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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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Fujita KT, DiLorenzo MP, Krishnan US, Turner ME, Barry OM, Torres AJ, Bacha EA, Kalfa D, Crystal MA. Outcomes and Risk Factors of Interventions for Pediatric Post-operative Pulmonary Vein Stenosis. Pediatr Cardiol 2023; 44:1778-1787. [PMID: 37422845 DOI: 10.1007/s00246-023-03214-w] [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: 01/31/2023] [Accepted: 06/14/2023] [Indexed: 07/11/2023]
Abstract
Pulmonary vein stenosis (PVS) in children is a challenging condition with poor outcomes. Post-operative stenosis can occur after repair of anomalous pulmonary venous return (APVR) or stenosis within native veins. There is limited data on the outcomes of post-operative PVS. Our objective was to review our experience and assess surgical and transcatheter outcomes. Single-center retrospective study was performed including patients < 18 years who developed restenosis after baseline pulmonary vein surgery that required additional intervention(s) from 1/2005 to 1/2020. Non-invasive imaging, catheterization and surgical data were reviewed. We identified 46 patients with post-operative PVS with 11 (23.9%) patient deaths. Median age at index procedure was 7.2 months (range 1 month-10 years), and median follow-up was 10.8 months (range 1 day-13 years). Index procedure was surgical in 36 (78.3%) and transcatheter in 10 (21.7%). Twenty-three (50%) patients developed vein atresia. Mortality was not associated with number of affected veins, vein atresia, or procedure type. Single ventricle physiology, complex congenital heart disease (CCHD), and genetic disorders were associated with mortality. Survival rate was higher in APVR patients (p = 0.03). Patients with three or more interventions had a higher survival rate compared to patients with 1-2 interventions (p = 0.02). Male gender, necrotizing enterocolitis, and diffuse hypoplasia were associated with vein atresia. In post-operative PVS, mortality is associated with CCHD, single ventricle physiology, and genetic disorders. Vein atresia is associated with male gender, necrotizing enterocolitis, and diffuse hypoplasia. Multiple repeated interventions may offer a patient survival benefit; however, larger prospective studies are necessary to elucidate this relationship further.
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Affiliation(s)
- Kristin T Fujita
- Division of Pediatric Cardiology, Department of Pediatrics, Columbia University Vagelos College of Physicians and Surgeons and New York-Presbyterian, New York, NY, USA.
| | - Michael P DiLorenzo
- Division of Pediatric Cardiology, Department of Pediatrics, Columbia University Vagelos College of Physicians and Surgeons and New York-Presbyterian, New York, NY, USA
| | - Usha S Krishnan
- Division of Pediatric Cardiology, Department of Pediatrics, Columbia University Vagelos College of Physicians and Surgeons and New York-Presbyterian, New York, NY, USA
| | - Mariel E Turner
- Division of Pediatric Cardiology, Department of Pediatrics, Columbia University Vagelos College of Physicians and Surgeons and New York-Presbyterian, New York, NY, USA
| | - Oliver M Barry
- Division of Pediatric Cardiology, Department of Pediatrics, Columbia University Vagelos College of Physicians and Surgeons and New York-Presbyterian, New York, NY, USA
| | - Alejandro J Torres
- Division of Pediatric Cardiology, Department of Pediatrics, Columbia University Vagelos College of Physicians and Surgeons and New York-Presbyterian, New York, NY, USA
| | - Emile A Bacha
- Division of Pediatric Cardiovascular Surgery, Department of Surgery, Columbia University Vagelos College of Physicians and Surgeons and New York-Presbyterian, New York, NY, USA
| | - David Kalfa
- Division of Pediatric Cardiovascular Surgery, Department of Surgery, Columbia University Vagelos College of Physicians and Surgeons and New York-Presbyterian, New York, NY, USA
| | - Matthew A Crystal
- Division of Pediatric Cardiology, Department of Pediatrics, Columbia University Vagelos College of Physicians and Surgeons and New York-Presbyterian, New York, NY, USA
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Fox MT, Meyer-Macaulay C, Roberts H, Lipsitz S, Siegel BD, Mastropietro C, Graham RJ, Moynihan KM. Tracheostomy Timing During Pediatric Cardiac Intensive Care: Single Referral Center Retrospective Cohort. Pediatr Crit Care Med 2023; 24:e556-e567. [PMID: 37607094 DOI: 10.1097/pcc.0000000000003345] [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: 08/24/2023]
Abstract
OBJECTIVES To describe associations between the timing of tracheostomy and patient characteristics or outcomes in the cardiac ICU (CICU). DESIGN Single-institution retrospective cohort study. SETTING Freestanding academic children's hospital. PATIENTS CICU patients with tracheostomy placed between July 1, 2011, and July 1, 2020. INTERVENTIONS We compared patient characteristics and outcomes between early and late tracheostomy based on the duration of positive pressure ventilation (PPV) before tracheostomy placement, fitting a receiver operating characteristic curve for current survival to define a cutoff. MEASUREMENTS AND MAIN RESULTS Sixty-one patients underwent tracheostomy placement (0.5% of CICU admissions). Median age was 7.8 months. Eighteen patients (30%) had single ventricle physiology and 13 patients (21%) had pulmonary vein stenosis (PVS). Primary indications for tracheostomy were pulmonary/lower airway (41%), upper airway obstruction (UAO) (31%), cardiac (15%), neuromuscular (4%), or neurologic (4%). In-hospital mortality was 26% with 41% survival at the current follow-up (median 7.8 [interquartile range, IQR 2.6-30.0] mo). Late tracheostomy was defined as greater than or equal to 7 weeks of PPV which was equivalent to the median PPV duration pre-tracheostomy. Patients with late tracheostomy were more likely to be younger, have single ventricle physiology, and have greater respiratory severity. Patients with early tracheostomy were more likely to have UAO or genetic comorbidities. In multivariable analysis, late tracheostomy was associated with 4.2 times greater mortality (95% CI, 1.9-9.0). PVS was associated with higher mortality (adjusted hazard ratio [HR] 5.2; 95% CI, 2.5-10.9). UAO was associated with lower mortality (adjusted HR 0.2; 95% CI, 0.1-0.5). Late tracheostomy was also associated with greater cumulative opioid exposure. CONCLUSIONS CICU patients who underwent tracheostomy had high in-hospital and longer-term mortality rates. Tracheostomy timing decisions are influenced by indication, disease, genetic comorbidities, illness severity, and age. Earlier tracheostomy was associated with lower sedative use and improved adjusted survival. Tracheostomy placement is a complex decision demanding individualized consideration of risk-benefit profiles and thoughtful family counseling.
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Affiliation(s)
- Miriam T Fox
- Department of Pediatrics, Harvard Medical School, Boston, MA
- Department of Pediatrics, Boston Medical Center, Boston, MA
- Department of Cardiology, Boston Children's Hospital, Boston, MA
| | - Colin Meyer-Macaulay
- Division of Cardiac Critical Care, Department of Pediatrics, Nemours Children's Health, Delaware Valley, Wilmington, DE
- Department of Pediatrics, Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, PA
| | - Hanna Roberts
- Department of Cardiology, Boston Children's Hospital, Boston, MA
| | - Stuart Lipsitz
- Division of General Internal Medicine, Brigham and Women's Hospital, Boston, MA
| | - Bryan D Siegel
- Department of Pediatrics, Harvard Medical School, Boston, MA
- Department of Cardiology, Boston Children's Hospital, Boston, MA
| | - Chris Mastropietro
- Division of Critical Care, Department of Pediatrics, Indiana University School of Medicine, Riley Hospital for Children at Indiana University Health, Indianapolis, IN
| | - Robert J Graham
- Department of Pediatrics, Harvard Medical School, Boston, MA
- Department of Anesthesia and Critical Care, Boston Children's Hospital, Boston, MA
| | - Katie M Moynihan
- Department of Pediatrics, Harvard Medical School, Boston, MA
- Department of Cardiology, Boston Children's Hospital, Boston, MA
- Department of Pediatrics, Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, PA
- Faculty of Medicine and Health, Children's Hospital at Westmead Clinical School, The University of Sydney, Sydney, NSW, Australia
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Moore CM, D'Amore A, Fustolo-Gunnink S, Hudson C, Newton A, Santamaria BL, Deary A, Hodge R, Hopkins V, Mora A, Llewelyn C, Venkatesh V, Khan R, Willoughby K, Onland W, Fijnvandraat K, New HV, Clarke P, Lopriore E, Watts T, Stanworth S, Curley A. Two-year outcomes following a randomised platelet transfusion trial in preterm infants. Arch Dis Child Fetal Neonatal Ed 2023; 108:452-457. [PMID: 36810309 PMCID: PMC10447411 DOI: 10.1136/archdischild-2022-324915] [Citation(s) in RCA: 9] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/21/2022] [Accepted: 02/13/2023] [Indexed: 02/24/2023]
Abstract
OBJECTIVE Assess mortality and neurodevelopmental outcomes at 2 years of corrected age in children who participated in the PlaNeT-2/MATISSE (Platelets for Neonatal Transfusion - 2/Management of Thrombocytopenia in Special Subgroup) study, which reported that a higher platelet transfusion threshold was associated with significantly increased mortality or major bleeding compared to a lower one. DESIGN Randomised clinical trial, enrolling from June 2011 to August 2017. Follow-up was complete by January 2020. Caregivers were not blinded; however, outcome assessors were blinded to treatment group. SETTING 43 level II/III/IV neonatal intensive care units (NICUs) across UK, Netherlands and Ireland. PATIENTS 660 infants born at less than 34 weeks' gestation with platelet counts less than 50×109/L. INTERVENTIONS Infants were randomised to undergo a platelet transfusion at platelet count thresholds of 50×109/L (higher threshold group) or 25×109/L (lower threshold group). MAIN OUTCOMES MEASURES Our prespecified long-term follow-up outcome was a composite of death or neurodevelopmental impairment (developmental delay, cerebral palsy, seizure disorder, profound hearing or vision loss) at 2 years of corrected age. RESULTS Follow-up data were available for 601 of 653 (92%) eligible participants. Of the 296 infants assigned to the higher threshold group, 147 (50%) died or survived with neurodevelopmental impairment, as compared with 120 (39%) of 305 infants assigned to the lower threshold group (OR 1.54, 95% CI 1.09 to 2.17, p=0.017). CONCLUSIONS Infants randomised to a higher platelet transfusion threshold of 50×109/L compared with 25×109/L had a higher rate of death or significant neurodevelopmental impairment at a corrected age of 2 years. This further supports evidence of harm caused by high prophylactic platelet transfusion thresholds in preterm infants. TRIAL REGISTRATION NUMBER ISRCTN87736839.
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Affiliation(s)
- Carmel Maria Moore
- School of Medicine, University College Dublin, Dublin, Ireland
- Neonatology, National Maternity Hospital, Dublin, Ireland
| | - Angela D'Amore
- Neonatology, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | | | - Cara Hudson
- Clinical Trials Unit, NHS Blood and Transplant, Bristol, UK
| | - Alice Newton
- Clinical Trials Unit, NHS Blood and Transplant, Bristol, UK
| | | | - Alison Deary
- Clinical Trials Unit, NHS Blood and Transplant, Bristol, UK
| | - Renate Hodge
- Clinical Trials Unit, NHS Blood and Transplant, Bristol, UK
| | | | - Ana Mora
- Clinical Trials Unit, NHS Blood and Transplant, Bristol, UK
| | | | | | - Rizwan Khan
- NICU, University Maternity Hospital Limerick, Limerick, Ireland
| | - Karen Willoughby
- Neonatology, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - Wes Onland
- Neonatology, Amsterdam UMC Locatie AMC, Amsterdam, The Netherlands
| | - Karin Fijnvandraat
- Pediatrics, Emma Children's Hospital, Pediatric Hematology, University of Amsterdam, Amsterdam, The Netherlands
| | - Helen V New
- Paediatric Transfusion Medicine, NHS Blood and Transplant, London, UK
| | - Paul Clarke
- Neonatal Intensive Care Unit, Norfolk and Norwich University Hospitals NHS Foundation Trust, Norwich, UK
- Norwich Medical School, University of East Anglia, Norwich, UK
| | - Enrico Lopriore
- Neonatology, Leiden Universitair Medisch Centrum, Leiden, The Netherlands
| | - Timothy Watts
- Neonatal Intensive Care Unit, Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - Simon Stanworth
- National Health Service Blood and Transplant, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Anna Curley
- School of Medicine, University College Dublin, Dublin, Ireland
- Neonatology, National Maternity Hospital, Dublin, Ireland
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5
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O'Callaghan B, Zablah JE, Weinman JP, Englund EK, Morgan GJ, Ivy DD, Frank BS, Mong DA, Malone LJ, Browne LP. Computed tomographic parenchymal lung findings in premature infants with pulmonary vein stenosis. Pediatr Radiol 2023; 53:1874-1884. [PMID: 37106091 DOI: 10.1007/s00247-023-05673-y] [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: 10/13/2022] [Revised: 04/10/2023] [Accepted: 04/11/2023] [Indexed: 04/29/2023]
Abstract
BACKGROUND Developmental pulmonary vein pulmonary vein stenosis in the setting of prematurity is a rare and poorly understood condition. Diagnosis can be challenging in the setting of chronic lung disease of prematurity. High-resolution non-contrast chest computed tomography (CT) is the conventional method of evaluating neonates for potential structural changes contributing to severe lung dysfunction and pulmonary hypertension but may miss pulmonary venous stenosis due to the absence of contrast and potential overlap in findings between developmental pulmonary vein pulmonary vein stenosis and lung disease of prematurity. OBJECTIVE To describe the parenchymal changes of pediatric patients with both prematurity and pulmonary vein stenosis, correlate them with venous disease and to describe the phenotypes associated with this disease. MATERIALS AND METHODS A 5-year retrospective review of chest CT angiography (CTA) imaging in patients with catheterization-confirmed pulmonary vein stenosis was performed to identify pediatric patients (< 18 years) who had a history of prematurity (< 35 weeks gestation). Demographic and clinical data associated with each patient were collected, and the patients' CTAs were re-reviewed to evaluate pulmonary veins and parenchyma. Patients with post-operative pulmonary vein stenosis and those with congenital heart disease were excluded. Data was analyzed and correlated for descriptive purposes. RESULTS A total of 17 patients met the inclusion criteria (12 female, 5 male). All had pulmonary hypertension. There was no correlation between mild, moderate, and severe grades of bronchopulmonary dysplasia and the degree of pulmonary vein stenosis. There was a median of 2 (range 1-4) diseased pulmonary veins per patient. In total, 41% of the diseased pulmonary veins were atretic. The right upper and left upper lobe pulmonary veins were the most frequently diseased (n = 13/17, 35%, n = 10/17, 27%, respectively). Focal ground glass opacification, interlobular septal thickening, and hilar soft tissue enlargement were always associated with the atresia of an ipsilateral vein. CONCLUSION Recognition of the focal parenchymal changes that imply pulmonary vein stenosis, rather than chronic lung disease of prematurity changes, may improve the detection of a potentially treatable source of pulmonary hypertension, particularly where nonangiographic studies result in a limited direct venous assessment.
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Affiliation(s)
| | - Jenny E Zablah
- The Heart Institute, Children's Hospital Colorado, Aurora, CO, USA
- University of Colorado Medical School, Anschutz Medical Campus, Aurora, CO, USA
| | - Jason P Weinman
- University of Colorado Medical School, Anschutz Medical Campus, Aurora, CO, USA
- Department of Pediatric Radiology, Children's Hospital Colorado, Aurora, CO, USA
| | - Erin K Englund
- University of Colorado Medical School, Anschutz Medical Campus, Aurora, CO, USA
- Department of Pediatric Radiology, Children's Hospital Colorado, Aurora, CO, USA
| | - Gareth J Morgan
- The Heart Institute, Children's Hospital Colorado, Aurora, CO, USA
- University of Colorado Medical School, Anschutz Medical Campus, Aurora, CO, USA
| | - D Dunbar Ivy
- The Heart Institute, Children's Hospital Colorado, Aurora, CO, USA
- University of Colorado Medical School, Anschutz Medical Campus, Aurora, CO, USA
| | - Benjamin S Frank
- The Heart Institute, Children's Hospital Colorado, Aurora, CO, USA
- University of Colorado Medical School, Anschutz Medical Campus, Aurora, CO, USA
| | - David Andrew Mong
- University of Colorado Medical School, Anschutz Medical Campus, Aurora, CO, USA
- Department of Pediatric Radiology, Children's Hospital Colorado, Aurora, CO, USA
| | - LaDonna J Malone
- University of Colorado Medical School, Anschutz Medical Campus, Aurora, CO, USA
- Department of Pediatric Radiology, Children's Hospital Colorado, Aurora, CO, USA
| | - Lorna P Browne
- University of Colorado Medical School, Anschutz Medical Campus, Aurora, CO, USA.
- Department of Pediatric Radiology, Children's Hospital Colorado, Aurora, CO, USA.
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6
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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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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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8
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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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9
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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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10
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Yang EL, Levy PT, Critser PJ, Dukhovny D, Evers PD. The Clinical and Cost Utility of Cardiac Catheterizations in Infants with Bronchopulmonary Dysplasia. J Pediatr 2022; 246:56-63.e3. [PMID: 35430250 DOI: 10.1016/j.jpeds.2022.04.009] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/09/2021] [Revised: 03/17/2022] [Accepted: 04/08/2022] [Indexed: 12/30/2022]
Abstract
OBJECTIVE To evaluate the cost-utility of catheterization-obligate treatment in preterm infants with pulmonary hypertension, as compared with empiric initiation of sildenafil based on echocardiographic findings alone. STUDY DESIGN A Markov state transition model was constructed to simulate the clinical scenario of a preterm infant with echocardiographic evidence of pulmonary hypertension associated with bronchopulmonary dysplasia (BPD) and without congenital heart disease under consideration for the initiation of pulmonary vasodilator therapy via one of two modeled treatment strategies-empiric or catheterization-obligate. Transitional probabilities, costs and utilities were extracted from the literature. Forecast quality-adjusted life-years was the metric for strategy effectiveness. Sensitivity analyses for each variable were performed. A 1000-patient Monte Carlo microsimulation was used to test the durability of our findings. RESULTS The catheterization-obligate strategy resulted in an increased cost of $10 778 and 0.02 fewer quality-adjusted life-years compared with the empiric treatment strategy. Empiric treatment remained the more cost-effective paradigm across all scenarios modeled through one-way sensitivity analyses and the Monte Carlo microsimulation (cost-effective in 98% of cases). CONCLUSIONS Empiric treatment with sildenafil in infants with pulmonary hypertension associated with BPD is a superior strategy with both decreased costs and increased effectiveness when compared with catheterization-obligate treatment. These findings suggest that foregoing catheterization before the initiation of sildenafil is a reasonable strategy in preterm infants with uncomplicated pulmonary hypertension associated with BPD.
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Affiliation(s)
- Emily L Yang
- Division of Pediatric Cardiology, Oregon Health and Sciences University, Portland, OR.
| | - Philip T Levy
- Division of Newborn Medicine, Boston Children's Hospital, Harvard Medical School, Boston, MA; Department of Pediatrics, Boston Children's Hospital, Harvard Medical School, Boston, MA
| | - Paul J Critser
- Heart Institute, Cincinnati Children's Hospital Medical Center, Cincinnati, OH; Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH
| | - Dmitry Dukhovny
- Division of Neonatology, Oregon Health and Sciences University, Portland, OR
| | - Patrick D Evers
- Division of Pediatric Cardiology, Oregon Health and Sciences University, Portland, OR
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11
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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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12
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Zablah JE, O'Callaghan B, Shorofsky M, Ivy D, Morgan GJ. Technical Feasibility on the Use of Optical Coherence Tomography in the Evaluation of Pediatric Pulmonary Venous Stenosis. Pediatr Cardiol 2022; 43:1054-1063. [PMID: 35037988 DOI: 10.1007/s00246-022-02824-0] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/13/2021] [Accepted: 01/07/2022] [Indexed: 11/26/2022]
Abstract
Pulmonary vein stenosis (PVS) in children is a morbid disease and limited progress has been made in improving outcomes for this heterogenous group of patients. Evaluation is currently limited to imaging techniques that fail to provide an adequate overview of the intraluminal and luminal pathology perpetuating our limited understanding of this condition. Optical coherence tomography (OCT) is an imaging modality which provides intraluminal profiling with microstructural detail through optical reflective technology. We sought to evaluate whether its use was technically feasible in pediatric PVS and whether the imaging data provided potentially useful outputs for clinical utility. Eleven patients were prospectively selected from our cardiac catheterization for OCT evaluation of their pulmonary veins (PV) during elective catheterization for PVS. Measurements were taken both pre and post intervention using both manual and automated tools. Stent morphology was characterized. Eleven patients had evaluation of 34 pulmonary veins, with 7 patients having more than one assessment, for a total of 25 overall catheterizations. Most patients were female (75%). Median age at cardiac catheterization was 35 months (range 5-45 months). Median weight of subjects was 10.6 kg (3.7-14.2) with a median BSA documented at 0.505 m2 (0.21-0.57). Median number of pulmonary veins involved was 3, (range 1-5 veins) and median contrast volume of 2.9 mL/kg (0.7-3.7) given. Median radiation dose (DAP) was 6095 µGy·cm2 (1670-12,400). Median number of previous cardiac catheterizations was 7 (range 1-11). All of the vessels with a diameter < 5 mm were adequately visualized. Of all the OCT images acquired, in 15 vessels (44%) contrast was used to clear the vessels from blood as an angiogram was required at the time, in the other 19 vessels (56%), saline was used with adequate imaging. There were no complications related to OCT. OCT is technically feasible to use in pediatric patients without any directly related complications. It provides intraluminal anatomy in children with both native and treated pulmonary venous stenosis when vessel size is less than 5 mm.
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Affiliation(s)
- Jenny E Zablah
- The Heart Institute, Children's Hospital Colorado, University of Colorado School of Medicine, Anschutz Medical Campus, Aurora, Colorado, USA.
| | - Barry O'Callaghan
- The Heart Institute, Children's Hospital Colorado, University of Colorado School of Medicine, Anschutz Medical Campus, Aurora, Colorado, USA
| | - Michael Shorofsky
- The Heart Institute, Children's Hospital Colorado, University of Colorado School of Medicine, Anschutz Medical Campus, Aurora, Colorado, USA
| | - Dunbar Ivy
- The Heart Institute, Children's Hospital Colorado, University of Colorado School of Medicine, Anschutz Medical Campus, Aurora, Colorado, USA
| | - Gareth J Morgan
- The Heart Institute, Children's Hospital Colorado, University of Colorado School of Medicine, Anschutz Medical Campus, Aurora, Colorado, USA
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13
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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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14
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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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15
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Lung and Pleural Findings of Children with Pulmonary Vein Stenosis with and without Aspiration: MDCT Evaluation. CHILDREN (BASEL, SWITZERLAND) 2022; 9:children9040543. [PMID: 35455587 PMCID: PMC9025679 DOI: 10.3390/children9040543] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/31/2021] [Revised: 04/01/2022] [Accepted: 04/07/2022] [Indexed: 11/19/2022]
Abstract
Purpose: To retrospectively compare the lung and pleural findings in children with pulmonary vein stenosis (PVS) with and without aspiration on multidetector computed tomography (MDCT). Materials and Methods: All consecutive children (≤18 years old) with PVS who underwent thoracic MDCT studies from August 2004 to December 2021 were categorized into two groups: children with PVS with aspiration (Group 1) and children with PVS without aspiration (Group 2). Two independent pediatric radiologists retrospectively evaluated thoracic MDCT studies for the presence of lung and pleural abnormalities as follows: (1) in the lung (ground-glass opacity (GGO), consolidation, nodule, mass, cyst(s), interlobular septal thickening, and fibrosis) and (2) in the pleura (thickening, effusion, and pneumothorax). Interobserver agreement between the two reviewers was evaluated by the proportion of agreement and the Kappa statistic. Results: The final study population consisted of 64 pediatric patients (36 males (56.3%) and 43 females (43.7%); mean age, 1.7 years; range, 1 day−17 years). Among these 64 patients, 19 patients (29.7%) comprised Group 1 and the remaining 45 patients (70.3%) comprised Group 2. In Group 1 (children with PVS with aspiration), the detected lung and pleural MDCT abnormalities were: GGO (17/19; 89.5%), pleural thickening (17/19; 89.5%), consolidation (16/19; 84.5%), and septal thickening (16/19; 84.5%). The lung and pleural MDCT abnormalities observed in Group 2 (children with PVS without aspiration) were: GGO (37/45; 82.2%), pleural thickening (37/45; 82.2%), septal thickening (36/45; 80%), consolidation (3/45; 6.7%), pleural effusion (1/45; 2.2%), pneumothorax (1/45; 2.2%), and cyst(s) (1/45; 2.2%). Consolidation was significantly more common in pediatric patients with both PVS and aspiration (Group 1) (p < 0.001). There was high interobserver agreement between the two independent reviewers for detecting lung and pleural abnormalities on thoracic MDCT studies (Kappa = 0.98; CI = 0.958, 0.992). Conclusion: Aspiration is common in pediatric patients with PVS who undergo MDCT and was present in nearly 30% of all children with PVS during our study period. Consolidation is not a typical radiologic finding of PVS in children without clinical evidence of aspiration. When consolidation is present on thoracic MDCT studies in pediatric patients with PVS, the additional diagnosis of concomitant aspiration should be considered.
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16
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Hocq C, Vanhoutte L, Guilloteau A, Massolo AC, Van Grambezen B, Carkeek K, Piersigilli F, Danhaive O. Early diagnosis and targeted approaches to pulmonary vascular disease in bronchopulmonary dysplasia. Pediatr Res 2022; 91:804-815. [PMID: 33674739 DOI: 10.1038/s41390-021-01413-w] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/09/2020] [Accepted: 01/25/2021] [Indexed: 01/31/2023]
Abstract
Pulmonary hypertension has emerged as a life-threatening disease in preterm infants suffering from bronchopulmonary dysplasia (BPD). Its development is closely linked to respiratory disease, as vasculogenesis and alveologenesis are closely interconnected. Once clinically significant, BPD-associated pulmonary hypertension (BPD-PH) can be challenging to manage, due to poor reversibility and multiple comorbidities frequently associated. The pulmonary vascular disease process underlying BPD-PH is the result of multiple innate and acquired factors, and emerging evidence suggests that it progressively develops since birth and, in certain instances, may begin as early as fetal life. Therefore, early recognition and intervention are of great importance in order to improve long-term outcomes. Based on the most recent knowledge of BPD-PH pathophysiology, we review state-of-the-art screening and diagnostic imaging techniques currently available, their utility for clinicians, and their applicability and limitations in this specific population. We also discuss some biochemical markers studied in humans as a possible complement to imaging for the detection of pulmonary vascular disease at its early stages and the monitoring of its progression. In the second part, we review pharmacological agents currently available for BPD-PH treatment or under preclinical investigation, and discuss their applicability, as well as possible approaches for early-stage interventions in fetuses and neonates. IMPACT: BPD-associated PH is a complex disease involving genetic and epigenetic factors, as well as environmental exposures starting from fetal life. The value of combining multiple imaging and biochemical biomarkers is emerging, but requires larger, multicenter studies for validation and diffusion. Since "single-bullet" approaches have proven elusive so far, combined pharmacological regimen and cell-based therapies may represent important avenues for research leading to future cure and prevention.
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Affiliation(s)
- Catheline Hocq
- Division of Neonatology, St-Luc University Hospital, Catholic University of Louvain, Brussels, Belgium
| | - Laetitia Vanhoutte
- Division of Pediatric Cardiology, St-Luc University Hospital, Catholic University of Louvain, Brussels, Belgium
| | - Axelle Guilloteau
- Division of Clinical Pharmacy, St-Luc University Hospital, Catholic University of Louvain, Brussels, Belgium
| | - Anna Claudia Massolo
- Department of Surgical and Medical Neonatology, Bambino Gesù Children's Hospital, Rome, Italy
| | - Bénédicte Van Grambezen
- Division of Neonatology, St-Luc University Hospital, Catholic University of Louvain, Brussels, Belgium
| | - Kate Carkeek
- Division of Neonatology, St-Luc University Hospital, Catholic University of Louvain, Brussels, Belgium
| | - Fiammetta Piersigilli
- Division of Neonatology, St-Luc University Hospital, Catholic University of Louvain, Brussels, Belgium
| | - Olivier Danhaive
- Division of Neonatology, St-Luc University Hospital, Catholic University of Louvain, Brussels, Belgium. .,Department of Pediatrics, Benioff Children's Hospital, University of California San Francisco, San Francisco, CA, USA.
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17
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Portero-Portaz JJ, Córdoba-Soriano JG, Gallardo-López A, Jiménez-Mazuecos JM. Intravascular ultrasound-guided drug-coated balloon venoplasty for in-stent restenosis in pulmonary veins stenosis: a case report. Eur Heart J Case Rep 2021; 5:ytab384. [PMID: 34870083 PMCID: PMC8637799 DOI: 10.1093/ehjcr/ytab384] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2020] [Revised: 01/14/2021] [Accepted: 09/24/2021] [Indexed: 11/13/2022]
Abstract
Background Pulmonary veins stenosis (PVS) after atrial fibrillation radiofrequency ablation is an uncommon complication. When it occurs, percutaneous treatment is the preferred approach. There is a lack of standardized procedures, and when stenting restenosis is relatively common. Case summary We present a young patient with recurrence of PVS after first percutaneous treatment. The recurrence of haemoptysis and dyspnoea after treatment in PVS allowed the diagnosis of significant stenosis again in our patient. In the Heart Team, we opted for a new percutaneous treatment, using intravascular ultrasound (IVUS) to optimize the final result. Discussion Nowadays, percutaneous approach is preferred and among percutaneous treatments for PVS, stenting has shown better results than balloon angioplasty (BA). Despite this, experience in in-stent restenosis is limited, and there is a lack of adequate and specific material for its approach. In this case, we present the possible role of the IVUS and the drug-coated BA in this entity.
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Affiliation(s)
- Juan J Portero-Portaz
- Haemodynamics and Interventional Cardiology Unit, University Hospital of Albacete, C/ Hermanos Falcó, 02006, Albacete, Spain
| | - Juan G Córdoba-Soriano
- Haemodynamics and Interventional Cardiology Unit, University Hospital of Albacete, C/ Hermanos Falcó, 02006, Albacete, Spain
| | - Arsenio Gallardo-López
- Haemodynamics and Interventional Cardiology Unit, University Hospital of Albacete, C/ Hermanos Falcó, 02006, Albacete, Spain
| | - Jesús M Jiménez-Mazuecos
- Haemodynamics and Interventional Cardiology Unit, University Hospital of Albacete, C/ Hermanos Falcó, 02006, Albacete, Spain
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18
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Feins EN, Ireland C, Gauvreau K, Chávez M, Callahan R, Jenkins KJ, Baird CW. Pulmonary vein stenosis: Anatomic considerations, surgical management, and outcomes. J Thorac Cardiovasc Surg 2021; 163:2198-2207.e3. [PMID: 34801262 DOI: 10.1016/j.jtcvs.2021.10.022] [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: 05/31/2020] [Revised: 09/08/2021] [Accepted: 10/01/2021] [Indexed: 12/29/2022]
Abstract
OBJECTIVE The study objective was to evaluate outcomes of pulmonary vein stenosis repair in a large single-center cohort. METHODS Clinical data from a pulmonary vein stenosis registry were retrospectively reviewed identifying patients who underwent pulmonary vein stenosis repair. The primary/index operation was defined as the patient's first pulmonary vein stenosis operation during the study period. RESULTS Between January 2007 and August 2019, 174 patients underwent pulmonary vein stenosis repair. Bilateral pulmonary vein stenosis occurred in 111 patients (64%); 71 patients (41%) had 4-vessel disease. Fifty-nine patients (34%) had primary pulmonary vein stenosis. Median age was 9 months (interquartile range, 5-27) and weight was 6.5 kg (4.7-10.2). Surgical techniques evolved and included ostial resection, unroofing, reimplantation, sutureless, modified sutureless, and a newer anatomically focused approach of pulmonary vein stenosis resection with lateralization or patch enlargement of the pulmonary vein-left atrium connection. Twenty-three patients (13%) required reoperation. Cumulative 2-year incidence of postoperative transcatheter intervention (balloon dilation ± stenting) was 64%. One-, 2-, and 5-year survivals were 71.2%, 66.8%, and 60.6%, respectively. There was no association between surgery type and reoperation rate (hazard ratio, 2.38, P = .25) or transcatheter intervention (hazard ratio, 0.97, P = .95). The anatomically focused repair was associated with decreased mortality on univariate (hazard ratio, 0.38, P = .042) and multivariable analyses (hazard ratio, 0.19, P = .014). Antiproliferative chemotherapy was also associated with decreased mortality (hazard ratio, 0.47, P = .026). CONCLUSIONS This large single-center surgical pulmonary vein stenosis experience demonstrates encouraging midterm results. A new anatomically focused repair strategy aims to alleviate pulmonary vein angulation to minimize turbulence and shows promising early outcomes. Continued follow-up is required to understand longer-term outcomes for this surgical approach.
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Affiliation(s)
- Eric N Feins
- Department of Cardiac Surgery, Boston Children's Hospital, Harvard Medical School, Boston, Mass.
| | - Christina Ireland
- Department of Cardiology, Boston Children's Hospital, Harvard Medical School, Boston, Mass
| | - Kimberlee Gauvreau
- Department of Cardiology, Boston Children's Hospital, Harvard Medical School, Boston, Mass
| | - Mariana Chávez
- Department of Cardiac Surgery, Boston Children's Hospital, Harvard Medical School, Boston, Mass
| | - Ryan Callahan
- Department of Cardiology, Boston Children's Hospital, Harvard Medical School, Boston, Mass
| | - Kathy J Jenkins
- Department of Cardiology, Boston Children's Hospital, Harvard Medical School, Boston, Mass
| | - Christopher W Baird
- Department of Cardiac Surgery, Boston Children's Hospital, Harvard Medical School, Boston, Mass
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19
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Case 1-2021: A 10-Year-Old Male With Respiratory Failure, Pleural Effusions, and Renal Failure 60 Days After Hematopoietic Stem Cell Transplant. Pediatr Crit Care Med 2021; 22:e524-e531. [PMID: 34605789 DOI: 10.1097/pcc.0000000000002792] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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20
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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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21
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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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22
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Feins EN, Callahan R, Baird CW. Pulmonary Vein Stenosis-Evolving Surgical Management of a Challenging Disease. CHILDREN (BASEL, SWITZERLAND) 2021; 8:631. [PMID: 34438522 PMCID: PMC8392559 DOI: 10.3390/children8080631] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/29/2021] [Revised: 06/27/2021] [Accepted: 07/20/2021] [Indexed: 11/18/2022]
Abstract
Pulmonary vein stenosis (PVS) is an extremely challenging clinical problem in congenital heart disease. It has traditionally required multimodal therapy given its complex underlying pathophysiology. As with other modalities, surgical therapy has undergone tremendous evolution since the 1950s. These evolving strategies have been based upon an improved understanding of the substrates that cause PVS and recurrent vein obstruction. More recent anatomic-based surgical strategies have focused on the pulmonary vein course, and how adjacent mediastinal structures can create a fulcrum effect on the pulmonary veins as they pass from the lung parenchyma to the left atrium. The consequent angulation of pulmonary veins creates altered wall shear stress and likely serves as a nidus for recurrent PVS. Encouraging early results suggest that eliminating pulmonary vein angulation and shortening/straightening the pulmonary vein course may prove effective in surgically managing PVS.
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Affiliation(s)
- Eric N. Feins
- Department of Cardiac Surgery, Boston Children’s Hospital and Harvard Medical School, Boston, MA 02115, USA;
| | - Ryan Callahan
- Department of Cardiology, Boston Children’s Hospital and Harvard Medical School, Boston, MA 02115, USA;
| | - Christopher W. Baird
- Department of Cardiac Surgery, Boston Children’s Hospital and Harvard Medical School, Boston, MA 02115, USA;
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Patient and Family-Centered Care for Pediatric Intraluminal Pulmonary Vein Stenosis: Case of a 3 Year Old Patient with Focus on Nurse Practitioner Role. CHILDREN-BASEL 2021; 8:children8070567. [PMID: 34356546 PMCID: PMC8305435 DOI: 10.3390/children8070567] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/01/2021] [Revised: 06/13/2021] [Accepted: 06/23/2021] [Indexed: 11/17/2022]
Abstract
A nurse practitioner’s experience in managing children with intraluminal pulmonary vein stenosis. A case study of a 3-year-old patient with multi–vessel intraluminal pulmonary vein stenosis.
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Zettler E, Rivera BK, Stiver C, Boe B, Cua C, Ball MK, Smith CV, Slaughter JL, Chen B, Callahan R, Backes CH. Primary pulmonary vein stenosis among premature infants with single-vessel disease. J Perinatol 2021; 41:1621-1626. [PMID: 32989220 PMCID: PMC8593792 DOI: 10.1038/s41372-020-00830-9] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/06/2020] [Revised: 08/25/2020] [Accepted: 09/14/2020] [Indexed: 12/25/2022]
Abstract
OBJECTIVES Describe outcomes among preterm infants diagnosed with single-vessel primary pulmonary vein stenosis (PPVS) initially treated using conservative management (active surveillance with deferral of treatment). STUDY DESIGN Retrospective cohort study at a single, tertiary-center (2009-2019) among infants <37 weeks' gestation with single-vessel PPVS. Infants were classified into two categories: disease progression and disease stabilization. Cardiopulmonary outcomes were examined, and a Kaplan-Meier survival analysis performed. RESULTS Twenty infants were included. Compared to infants in the stable group (0/10, 0%), all infants in the progressive group had development of at least severe stenosis or atresia (10/10, 100%; P < 0.01). Severe pulmonary hypertension at diagnosis was increased in the progressive (5/10, 50%) versus the stable group (0/10, 0%; P = 0.03). Survival was lower among infants in the progressive than the stable group (log-rank test, P < 0.01). CONCLUSION Among preterm infants with single-vessel PPVS, risk stratification may be possible, wherein more targeted, individualized therapies could be applied.
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Affiliation(s)
- Eli Zettler
- Center for Perinatal Research, The Abigail Wexner Research Institute at Nationwide Children's Hospital, Columbus, OH, USA
| | - Brian K Rivera
- Center for Perinatal Research, The Abigail Wexner Research Institute at Nationwide Children's Hospital, Columbus, OH, USA
| | - Corey Stiver
- The Heart Center at Nationwide Children's Hospital, Columbus, OH, USA
| | - Brian Boe
- The Heart Center at Nationwide Children's Hospital, Columbus, OH, USA
| | - Clifford Cua
- The Heart Center at Nationwide Children's Hospital, Columbus, OH, USA
| | - Molly K Ball
- Division of Neonatology, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Charles V Smith
- Seattle Children's Research Institute, University of Washington School of Medicine, Seattle, WA, USA
| | - Jonathan L Slaughter
- Center for Perinatal Research, The Abigail Wexner Research Institute at Nationwide Children's Hospital, Columbus, OH, USA
- Division of Neonatology, The Ohio State University Wexner Medical Center, Columbus, OH, USA
- Department of Pediatrics, The Ohio State University College of Medicine, Columbus, OH, USA
- Division of Epidemiology, The Ohio State University College of Public Health, Columbus, OH, USA
| | - Bernadette Chen
- Center for Perinatal Research, The Abigail Wexner Research Institute at Nationwide Children's Hospital, Columbus, OH, USA
- Division of Neonatology, The Ohio State University Wexner Medical Center, Columbus, OH, USA
- Department of Pediatrics, The Ohio State University College of Medicine, Columbus, OH, USA
| | - Ryan Callahan
- Department of Cardiology, Boston Children's Hospital and Harvard Medical School, Boston, MA, USA
| | - Carl H Backes
- Center for Perinatal Research, The Abigail Wexner Research Institute at Nationwide Children's Hospital, Columbus, OH, USA.
- The Heart Center at Nationwide Children's Hospital, Columbus, OH, USA.
- Division of Neonatology, The Ohio State University Wexner Medical Center, Columbus, OH, USA.
- Department of Pediatrics, The Ohio State University College of Medicine, Columbus, OH, USA.
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Frank DB, Levy PT, Stiver CA, Boe BA, Baird CW, Callahan RM, Smith CV, Vanderlaan RD, Backes CH. Primary pulmonary vein stenosis during infancy: state of the art review. J Perinatol 2021; 41:1528-1539. [PMID: 33674714 DOI: 10.1038/s41372-021-01008-7] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/19/2020] [Revised: 01/13/2021] [Accepted: 02/11/2021] [Indexed: 12/15/2022]
Abstract
Primary pulmonary vein stenosis (PPVS) is an emerging problem among infants. In contrast to acquired disease, PPVS is the development of stenosis in the absence of preceding intervention. While optimal care approaches remain poorly characterized, over the past decade, understanding of potential pathophysiological mechanisms and development of novel therapeutic strategies are increasing. A multidisciplinary team of health care providers was assembled to review the available evidence and provide a common framework for the diagnosis, management, and treatment of PPVS during infancy. To address knowledge gaps, institutional and multi-institutional approaches must be employed to generate knowledge specific to ex-premature infants with PPVS. Within individual institutions, creation of a team comprised of dedicated health care providers from diverse backgrounds is critical to accelerate clinical learning and provide care for infants with PPVS. Multi-institutional collaborations, such as the PVS Network, provide the infrastructure and statistical power to advance knowledge for this rare disease.
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Affiliation(s)
- David B Frank
- Division of Cardiology, Children's Hospital of Philadelphia, Philadelphia, PA, USA
- Department of Pediatrics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Philip T Levy
- Division of Newborn Medicine, Boston Children's Hospital, Boston, MA, USA
- Department of Pediatrics, Harvard Medical School, Boston, MA, USA
| | - Corey A Stiver
- The Heart Center, Nationwide Children's Hospital, Columbus, OH, USA
- Department of Pediatrics, The Ohio State University College of Medicine, Columbus, OH, USA
| | - Brian A Boe
- The Heart Center, Nationwide Children's Hospital, Columbus, OH, USA
- Department of Pediatrics, The Ohio State University College of Medicine, Columbus, OH, USA
| | - Christopher W Baird
- Department of Pediatrics, Harvard Medical School, Boston, MA, USA
- Department of Cardiac Surgery, Boston Children's Hospital, Boston, MA, USA
| | - Ryan M Callahan
- Department of Pediatrics, Harvard Medical School, Boston, MA, USA
- Department of Cardiology, Boston Children's Hospital, Boston, MA, USA
| | - Charles V Smith
- Center for Developmental Therapeutics, Seattle Children's Research Institute, University of Washington School of Medicine, Seattle, WA, USA
| | - Rachel D Vanderlaan
- Department of Thoracic Surgery, New York Presbyterian Morgan Stanley Children's Hospital, New York, NY, USA
| | - Carl H Backes
- The Heart Center, Nationwide Children's Hospital, Columbus, OH, USA.
- Department of Pediatrics, The Ohio State University College of Medicine, Columbus, OH, USA.
- Division of Neonatology, The Ohio State University Wexner Medical Center, Columbus, OH, USA.
- Center for Perinatal Research, The Abigail Wexner Research Institute, Nationwide Children's Hospital, Columbus, OH, USA.
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Vanderlaan RD, Caldarone CA. Pulmonary Vein Stenosis: Incremental Knowledge Gains to Improve Outcomes. CHILDREN-BASEL 2021; 8:children8060481. [PMID: 34200142 PMCID: PMC8229191 DOI: 10.3390/children8060481] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/11/2021] [Revised: 05/28/2021] [Accepted: 06/04/2021] [Indexed: 11/16/2022]
Abstract
Pulmonary vein stenosis remains a considerable clinical challenge, with high mortality still present in children with progressive disease. In this review, we discuss the clinical spectrum of pulmonary vein stenosis and what is known about the etiology and potential modifying and contributing factors in progressive pulmonary vein stenosis.
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Affiliation(s)
- Rachel D. Vanderlaan
- Division of Cardiovascular Surgery, Hospital for Sick Children, Toronto, ON M5G 1X8, Canada
- Correspondence: ; Tel.: +1-416-813-1500
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27
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Pulmonary vein stenosis: Treatment and challenges. J Thorac Cardiovasc Surg 2021; 161:2169-2176. [DOI: 10.1016/j.jtcvs.2020.05.117] [Citation(s) in RCA: 21] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/13/2020] [Revised: 05/19/2020] [Accepted: 05/23/2020] [Indexed: 11/15/2022]
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28
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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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29
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Systemic Sirolimus Therapy for Infants and Children With Pulmonary Vein Stenosis. J Am Coll Cardiol 2021; 77:2807-2818. [PMID: 34082911 DOI: 10.1016/j.jacc.2021.04.013] [Citation(s) in RCA: 23] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/01/2021] [Revised: 04/01/2021] [Accepted: 04/02/2021] [Indexed: 01/10/2023]
Abstract
BACKGROUND Anatomic interventions for pulmonary vein stenosis (PVS) in infants and children have been met with limited success. Sirolimus, a mammalian target of rapamycin inhibitor, has demonstrated promise as a primary medical therapy for PVS, but the impact on patient survival is unknown. OBJECTIVES The authors sought to investigate whether mTOR inhibition with sirolimus as a primary medical therapy would improve outcomes in high-risk infants and children with PVS. METHODS In this single-center study, patients with severe PVS were considered for systemic sirolimus therapy (SST) following a strict protocol while receiving standardized surveillance and anatomic therapies. The SST cohort was compared with a contemporary control group. The primary endpoint for this study was survival. The primary safety endpoint was adverse events (AEs) related to SST. RESULTS Between 2015 and 2020, our PVS program diagnosed and treated 67 patients with ≥moderate PVS. Of these, 15 patients were treated with sirolimus, whereas the remaining patients represent the control group. There was 100% survival in the SST group compared with 45% survival in the control group (log-rank p = 0.004). A sensitivity analysis was completed to address survival bias using median time from diagnosis of PVS to SST. A survival advantage persisted (log-rank p = 0.027). Two patients on sirolimus developed treatable AEs. Patients in the SST group underwent frequent transcatheter interventions with 3.7 catheterizations per person-year (25th to 75th percentile: 2.7 to 4.4 person-years). Median follow up time was 2.2 years (25th to 75th percentile: 1.2 to 2.9 years) in the SST group versus 0.9 years (25th to 75th percentile: 0.5 to 2.7 years) in the control group. CONCLUSIONS The authors found a survival benefit associated with SST in infants and children with moderate-to-severe PVS. This survival benefit persisted after adjusting the analysis for survival bias. There were 2 mild AEs associated with SST during the study period; both patients were able to resume therapy without recurrence.
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Matsuzaki Y, Wiet MG, Boe BA, Shinoka T. The Real Need for Regenerative Medicine in the Future of Congenital Heart Disease Treatment. Biomedicines 2021; 9:478. [PMID: 33925558 PMCID: PMC8145070 DOI: 10.3390/biomedicines9050478] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2021] [Revised: 04/19/2021] [Accepted: 04/24/2021] [Indexed: 11/23/2022] Open
Abstract
Bioabsorbable materials made from polymeric compounds have been used in many fields of regenerative medicine to promote tissue regeneration. These materials replace autologous tissue and, due to their growth potential, make excellent substitutes for cardiovascular applications in the treatment of congenital heart disease. However, there remains a sizable gap between their theoretical advantages and actual clinical application within pediatric cardiovascular surgery. This review will focus on four areas of regenerative medicine in which bioabsorbable materials have the potential to alleviate the burden where current treatment options have been unable to within the field of pediatric cardiovascular surgery. These four areas include tissue-engineered pulmonary valves, tissue-engineered patches, regenerative medicine options for treatment of pulmonary vein stenosis and tissue-engineered vascular grafts. We will discuss the research and development of biocompatible materials reported to date, the evaluation of materials in vitro, and the results of studies that have progressed to clinical trials.
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Affiliation(s)
- Yuichi Matsuzaki
- Center for Regenerative Medicine, The Abigail Wexner Research Institute at Nationwide Children’s Hospital, 700 Children’s Drive, T2294, Columbus, OH 43205, USA; (Y.M.); (M.G.W.)
| | - Matthew G. Wiet
- Center for Regenerative Medicine, The Abigail Wexner Research Institute at Nationwide Children’s Hospital, 700 Children’s Drive, T2294, Columbus, OH 43205, USA; (Y.M.); (M.G.W.)
| | - Brian A. Boe
- Department of Cardiology, The Heart Center, Nationwide Children’s Hospital, 700 Children’s Drive, T2294, Columbus, OH 43205, USA;
| | - Toshiharu Shinoka
- Center for Regenerative Medicine, The Abigail Wexner Research Institute at Nationwide Children’s Hospital, 700 Children’s Drive, T2294, Columbus, OH 43205, USA; (Y.M.); (M.G.W.)
- Department of Cardiothoracic Surgery, The Heart Center, Nationwide Children’s Hospital, 700 Children’s Drive, T2294, Columbus, OH 43205, USA
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31
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Welch TP, Trivedi PM, Fang ZA, Ing RJ, Mittnacht AJC, Mossad EB. Selected 2020 Highlights in Congenital Cardiac Anesthesia. J Cardiothorac Vasc Anesth 2021; 35:2848-2854. [PMID: 33934987 DOI: 10.1053/j.jvca.2021.03.047] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/22/2021] [Accepted: 03/24/2021] [Indexed: 11/11/2022]
Abstract
This article is a review of the highlights of pertinent literature published during the 12 months of 2020 that are of interest to the congenital cardiac anesthesiologist. After a search of the US National Library of Medicine's PubMed database, several topics emerged for which significant contributions were made in 2020. The authors of the present article considered the following topics noteworthy to be included in this review: pediatric cardiac care in the coronavirus disease 2019 era, the use of mechanical circulatory support in coronavirus disease 2019-related multisystem inflammatory syndrome in children, transfusion and coagulation management in children undergoing congenital heart surgery, and pulmonary vein stenosis.
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Affiliation(s)
- Timothy P Welch
- Division of Pediatric Cardiovascular Anesthesia, Baylor College of Medicine, Texas Children's Hospital, Houston, TX
| | - Premal M Trivedi
- Division of Pediatric Cardiovascular Anesthesia, Baylor College of Medicine, Texas Children's Hospital, Houston, TX
| | - Zhe A Fang
- Department of Anesthesia and Pain Medicine, Hospital for Sick Children Toronto, Ontario, Canada
| | - Richard J Ing
- Department of Anesthesiology, Children's Hospital Colorado, University of Colorado School of Medicine, Aurora, CO
| | - Alexander J C Mittnacht
- Department of Anesthesiology, Westchester Medical Center, New York Medical College, Valhalla, NY.
| | - Emad B Mossad
- Division of Pediatric Cardiovascular Anesthesia, Baylor College of Medicine, Texas Children's Hospital, Houston, TX
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32
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Outcomes in Establishing Individual Vessel Patency for Pediatric Pulmonary Vein Stenosis. CHILDREN-BASEL 2021; 8:children8030210. [PMID: 33802089 PMCID: PMC8000090 DOI: 10.3390/children8030210] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/31/2021] [Revised: 03/05/2021] [Accepted: 03/07/2021] [Indexed: 02/06/2023]
Abstract
The purpose of this study was to determine what patient and pulmonary vein characteristics at the diagnosis of intraluminal pulmonary vein stenosis (PVS) are predictive of individual vein outcomes. A retrospective, single-center, cohort sub-analysis of individual pulmonary veins of patients enrolled in the clinical trial NCT00891527 using imatinib mesylate +/− bevacizumab as adjunct therapy for the treatment of multi-vessel pediatric PVS between March 2009 and December 2014 was performed. The 72-week outcomes of the individual veins are reported. Among the 48 enrolled patients, 46 patients and 182 pulmonary veins were included in the study. Multivariable analysis demonstrated that patients with veins without distal disease at baseline (odds ratio, OR 3.69, 95% confidence interval, CI [1.52, 8.94], p = 0.004), location other than left upper vein (OR 2.58, 95% CI [1.07, 6.19], p = 0.034), or veins in patients ≥ 1 y/o (OR 5.59, 95% CI [1.81, 17.3], p = 0.003) were at higher odds of having minimal disease at the end of the study. Veins in patients who received a higher percentage of eligible drug doses required fewer reinterventions (IRR 0.76, 95% CI [0.68, 0.85], p < 0.001). The success of a multi-modal treatment approach to aggressive PVS depends on the vein location, disease severity, and drug dose intensity.
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33
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Schramm J, Sivalingam S, Moreno GE, Thanh DQL, Gauvreau K, Doherty-Schmeck K, Jenkins KJ. Pulmonary Vein Stenosis: A Rare Disease with a Global Reach. CHILDREN-BASEL 2021; 8:children8030198. [PMID: 33800765 PMCID: PMC8000109 DOI: 10.3390/children8030198] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/31/2021] [Revised: 02/26/2021] [Accepted: 03/03/2021] [Indexed: 11/16/2022]
Abstract
Pulmonary vein stenosis (PVS) is a rare, but high mortality and resource intensive disease caused by mechanical obstruction or intraluminal myofibroproliferation, which can be post-surgical or idiopathic. There are increasing options for management including medications, cardiac catheterization procedures, and surgery. We queried the International Quality Improvement Collaborative for Congenital Heart Disease (IQIC) database for cases of PVS and described the cohort including additional congenital lesions and surgeries as well as infectious and mortality outcomes. IQIC is a quality improvement project in low-middle-income countries with the goal of reducing mortality after congenital heart surgery. Three cases were described in detail with relevant images. We identified 57 cases of PVS surgery, with similar mortality to higher income countries. PVS should be recognized as a global disease. More research and collaboration are needed to understand the disease, treatments, and outcomes, and to devise treatment approaches for low resource environments.
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Affiliation(s)
- Jennifer Schramm
- Department of Cardiology, Children’s National Hospital, Washington, DC 20010, USA;
| | - Sivakumar Sivalingam
- Department of Cardiothoracic Surgery, National Heart Institute, 50400 Kuala Lumpur, Malaysia;
| | - Guillermo E. Moreno
- Department of Cardiac Intensive Care, Hospital de Pediatría “Professor Dr. Juan P. Garrahan”, 412-6000 Ciudad de Buenos Aires, Argentina;
| | - Dinh Quang Le Thanh
- Department of Cardiac Surgery, Children’s Hospital 1, 700000 Ho Chi Minh City, Vietnam;
| | - Kimberlee Gauvreau
- Center for Applied Pediatric Quality Analytics, Department of Cardiology, Boston Children’s Hospital, Boston, MA 02115, USA; (K.G.); (K.D.-S.)
| | - Kaitlin Doherty-Schmeck
- Center for Applied Pediatric Quality Analytics, Department of Cardiology, Boston Children’s Hospital, Boston, MA 02115, USA; (K.G.); (K.D.-S.)
| | - Kathy J. Jenkins
- Center for Applied Pediatric Quality Analytics, Department of Cardiology, Boston Children’s Hospital, Boston, MA 02115, USA; (K.G.); (K.D.-S.)
- Correspondence:
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Callahan R, Gauthier Z, Toba S, Sanders SP, Porras D, Vargas SO. Correlation of Intravascular Ultrasound with Histology in Pediatric Pulmonary Vein Stenosis. CHILDREN-BASEL 2021; 8:children8030193. [PMID: 33806479 PMCID: PMC7999454 DOI: 10.3390/children8030193] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/21/2021] [Revised: 02/16/2021] [Accepted: 03/01/2021] [Indexed: 11/16/2022]
Abstract
Preliminary intravascular ultrasound (IVUS) images of suspected pediatric intraluminal pulmonary vein stenosis (PVS) demonstrate wall thickening. It is unclear how the IVUS-delineated constituents of wall thickening correlate with the histology. We analyzed six postmortem formalin-fixed heart/lung specimens and four live patients with PVS as well as control pulmonary veins using IVUS and light microscopic examination. In PVS veins, IVUS demonstrated wall thickening with up to two layers of variable echogenicity, often with indistinct borders. Histologically, the veins showed fibroblastic proliferation with areas rich in myxoid matrix as well as areas with abundant collagen and elastic fibers. Discrete vein layers were obscured by scarring and elastic degeneration. A lower reflective periluminal layer by IVUS corresponded with hyperplasia of myofibroblast-like cells in abundant myxoid matrix. The hyper-reflective layer by IVUS extended to the outer edge of the vessel and corresponded to a less myxoid area with more collagen, smooth muscle and elastic fibers. The outer less reflective edge of the IVUS image correlated with a gradual transition into adventitia. Normal veins had a thin wall, correlating with histologically normal cellular and extracellular components, without intimal proliferation. IVUS may provide further understanding of the anatomy and mechanisms of pediatric pulmonary vein obstruction.
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Affiliation(s)
- Ryan Callahan
- Department of Cardiology, Boston Children’s Hospital and Harvard Medical School, Boston, MA 02115, USA; (Z.G.); (S.T.); (S.P.S.); (D.P.)
- Correspondence:
| | - Zachary Gauthier
- Department of Cardiology, Boston Children’s Hospital and Harvard Medical School, Boston, MA 02115, USA; (Z.G.); (S.T.); (S.P.S.); (D.P.)
| | - Shuhei Toba
- Department of Cardiology, Boston Children’s Hospital and Harvard Medical School, Boston, MA 02115, USA; (Z.G.); (S.T.); (S.P.S.); (D.P.)
- Department of Pathology, Boston Children’s Hospital and Harvard Medical School, Boston, MA 02115, USA;
| | - Stephen P. Sanders
- Department of Cardiology, Boston Children’s Hospital and Harvard Medical School, Boston, MA 02115, USA; (Z.G.); (S.T.); (S.P.S.); (D.P.)
- Department of Pathology, Boston Children’s Hospital and Harvard Medical School, Boston, MA 02115, USA;
| | - Diego Porras
- Department of Cardiology, Boston Children’s Hospital and Harvard Medical School, Boston, MA 02115, USA; (Z.G.); (S.T.); (S.P.S.); (D.P.)
| | - Sara O. Vargas
- Department of Pathology, Boston Children’s Hospital and Harvard Medical School, Boston, MA 02115, USA;
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35
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Aljohani OA, Mackie D, Frazer J, You H, Nageotte SJ, Ratnayaka K, Moore JW, El-Said HG. Pulmonary vein rehabilitation. PROGRESS IN PEDIATRIC CARDIOLOGY 2021. [DOI: 10.1016/j.ppedcard.2020.101277] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Humpl T, Fineman J, Qureshi AM. The many faces and outcomes of pulmonary vein stenosis in early childhood. Pediatr Pulmonol 2021; 56:649-655. [PMID: 32506838 DOI: 10.1002/ppul.24848] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/23/2019] [Revised: 04/22/2020] [Accepted: 05/11/2020] [Indexed: 11/10/2022]
Abstract
Pulmonary vein stenosis is a rare and poorly understood condition causing obstruction of the large pulmonary veins and of blood flow from the lungs to the left atrium. This results in elevated pulmonary venous pressure and pulmonary edema, pulmonary hypertension, potentially cardiac failure, and death. Clinical signs of the disease include failure to thrive, increasingly severe dyspnea, hemoptysis, respiratory difficulty, recurrent respiratory tract infections/pneumonia, cyanosis, and subcostal retractions. On chest radiograph, the most frequent finding is increased interstitial, ground-glass and/or reticular opacity. Transthoracic echocardiography with pulsed Doppler delineates the stenosis, magnetic resonance imaging and multislice computerized tomography are used for further evaluation. Interventional cardiac catherization, surgical techniques, and medical therapies have been used with varying success as treatment options.
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Affiliation(s)
- Tilman Humpl
- Division of Pediatric Intensive Care, University Children's Hospital Berne, Inselspital, Berne, Switzerland
| | - Jeffrey Fineman
- Department of Pediatrics, Pediatric Critical Care University of California, San Francisco, California
| | - Athar M Qureshi
- The Lillie Frank Abercrombie Section of Cardiology, Texas Children's Hospital, Baylor College of Medicine, Houston, Texas
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Clinical Syndromic Phenotypes and the Potential Role of Genetics in Pulmonary Vein Stenosis. CHILDREN-BASEL 2021; 8:children8020128. [PMID: 33578785 PMCID: PMC7916466 DOI: 10.3390/children8020128] [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: 12/31/2020] [Revised: 01/25/2021] [Accepted: 02/06/2021] [Indexed: 11/18/2022]
Abstract
Pulmonary vein stenosis (PVS) is a rare, frequently lethal disease with heterogeneous phenotypes and an unclear etiology. Limited studies have reported associations between PVS and congenital heart disease (CHD), chronic lung disease (CLD), and/or prematurity; however, to date, there have been no studies that report detailed clinical syndromic phenotypes and the potential role of genetics in PVS. An existing registry of multivessel PVS patients seen at Boston Children’s Hospital (BCH) was queried between August 2006 and January 2017 for all existing genetic testing data on these patients. PVS was defined as an intraluminal pulmonary venous obstruction in ≥2 vessels with mean pressure gradients > 4 mmHg. One-hundred-and-fifty-seven patients (46% female, with a median age at PVS diagnosis of 3 months) formed the cohort. Seventy-one (45%) patients had available genetic testing information. Of the 71 patients, a likely genetic diagnosis was found in 23 (32%) patients: 13 (57%) were diagnosed with Trisomy 21 (T21), five (22%) with Smith–Lemli–Opitz Syndrome, five (22%) had other pathologic genetic disease, and 24 (33%) had variants of unknown significance. The majority of 13 patients with T21 and PVS had common atrioventricular canal (CAVC) (10, 77%) and all had severe pulmonary hypertension (PHTN), which led to their PVS diagnosis. In our study, PVS was associated with T21, the majority of whom also had CAVC and PHTN. Therefore, complete assessment of the pulmonary veins should be considered for all T21 patients, especially those with CAVC presenting with PHTN. Furthermore, prospective standardized genetic testing with detailed clinical phenotyping may prove informative about potential genetic etiologies of PVS.
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Screening for potential targets to reduce stenosis in bioprosthetic heart valves. Sci Rep 2021; 11:2464. [PMID: 33510256 PMCID: PMC7843970 DOI: 10.1038/s41598-021-81340-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2020] [Accepted: 12/24/2020] [Indexed: 12/02/2022] Open
Abstract
Progressive stenosis is one of the main factors that limit the lifetime of bioprosthetic valved conduits. To improve long-term performance we aimed to identify targets that inhibit pannus formation on conduit walls. From 11 explanted, obstructed, RNAlater presevered pulmonary valved conduits, we dissected the thickened conduit wall and the thin leaflet to determine gene expression-profiles using ultra deep sequencing. Differential gene expression between pannus and leaflet provided the dataset that was screened for potential targets. Promising target candidates were immunohistologically stained to see protein abundance and the expressing cell type(s). While immunostainings for DDR2 and FGFR2 remained inconclusive, EGFR, ErbB4 and FLT4 were specifically expressed in a subset of tissue macrophages, a cell type known to regulate the initiation, maintenance, and resolution of tissue repair. Taken toghether, our data suggest EGFR, ErbB4 and FLT4 as potential target candidates to limit pannus formation in bioprosthestic replacement valves.
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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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Lake D. The Brightest Rainbow Follows the Darkest Storm. CHILDREN 2020; 7:children7110223. [PMID: 33182595 PMCID: PMC7697646 DOI: 10.3390/children7110223] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 11/01/2020] [Accepted: 11/05/2020] [Indexed: 11/16/2022]
Abstract
A parent’s perspective on pulmonary vein stenosis through the experience of two children with the disease.
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Affiliation(s)
- Douglas Lake
- Department of Radiology, McFarland Clinic, 1215 Duff Avenue, Ames, IA 50010, USA;
- Department of Radiology, Stanford School of Medicine 300 Pasteur Drive, Palo Alto, CA 94301, USA
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Kirkpatrick EC, Mitchell ME, Thilly WG, Cava J, Tomita-Mitchell A, Gostjeva EV. Use of Metformin in Pulmonary Vein Stenosis after TAPVR Repair. Glob Pediatr Health 2020; 7:2333794X20958924. [PMID: 33029553 PMCID: PMC7522838 DOI: 10.1177/2333794x20958924] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2020] [Revised: 08/13/2020] [Accepted: 08/21/2020] [Indexed: 11/15/2022] Open
Affiliation(s)
- Edward C Kirkpatrick
- Children's Hospital of Wisconsin, Milwaukee, WI, USA.,Medical College of Wisconsin, Milwaukee, WI, USA
| | - Michael E Mitchell
- Children's Hospital of Wisconsin, Milwaukee, WI, USA.,Medical College of Wisconsin, Milwaukee, WI, USA
| | | | - Joseph Cava
- Children's Hospital of Wisconsin, Milwaukee, WI, USA.,Medical College of Wisconsin, Milwaukee, WI, USA
| | - Aoy Tomita-Mitchell
- Children's Hospital of Wisconsin, Milwaukee, WI, USA.,Medical College of Wisconsin, Milwaukee, WI, USA
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Abstract
PURPOSE OF REVIEW Pulmonary vein stenosis (PVS) is a rare entity that until the last 2 decades was seen primarily in infants and children. Percutaneous and surgical interventions have limited success due to relentless restenosis, and mortality remains high. In adults, acquired PVS following ablation for atrial fibrillation has emerged as a new syndrome. This work will review these two entities with emphasis on current treatment. RECENT FINDINGS Greater emphasis on understanding and addressing the mechanism of restenosis for congenital PVS has led to the use of drug-eluting stents (DES) and systemic drug therapy to target neo-intimal growth. Frequent reinterventions are positively affecting outcomes. Longer-term outcomes of percutaneous treatment for acquired PVS are emerging. Treatment of congenital PVS continues to be plagued by restenosis. DES show promise, but frequent reinterventions are required. Larger upstream vein diameter predicts success for congenital and acquired PVS interventions. Efforts to induce/maintain vessel growth are important for future treatment strategies.
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Affiliation(s)
- Patcharapong Suntharos
- Division of Pediatric Cardiology, Nicklaus Children's Hospital, 3100 SW 62nd Avenue, Miami, FL, 33155, USA
| | - Lourdes R Prieto
- Division of Pediatric Cardiology, Nicklaus Children's Hospital, 3100 SW 62nd Avenue, Miami, FL, 33155, USA.
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43
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Callahan R, Jenkins KJ, Gauthier Z, Gauvreau K, Porras D. Preliminary findings on the use of intravascular ultrasound in the assessment of pediatric pulmonary vein stenosis. Catheter Cardiovasc Interv 2020; 97:E362-E370. [PMID: 32936535 DOI: 10.1002/ccd.29264] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/21/2020] [Revised: 08/24/2020] [Accepted: 08/31/2020] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Determine the feasibility of performing intravascular ultrasound (IVUS) in pediatric pulmonary vein stenosis (PVS) and investigate whether IVUS can delineate the mechanism of PVS. BACKGROUND The use of IVUS in pediatric patients with PVS has not been reported. METHODS Retrospective, single center, cohort analysis of all patients who underwent IVUS of pulmonary veins from August 2016 to December 2019. RESULTS IVUS was performed on 81 pulmonary veins in 50 pediatric patients (median age = 1.7 years [0.9, 3.1], median weight = 8.6 kg [7.3, 11.8]). All veins accepted the IVUS catheter (.014 or .018), with adequate visualization in 88% (71/81) of imaged veins, and improvement in visualization in the more recent period (23/24; 96%). Veins were categorized as having presumed intimal thickening (PIT) with luminal narrowing (n = 36), ostial narrowing without PIT (n = 14), distortion/compression (n = 6), normal (n = 2), and stent with (n = 9) or without in-stent stenosis (n = 4). In veins with at least 6 months of follow up, (re)intervention occurred more commonly in veins with PIT (14/19; 74%) versus veins without PIT (3/13; 23%; p = 0.01). There were no IVUS related adverse events. CONCLUSION IVUS can be used safely in pediatric patients and can reliably demonstrate vein lumen and wall architecture. With further refinement, IVUS has the potential to differentiate intimal neo-proliferation from other mechanisms of obstruction. The exact role of IVUS in the assessment of pediatric PVS is yet to be determined.
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Affiliation(s)
- Ryan Callahan
- Department of Cardiology, Boston Children's Hospital and Harvard Medical School, Boston, Massachusetts
| | - Kathy J Jenkins
- Department of Cardiology, Boston Children's Hospital and Harvard Medical School, Boston, Massachusetts
| | - Zachary Gauthier
- Department of Cardiology, Boston Children's Hospital and Harvard Medical School, Boston, Massachusetts
| | - Kimberlee Gauvreau
- Department of Cardiology, Boston Children's Hospital and Harvard Medical School, Boston, Massachusetts
| | - Diego Porras
- Department of Cardiology, Boston Children's Hospital and Harvard Medical School, Boston, Massachusetts
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Fender EA, Widmer RJ, Mahowald MK, Hodge DO, Packer DL, Holmes DR. Recurrent pulmonary vein stenosis after successful intervention: Prognosis and management of restenosis. Catheter Cardiovasc Interv 2020; 95:954-958. [PMID: 31854110 DOI: 10.1002/ccd.28645] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/13/2019] [Revised: 10/15/2019] [Accepted: 12/07/2019] [Indexed: 12/31/2022]
Abstract
OBJECTIVES The aim of this study was to describe management of recurrent pulmonary vein stenosis (PVS) and determine if stenting is superior to balloon angioplasty (BA) in preventing subsequent restenosis. BACKGROUND PVS is a serious complication of atrial fibrillation ablation. BA and stenting are effective therapies; however, restenosis frequently occurs. Here we report management of recurrent stenosis. METHODS This was a prospective observational study performed from 2000 to 2014. RESULTS One hundred and thirteen patients with severe PVS underwent intervention in 88 veins treated with BA and 81 treated with stenting. Forty-two patients experienced restenosis. Restenosis was more common in veins treated with BA (RRR 53% [95% CI 32-70%, p = .008]). A second intervention was performed in 41 patients. In the 34 vessels treated with initial BA, 24 were treated for restenosis with a stent and 10 were treated with a second BA. The recurrence rate was 46% in those treated with BA followed by stenting and 50% in those treated with two BA procedures. In the 22 veins treated with initial stenting, 9 were treated with another stent and 13 were treated with BA. The recurrence rate was 44% in those treated with a second stent and 46% for those treated with a stent followed by BA. The risk of a third stenosis was the same among all groups (Analysis of variance [ANOVA] p = .99). Limited sample size precluded analysis of outcome by stent size. CONCLUSIONS Restenosis occurred in 44% of patients overall. Management is challenging; stenting does not appear to be superior to BA.
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Affiliation(s)
- Erin A Fender
- Department of Cardiovascular Diseases, Mayo Clinic, Rochester, Minnesota
| | - R Jay Widmer
- Department of Internal Medicine, Division of Cardiovascular Diseases, Baylor Scott and White, Temple, Texas
| | | | - David O Hodge
- Department of Health Sciences Research, Mayo Clinic, Jacksonville, Florida
| | - Douglas L Packer
- Department of Cardiovascular Diseases, Mayo Clinic, Rochester, Minnesota
| | - David R Holmes
- Department of Cardiovascular Diseases, Mayo Clinic, Rochester, Minnesota
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Vanderlaan RD. Commentary: Targeting neointimal lesions in pulmonary vein stenosis: Fact or fiction? J Thorac Cardiovasc Surg 2020; 160:794-795. [PMID: 32145910 DOI: 10.1016/j.jtcvs.2020.02.021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/04/2020] [Accepted: 02/04/2020] [Indexed: 11/16/2022]
Affiliation(s)
- Rachel D Vanderlaan
- Division of Cardiovascular Surgery, Hospital for Sick Children, Toronto, Ontario, Canada.
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Systemic Sirolimus to Prevent In-Stent Stenosis in Pediatric Pulmonary Vein Stenosis. Pediatr Cardiol 2020; 41:282-289. [PMID: 31720783 DOI: 10.1007/s00246-019-02253-6] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/13/2019] [Accepted: 11/05/2019] [Indexed: 10/25/2022]
Abstract
Evaluate the efficacy of systemic sirolimus (rapamycin) in preventing in-stent stenosis (ISS) in pediatric intraluminal pulmonary vein stenosis (PVS). Report the adverse events related to sirolimus therapy. There is a high incidence of ISS following stent implantation in PVS. The use of sirolimus in preventing ISS has not been reported. Retrospective review of all patients who received sirolimus (8 week course) for treatment of ISS for PVS between January 2013 and June 2018. Forty stents (37 bare metal, 3 drug-eluting) in 20 patients were treated with sirolimus; 20 at the time of implantation (primary prevention [1P]) and 20 following documented ISS requiring transcatheter reintervention (secondary prevention [2P]). Treated patients were young (median 2 y/o [0.7-5.7]) and most had PVS associated with congenital heart disease (75%, 15/20; 4/15 with TAPVC). In the 1P group, 85% (17/20) of stents were without significant (< 50%) ISS at median of 102 days (range 56-527); the growth rate of ISS in this group was 7.5 ± 7.1%/month. In the 2P group, most stents had a slower growth rate of ISS after sirolimus therapy compared to pre-treatment (median 3.7 [- 0.2 to 13.1] vs. 10.4 [1.3 to 19.5] %/month; p < 0.001). One patient developed pneumonia on drug while concurrently taking another immunosuppressive agent. No other serious adverse events were related to sirolimus therapy. Systemic sirolimus slows the growth rate of ISS following stent implantation in PVS compared to pre-treatment rates and was administered safely in a small number of pediatric patients with complex heart disease.
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Abstract
Positive pressure ventilation can significantly alter hemodynamics. The reduction in systemic venous return and increase in right ventricular afterload in response to an inappropriately high mean airway pressure can decrease pulmonary blood flow and compromise systemic perfusion as a result. In addition to ventilator parameters, the degree of hemodynamic effects depends on the baseline cardiac function and lung compliance. Furthermore, the chronically ventilated infants often have a multitude of comorbidities which may also impact hemodynamics. These include pulmonary and systemic hypertension which can lead to myocardial dysfunction as a result of the increase in the right and left ventricular afterload, respectively. In this section, we aim to outline the hemodynamic changes associated with chronic lung disease and mechanical ventilation and discuss management options.
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Affiliation(s)
- Shazia Bhombal
- Division of Neonatal and Developmental Medicine, Department of Pediatrics, Stanford University, Palo Alto, CA, USA
| | - Shahab Noori
- Fetal and Neonatal Institute, Division of Neonatology, Children's Hospital Los Angeles, Department of Pediatrics, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA.
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48
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Clinical outcomes after the endovascular treatments of pulmonary vein stenosis in patients with congenital heart disease. Cardiol Young 2019; 29:1057-1065. [PMID: 31287033 DOI: 10.1017/s1047951119001495] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND Pulmonary vein stenosis (PVS) is a condition with challenging treatment and leads to severe cardiac failure and pulmonary hypertension. Despite aggressive surgical or catheter-based intervention, the prognosis of PVS is unsatisfactory. This study aimed to assess the prognosis and to establish appropriate treatment strategies. METHODS We retrospectively reviewed endovascular treatments for PVS (2001-2017) from the clinical database at the Okayama University Hospital. RESULTS A total of 24 patients underwent PVS associated with total anomalous pulmonary venous connection and 7 patients underwent isolated congenital PVS. In total, 53 stenotic pulmonary veins were subjected to endovascular treatments; 40 of them were stented by hybrid (29) and percutaneous procedures (11) (bare-metal stent, n = 34; drug-eluting stent, n = 9). Stent size of hybrid stenting was larger than percutaneous stenting. Median follow-up duration from the onset of PVS was 24 months (4-134 months). Survival rate was 71 and 49% at 1 and 5 years, respectively. There was no statistically significant difference between stent placement and survival; however, patients who underwent bare-metal stent implantation had statistically better survival than those who underwent drug-eluting stent implantation or balloon angioplasty. Early onset of stenosis, timing of stenting, and small vessel diameter of pulmonary vein before stenting were considered as risk factors for in-stent restenosis. Freedom from re-intervention was 50 and 26% at 1 and 2 years. CONCLUSIONS To improve survival and stent patency, implantation of large stent is important. However, re-intervention after stenting is also significant to obtain good outcome.
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49
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Nasr VG, Callahan R, Wichner Z, Odegard KC, DiNardo JA. Intraluminal Pulmonary Vein Stenosis in Children. Anesth Analg 2019; 129:27-40. [DOI: 10.1213/ane.0000000000003924] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
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50
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Khan A, Qureshi AM, Justino H. Comparison of drug eluting versus bare metal stents for pulmonary vein stenosis in childhood. Catheter Cardiovasc Interv 2019; 94:233-242. [DOI: 10.1002/ccd.28328] [Citation(s) in RCA: 29] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/20/2018] [Revised: 04/08/2019] [Accepted: 04/24/2019] [Indexed: 11/11/2022]
Affiliation(s)
- Asra Khan
- Charles E. Mullins Cardiac Catheterization LaboratoriesLillie Frank Abercrombie Section of Pediatric Cardiology, Texas Children's Hospital, Baylor College of Medicine Houston Texas
| | - Athar M. Qureshi
- Charles E. Mullins Cardiac Catheterization LaboratoriesLillie Frank Abercrombie Section of Pediatric Cardiology, Texas Children's Hospital, Baylor College of Medicine Houston Texas
| | - Henri Justino
- Charles E. Mullins Cardiac Catheterization LaboratoriesLillie Frank Abercrombie Section of Pediatric Cardiology, Texas Children's Hospital, Baylor College of Medicine Houston Texas
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