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Jacquemyn X, Singh TP, Gossett JG, Averin K, Kutty S, Zühlke LJ, Abdullahi LH, Kulkarni A. Mortality and Heart Transplantation After Hybrid Palliation of Hypoplastic Left Heart Syndrome: A Systematic Review and Meta-Analysis. World J Pediatr Congenit Heart Surg 2024; 15:215-223. [PMID: 38404131 DOI: 10.1177/21501351231224323] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/27/2024]
Abstract
BACKGROUND Newborns with hypoplastic left heart syndrome (HLHS) who are considered at increased risk for death following Norwood/Sano surgery often undergo hybrid palliation (HP) as initial surgery. We aimed to compile the HP experience in HLHS and its variants and assess the rates of, and risk factors for, death and heart transplantation. METHODS CINAHL, CINAHL PLUS, PubMed/MEDLINE, and SCOPUS were systematically searched for HP outcome studies of death or heart transplantation in HLHS between 1998 and 2022. Pooled incidence was estimated, and potential risk factors were identified using random-effects meta-analysis and reconstructed time-to-event data from Kaplan-Meier curves. RESULTS Thirty-three publications were included in our review. Overall, of 1,162 patients 417 died and 57 underwent heart transplantation, resulting in a combined outcome of 40.7%, (474/1,162). There was a trend toward decreasing mortality risk across the stages of palliation. Pooled mortality between HP and comprehensive stage 2 palliation was 25%, after stage 2 up to Fontan palliation was 16%, and 6% post-Fontan. The incidence of death or heart transplantation was higher in high-risk patients-43% died and 10% received heart transplantation. CONCLUSION Our systematic review and meta-analysis found high rates of death or heart transplantation in HP of HLHS patients between HP and Fontan surgeries. All patients should be closely followed during the initial interstage period, which is associated with the highest hazard. Prospective studies on appropriate patient selection, indications, and / or alternatives, as well as refining HP strategies for managing newborns with HLHS are needed to improve outcomes.
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Affiliation(s)
- Xander Jacquemyn
- Helen B. Taussig Heart Center, Department of Pediatrics, Johns Hopkins Hospital, Baltimore, MD, USA
- Department of Cardiovascular Sciences, KU Leuven, Leuven, Belgium
| | - Tajinder P Singh
- Department of Cardiology, Boston Children's Hospital, Boston, MA, USA
| | - Jeffrey G Gossett
- Cohen Children's Heart Center, Donald and Barbara Zucker School of Medicine at Hofstra/ Northwell, New Hyde Park, NY, USA
| | - Konstantin Averin
- Cohen Children's Heart Center, Donald and Barbara Zucker School of Medicine at Hofstra/ Northwell, New Hyde Park, NY, USA
| | - Shelby Kutty
- Helen B. Taussig Heart Center, Department of Pediatrics, Johns Hopkins Hospital, Baltimore, MD, USA
| | - Liesl J Zühlke
- President's Office, South African Medical Research Council, Cape Town, South Africa
- Division of Paediatric Cardiology, Department of Paediatrics, Institute of Child Health, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa
| | - Leila H Abdullahi
- Save the Children International (SCI), Somalia/Somaliland Country Office. Nairobi, Kenya
| | - Aparna Kulkarni
- Cohen Children's Heart Center, Donald and Barbara Zucker School of Medicine at Hofstra/ Northwell, New Hyde Park, NY, USA
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Theurel Martín DE, Alvarado Socarras JL, Manrique Hernández EF, Sandoval MA, Coronado Munoz AJ. Presurgical Use of Hypoxic Mixture for Systemic Perfusion Improvement in Neonates With Complex Congenital Heart Disease: A Systematic Review and Meta-Analysis. Cureus 2024; 16:e53409. [PMID: 38435156 PMCID: PMC10908418 DOI: 10.7759/cureus.53409] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/01/2024] [Indexed: 03/05/2024] Open
Abstract
Oxygen therapy is essential for the survival of preterm babies and critically ill newborns; however, it has the potential to cause harm through hypoxemia or hyperoxemia. Newborns with complex congenital heart diseases (CHD) suffer from oxygen fluctuations due to the disease and its treatments, altering pre and postnatal development. The objective of this study is to evaluate the evidence for using a hypoxic mixture to decrease pulmonary over-circulation and improve systemic perfusion before surgical interventions in newborns with complex CHD that course with pulmonary over-circulation and systemic hypoperfusion. A search was conducted in PubMed, EMBASE, LILACS, Scielo, Taylor and Francis, SAGE, and Science Direct databases from 2000 to 2022 by two independent authors, including articles with hypoxic mixture treatment in observational studies or trials, with pre-treatment and post-treatment measurements in the same patient, or two groups or more comparisons. Six articles were selected, with a total of 75 patients. The primary outcome was improved systemic circulation and decreased pulmonary over-circulation measured directly with Qp/Qs and indirectly with oxygen saturation and cerebral near-infrared spectroscopy (NIRS). In addition, we performed a meta-analysis for oxygen saturation and cerebral NIRS. Oxygen saturation was the value uniformly reported; three studies reported a significantly lower oxygen saturation after the hypoxic mixture. The cerebral NIRS was measured in 4 studies, with inconsistent results. After using the hypoxic mixture, the Qp/Qs calculation was lower in the two studies but was not statistically significant. The meta-analysis for oxygen saturation showed a fixed effect post-hypoxic therapy of -0.7 (-1.06; -0.35), p < 0.001. The meta-analysis of two studies that measured cerebral NIRS did not show a statistically significant difference at 12 and 24 hours. In conclusion, this is the first systematic review and meta-analysis regarding the pre-operative use of hypoxic gas mixtures for newborns with complex congenital heart disease. Treatment results in lower oxygen saturations, but there is a lack of evidence of improvement in systemic perfusion. The utilization of this therapy is controversial, and better evidence is necessary.
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Affiliation(s)
| | | | | | - Mónica A Sandoval
- Pediatric Critical Care Medicine, University of Miami, Coral Gables, USA
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3
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Oreto L, Guccione P, Gitto P, Bruno L, Zanai R, Grasso N, Iannace E, Zito C, Carerj S, Agati S. Hybrid Palliation for Hypoplastic Left Heart Syndrome: Role of Echocardiography. CHILDREN (BASEL, SWITZERLAND) 2023; 10:1012. [PMID: 37371244 DOI: 10.3390/children10061012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/15/2023] [Revised: 05/24/2023] [Accepted: 06/01/2023] [Indexed: 06/29/2023]
Abstract
Hypoplastic left heart syndrome is a spectrum of complex congenital cardiac defects. Although in borderline cases, biventricular repair is a viable option, in the majority of cases, univentricular palliation is the treatment of choice. Hybrid palliation can be a valid alternative to classic Norwood operation in the neonatal period, especially in selected cases such as high-risk patients or borderline left ventricles. Echocardiography is the main diagnostic modality in this pediatric population, from the fetal diagnosis to the subsequent surgical steps of palliative treatment. Hybrid palliation is performed after birth and is characterized by surgical banding of the pulmonary arteries along with transcatheter stenting of the ductus arteriosus. There are some peculiar aspects of cardiac imaging that characterize this type of palliation, and that should be considered in the different phases before and after the procedure. We aimed to review the current literature about the role of echocardiography in the management of patients with hypoplastic left heart undergoing hybrid palliation.
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Affiliation(s)
- Lilia Oreto
- Department of Clinical and Experimental Medicine, University of Messina, 98122 Messina, Italy
- Mediterranean Pediatric Cardiology Center, Bambino Gesù Children's Hospital, 98035 Taormina, Italy
| | - Paolo Guccione
- Mediterranean Pediatric Cardiology Center, Bambino Gesù Children's Hospital, 98035 Taormina, Italy
| | - Placido Gitto
- Mediterranean Pediatric Cardiology Center, Bambino Gesù Children's Hospital, 98035 Taormina, Italy
| | - Letteria Bruno
- Department of Human Pathology in Adult and Developmental Age, University of Messina, 98122 Messina, Italy
| | - Rosanna Zanai
- Mediterranean Pediatric Cardiology Center, Bambino Gesù Children's Hospital, 98035 Taormina, Italy
| | - Nadia Grasso
- Mediterranean Pediatric Cardiology Center, Bambino Gesù Children's Hospital, 98035 Taormina, Italy
| | - Enrico Iannace
- Mediterranean Pediatric Cardiology Center, Bambino Gesù Children's Hospital, 98035 Taormina, Italy
| | - Concetta Zito
- Department of Clinical and Experimental Medicine, University of Messina, 98122 Messina, Italy
| | - Scipione Carerj
- Department of Clinical and Experimental Medicine, University of Messina, 98122 Messina, Italy
| | - Salvatore Agati
- Mediterranean Pediatric Cardiology Center, Bambino Gesù Children's Hospital, 98035 Taormina, Italy
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Rigatelli G, Chiastra C, Pennati G, Dubini G, Migliavacca F, Zuin M. Applications of computational fluid dynamics to congenital heart diseases: a practical review for cardiovascular professionals. Expert Rev Cardiovasc Ther 2021; 19:907-916. [PMID: 34704881 DOI: 10.1080/14779072.2021.1999229] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
INTRODUCTION The increased survival rate of patients with congenital heart disease (CHD) has made it likely that 70%-95% of infants with CHDs surviving into adulthood often require careful follow-up and (repeat) interventions. Patients with CHDs often have abnormal blood flow patterns, due to both primary cardiac defect and the consequent surgical or endovascular repair. AREA COVERED Computational fluid dynamics (CFD) alone or coupled with advanced imaging tools can assess blood flow patterns of CHDs to both understand their pathophysiology and anticipate the results of surgical or interventional repair. EXPERT OPINION CFD is a mathematical technique that quantifies and describes the characteristics of fluid flow using the laws of physics. Through dedicated software based on virtual reconstruction and simulation and patients' real data coming from computed tomography, magnetic resonance imaging, and 3/4 D-ultrasound, reconstruction of models of circulation of most CHD can be accomplished. CFD can provide insights about the pathophysiology of coronary artery anomalies, interatrial shunts, coarctation of the aorta and aortic bicuspid valve, tetralogy of Fallot and univentricular heart, with the capability in some cases of simulating different types of surgical or interventional repair and tailoring the treatment on the basis of these findings.
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Affiliation(s)
- Gianluca Rigatelli
- Cardiovascular Diagnosis and Endoluminal Interventions Unit, Rovigo General Hospital, Rovigo, Italy
| | - Claudio Chiastra
- PoliToBIOMed Lab, Department of Mechanical and Aerospace Engineering, Politecnico di Torino, Turin, Italy
| | - Giancarlo Pennati
- Laboratory of Biological Structure Mechanics (Labs), Department of Chemistry, Materials and Chemical Engineering Giulio Natta, Politecnico di Milano, Milan, Italy
| | - Gabriele Dubini
- Laboratory of Biological Structure Mechanics (Labs), Department of Chemistry, Materials and Chemical Engineering Giulio Natta, Politecnico di Milano, Milan, Italy
| | - Francesco Migliavacca
- Laboratory of Biological Structure Mechanics (Labs), Department of Chemistry, Materials and Chemical Engineering Giulio Natta, Politecnico di Milano, Milan, Italy
| | - Marco Zuin
- Section of Internal and Cardiopulmonary Medicine, University of Ferrara, Ferrara, Italy
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Hameed M, Prather R, Divo E, Kassab A, Nykanen D, Farias M, DeCampli WM. Computational fluid dynamics investigation of the novel hybrid comprehensive stage II operation. JTCVS OPEN 2021; 7:308-323. [PMID: 36003745 PMCID: PMC9390546 DOI: 10.1016/j.xjon.2021.04.009] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/15/2021] [Accepted: 04/19/2021] [Indexed: 05/31/2023]
Abstract
BACKGROUND The hybrid comprehensive stage 2 (HCS2) procedure is a novel palliative operation applicable to a select subset of single ventricle patients with adequate native antegrade aortic flow to the upper body. Flow to the descending aorta, through the pulmonary outlet and ductal arch, is influenced by a stented intrapulmonary baffle connecting the branch pulmonary arteries. We used computational fluid dynamics (CFD) to elucidate the hemodynamic characteristics of this reconstruction. METHODS We used multiscale CFD analysis of a synthetic, patient-derived HCS2 anatomic configuration with unsteady laminar flow conditions and a non-Newtonian blood model to quantify the resultant hemodynamics. The 3-dimensional CFD model was coupled to a 0-dimensional lumped parameter model of the peripheral circulation to determine the required boundary conditions. RESULTS For the specific anatomy studied, the intrapulmonary baffle did not obstruct flow from the pulmonary trunk to ductal arch as long as the distance between the anterior pulmonary artery wall and baffle wall exceeded ∼7 mm. Vortex shedding off of the baffle wall did not develop, because of the short distance to the ductal arch. The stented baffle experienced significantly uneven "inward" loading from the systemic side. Pulmonary outlet flow separation distal to the baffle produced a low-speed recirculation region. CONCLUSIONS Hemodynamic patterns in this complex anatomy are generally favorable. Low flow recirculation could be mitigated by preoperative shape optimization. Calculated inward stresses on the pulmonary baffle can be used in the future to study baffle stent deformation, which is expected to be small.
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Key Words
- AA, ascending aorta
- BC, boundary condition
- CFD, computational fluid dynamics
- CHD, congenital heart disease
- DA, descending aorta
- HCS2, hybrid comprehensive stage 2
- HLHS, hypoplastic left heart syndrome
- LCA, left coronary artery
- LCCA, left common carotid artery
- LPA, left pulmonary artery
- LPM, lumped parameter model
- LSCA, left subclavian artery
- MPA, main pulmonary artery
- ODE, ordinary differential equation
- PA, pulmonary artery/trunk
- RCA, right coronary artery
- RCCA, right common carotid artery
- RPA, right pulmonary artery
- RSCA, right subclavian artery
- SV, single ventricle
- SVC, superior vena cava
- VSD, ventricular septal defect
- WSS, wall shear stress
- computational fluid dynamics
- congenital heart disease
- hypoplastic left heart syndrome
- lumped parameter model
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Affiliation(s)
- Marwan Hameed
- Department of Mechanical and Aerospace Engineering, University of Central Florida, Orlando, Fla
- Department of Mechanical Engineering, Embry-Riddle Aeronautical University, Daytona Beach, Fla
| | - Ray Prather
- Department of Mechanical and Aerospace Engineering, University of Central Florida, Orlando, Fla
- Department of Mechanical Engineering, Embry-Riddle Aeronautical University, Daytona Beach, Fla
- Pediatric Cardiology, Arnold Palmer Hospital for Children, Orlando, Fla
| | - Eduardo Divo
- Department of Mechanical Engineering, Embry-Riddle Aeronautical University, Daytona Beach, Fla
| | - Alain Kassab
- Department of Mechanical and Aerospace Engineering, University of Central Florida, Orlando, Fla
| | - David Nykanen
- Pediatric Cardiology, Arnold Palmer Hospital for Children, Orlando, Fla
| | - Michael Farias
- Pediatric Cardiology, Arnold Palmer Hospital for Children, Orlando, Fla
| | - William M. DeCampli
- Department of Mechanical and Aerospace Engineering, University of Central Florida, Orlando, Fla
- Pediatric Cardiology, Arnold Palmer Hospital for Children, Orlando, Fla
- Department of Clinical Sciences, College of Medicine, University of Central Florida, Orlando, Fla
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Primeaux J, Salavitabar A, Lu JC, Grifka RG, Figueroa CA. Characterization of Post-Operative Hemodynamics Following the Norwood Procedure Using Population Data and Multi-Scale Modeling. Front Physiol 2021; 12:603040. [PMID: 34054563 PMCID: PMC8155503 DOI: 10.3389/fphys.2021.603040] [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: 09/04/2020] [Accepted: 04/19/2021] [Indexed: 11/22/2022] Open
Abstract
Children with hypoplastic left heart syndrome (HLHS) must undergo multiple surgical stages to reconstruct the anatomy to a sustainable single ventricle system. Stage I palliation, or the Norwood procedure, provides circulation to both pulmonary and systemic vasculature. The aorta is reconstructed and attached to the right ventricle and a fraction of systemic flow is redirected to the pulmonary arteries (PAs) through a systemic-to-PA shunt. Despite abundant hemodynamic data available 4-5 months after Norwood palliation, data is very scarce immediately following stage I. This data is critical in determining post-operative success. In this work, we combined population data and computational fluid dynamics (CFD) to characterize hemodynamics immediately following stage I (post-stage I) and prior to stage II palliation (pre-stage II). A patient-specific model was constructed as a baseline geometry, which was then scaled to reflect population-based morphological data at both time-points. Population-based hemodynamic data was then used to calibrate each model to reproduce blood flow representative of HLHS patients. The post-stage I simulation produced a PA pressure of 22 mmHg and high-frequency oscillations within the flow field indicating highly disturbed hemodynamics. Despite PA mean pressure dropping to 14 mmHg, the pre-stage II model also produced high-frequency flow components and PA wall shear stress increases. These suboptimal conditions may be necessary to ensure adequate PA flow throughout the pre-stage II period, as the shunt becomes relatively smaller compared to the patient's somatic growth. In the future, CFD can be used to optimize shunt design and minimize these suboptimal conditions.
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Affiliation(s)
- Jonathan Primeaux
- Department of Biomedical Engineering, University of Michigan, Ann Arbor, MI, United States
| | - Arash Salavitabar
- C.S. Mott Children’s Hospital, University of Michigan Congenital Heart Center, Ann Arbor, MI, United States
| | - Jimmy C. Lu
- C.S. Mott Children’s Hospital, University of Michigan Congenital Heart Center, Ann Arbor, MI, United States
| | | | - C. Alberto Figueroa
- Department of Biomedical Engineering, University of Michigan, Ann Arbor, MI, United States
- Department of Surgery, University of Michigan, Ann Arbor, MI, United States
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Civilla L, Sbrollini A, Burattini L, Morettini M. An integrated lumped-parameter model of the cardiovascular system for the simulation of acute ischemic stroke: description of instantaneous changes in hemodynamics. MATHEMATICAL BIOSCIENCES AND ENGINEERING : MBE 2021; 18:3993-4010. [PMID: 34198422 DOI: 10.3934/mbe.2021200] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/13/2023]
Abstract
Acute Ischemic Stroke (AIS) is defined as the acute condition of occlusion of a cerebral artery and is often caused by a Hypertensive Condition (HC). Due to its sudden occurrence, AIS is not observable the right moment it occurs, thus information about instantaneous changes in hemodynamics is limited. This study aimed to propose an integrated Lumped Parameter (LP) model of the cardiovascular system to simulate an AIS and describe instantaneous changes in hemodynamics. In the integrated LP model of the cardiovascular system, heart chambers have been modelled with elastance systems with controlled pressure inputs; heart valves have been modelled with static open/closed pressure-controlled valves; eventually, the vasculature has been modelled with resistor-inductor-capacitor (RLC) direct circuits and have been linked to the rest of the system through a series connection. After simulating physiological conditions, HC has been simulated by changing pressure inputs and constant RLC parameters. Then, AIS occurring in arteries of different sizes have been simulated by considering time-dependent RLC parameters due to the elimination from the model of the occluding artery; instantaneous changes in hemodynamics have been evaluated by Systemic Arteriolar Flow (Qa) and Systemic Arteriolar Pressure (Pa) drop with respect to those measured in HC. Occlusion of arteries of different sizes leaded to an average Qa drop of 0.38 ml/s per cardiac cycle (with minimum and maximum values of 0.04 ml/s and 1.93 ml/s) and average Pa drop of 0.39 mmHg, (with minimum and maximum values of 0.04 mmHg and 1.98 mmHg). In conclusion, hemodynamic variations due to AIS are very small with respect to HC. A direct relation between the inverse of the length of the artery in which the occlusion occurs and the hemodynamic variations has been highlighted; this may allow to link the severity of AIS to the length of the interested artery.
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Affiliation(s)
- Lorenzo Civilla
- Department of Information Engineering, UniversitȤ Politecnica delle Marche, Ancona 60131, Italy
| | - Agnese Sbrollini
- Department of Information Engineering, UniversitȤ Politecnica delle Marche, Ancona 60131, Italy
| | - Laura Burattini
- Department of Information Engineering, UniversitȤ Politecnica delle Marche, Ancona 60131, Italy
| | - Micaela Morettini
- Department of Information Engineering, UniversitȤ Politecnica delle Marche, Ancona 60131, Italy
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Vardhan M, Randles A. Application of physics-based flow models in cardiovascular medicine: Current practices and challenges. BIOPHYSICS REVIEWS 2021; 2:011302. [PMID: 38505399 PMCID: PMC10903374 DOI: 10.1063/5.0040315] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/11/2020] [Accepted: 02/18/2021] [Indexed: 03/21/2024]
Abstract
Personalized physics-based flow models are becoming increasingly important in cardiovascular medicine. They are a powerful complement to traditional methods of clinical decision-making and offer a wealth of physiological information beyond conventional anatomic viewing using medical imaging data. These models have been used to identify key hemodynamic biomarkers, such as pressure gradient and wall shear stress, which are associated with determining the functional severity of cardiovascular diseases. Importantly, simulation-driven diagnostics can help researchers understand the complex interplay between geometric and fluid dynamic parameters, which can ultimately improve patient outcomes and treatment planning. The possibility to compute and predict diagnostic variables and hemodynamics biomarkers can therefore play a pivotal role in reducing adverse treatment outcomes and accelerate development of novel strategies for cardiovascular disease management.
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Affiliation(s)
- M. Vardhan
- Department of Biomedical Engineering, Duke University, Durham, North Carolina 27708, USA
| | - A. Randles
- Department of Biomedical Engineering, Duke University, Durham, North Carolina 27708, USA
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Gerrah R, Haller SJ. Computational fluid dynamics: a primer for congenital heart disease clinicians. Asian Cardiovasc Thorac Ann 2020; 28:520-532. [PMID: 32878458 DOI: 10.1177/0218492320957163] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
Computational fluid dynamics has become an important tool for studying blood flow dynamics. As an in-silico collection of methods, computational fluid dynamics is noninvasive and provides numerical values for the most important parameters of blood flow, such as velocity and pressure that are crucial in hemodynamic studies. In this primer, we briefly explain the basic theory and workflow of the two most commonly applied computational fluid dynamics techniques used in the congenital heart disease literature: the finite element method and the finite volume method. We define important terminology and include specific examples of how using these methods can answer important clinical questions in congenital cardiac surgery planning and perioperative patient management.
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Affiliation(s)
- Rabin Gerrah
- Stanford University, Samaritan Cardiovascular Surgery, Corvallis, OR, USA
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10
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Kung E, Corsini C, Marsden A, Vignon-Clementel I, Pennati G, Figliola R, Hsia TY. Multiscale Modeling of Superior Cavopulmonary Circulation: Hemi-Fontan and Bidirectional Glenn Are Equivalent. Semin Thorac Cardiovasc Surg 2019; 32:883-892. [PMID: 31520732 DOI: 10.1053/j.semtcvs.2019.09.007] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2019] [Accepted: 09/04/2019] [Indexed: 11/11/2022]
Abstract
Superior cavopulmonary circulation (SCPC) can be achieved by either the Hemi-Fontan (hF) or Bidirectional Glenn (bG) connection. Debate remains as to which results in best hemodynamic results. Adopting patient-specific multiscale computational modeling, we examined both the local dynamics and global physiology to determine if surgical choice can lead to different hemodynamic outcomes. Six patients (age: 3-6 months) underwent cardiac magnetic resonance imaging and catheterization prior to SCPC surgery. For each patient: (1) a finite 3-dimensional (3D) volume model of the preoperative anatomy was constructed to include detailed definition of the distal branch pulmonary arteries, (2) virtual hF and bG operations were performed to create 2 SCPC 3D models, and (3) a specific lumped network representing each patient's entire cardiovascular circulation was developed from clinical data. Using a previously validated multiscale algorithm that couples the 3D models with lumped network, both local flow dynamics, that is, power loss, and global systemic physiology can be quantified. In 2 patients whose preoperative imaging demonstrated significant left pulmonary artery (LPA) stenosis, we performed virtual pulmonary arterioplasty to assess its effect. In one patient, the hF model showed higher power loss (107%) than the bG, while in 3, the power losses were higher in the bG models (18-35%). In the remaining 2 patients, the power loss differences were minor. Despite these variations, for all patients, there were no significant differences between the hF and bG models in hemodynamic or physiological outcomes, including cardiac output, superior vena cava pressure, right-left pulmonary flow distribution, and systemic oxygen delivery. In the 2 patients with LPA stenosis, arterioplasty led to better LPA flow (5-8%) while halving the power loss, but without important improvements in SVC pressure or cardiac output. Despite power loss differences, both hF and bG result in similar SCPC hemodynamics and physiology outcome. This suggests that for SCPC, the pre-existing patient-specific physiology and condition, such as pulmonary vascular resistance, are more deterministic in the hemodynamic performance than the type of surgical palliation. Multiscale modeling can be a decision-assist tool to assess whether an extensive LPA reconstruction is needed at the time of SCPC for LPA stenosis.
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Affiliation(s)
- Ethan Kung
- Clemson University, Clemson, South Carolina
| | | | | | - Irene Vignon-Clementel
- National Institute for Research in Computer Science and Automation (INRIA), Paris, France
| | | | | | - Tain-Yen Hsia
- Pediatric Cardiac Surgery, Yale New Haven Children's Hospital, New Haven, Connecticut.
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11
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Asada S, Yamagishi M, Nishida K, Okazaki S, Nakayama Y, Monta O, Tsutsumi Y, Ohashi H. Anomalous Origin of Left Coronary Artery From Aortic Arch Associated With Hypoplastic Left Heart Syndrome. Ann Thorac Surg 2019; 107:e51-e53. [DOI: 10.1016/j.athoracsur.2018.05.028] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/26/2018] [Revised: 05/07/2018] [Accepted: 05/12/2018] [Indexed: 10/14/2022]
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12
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Ceballos A, Prather R, Divo E, Kassab AJ, DeCampli WM. Patient-Specific Multi-Scale Model Analysis of Hemodynamics Following the Hybrid Norwood Procedure for Hypoplastic Left Heart Syndrome: Effects of Reverse Blalock-Taussig Shunt Diameter. Cardiovasc Eng Technol 2018; 10:136-154. [PMID: 30515683 DOI: 10.1007/s13239-018-00396-w] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/20/2018] [Accepted: 11/20/2018] [Indexed: 11/26/2022]
Abstract
INTRODUCTION The hybrid Norwood (HN) is a relatively new first stage palliative procedure for neonates with hypoplastic left heart syndrome, in which a sustainable uni-ventricular circulation is established in a less invasive manner than with the standard Norwood procedure. A computational multiscale model of the circulation following the HN procedure was used to obtain detailed hemodynamics. Implementation of a reverse-BT shunt (RBTS), a synthetic bypass from the main pulmonary to the innominate artery placed to counteract aortic arch stenosis, and its effects on local and global hemodynamics were studied. METHODS A post-op patient-derived anatomy of the HN procedure was utilized with varying degrees of distal arch obstruction, or stenosis, (nominal and 90% lumenal area reduction) and varying RBTS diameters (3.0, 3.5, 4.0 mm). A closed lumped parameter model (LPM) for the proximal and peripheral circulations was coupled to a 3D computational fluid dynamics (CFD) model in order to obtain converged flow fields for analysis. RESULTS CFD analyses of patient-derived anatomic configurations demonstrated consistent trends of vascular bed perfusion, vorticity, oscillatory shear index and wall shear stress levels. In the models with severe stenosis, implementation of the RBTS resulted in a restoration of arterial perfusion to near-nominal levels regardless of the shunt diameter. Shunt flow velocity, vorticity, and overall wall shear stress levels decreased with increasing shunt diameter, while shunt flow and systemic oxygen delivery increased with increased shunt diameter. In the absence of distal arch stenosis, large (4.0 mm) grafts may risk thrombosis due to low velocities and flow patterns. CONCLUSION Among the three graft sizes, the best option seems to be the 3.5 mm RBTS which provides a more organized flow similar to that of the 3.0 mm configuration with lower levels of wall shear stress. As such, in the setting of this study and for comparable HN physiologies our results suggest that: (1) the 4.0 mm shunt is a generous shunt diameter choice that may be problematic particularly when implemented prophylactically in the absence of stenosis, and (2) the 3.5 mm shunt may be a more suitable alternative since it exhibits more favorable hemodynamics at lower levels of wall shear stress.
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Affiliation(s)
- Andres Ceballos
- Mechanical and Aerospace Engineering, University of Central Florida, Orlando, FL, USA
| | - Ray Prather
- Mechanical and Aerospace Engineering, University of Central Florida, Orlando, FL, USA.
| | - Eduardo Divo
- Mechanical Engineering, Embry-Riddle Aeronautical University, Daytona Beach, FL, USA
| | - Alain J Kassab
- Mechanical and Aerospace Engineering, University of Central Florida, Orlando, FL, USA
| | - William M DeCampli
- The Heart Center, Arnold Palmer Hospital for Children, Orlando, FL, USA
- College of Medicine, University of Central Florida, Orlando, FL, USA
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Kido T, Hoashi T, Kitano M, Shimada M, Kurosaki K, Ishibashi-Ueda H, Ichikawa H. Impact of Hybrid Stage 1 Palliation for Hypoplastic Left Heart Syndrome: Histopathological Findings. Pediatr Cardiol 2018. [PMID: 29523921 DOI: 10.1007/s00246-018-1851-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
The purpose of the study is to analyze the impact of hybrid stage 1 palliation on right ventricular myocardial pathology in hypoplastic left heart syndrome. Sufficient amount of right ventricular biopsies could be obtained from 16 of 32 patients who underwent Norwood operation between 2007 and 2013. Histopathological findings of right ventricle in patients who underwent primary Norwood operation (primary group, n = 5), patients with aortic atresia (HS1P AA group, n = 6) or aortic stenosis (HS1P AS group, n = 5) who underwent staged Norwood palliation following hybrid stage 1 palliation were compared. To eliminate the influence of right ventricular pressure afterload, right ventricular biopsies were obtained from patients with truncus arteriosus communis (TAC group, n = 6) at total correction. The percentage of myocardial fibrosis was significantly higher in both HS1P groups than in TAC group; moreover, it was significantly higher in HS1P AA group than in primary group. Capillary vascular density was significantly lower in all hypoplastic left heart syndrome groups than in TAC group. At the sub-endocardial layer, collagen type I/III ratios were higher in HS1P AA group than in other hypoplastic left heart syndrome groups. The proportions of N-cadherin immunolocalized to myocyte termini were lower in all hypoplastic left heart syndrome groups than in TAC group. Right ventricle in hypoplastic left heart syndrome showed more significant ischemic change and myocardial immaturity than that in truncus arteriosus communis. Hybrid stage 1 palliation for aortic atresia would be a risk factor for further right ventricular myocardial ischemia.
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Affiliation(s)
- Takashi Kido
- Department of Pediatric Cardiovascular Surgery, National Cardiovascular and Cerebral Center, 5-7-1, Fujishiro-dai, Suita, Osaka, 565-8565, Japan
| | - Takaya Hoashi
- Department of Pediatric Cardiovascular Surgery, National Cardiovascular and Cerebral Center, 5-7-1, Fujishiro-dai, Suita, Osaka, 565-8565, Japan.
| | - Masataka Kitano
- Department of Pediatric Cardiology, National Cardiovascular and Cerebral Center, 5-7-1, Fujishiro-dai, Suita, Osaka, 565-8565, Japan
| | - Masatoshi Shimada
- Department of Pediatric Cardiovascular Surgery, National Cardiovascular and Cerebral Center, 5-7-1, Fujishiro-dai, Suita, Osaka, 565-8565, Japan
| | - Kenichi Kurosaki
- Department of Pediatric Cardiology, National Cardiovascular and Cerebral Center, 5-7-1, Fujishiro-dai, Suita, Osaka, 565-8565, Japan
| | - Hatsue Ishibashi-Ueda
- Department of Pathology, National Cardiovascular and Cerebral Center, 5-7-1, Fujishiro-dai, Suita, Osaka, 565-8565, Japan
| | - Hajime Ichikawa
- Department of Pediatric Cardiovascular Surgery, National Cardiovascular and Cerebral Center, 5-7-1, Fujishiro-dai, Suita, Osaka, 565-8565, Japan
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Prather R, Seligson J, Ni M, Divo E, Kassab A, DeCampli W. Patient-specific multiscale computational fluid dynamics assessment of embolization rates in the hybrid Norwood: effects of size and placement of the reverse Blalock-Taussig shunt. Can J Physiol Pharmacol 2018; 96:690-700. [PMID: 29787689 DOI: 10.1139/cjpp-2018-0002] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
The hybrid Norwood operation is performed to treat hypoplastic left heart syndrome. Distal arch obstruction may compromise flow to the brain. In a variant of this procedure, a synthetic graft (reverse Blalock-Taussig shunt) is placed between the pulmonary trunk and innominate artery to improve upper torso blood flow. Thrombi originating in the graft may embolize to the brain. In this study, we used computational fluid dynamics and particle tracking to investigate the patterns of particle embolization as a function of the anatomic position of the reverse Blalock-Taussig shunt. The degree of distal arch obstruction and position of particle origin influence embolization probabilities to the cerebral arteries. Cerebral embolization probabilities can be reduced by as much as 20% by optimizing graft position, for a given arch geometry, degree of distal arch obstruction, and particle origin. There is a tradeoff, however, between cerebral pulmonary and coronary embolization probabilities.
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Affiliation(s)
- Ray Prather
- a Department of Mechanical and Aerospace Engineering, University of Central Florida, 4000 Central Florida Blvd., Orlando, FL 32816, USA
| | - John Seligson
- a Department of Mechanical and Aerospace Engineering, University of Central Florida, 4000 Central Florida Blvd., Orlando, FL 32816, USA
| | - Marcus Ni
- a Department of Mechanical and Aerospace Engineering, University of Central Florida, 4000 Central Florida Blvd., Orlando, FL 32816, USA
| | - Eduardo Divo
- b Department of Mechanical Engineering, Embry-Riddle Aeronautical University, 600 South Clyde Morris Blvd., Daytona Beach, FL 32114, USA
| | - Alain Kassab
- a Department of Mechanical and Aerospace Engineering, University of Central Florida, 4000 Central Florida Blvd., Orlando, FL 32816, USA
| | - William DeCampli
- c Arnold Palmer Children's Hospital, 1222 S. Orange Ave., Orlando, FL 32806, USA.,d College of Medicine, University of Central Florida, 6850 Lake Nona Blvd, Orlando, FL 32827, USA
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Shimizu S, Une D, Kawada T, Hayama Y, Kamiya A, Shishido T, Sugimachi M. Lumped parameter model for hemodynamic simulation of congenital heart diseases. J Physiol Sci 2018; 68:103-111. [PMID: 29270856 PMCID: PMC10717555 DOI: 10.1007/s12576-017-0585-1] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2017] [Accepted: 12/05/2017] [Indexed: 10/18/2022]
Abstract
The recent development of computer technology has made it possible to simulate the hemodynamics of congenital heart diseases on a desktop computer. However, multi-scale modeling of the cardiovascular system based on computed tomographic and magnetic resonance images still requires long simulation times. The lumped parameter model is potentially beneficial for real-time bedside simulation of congenital heart diseases. In this review, we introduce the basics of the lumped parameter model (time-varying elastance chamber model combined with modified Windkessel vasculature model) and illustrate its usage in hemodynamic simulation of congenital heart diseases using examples such as hypoplastic left heart syndrome and Fontan circulation. We also discuss the advantages of the lumped parameter model and the problems for clinical use.
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Affiliation(s)
- Shuji Shimizu
- Department of Cardiovascular Dynamics, National Cerebral and Cardiovascular Center, 5-7-1 Fujishiro-dai, Suita, Osaka, 565-5685, Japan.
| | - Dai Une
- Department of Cardiovascular Dynamics, National Cerebral and Cardiovascular Center, 5-7-1 Fujishiro-dai, Suita, Osaka, 565-5685, Japan
| | - Toru Kawada
- Department of Cardiovascular Dynamics, National Cerebral and Cardiovascular Center, 5-7-1 Fujishiro-dai, Suita, Osaka, 565-5685, Japan
| | - Yohsuke Hayama
- Department of Cardiovascular Dynamics, National Cerebral and Cardiovascular Center, 5-7-1 Fujishiro-dai, Suita, Osaka, 565-5685, Japan
| | - Atsunori Kamiya
- Department of Cardiovascular Dynamics, National Cerebral and Cardiovascular Center, 5-7-1 Fujishiro-dai, Suita, Osaka, 565-5685, Japan
| | - Toshiaki Shishido
- Department of Research Promotion, National Cerebral and Cardiovascular Center, 5-7-1 Fujishiro-dai, Suita, Osaka, 565-8565, Japan
| | - Masaru Sugimachi
- Department of Cardiovascular Dynamics, National Cerebral and Cardiovascular Center, 5-7-1 Fujishiro-dai, Suita, Osaka, 565-5685, Japan
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Conover T, Hlavacek AM, Migliavacca F, Kung E, Dorfman A, Figliola RS, Hsia TY, Taylor A, Khambadkone S, Schievano S, de Leval M, Hsia TY, Bove E, Dorfman A, Baker GH, Hlavacek A, Migliavacca F, Pennati G, Dubini G, Marsden A, Vignon-Clementel I, Figliola R, McGregor J. An interactive simulation tool for patient-specific clinical decision support in single-ventricle physiology. J Thorac Cardiovasc Surg 2018; 155:712-721. [DOI: 10.1016/j.jtcvs.2017.09.046] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/13/2016] [Revised: 08/20/2017] [Accepted: 09/10/2017] [Indexed: 10/18/2022]
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Shinbane JS, Saxon LA. Virtual medicine: Utilization of the advanced cardiac imaging patient avatar for procedural planning and facilitation. J Cardiovasc Comput Tomogr 2017; 12:16-27. [PMID: 29198733 DOI: 10.1016/j.jcct.2017.11.004] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/25/2017] [Revised: 11/08/2017] [Accepted: 11/12/2017] [Indexed: 01/17/2023]
Abstract
Advances in imaging technology have led to a paradigm shift from planning of cardiovascular procedures and surgeries requiring the actual patient in a "brick and mortar" hospital to utilization of the digitalized patient in the virtual hospital. Cardiovascular computed tomographic angiography (CCTA) and cardiovascular magnetic resonance (CMR) digitalized 3-D patient representation of individual patient anatomy and physiology serves as an avatar allowing for virtual delineation of the most optimal approaches to cardiovascular procedures and surgeries prior to actual hospitalization. Pre-hospitalization reconstruction and analysis of anatomy and pathophysiology previously only accessible during the actual procedure could potentially limit the intrinsic risks related to time in the operating room, cardiac procedural laboratory and overall hospital environment. Although applications are specific to areas of cardiovascular specialty focus, there are unifying themes related to the utilization of technologies. The virtual patient avatar computer can also be used for procedural planning, computational modeling of anatomy, simulation of predicted therapeutic result, printing of 3-D models, and augmentation of real time procedural performance. Examples of the above techniques are at various stages of development for application to the spectrum of cardiovascular disease processes, including percutaneous, surgical and hybrid minimally invasive interventions. A multidisciplinary approach within medicine and engineering is necessary for creation of robust algorithms for maximal utilization of the virtual patient avatar in the digital medical center. Utilization of the virtual advanced cardiac imaging patient avatar will play an important role in the virtual health care system. Although there has been a rapid proliferation of early data, advanced imaging applications require further assessment and validation of accuracy, reproducibility, standardization, safety, efficacy, quality, cost effectiveness, and overall value to medical care.
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Affiliation(s)
- Jerold S Shinbane
- Division of Cardiovascular Medicine/USC Center for Body Computing, Keck School of Medicine of the University of Southern California, Los Angeles, CA, United States.
| | - Leslie A Saxon
- Division of Cardiovascular Medicine/USC Center for Body Computing, Keck School of Medicine of the University of Southern California, Los Angeles, CA, United States
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Cutrì E, Meoli A, Dubini G, Migliavacca F, Hsia TY, Pennati G. Patient-specific biomechanical model of hypoplastic left heart to predict post-operative cardio-circulatory behaviour. Med Eng Phys 2017; 47:85-92. [DOI: 10.1016/j.medengphy.2017.06.024] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2017] [Revised: 05/02/2017] [Accepted: 06/01/2017] [Indexed: 10/19/2022]
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Moore J, Paulus D, Cua CL, Kertesz NJ, Miao Y, Cheatham JP, Galantowicz M, Fernandez R. Arrhythmias After Stage I Hybrid Palliation in Single-Ventricle Patients. Pediatr Cardiol 2016; 37:1416-1421. [PMID: 27425423 DOI: 10.1007/s00246-016-1450-3] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/07/2016] [Accepted: 05/24/2016] [Indexed: 11/29/2022]
Abstract
The hybrid procedure is an alternative palliative strategy for patients with single-ventricle physiology. No data exist documenting the incidence of arrhythmias after the hybrid procedure. Goal of this study was to determine the incidence and type of arrhythmias in patients undergoing the hybrid procedure. A retrospective chart review was performed including all patients undergoing the hybrid procedure between January of 2010 through December of 2013. Sixty-five patients underwent the hybrid procedure during this time period (43 HLHS, 22 other). Average gestational age at admission was 37.7 weeks. Average age at time of procedure was 7.6 days. Five patients had documented arrhythmias (7.7 %). Four were supraventricular tachycardias, and 1 was a sinus bradycardia. One patient with arrhythmia died during hospitalization, and another patient with arrhythmia died during the interstage period. Hybrid palliation for patients with single-ventricle physiology has a low incidence of arrhythmias. In this cohort of patients, arrhythmias did not contribute to mortality. There was a trend toward association between arrhythmias and longer total length of hospital stay.
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Affiliation(s)
- Jeffrey Moore
- Nationwide Children's Hospital, 700 Children's Dr., Columbus, OH, 43205-2664, USA.
| | - Diane Paulus
- Nationwide Children's Hospital, 700 Children's Dr., Columbus, OH, 43205-2664, USA
| | - Clifford L Cua
- Nationwide Children's Hospital, 700 Children's Dr., Columbus, OH, 43205-2664, USA
| | - Naomi J Kertesz
- Nationwide Children's Hospital, 700 Children's Dr., Columbus, OH, 43205-2664, USA
| | - Yongjie Miao
- Nationwide Children's Hospital, 700 Children's Dr., Columbus, OH, 43205-2664, USA
| | - John P Cheatham
- Nationwide Children's Hospital, 700 Children's Dr., Columbus, OH, 43205-2664, USA
| | - Mark Galantowicz
- Nationwide Children's Hospital, 700 Children's Dr., Columbus, OH, 43205-2664, USA
| | - Richard Fernandez
- Nationwide Children's Hospital, 700 Children's Dr., Columbus, OH, 43205-2664, USA
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20
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The functional single ventricle: how imaging guides treatment. Clin Imaging 2016; 40:1146-1155. [DOI: 10.1016/j.clinimag.2016.08.003] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2016] [Revised: 07/06/2016] [Accepted: 08/02/2016] [Indexed: 11/19/2022]
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Wilder TJ, McCrindle BW, Hickey EJ, Ziemer G, Tchervenkov CI, Jacobs ML, Gruber PJ, Blackstone EH, Williams WG, DeCampli WM, Caldarone CA, Pizarro C. Is a hybrid strategy a lower-risk alternative to stage 1 Norwood operation? J Thorac Cardiovasc Surg 2016; 153:163-172.e6. [PMID: 27671550 DOI: 10.1016/j.jtcvs.2016.08.021] [Citation(s) in RCA: 45] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/24/2016] [Revised: 07/17/2016] [Accepted: 08/06/2016] [Indexed: 11/19/2022]
Abstract
BACKGROUND For neonates with critical left ventricular outflow tract obstruction (LVOTO), hybrid procedures are an alternative to the Norwood stage 1 procedure. Despite perceived advantages, however, outcomes are not well defined. Therefore, we compared outcomes after stage 1 hybrid and Norwood procedures. METHODS In a critical LVOTO inception cohort (2005-2014; 20 institutions), a total of 564 neonates underwent stage 1 palliation with the Norwood operation with a modified Blalock-Taussig shunt (NW-BT; n = 232; 41%), Norwood operation with a right ventricle-to-pulmonary artery conduit (NW-RVPA; n = 222; 39%), or a hybrid procedure (n = 110; 20%). Post-stage 1 outcomes were analyzed via competing-risks and parametric hazard analyses and compared among all 564 patients and between patients who underwent propensity-matched hybrid and those who underwent NW-BT/NW-RVPA. RESULTS By 6 years after the stage 1 operation, 50% ± 3%, 7% ± 2%, and 4% ± 1% of patients transitioned to Fontan, transplantation, and biventricular repair, respectively, whereas 7% ± 2% were alive without transition and 32% ± 2% died. Risk factors for death without transition included procedure type, smaller ascending aorta, aortic valve atresia, and lower birth weight. Risk-adjusted 4-year survival was better after NW-RVPA than after NW-BT or hybrid (76% vs 60% vs 61%; P < .001). Furthermore, for neonates with lower birth weight (<∼2 kg), an interaction between birth weight and hybrid resulted in a trend toward better survival after hybrid compared with NW-BT or NW-RVPA. For propensity-matched neonates between hybrid and NW-BT (88 pairs), 4-year survival was similar (62% vs 57%; P = .58). For propensity-matched neonates between hybrid and NW-RVPA (81 pairs), 4-year survival was better after NW-RVPA (59% vs 75%; P = .008). CONCLUSIONS For neonates with critical LVOTO undergoing single-ventricle palliation, NW-RVPA was associated with the best overall survival. Hybrid strategies are not a lower-risk alternative to Norwood operations overall; however, the impact of lower birth weight on survival may be mitigated after hybrid procedures compared with Norwood operations.
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Affiliation(s)
- Travis J Wilder
- Congenital Heart Surgeons' Society Data Center, University of Toronto, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Brian W McCrindle
- Division of Pediatric Cardiology, Department of Pediatrics, University of Toronto, The Hospital for Sick Children, Toronto, Ontario, Canada.
| | - Edward J Hickey
- Department of Cardiovascular Surgery, University of Toronto, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Gerhard Ziemer
- Division of Cardiac and Thoracic Surgery, Department of Surgery, University of Chicago Medicine, Chicago, Ill
| | - Christo I Tchervenkov
- Department of Cardiothoracic Surgery, Montreal Children's Hospital of the McGill University Health Center, Montreal, Quebec, Canada
| | - Marshall L Jacobs
- Department of Surgery, Johns Hopkins School of Medicine, Baltimore, Md
| | - Peter J Gruber
- Division of Cardiothoracic Surgery, Department of Surgery, University of Iowa Carver College of Medicine, Iowa City, Iowa
| | | | - William G Williams
- Congenital Heart Surgeons' Society Data Center, University of Toronto, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - William M DeCampli
- Department of Cardiothoracic Surgery, Arnold Palmer Hospital for Children, Orlando, Fla
| | - Christopher A Caldarone
- Department of Cardiovascular Surgery, University of Toronto, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Christian Pizarro
- Nemours Cardiac Center, Alfred I. DuPont Hospital for Children, Wilmington, Del
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22
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Mitchell EA, Gomez D, Joy BF, Fernandez RP, Cheatham JP, Galantowicz M, Cua CL. ECMO: Incidence and Outcomes of Patients Undergoing the Hybrid Procedure. CONGENIT HEART DIS 2016; 11:169-74. [PMID: 27037636 DOI: 10.1111/chd.12311] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 09/15/2015] [Indexed: 11/29/2022]
Abstract
OBJECTIVE To document the extracorporeal membrane oxygenation (ECMO) incidence and outcome in patients undergoing the hybrid procedure at an institution that routinely performs this procedure. DESIGN A retrospective chart review on all patients with single ventricle physiology that underwent the hybrid procedure between 7/2002 and 12/2014. Patients were excluded if they underwent the hybrid procedure after 60 days of birth or subsequently underwent a biventricular repair. SETTING A single center, tertiary pediatric hospital. PATIENTS One hundred eighty-one patients with single ventricle physiology that underwent the hybrid procedure between 7/2002 and 12/2014. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS We studied a total of 181 patients (105 males: 76 females). Gestational age was 37.8 ± 2.0 weeks and birth weight was 3.0 ± 0.7 kg. Underlying diagnosis was hypoplastic left heart syndrome in 149 patients and other in 32 patients. Age at surgery was 7.8 ± 6.8 days and weight at surgery was 3.1 ± 0.6 kg. Two patients underwent ECMO support after the hybrid procedure. One patient had aortic atresia/mitral atresia and weighed 2.3 kg and the other patient had aortic atresia/mitral stenosis and weighed 2.1 kg at time of surgery. Both patients died. Incidence of ECMO support after hybrid procedure was 1.3% (2/149) for the hypoplastic left heart syndrome patients and 1.1% (2/181) for the entire cohort. CONCLUSION Mortality in patients who underwent ECMO after the hybrid procedure was higher than reported for the Norwood procedure, however, the incidence of ECMO after hybrid procedure was also significantly lower than reported for the Norwood procedure. Future studies are needed to determine how to improve outcomes in this complex patient population.
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Affiliation(s)
| | - Daniel Gomez
- Heart Center, Nationwide Children's Hospital, Columbus, Ohio, USA
| | - Brian F Joy
- Heart Center, Nationwide Children's Hospital, Columbus, Ohio, USA
| | | | - John P Cheatham
- Heart Center, Nationwide Children's Hospital, Columbus, Ohio, USA
| | - Mark Galantowicz
- Heart Center, Nationwide Children's Hospital, Columbus, Ohio, USA
| | - Clifford L Cua
- Heart Center, Nationwide Children's Hospital, Columbus, Ohio, USA
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23
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Mosca RS. Hybrid therapy for hypoplastic left heart syndrome: Myth, alternative, or standard--neither Minotaur nor Midas. J Thorac Cardiovasc Surg 2015; 151:1123-5. [PMID: 26682621 DOI: 10.1016/j.jtcvs.2015.10.099] [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: 10/26/2015] [Accepted: 10/27/2015] [Indexed: 10/22/2022]
Affiliation(s)
- Ralph S Mosca
- Department of Cardiothoracic Surgery, New York University Langone Medical Center, New York, NY.
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24
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Redaelli A. A Model of Health: Mathematical modeling tools play an important role in optimizing new treatment options for heart disease. IEEE Pulse 2015; 6:27-32. [PMID: 26186050 DOI: 10.1109/mpul.2015.2428683] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
Models are crucial in the biomedical sciences since they provide information that is not otherwise accessible and help in discriminating among possible schemes of interpretation of complex phenomena. Italian research teams have been very active in this field with important contributions in the area of heart mechanics, which typically requires sophisticated three-dimensional (3-D) approaches to simulate wall and blood fluid mechanics. These models are increasingly being used to assess the patient-specific pathological scenario and to predict possible therapy outcomes.
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25
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Hibino N, Cismowski MJ, Lilly B, McConnell PI, Shinoka T, Cheatham JP, Lucchesi PA, Galantowicz ME, Trask AJ. Potential Molecular Mechanism of Retrograde Aortic Arch Stenosis in the Hybrid Approach to Hypoplastic Left Heart Syndrome. Ann Thorac Surg 2015; 100:1013-9; discussion 1019-20. [PMID: 26163359 DOI: 10.1016/j.athoracsur.2015.04.125] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/26/2015] [Revised: 04/14/2015] [Accepted: 04/17/2015] [Indexed: 01/13/2023]
Abstract
BACKGROUND The hybrid palliation for hypoplastic left heart syndrome has emerged as an alternative approach to the Norwood procedure. The development of patent ductus arteriosus (PDA) in-stent stenosis can cause retrograde aortic arch stenosis (RAAS), leading to significant morbidity. This study aimed to identify potential mechanisms of PDA in-stent stenosis contributing to RAAS. METHODS Tissues from stented PDAs were collected from 17 patients undergoing comprehensive stage II repair between 2009 and 2014. Patients requiring RAAS intervention based on cardiology-surgery consensus were defined as RAAS(+) (n = 10), whereas patients without any RAAS intervention were defined as RAAS(-) (n = 7). Tissues were examined by quantitative polymerase chain reaction analysis for vascular smooth muscle cell (VSMC) differentiation and proliferation markers. RESULTS Patient characteristics were hypoplastic left heart syndrome with aortic atresia in 6 and with aortic stenosis in 3; unbalanced atrioventricular canal in 3; double-inlet left ventricle/transposition of the great arteries in 3; and double-outlet right ventricle in 2. VSMC differentiation markers (β-actin, SM22, and calponin) and signaling pathways for VSMC modulation (transforming growth factor-β1, Notch, and platelet derived growth factor-BB) were significantly higher in the RAAS(+) than in RAAS(-) patients. The proliferation marker Ki67 was increased in RAAS(+) patients. Cell cycle markers were comparable in both groups. CONCLUSIONS Increased VSMC differentiation and proliferation markers suggest a mechanism for inward neointima formation of the PDA in RAAS. The apparent lack of change in cell cycle markers is contrary to coronary artery in-stent stenosis, suggesting further targets should be examined. Combined primary in vitro PDA cell culture and proteomics can be strong tools to elucidate targets to reduce PDA in-stent stenosis for RAAS in the future.
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Affiliation(s)
- Narutoshi Hibino
- The Heart Center, The Research Institute at Nationwide Children's Hospital, Columbus, Ohio
| | - Mary J Cismowski
- The Heart Center, The Research Institute at Nationwide Children's Hospital, Columbus, Ohio; Center for Cardiovascular and Pulmonary Research, The Research Institute at Nationwide Children's Hospital, Columbus, Ohio; Department of Pediatrics, The Ohio State University College of Medicine, Columbus, Ohio
| | - Brenda Lilly
- The Heart Center, The Research Institute at Nationwide Children's Hospital, Columbus, Ohio; Center for Cardiovascular and Pulmonary Research, The Research Institute at Nationwide Children's Hospital, Columbus, Ohio; Department of Pediatrics, The Ohio State University College of Medicine, Columbus, Ohio
| | - Patrick I McConnell
- The Heart Center, The Research Institute at Nationwide Children's Hospital, Columbus, Ohio; Department of Cardiothoracic Surgery, The Ohio State University College of Medicine, Columbus, Ohio
| | - Toshiharu Shinoka
- The Heart Center, The Research Institute at Nationwide Children's Hospital, Columbus, Ohio; Department of Cardiothoracic Surgery, The Ohio State University College of Medicine, Columbus, Ohio
| | - John P Cheatham
- The Heart Center, The Research Institute at Nationwide Children's Hospital, Columbus, Ohio; Department of Pediatrics, The Ohio State University College of Medicine, Columbus, Ohio
| | - Pamela A Lucchesi
- The Heart Center, The Research Institute at Nationwide Children's Hospital, Columbus, Ohio; Center for Cardiovascular and Pulmonary Research, The Research Institute at Nationwide Children's Hospital, Columbus, Ohio; Department of Pediatrics, The Ohio State University College of Medicine, Columbus, Ohio
| | - Mark E Galantowicz
- The Heart Center, The Research Institute at Nationwide Children's Hospital, Columbus, Ohio; Department of Cardiothoracic Surgery, The Ohio State University College of Medicine, Columbus, Ohio
| | - Aaron J Trask
- The Heart Center, The Research Institute at Nationwide Children's Hospital, Columbus, Ohio; Center for Cardiovascular and Pulmonary Research, The Research Institute at Nationwide Children's Hospital, Columbus, Ohio; Department of Pediatrics, The Ohio State University College of Medicine, Columbus, Ohio.
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Hemodynamic effects of left pulmonary artery stenosis after superior cavopulmonary connection: a patient-specific multiscale modeling study. J Thorac Cardiovasc Surg 2014; 149:689-96.e1-3. [PMID: 25659189 DOI: 10.1016/j.jtcvs.2014.12.040] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/14/2014] [Revised: 08/20/2014] [Accepted: 08/22/2014] [Indexed: 11/22/2022]
Abstract
OBJECTIVE Currently, no quantitative guidelines have been established for treatment of left pulmonary artery (LPA) stenosis. This study aims to quantify the effects of LPA stenosis on postoperative hemodynamics for single-ventricle patients undergoing stage II superior cavopulmonary connection (SCPC) surgery, using a multiscale computational approach. METHODS Image data from 6 patients were segmented to produce 3-dimensional models of the pulmonary arteries before stage II surgery. Pressure and flow measurements were used to tune a 0-dimensional model of the entire circulation. Postoperative geometries were generated through stage II virtual surgery; varying degrees of LPA stenosis were applied using mesh morphing and hemodynamics assessed through coupled 0-3-dimensional simulations. To relate metrics of stenosis to clinical classifications, pediatric cardiologists and surgeons ranked the degrees of stenosis in the models. The effects of LPA stenosis were assessed based on left-to-right pulmonary artery flow split ratios, mean pressure drop across the stenosis, cardiac pressure-volume loops, and other clinically relevant parameters. RESULTS Stenosis of >65% of the vessel diameter was required to produce a right pulmonary artery:LPA flow split <30%, and/or a mean pressure drop of >3.0 mm Hg, defined as clinically significant changes. CONCLUSIONS The effects of <65% stenosis on SCPC hemodynamics and physiology were minor and may not justify the increased complexity of adding LPA arterioplasty to the SCPC operation. However, in the longer term, pulmonary augmentation may affect outcomes of the Fontan completion surgery, as pulmonary artery distortion is a risk factor that may influence stage III physiology.
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Young A, Gourlay T, McKee S, Danton MH. Computational modelling of the hybrid procedure in hypoplastic left heart syndrome: A comparison of zero-dimensional and three-dimensional approach. Med Eng Phys 2014; 36:1549-53. [DOI: 10.1016/j.medengphy.2014.08.015] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2014] [Revised: 08/13/2014] [Accepted: 08/25/2014] [Indexed: 11/30/2022]
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Corsini C, Biglino G, Schievano S, Hsia TY, Migliavacca F, Pennati G, Taylor AM. The effect of modified Blalock-Taussig shunt size and coarctation severity on coronary perfusion after the Norwood operation. Ann Thorac Surg 2014; 98:648-54. [PMID: 24906601 DOI: 10.1016/j.athoracsur.2014.04.047] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/24/2014] [Revised: 03/31/2014] [Accepted: 04/08/2014] [Indexed: 10/25/2022]
Abstract
BACKGROUND The size of the modified Blalock-Taussig shunt and the additional presence of aortic coarctation can affect the hemodynamics of the Norwood physiology. Multiscale modeling was used to gather insight into the effects of these variables, in particular on coronary perfusion. METHODS A model was reconstructed from cardiac magnetic resonance imaging data of a representative patient, and then simplified with computer-aided design software. Changes were systematically imposed to the semi-idealized three-dimensional model, resulting in a family of nine models (3-, 3.5-, and 4-mm shunt diameter; 0%, 60%, and 90% coarctation severity). Each model was coupled to a lumped parameter network representing the remainder of the circulation to run multiscale simulations. Simulations were repeated including the effect of preserved cerebral perfusion. RESULTS The concomitant presence of a large shunt and tight coarctation was detrimental in terms of coronary perfusion (13.4% maximal reduction, 1.07 versus 0.927 mL/s) and oxygen delivery (29% maximum reduction, 422 versus 300 mL·min(-1)·m(-2)). A variation in the ratio of pulmonary to systemic blood flow from 0.9 to 1.6 also indicated a "stealing" phenomenon to the detriment of the coronary circulation. A difference could be further appreciated in the computational ventricular pressure-volume loops, with augmented systolic pressures and decreased stroke volumes for tighter coarctation. Accounting for constant cerebral perfusion did not produce substantially different results. CONCLUSIONS Multiscale simulations performed in a parametric fashion revealed a reduction in coronary perfusion in the presence of a large modified Blalock-Taussig shunt and severe coarctation in Norwood patients.
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Affiliation(s)
- Chiara Corsini
- Laboratory of Biological Structure Mechanics, Politecnico di Milano, Milan, Italy
| | - Giovanni Biglino
- Centre for Cardiovascular Imaging, UCL Institute of Cardiovascular Science, and Great Ormond Street Hospital for Children, NHS Foundation Trust, London, United Kingdom.
| | - Silvia Schievano
- Centre for Cardiovascular Imaging, UCL Institute of Cardiovascular Science, and Great Ormond Street Hospital for Children, NHS Foundation Trust, London, United Kingdom
| | - Tain-Yen Hsia
- Centre for Cardiovascular Imaging, UCL Institute of Cardiovascular Science, and Great Ormond Street Hospital for Children, NHS Foundation Trust, London, United Kingdom
| | | | - Giancarlo Pennati
- Laboratory of Biological Structure Mechanics, Politecnico di Milano, Milan, Italy
| | - Andrew M Taylor
- Centre for Cardiovascular Imaging, UCL Institute of Cardiovascular Science, and Great Ormond Street Hospital for Children, NHS Foundation Trust, London, United Kingdom
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Davies RR, Radtke WA, Klenk D, Pizarro C. Bilateral pulmonary arterial banding results in an increased need for subsequent pulmonary artery interventions. J Thorac Cardiovasc Surg 2014; 147:706-12. [DOI: 10.1016/j.jtcvs.2013.10.038] [Citation(s) in RCA: 59] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/06/2013] [Revised: 09/27/2013] [Accepted: 10/11/2013] [Indexed: 11/28/2022]
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Harada Y. Current status of the hybrid approach for the treatment of hypoplastic left heart syndrome. Gen Thorac Cardiovasc Surg 2013; 62:334-41. [PMID: 24307510 DOI: 10.1007/s11748-013-0347-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2013] [Indexed: 11/29/2022]
Abstract
The hybrid approach for hypoplastic left heart syndrome (HLHS), consisting of bilateral pulmonary artery banding and ductal stenting, has emerged as an alternative to the traditional Norwood approach. This approach defers open heart surgery to beyond the neonatal period, which is believed to reduce postoperative mortality and morbidity and improve neurological development as compared with the conventional approach. However, there have been no scientific studies supporting these hypotheses. Recently, there seems to be a tendency that many centers recommend the hybrid approach as an interim procedure to rescue preoperative high-risk patients. Currently, the decision to adopt the hybrid approach or the Norwood approach seemed to be based on the preference of congenital heart surgeons and cardiologists. Further investigation including a randomized multi-center study would allow a scientific decision as to which approach is more appropriate for the patient with HLHS.
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Affiliation(s)
- Yorikazu Harada
- Nagano Children's Hospital, 3100 Toyoshina, Azumino, Nagano, 399-8288, Japan,
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