analysis, age less than 6 months, low systemic arterial saturation (< 95% in patients with biventricular [BiV] physiology, < 78% in single ventricle [SV] physiology), and severely elevated mean PA pressure (≥ 45 mmHg in BiV, ≥ 17 mmHg in SV) were associated with SAEs. Age less than 1 year, hospitalization prior to catheterization, and moderate-severe RV dysfunction were associated with high-level support after catheterization. Serious AEs during transcatheter PV interventions in patients with PVS are common, although major events such as stroke or death are uncommon. Younger patients and those with abnormal hemodynamics are more likely to experience serious AEs and require high-level cardiorespiratory support after catheterization.
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15
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Combination Chemotherapy in Severe Pulmonary Vein Stenosis-A Case Series. CHILDREN (BASEL, SWITZERLAND) 2023; 10:children10020364. [PMID: 36832493 PMCID: PMC9954861 DOI: 10.3390/children10020364] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 12/17/2022] [Revised: 01/20/2023] [Accepted: 02/09/2023] [Indexed: 02/15/2023]
Abstract
Pulmonary vein stenosis results from a proliferative process that leads to the progressive obstruction of venous return to the left atrium. It is often resistant to catheterization and surgical based interventions and is frequently fatal when encountered in its severe form. Here, we describe three patients with severe, primary pulmonary vein stenosis that was progressing despite aggressive conventional management strategies. All three patients were initiated on combination chemotherapy with imatinib and sirolimus, drugs which have been previously shown to independently have potential benefit against PVS. Soon after the initiation of these therapies, all three patients experienced a stabilization of their disease process and clinical improvement. All three patients remain alive, with tolerable side effects from the medications. Although early in our experience and with only a small number of patients, combination chemotherapy with imatinib and sirolimus shows promise and merits further investigation as a therapeutic option for this aggressive disease.
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16
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Management of Complex Pulmonary Vein Stenosis at Altitude Combining Comprehensive Percutaneous Interventional Treatment with Sirolimus, Pulmonary Hypertension Medications and Intraluminal Imaging with Optical Coherence Tomography. Pediatr Cardiol 2023; 44:1125-1134. [PMID: 36723625 DOI: 10.1007/s00246-023-03102-3] [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: 11/24/2022] [Accepted: 01/10/2023] [Indexed: 02/02/2023]
Abstract
BACKGROUND Pulmonary vein stenosis (PVS) is a growing problem for the pediatric congenital heart population. Sirolimus has previously been shown to improve survival and slow down the progression of in-stent stenosis in patients with PVS. We evaluated patients before and after initiation of sirolimus to evaluate its effects on re-intervention and vessel patency utilizing Optical Coherence Tomography (OCT). METHODS We performed a retrospective study, reviewing the charts of patients with PVS, who had been prescribed sirolimus between October 2020 and December 2021. OCT was performed in the pulmonary vein of interest as per our published protocol. Angiographic and OCT imaging was retrospectively reviewed. Statistical analysis was performed using Chi square and Wilcoxon signed-rank test to compare pre-and post-sirolimus data. RESULTS Ten patients had been started and followed on sirolimus. Median age at sirolimus initiation was 25 months with median weight of 10.6 kg and average follow-up of 1 year. Median total catheterizations were 7 for patients prior to starting sirolimus and 2 after starting treatment (p = 0.014). Comparing pre- and post-sirolimus, patients were catheterized every 3 months vs every 11 months (p = 0.011), median procedure time was 203 min vs 145 min (p = 0.036) and fluoroscopy time, 80 min vs 57.2 min (p = 0.036). 23 veins had severe in-stent tissue ingrowth prior to SST (luminal diameter < 30% of stent diameter). Post-sirolimus, 23 pulmonary veins had moderate to severe in-stent tissue ingrowth that responded to non-compliant balloon inflation only with stent luminal improvement of > 75%. CONCLUSION Our study suggests that the addition of sirolimus in patients with moderate-severe PVS helps to decrease disease progression with decrease frequency of interventions. Reaching therapeutic levels for sirolimus is critical and medication interactions and side-effects need careful consideration. OCT continues to be important for evaluation and treatment guidance in this patient population.
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17
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Almakadma AH, Sarma D, Hassett L, Miranda W, Alkhouli M, Reeder GS, Munger TM, Packer DL, Simard T, Holmes DR. Pulmonary Vein Stenosis-Balloon Angioplasty Versus Stenting: A Systematic Review and Meta-Analysis. JACC Clin Electrophysiol 2022; 8:1323-1333. [PMID: 36117046 DOI: 10.1016/j.jacep.2022.08.008] [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: 04/22/2022] [Revised: 08/05/2022] [Accepted: 08/10/2022] [Indexed: 10/14/2022]
Abstract
Pulmonary vein stenosis (PVS) may arise from a variety of conditions and result in major morbidity and mortality. In some patients, pharmacologic therapy may help, but more often in advanced stages, mechanical treatment must be considered. Transcatheter approaches, both balloon angioplasty (BA) and stent implantation, have been applied. Although both are effective, they continue to be limited by restenosis. In this systematic review and meta-analysis, Ovid MEDLINE, Ovid Embase, Ovid Cochrane Central Register of Controlled Trials, Ovid Cochrane Database of Systematic Reviews, and Scopus were searched for English-language studies in humans published between January 1, 2010, and August 2, 2021. Two independent reviewers screened for studies in which BA or stenting was performed for PVS with reporting of restenosis outcomes, and data were independently extracted. A systematic review was performed, and overall restenosis rates were reported across all 34 included studies. Meta-analysis was then performed using RevMan version 5.4, assessing rates of restenosis and restenosis requiring reintervention. For restenosis rates, 4 studies treated in those studies with available data reported. For restenosis rates, 4 studies treated a total of 340 patients with 579 pulmonary vein interventions (225 with BA and 354 with stenting, mean follow-up 13-69 months). Restenosis requiring repeat intervention was reported in 3 studies, including 301 patients with 495 pulmonary vein interventions (157 with BA and 338 with stenting). Compared with BA, stenting was associated with both a lower risk for restenosis (risk ratio: 0.36; 95% CI: 0.18-0.73; P = 0.005) and a lower risk for restenosis requiring reintervention (RR: 0.36; 95% CI: 0.15-0.86; P = 0.02). For PVS intervention, restenosis and reintervention rates may be improved by stent implantation compared with BA.
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Affiliation(s)
- Abdul Hakim Almakadma
- Department of Cardiovascular Medicine, Mayo Clinic School of Medicine, Rochester, Minnesota, USA
| | - Dhruv Sarma
- Department of Internal Medicine, Mayo Clinic School of Medicine, Rochester, Minnesota, USA
| | - Leslie Hassett
- Mayo Clinic Libraries, Mayo Clinic, Rochester, Minnesota, USA
| | - William Miranda
- Department of Cardiovascular Medicine, Mayo Clinic School of Medicine, Rochester, Minnesota, USA
| | - Mohamad Alkhouli
- Department of Cardiovascular Medicine, Mayo Clinic School of Medicine, Rochester, Minnesota, USA
| | - Guy S Reeder
- Department of Cardiovascular Medicine, Mayo Clinic School of Medicine, Rochester, Minnesota, USA
| | - Thomas M Munger
- Department of Cardiovascular Medicine, Mayo Clinic School of Medicine, Rochester, Minnesota, USA
| | - Douglas L Packer
- Department of Cardiovascular Medicine, Mayo Clinic School of Medicine, Rochester, Minnesota, USA
| | - Trevor Simard
- Department of Cardiovascular Medicine, Mayo Clinic School of Medicine, Rochester, Minnesota, USA
| | - David R Holmes
- Department of Cardiovascular Medicine, Mayo Clinic School of Medicine, Rochester, Minnesota, USA.
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18
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Zhang H, Shi G, Chen H. Risk factors for postoperative pulmonary venous obstruction after surgical repair of total anomalous pulmonary venous connection: a systemic review and meta-analysis. Interact Cardiovasc Thorac Surg 2022; 35:6609775. [PMID: 35713512 PMCID: PMC9270848 DOI: 10.1093/icvts/ivac162] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2022] [Revised: 05/21/2022] [Accepted: 06/15/2022] [Indexed: 11/16/2022] Open
Affiliation(s)
- Han Zhang
- Department of Cardiothoracic Surgery, Congenital Heart Center, Shanghai Children’s Medical Center, Shanghai Jiao Tong University School of Medicine , Shanghai, China
| | - Guocheng Shi
- Department of Cardiothoracic Surgery, Congenital Heart Center, Shanghai Children’s Medical Center, Shanghai Jiao Tong University School of Medicine , Shanghai, China
| | - Huiwen Chen
- Department of Cardiothoracic Surgery, Congenital Heart Center, Shanghai Children’s Medical Center, Shanghai Jiao Tong University School of Medicine , Shanghai, China
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19
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Dimas VV. Pulmonary Vein Atresia: Is There Hope for a Good Outcome? Circ Cardiovasc Interv 2022; 15:e012172. [PMID: 35727879 DOI: 10.1161/circinterventions.122.012172] [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: 11/16/2022]
Affiliation(s)
- V Vivian Dimas
- Department of Pediatrics, Section of Cardiology, Medical City Children's Hospital, Dallas, TX
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20
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Patel JD, Mandhani M, Gray R, Pettus J, McCracken CE, Thomas A, Bauser-Heaton H, Kim DW, Petit CJ. Transcatheter Recanalization of Atretic Pulmonary Veins in Infants and Children. Circ Cardiovasc Interv 2022; 15:e011351. [PMID: 35727880 DOI: 10.1161/circinterventions.121.011351] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Pulmonary vein stenosis is a progressive disease associated with a high rate of mortality in children. If left untreated, myofibroblastic proliferation can lead to pulmonary vein atresia (PVA). In our experience, transcatheter recanalization has emerged as a favorable interventional option. We sought to determine the acute success rate of recanalization of atretic pulmonary veins and mid-term outcomes of individual veins after recanalization. METHODS We reviewed all patients with PVA at our institution between 2008 and 2020 diagnosed by either catheterization or cardiac computed tomography. All veins with successful recanalization were reviewed and procedural success rate and patency rate were noted. Competing risk analysis was performed to demonstrate outcomes of individual atretic veins longitudinally. RESULTS Between 2008 and 2020, our institution diagnosed and treated 131 patients with pulmonary vein stenosis. Of these, 61 patients developed atresia of at least one pulmonary vein. In total, there were 97 atretic pulmonary veins within this group. Successful recanalization was accomplished in 47/97 (48.5%) atretic veins. No atretic pulmonary veins were successfully recanalized before 2012. The majority of veins were recanalized between 2017 and 2020-39/56 (70%). The most common intervention after recanalization was drug-eluting stent placement. At 2-year follow-up 42.6% of recanalized veins (20.6% of all atretic veins) remained patent with a median of 4 reinterventions per person. CONCLUSIONS Transcatheter recanalization of PVA can result in successful reestablishment of flow to affected pulmonary veins in many cases. Drug-eluting stent implantation was the most common intervention performed immediately post-recanalization. Vein patency was maintained in 42.6% of patients at 2-year follow-up from recanalization with appropriate surveillance and reintervention. Overall, only a small portion of atretic pulmonary veins underwent successful recanalization with maintained vessel patency at follow-up. Irrespective of successful recanalization, there was no detectable survival difference between the more recently treated PVA cohort and non-PVA cohort.
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Affiliation(s)
- Jay D Patel
- Division of Cardiology, Department of Pediatrics, Emory University, Children's Healthcare of Atlanta, GA (J.D.P., M.M., R.G., J.P., C.E.M., A.T., H.B.-H., D.W.K., C.J.P.)
| | - Mansi Mandhani
- Division of Cardiology, Department of Pediatrics, Emory University, Children's Healthcare of Atlanta, GA (J.D.P., M.M., R.G., J.P., C.E.M., A.T., H.B.-H., D.W.K., C.J.P.)
| | - Rosemary Gray
- Division of Cardiology, Department of Pediatrics, Emory University, Children's Healthcare of Atlanta, GA (J.D.P., M.M., R.G., J.P., C.E.M., A.T., H.B.-H., D.W.K., C.J.P.)
| | - Joelle Pettus
- Division of Cardiology, Department of Pediatrics, Emory University, Children's Healthcare of Atlanta, GA (J.D.P., M.M., R.G., J.P., C.E.M., A.T., H.B.-H., D.W.K., C.J.P.)
| | - Courtney E McCracken
- Division of Cardiology, Department of Pediatrics, Emory University, Children's Healthcare of Atlanta, GA (J.D.P., M.M., R.G., J.P., C.E.M., A.T., H.B.-H., D.W.K., C.J.P.)
| | - Amanda Thomas
- Division of Cardiology, Department of Pediatrics, Emory University, Children's Healthcare of Atlanta, GA (J.D.P., M.M., R.G., J.P., C.E.M., A.T., H.B.-H., D.W.K., C.J.P.)
| | - Holly Bauser-Heaton
- Division of Cardiology, Department of Pediatrics, Emory University, Children's Healthcare of Atlanta, GA (J.D.P., M.M., R.G., J.P., C.E.M., A.T., H.B.-H., D.W.K., C.J.P.)
| | - Dennis W Kim
- Division of Cardiology, Department of Pediatrics, Emory University, Children's Healthcare of Atlanta, GA (J.D.P., M.M., R.G., J.P., C.E.M., A.T., H.B.-H., D.W.K., C.J.P.)
| | - Christopher J Petit
- Division of Cardiology, Department of Pediatrics, Emory University, Children's Healthcare of Atlanta, GA (J.D.P., M.M., R.G., J.P., C.E.M., A.T., H.B.-H., D.W.K., C.J.P.)
- Division of Cardiology, Department of Pediatrics, Columbia University Vagelos College of Physicians and Surgeons, NewYork-Presbyterian Morgan Stanley Children's Hospital (C.J.P.)
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21
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Jenkins KJ, Fineman JR. Progress in Pulmonary Vein Stenosis: Lessons from Success in Treating Pulmonary Arterial Hypertension. CHILDREN 2022; 9:children9060799. [PMID: 35740736 PMCID: PMC9222029 DOI: 10.3390/children9060799] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 04/27/2022] [Revised: 05/26/2022] [Accepted: 05/27/2022] [Indexed: 11/30/2022]
Abstract
Pulmonary vein stenosis (PVS) is a rare and poorly understood condition that can be classified as primary, acquired, status-post surgical repair of PVS, and/or associated with developmental lung disease. Immunohistochemical studies demonstrate that obstruction of the large (extrapulmonary) pulmonary veins is associated with the neointimal proliferation of myofibroblasts. This rare disorder is likely multifactorial with a spectrum of pathobiology. Treatments have been historically surgical, with an increasing repetitive interventional approach. Understanding the biology of these disorders is in its infancy; thus, medical management has lagged behind. Throughout medical history, an increased understanding of the underlying biology of a disorder has led to significant improvements in care and outcomes. One example is the treatment of pulmonary arterial hypertension (PAH). PAH shares several common themes with PVS. These include the spectrum of disease and biological alterations, such as vascular remodeling and vasoconstriction. Over the past two decades, an exponential increase in the understanding of the pathobiology of PAH has led to a dramatic increase in medical therapies that have changed the landscape of the disease. We believe that a similar approach to PVS can generate novel medical therapeutic targets that will markedly improve the outcome of these vulnerable patients.
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Affiliation(s)
- Kathy J. Jenkins
- Department of Cardiology, Boston Children’s Hospital, Boston, MA 02115, USA;
| | - Jeffrey R. Fineman
- Department of Pediatrics, University of California, San Francisco, CA 94143, USA
- Correspondence:
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22
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Prematurity and Pulmonary Vein Stenosis: The Role of Parenchymal Lung Disease and Pulmonary Vascular Disease. CHILDREN 2022; 9:children9050713. [PMID: 35626890 PMCID: PMC9139735 DOI: 10.3390/children9050713] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/01/2022] [Revised: 04/29/2022] [Accepted: 05/10/2022] [Indexed: 11/25/2022]
Abstract
Pulmonary vein stenosis (PVS) has emerged as a critical problem in premature infants with persistent respiratory diseases, particularly bronchopulmonary dysplasia (BPD). As a parenchymal lung disease, BPD also influences vascular development with associated pulmonary hypertension recognized as an important comorbidity of both BPD and PVS. PVS is commonly detected later in infancy, suggesting additional postnatal factors that contribute to disease development, progression, and severity. The same processes that result in BPD, some of which are inflammatory-mediated, may also contribute to the postnatal development of PVS. Although both PVS and BPD are recognized as diseases of inflammation, the link between them is less well-described. In this review, we explore the relationship between parenchymal lung diseases, BPD, and PVS, with a specific focus on the epidemiology, clinical presentation, risk factors, and plausible biological mechanisms in premature infants. We offer an algorithm for early detection and prevention and provide suggestions for research priorities.
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23
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Yung D, Freeman K, Mirzaa G. Pulmonary Vein Stenosis Associated with Germline PIK3CA Mutation. CHILDREN 2022; 9:children9050671. [PMID: 35626846 PMCID: PMC9139298 DOI: 10.3390/children9050671] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/16/2022] [Revised: 04/07/2022] [Accepted: 05/02/2022] [Indexed: 11/25/2022]
Abstract
Pulmonary vein stenosis is a rare and frequently lethal childhood disease. There are few known genetic associations, and the pathophysiology is not well known. Current treatments include surgery, interventional cardiac catheterization, and more recently, medications targeting cell proliferation, which are not uniformly effective. We present a patient with PVS and a PIK3CA mutation, who demonstrated a good response to the targeted inhibitor, alpelisib.
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Affiliation(s)
- Delphine Yung
- Department of Pediatrics, Division of Cardiology, University of Washington School of Medicine, Seattle, WA 98195, USA;
- Center for Integrative Brain Research, Seattle Children’s Research Institute, Seattle, WA 98105, USA;
- Correspondence:
| | - Kaitlyn Freeman
- Department of Pediatrics, Division of Cardiology, University of Washington School of Medicine, Seattle, WA 98195, USA;
| | - Ghayda Mirzaa
- Center for Integrative Brain Research, Seattle Children’s Research Institute, Seattle, WA 98105, USA;
- Department of Pediatrics, University of Washington School of Medicine, Seattle, WA 98195, USA
- Brotman Baty Institute for Precision Medicine, Seattle, WA 98195, USA
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24
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Niccum M, Callahan R, Gauvreau K, Jenkins KJ. Aspiration Is Associated with Poor Treatment Response in Pediatric Pulmonary Vein Stenosis. CHILDREN (BASEL, SWITZERLAND) 2021; 8:783. [PMID: 34572215 PMCID: PMC8471903 DOI: 10.3390/children8090783] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/16/2021] [Revised: 08/31/2021] [Accepted: 08/31/2021] [Indexed: 12/02/2022]
Abstract
Intraluminal pulmonary vein stenosis is a disease with significant morbidity and mortality, though recent progress has been made using multimodal therapy with antiproliferative agents. The aim of this study was to evaluate the association between aspiration and poor treatment response in patients with intraluminal pulmonary vein stenosis. A retrospective, single-center cohort analysis was performed of patients treated with a combination of imatinib mesylate and multimodal anatomic relief between March 2009 and November 2019. Analysis focused on 2-ventricle patients due to small numbers and clinical heterogeneity of single ventricle patients. Among the 84 patients included, 15 had single ventricle physiology and 69 had 2-ventricle physiology. Among the 2-ventricle group, multivariable analysis revealed that patients with clinical aspiration had nearly five times higher odds of poor treatment response than patients without aspiration (OR 4.85, 95% CI [1.37, 17.2], p = 0.014). Furthermore, male patients had higher odds of poor treatment response than their female counterparts (OR 3.67, 95% CI [1.04, 12.9], p = 0.043). Aspiration is a novel, potentially modifiable risk factor for poor treatment response in pediatric multi-vessel intraluminal pulmonary vein stenosis in patients with 2-ventricle physiology.
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Affiliation(s)
- Maria Niccum
- Department of Pediatrics, Boston Children’s Hospital and Harvard Medical School, 300 Longwood Avenue, Boston, MA 02115, USA;
| | - Ryan Callahan
- Department of Cardiology, Boston Children’s Hospital and Harvard Medical School, 300 Longwood Avenue, Boston, MA 02115, USA; (R.C.); (K.G.)
| | - Kimberlee Gauvreau
- Department of Cardiology, Boston Children’s Hospital and Harvard Medical School, 300 Longwood Avenue, Boston, MA 02115, USA; (R.C.); (K.G.)
| | - Kathy J. Jenkins
- Department of Cardiology, Boston Children’s Hospital and Harvard Medical School, 300 Longwood Avenue, Boston, MA 02115, USA; (R.C.); (K.G.)
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25
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The Role of Elevated Wall Shear Stress in Progression of Pulmonary Vein Stenosis: Evidence from Two Case Studies. CHILDREN-BASEL 2021; 8:children8090729. [PMID: 34572161 PMCID: PMC8470228 DOI: 10.3390/children8090729] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/30/2021] [Revised: 08/21/2021] [Accepted: 08/24/2021] [Indexed: 12/03/2022]
Abstract
Pulmonary vein stenosis is a serious condition characterized by restriction or blockage due to fibrotic tissue ingrowth that develops in the pulmonary veins of infants or children. It is often progressive and can lead to severe pulmonary hypertension and death. Efforts to halt or reverse disease progression include surgery and catheter-based balloon dilation and stent implantation. Its cause and mechanism of progression are unknown. In this pilot study, we propose and explore the hypothesis that elevated wall shear stress at discrete pulmonary venous sites triggers stenosis. To assess this theory, we retrospectively analyzed cardiac catheterization, lung scan, and X-ray computed tomography data to estimate wall shear stress in the pulmonary veins at multiple time points during disease progression in two patients. Results are consistent with the existence of a level of elevated wall shear stress above which the disease is progressive and below which progression is halted. The analysis also suggests the possibility of predicting the target lumen size necessary in a given vein to reduce wall shear stress to normal levels and remove the trigger for stenosis progression.
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26
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Kuo JA, Petit CJ. Pulmonary Vein Stenosis in Children: A Programmatic Approach Employing Primary and Anatomic Therapy. CHILDREN 2021; 8:children8080663. [PMID: 34438554 PMCID: PMC8392344 DOI: 10.3390/children8080663] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/07/2021] [Revised: 07/16/2021] [Accepted: 07/26/2021] [Indexed: 11/16/2022]
Abstract
Pulmonary vein stenosis (PVS) is a difficult condition to treat due to recurrence and progression. In 2017, we developed a comprehensive PVS Program at our center to address the multidisciplinary needs of these patients. We discuss the components of our program and our approach to these patients, using a combination of primary (medical) therapy in addition to anatomic therapy to preserve vessel patency. A multidisciplinary approach to treating these challenging patients is critical.
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Affiliation(s)
- James A. Kuo
- Division of Pediatric Cardiology, Children’s Healthcare of Atlanta, Emory University, Atlanta, GA 30322, USA;
| | - Christopher J. Petit
- Division of Cardiology, Department of Pediatrics, Columbia University Vagelos College of Physicians and Surgeons, Morgan Stanley Children’s Hospital of New York, BN-263a, Pediatric Cardiology, 3859 Broadway, New York, NY 10032, USA
- Correspondence:
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Prieto LR. In Search of the Holy Grail for Pediatric Pulmonary Vein Stenosis. J Am Coll Cardiol 2021; 77:2819-2821. [PMID: 34082912 DOI: 10.1016/j.jacc.2021.04.029] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/13/2021] [Accepted: 04/15/2021] [Indexed: 11/19/2022]
Affiliation(s)
- Lourdes R Prieto
- Heart Institute, Nicklaus Children's Hospital, Miami, Florida, USA.
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McLennan DI, Solano ECR, Handler SS, Lincoln J, Mitchell ME, Kirkpatrick EC. Pulmonary Vein Stenosis: Moving From Past Pessimism to Future Optimism. Front Pediatr 2021; 9:747812. [PMID: 34676188 PMCID: PMC8524035 DOI: 10.3389/fped.2021.747812] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/26/2021] [Accepted: 09/13/2021] [Indexed: 01/07/2023] Open
Abstract
Pulmonary Vein Stenosis (PVS) is a rare disease with a prevalence of around 1. 7 cases per 100,000 children under 2 years old. Treatment options for this disease have not provided great results and pathophysiology of this condition is still poorly understood. Here, we will review the history of PVS including diagnostic tools and treatments, the current management approach, and what the future holds for this devastating disease.
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Affiliation(s)
- Daniel I McLennan
- Section of Pediatric Cardiology, Department of Pediatrics, Medical College of Wisconsin, Milwaukee, WI, United States.,Herma Heart Institute, Children's Wisconsin, Milwaukee, WI, United States
| | - Elyan C Ruiz Solano
- Herma Heart Institute, Children's Wisconsin, Milwaukee, WI, United States.,Section of Cardiothoracic Surgery, Department of Surgery, Medical College of Wisconsin, Milwaukee, WI, United States
| | - Stephanie S Handler
- Section of Pediatric Cardiology, Department of Pediatrics, Medical College of Wisconsin, Milwaukee, WI, United States.,Herma Heart Institute, Children's Wisconsin, Milwaukee, WI, United States
| | - Joy Lincoln
- Section of Pediatric Cardiology, Department of Pediatrics, Medical College of Wisconsin, Milwaukee, WI, United States.,Herma Heart Institute, Children's Wisconsin, Milwaukee, WI, United States
| | - Michael E Mitchell
- Herma Heart Institute, Children's Wisconsin, Milwaukee, WI, United States.,Section of Cardiothoracic Surgery, Department of Surgery, Medical College of Wisconsin, Milwaukee, WI, United States
| | - Edward C Kirkpatrick
- Section of Pediatric Cardiology, Department of Pediatrics, Medical College of Wisconsin, Milwaukee, WI, United States.,Herma Heart Institute, Children's Wisconsin, Milwaukee, WI, United States
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