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Denby KJ, Tereshchenko LG, Kanj M, Taigen T, Callahan T, Dresing T, Tanaka Esposito C, Santangeli P, Hussein A, Hargrave J, Wakefield B, Skubas NJ, Tovar Camargo O, Krishnaswamy A, Nanjundappa A, Puri R, Khatri J, Kapadia S, Suntharos P, Prieto L, Ghobrial J. Efficacy of Drug-Coated Balloon Angioplasty in Pulmonary Vein Stenosis or Total Occlusion. JACC Clin Electrophysiol 2024; 10:1840-1847. [PMID: 38904577 DOI: 10.1016/j.jacep.2024.04.020] [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: 01/03/2024] [Revised: 04/09/2024] [Accepted: 04/10/2024] [Indexed: 06/22/2024]
Abstract
BACKGROUND Current therapies for pulmonary vein stenosis (PVS) or pulmonary vein total occlusion (PVTO) involving angioplasty and stenting are hindered by high rates of restenosis. OBJECTIVES This study compares a novel approach of drug-coated balloon (DCB) angioplasty and stenting with the current standard of care in PVS or PVTO due to pulmonary vein isolation (PVI). METHODS A retrospective single-center study analyzed patients with PVS or PVTO due to PVI who underwent either angioplasty and stenting (NoDCB group; December 2012-December 2016) or DCB angioplasty and stenting (DCB group; January 2018-January 2021). Multivariable Andersen-Gill regression analysis assessed the risk of restenosis and target lesion revascularization (TLR). RESULTS The NoDCB group comprised 58 patients and 89 veins, with a longer median follow-up of 35 months, whereas the DCB group included 26 patients and 33 veins, with a median follow-up of 11 months. The DCB group exhibited more PVTO (NoDCB: 12.3%; DCB: 42.4%; P = 0.0001), with a smaller reference vessel size (NoDCB: 10.2 mm; DCB: 8.4 mm; P = 0.0004). Follow-up computed tomography was performed in 82% of NoDCB and 85% of DCB, revealing lower unadjusted rates of restenosis (NoDCB: 26%; DCB: 14.3%) and TLR (NoDCB: 34.2%; DCB: 10.7%) in the DCB group. DCB use was associated with a significantly lower risk of restenosis and TLR (HR: 0.003: CI: 0.00009-0.118; P = 0.002). CONCLUSIONS The novel approach of DCB angioplasty followed by stenting is effective and safe and significantly reduces the risk of restenosis and reintervention compared with the standard of care in PVS or PVTO due to PVI.
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Affiliation(s)
- Kara J Denby
- Division of Cardiology, Saint Alphonsus Health System, Boise, Idaho, USA
| | - Larisa G Tereshchenko
- Heart, Vascular, and Thoracic Institute, Cleveland Clinic Foundation, Cleveland, Ohio, USA; Cleveland Clinic Lerner Research Institute, Quantitative Health Sciences, Cleveland, Ohio, USA
| | - Mohamed Kanj
- Heart, Vascular, and Thoracic Institute, Cleveland Clinic Foundation, Cleveland, Ohio, USA
| | - Tyler Taigen
- Heart, Vascular, and Thoracic Institute, Cleveland Clinic Foundation, Cleveland, Ohio, USA
| | - Thomas Callahan
- Heart, Vascular, and Thoracic Institute, Cleveland Clinic Foundation, Cleveland, Ohio, USA
| | - Thomas Dresing
- Heart, Vascular, and Thoracic Institute, Cleveland Clinic Foundation, Cleveland, Ohio, USA
| | | | - Pasquale Santangeli
- Heart, Vascular, and Thoracic Institute, Cleveland Clinic Foundation, Cleveland, Ohio, USA
| | - Ayman Hussein
- Heart, Vascular, and Thoracic Institute, Cleveland Clinic Foundation, Cleveland, Ohio, USA
| | - Jennifer Hargrave
- Department of Cardiothoracic Anesthesiology, Cleveland Clinic Foundation, Cleveland, Ohio, USA
| | - Brett Wakefield
- Department of Cardiothoracic Anesthesiology, Cleveland Clinic Foundation, Cleveland, Ohio, USA
| | - Nikolaos J Skubas
- Department of Cardiothoracic Anesthesiology, Cleveland Clinic Foundation, Cleveland, Ohio, USA
| | - Oscar Tovar Camargo
- Department of Cardiothoracic Anesthesiology, Cleveland Clinic Foundation, Cleveland, Ohio, USA
| | - Amar Krishnaswamy
- Heart, Vascular, and Thoracic Institute, Cleveland Clinic Foundation, Cleveland, Ohio, USA
| | - Aravinda Nanjundappa
- Heart, Vascular, and Thoracic Institute, Cleveland Clinic Foundation, Cleveland, Ohio, USA
| | - Rishi Puri
- Heart, Vascular, and Thoracic Institute, Cleveland Clinic Foundation, Cleveland, Ohio, USA
| | - Jaikirshan Khatri
- Heart, Vascular, and Thoracic Institute, Cleveland Clinic Foundation, Cleveland, Ohio, USA
| | - Samir Kapadia
- Heart, Vascular, and Thoracic Institute, Cleveland Clinic Foundation, Cleveland, Ohio, USA
| | - Patcharapong Suntharos
- Heart, Vascular, and Thoracic Institute, Cleveland Clinic Foundation, Cleveland, Ohio, USA
| | - Lourdes Prieto
- The Heart Institute, Nicklaus Children's Hospital, Miami, Florida, USA
| | - Joanna Ghobrial
- Heart, Vascular, and Thoracic Institute, Cleveland Clinic Foundation, Cleveland, Ohio, USA.
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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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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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Ponzoni M, Coles JG, Maynes JT. Rodent Models of Dilated Cardiomyopathy and Heart Failure for Translational Investigations and Therapeutic Discovery. Int J Mol Sci 2023; 24:ijms24043162. [PMID: 36834573 PMCID: PMC9963155 DOI: 10.3390/ijms24043162] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2023] [Revised: 01/22/2023] [Accepted: 02/01/2023] [Indexed: 02/09/2023] Open
Abstract
Even with modern therapy, patients with heart failure only have a 50% five-year survival rate. To improve the development of new therapeutic strategies, preclinical models of disease are needed to properly emulate the human condition. Determining the most appropriate model represents the first key step for reliable and translatable experimental research. Rodent models of heart failure provide a strategic compromise between human in vivo similarity and the ability to perform a larger number of experiments and explore many therapeutic candidates. We herein review the currently available rodent models of heart failure, summarizing their physiopathological basis, the timeline of the development of ventricular failure, and their specific clinical features. In order to facilitate the future planning of investigations in the field of heart failure, a detailed overview of the advantages and possible drawbacks of each model is provided.
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Affiliation(s)
- Matteo Ponzoni
- Division of Cardiovascular Surgery, The Hospital for Sick Children, Toronto, ON M5G 1X8, Canada
- Program in Translational Medicine, SickKids Research Institute, Toronto, ON M5G 0A4, Canada
| | - John G. Coles
- Division of Cardiovascular Surgery, The Hospital for Sick Children, Toronto, ON M5G 1X8, Canada
- Program in Translational Medicine, SickKids Research Institute, Toronto, ON M5G 0A4, Canada
- Correspondence: (J.G.C.); (J.T.M.)
| | - Jason T. Maynes
- Department of Anesthesia and Pain Medicine, The Hospital for Sick Children, Toronto, ON M5G 1X8, Canada
- Program in Molecular Medicine, SickKids Research Institute, Toronto, ON M5G 0A4, Canada
- Department of Anesthesiology and Pain Medicine, University of Toronto, Toronto, ON M5G 1E2, Canada
- Correspondence: (J.G.C.); (J.T.M.)
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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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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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7
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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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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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9
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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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11
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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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12
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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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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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15
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Clinical Outcomes Predictors and Surgical Management of Primary Pulmonary Vein Stenosis. Ann Thorac Surg 2021; 113:1239-1247. [PMID: 33745903 DOI: 10.1016/j.athoracsur.2021.03.015] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/23/2020] [Revised: 03/01/2021] [Accepted: 03/09/2021] [Indexed: 11/21/2022]
Abstract
BACKGROUND Surgical outcomes for primary pulmonary vein stenosis (PPVS) remain unfavorable, and risk factors are still poorly understood. The purpose of this study is to evaluate outcomes and risk factors after PPVS repair. METHODS Forty patients with PPVS undergoing surgical repair in Fuwai Hospital from 2010 to 2020 were included retrospectively. Adverse outcomes included mortality, pulmonary vein (PV) restenosis and reintervention. A univariate and multivariate risk analysis was performed to determine risk factors. RESULTS The mean follow-up duration was 37.5 ± 31.5 months. Sutureless technique was performed in 7 patients (17.5%), endovenectomy in 9 patients (22.5%), and patch venoplasty in 24 patients (60%). Bilateral PV involvement was documented in 12 patients (30%). Overall mortality, PV reintervention, and restenosis occurred in 15%, 12.5%, and 25% of patients, respectively. Freedom from overall mortality, PV reintervention, and restenosis at 5 years was 85%±6.3%, 88.9%±5.2%, and 65.1%±13.2%, respectively. Multivariate analysis revealed that bilateral PV involvement was an independent risk factor for mortality or PV reintervention (hazard ratio, 10.4; 95% confident interval, 1.9-56; p = 0.006), and involvement of left inferior PV was an independent risk factor for postoperative restenosis of left inferior PV (hazard ratio, 13.1; confident interval, 2.2-76.8; p = 0.004). CONCLUSIONS Surgical treatment for PPVS remains a challenging issue with imperfect prognosis. Therefore, it is right and appropriate to take close surveillance on mild or moderate stenosis on a single pulmonary vein. Bilateral and left inferior pulmonary vein involvement are independent risk factors for adverse outcomes.
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16
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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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17
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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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18
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Effect of Oral Losartan on Orthobiologics: Implications for Platelet-Rich Plasma and Bone Marrow Concentrate-A Rabbit Study. Int J Mol Sci 2020; 21:ijms21197374. [PMID: 33036225 PMCID: PMC7584049 DOI: 10.3390/ijms21197374] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2020] [Revised: 09/29/2020] [Accepted: 10/01/2020] [Indexed: 12/14/2022] Open
Abstract
Recent efforts have focused on customizing orthobiologics, such as platelet-rich plasma (PRP) and bone marrow concentrate (BMC), to improve tissue repair. We hypothesized that oral losartan (a TGF-β1 blocker with anti-fibrotic properties) could decrease TGF-β1 levels in leukocyte-poor PRP (LP-PRP) and fibrocytes in BMC. Ten rabbits were randomized into two groups (N = 5/group): osteochondral defect + microfracture (control, group 1) and osteochondral defect + microfracture + losartan (losartan, group 2). For group 2, a dose of 10mg/kg/day of losartan was administrated orally for 12 weeks post-operatively. After 12 weeks, whole blood (WB) and bone marrow aspirate (BMA) samples were collected to process LP-PRP and BMC. TGF-β1 concentrations were measured in WB and LP-PRP with multiplex immunoassay. BMC cell populations were analyzed by flow cytometry with CD31, CD44, CD45, CD34, CD146 and CD90 antibodies. There was no significant difference in TGF-β1 levels between the losartan and control group in WB or LP-PRP. In BMC, the percentage of CD31+ cells (endothelial cells) in the losartan group was significantly higher than the control group (p = 0.008), while the percentage of CD45+ cells (hematopoietic cells-fibrocytes) in the losartan group was significantly lower than the control group (p = 0.03).
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19
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Sehgal A, Steenhorst JJ, Mclennan DI, Merkus D, Ivy D, McNamara PJ. The Left Heart, Systemic Circulation, and Bronchopulmonary Dysplasia: Relevance to Pathophysiology and Therapeutics. J Pediatr 2020; 225:13-22.e2. [PMID: 32553872 DOI: 10.1016/j.jpeds.2020.06.031] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/04/2020] [Revised: 06/06/2020] [Accepted: 06/09/2020] [Indexed: 12/25/2022]
Affiliation(s)
- Arvind Sehgal
- Monash Children's Hospital, Monash University, Melbourne, Australia; Department of Pediatrics, Monash University, Melbourne, Australia.
| | - Jarno J Steenhorst
- Department of Cardiology, Erasmus MC, Rotterdam, the Netherlands; Department of Pediatrics, Erasmus MC, Rotterdam, the Netherlands
| | - Daniel I Mclennan
- Department of Pediatrics, University of Iowa Children's Hospital, Dr, Iowa City, IA; Internal Medicine, University of Iowa Children's Hospital, Dr, Iowa City, IA
| | - Daphne Merkus
- Department of Cardiology, Erasmus MC, Rotterdam, the Netherlands; Department of Pediatrics, Erasmus MC, Rotterdam, the Netherlands; Institut für Chirurgische Forschung, Klinikum Universität München, Ludwig Maximillian Universität München, München, Germany
| | - Dunbar Ivy
- Pediatric Cardiology, University of Colorado School of Medicine, Children's Hospital Colorado, Aurora, CO
| | - Patrick J McNamara
- Department of Pediatrics, University of Iowa Children's Hospital, Dr, Iowa City, IA; Internal Medicine, University of Iowa Children's Hospital, Dr, Iowa City, IA
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20
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Shi G, Zhu F, Wen C, Qiu L, Zhang H, Zhu Z, Chen H. Single-institution outcomes of surgical repair of infracardiac total anomalous pulmonary venous connection. J Thorac Cardiovasc Surg 2020; 161:1408-1417.e2. [PMID: 32739162 DOI: 10.1016/j.jtcvs.2020.06.023] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/14/2019] [Revised: 06/08/2020] [Accepted: 06/09/2020] [Indexed: 01/08/2023]
Abstract
OBJECTIVE This contemporary study sought to describe the outcomes of patients undergoing biventricular repair of infracardiac total anomalous pulmonary venous connection. METHODS A retrospective study was performed on patients with infracardiac total anomalous pulmonary venous connection who underwent sutureless technique or conventional repair between 2006 and 2018. Risk factors for survival and post-repair pulmonary vein stenosis (PVS) were assessed with Cox regression model. Time-to-event analysis was conducted using Kaplan-Meier estimates. RESULTS This study included 82 consecutive patients with the median age of 21 days (interquartile range, 9-40 days). The median follow-up was 29 months (interquartile range, 12.5-59 months) and was available in 95% of the survivors at the end of the study period in 2019. Overall, 8 deaths (8.5%) occurred in the conventional repair group. There was a trend of higher mortality in the conventional repair group, although it did not reach a statistical difference (P = .2). Postrepair PVS occurred at a median of 2 months (interquartile range, 1.2-3.6 months) postoperatively and all occurred in the conventional repair group. Time-to-event analysis with the event of postrepair PVS showed significantly higher freedom from restenosis in the sutureless technique group (P = .0004). Adjusted hazard ratios from time-dependent Cox model described the association between postrepair PVS and pulmonary venous confluence of antler configuration (hazard ratio, 2.14; 95% confidence interval, 1.03-5.47; P = .002) and the use of sutureless technique (hazard ratio, 0.72; 95% confidence interval, 0.39-0.97; P = .003). CONCLUSIONS Sutureless technique is associated with a lower risk of postrepair PVS in patients with infracardiac total anomalous pulmonary venous connection. pulmonary venous confluence configuration of antler appearance appears to be associated with restenosis and mortality.
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Affiliation(s)
- Guocheng Shi
- Department of Cardiothoracic Surgery, Congenital Heart Center, Shanghai Children's Medical Center, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Fang Zhu
- Department of Cardiothoracic Surgery, Congenital Heart Center, Shanghai Children's Medical Center, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Chen Wen
- Department of Cardiothoracic Surgery, Congenital Heart Center, Shanghai Children's Medical Center, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Lisheng Qiu
- Department of Cardiothoracic Surgery, Congenital Heart Center, Shanghai Children's Medical Center, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Haibo Zhang
- Department of Cardiothoracic Surgery, Congenital Heart Center, Shanghai Children's Medical Center, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Zhongqun Zhu
- Department of Cardiothoracic Surgery, Congenital Heart Center, Shanghai Children's Medical Center, Shanghai Jiao Tong University School of Medicine, Shanghai, China.
| | - Huiwen Chen
- Department of Cardiothoracic Surgery, Congenital Heart Center, Shanghai Children's Medical Center, Shanghai Jiao Tong University School of Medicine, Shanghai, China.
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21
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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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22
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Management outcomes of primary pulmonary vein stenosis. J Thorac Cardiovasc Surg 2020; 159:1029-1036.e1. [DOI: 10.1016/j.jtcvs.2019.08.105] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/04/2017] [Revised: 08/23/2019] [Accepted: 08/24/2019] [Indexed: 01/07/2023]
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23
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Masaki N, Adachi O, Katahira S, Saiki Y, Horii A, Kawamoto S, Saiki Y. Progression of vascular remodeling in pulmonary vein obstruction. J Thorac Cardiovasc Surg 2020; 160:777-790.e5. [PMID: 32222412 DOI: 10.1016/j.jtcvs.2020.01.098] [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: 01/16/2019] [Revised: 12/24/2019] [Accepted: 01/20/2020] [Indexed: 01/24/2023]
Abstract
OBJECTIVES Pulmonary vein obstruction (PVO) frequently occurs after repair of total anomalous pulmonary vein connection with progression of intimal hyperplasia from the anastomotic site toward upstream pulmonary veins (PVs). However, the understanding of mechanism in PVO progression is constrained by lack of data derived from a physiological model of the disease, and no prophylaxis has been established. We developed a new PVO animal model, investigated the mechanisms of PVO progression, and examined a new prophylactic strategy. METHODS We developed a chronic PVO model using infant domestic pigs by cutting and resuturing the left lower PV followed by weekly hemodynamic parameter measurement and angiographic assessment of the anastomosed PV. Subsequently, we tested a novel therapeutic strategy with external application of rapamycin-eluting film to the anastomotic site. RESULTS We found the pig PVO model mimicked human PVO hemodynamically and histopathologically. This model exhibited increased expression levels of Ki-67 and phospho-mammalian target of rapamycin in smooth muscle-like cells at the anastomotic neointima. In addition, contractile to synthetic phenotypic transition; that is, dedifferentiation of smooth muscle cells and mammalian target of rapamycin pathway activation in the neointima of upstream PVs were observed. Rapamycin-eluting films externally applied around the anastomotic site inhibited the activation of mammalian target of rapamycin in the smooth muscle-like cells of neointima, and delayed PV anastomotic stenosis. CONCLUSIONS We demonstrate the evidence on dedifferentiation of smooth muscle-like cells and mammalian target of rapamycin pathway activation in the pathogenesis of PVO progression. Delivery of rapamycin to the anastomotic site from the external side delayed PV anastomotic stenosis, implicating a new therapeutic strategy to prevent PVO progression.
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Affiliation(s)
- Naoki Masaki
- Division of Cardiovascular Surgery, Tohoku University Graduate School of Medicine, Aoba-ku, Sendai, Japan
| | - Osamu Adachi
- Division of Cardiovascular Surgery, Tohoku University Graduate School of Medicine, Aoba-ku, Sendai, Japan
| | - Shintaro Katahira
- Division of Cardiovascular Surgery, Tohoku University Graduate School of Medicine, Aoba-ku, Sendai, Japan
| | - Yuriko Saiki
- Department of Molecular Pathology, Tohoku University Graduate School of Medicine, Aoba-ku, Sendai, Japan
| | - Akira Horii
- Department of Molecular Pathology, Tohoku University Graduate School of Medicine, Aoba-ku, Sendai, Japan
| | - Shunsuke Kawamoto
- Division of Cardiovascular Surgery, Tohoku University Graduate School of Medicine, Aoba-ku, Sendai, Japan
| | - Yoshikatsu Saiki
- Division of Cardiovascular Surgery, Tohoku University Graduate School of Medicine, Aoba-ku, Sendai, Japan.
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24
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Ulus T, Dural M, Şener E, Meşe P, Kurt E, Aydın N. Medical treatment of a symptomatic acute pulmonary vein stenosis following antral pulmonary vein isolation. J Atr Fibrillation 2020; 12:2261. [PMID: 32435356 DOI: 10.4022/jafib.2261] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2019] [Revised: 12/26/2019] [Accepted: 01/19/2020] [Indexed: 11/10/2022]
Abstract
Pulmonary vein (PV) stenosis is a rare but serious complication of PV isolation. It usually develops 3-6 months after the procedure, but may rarely develop in the acute phase. We present a case of symptomatic PV stenosis within 48 hours after antral PV isolation. Following the initiation of medical treatment including a glucocorticoid, acute changes in the PV wall regressed and the patient's complaint of dyspnea at rest improved rapidly. In addition, long-term renin-angiotensin-aldosterone system (RAAS) blockers were given. The complaint did not recur during follow-up and PV stenosis was mild at 6 months.
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Affiliation(s)
- Taner Ulus
- Department of Cardiology, Faculty of Medicine, Eskişehir Osmangazi University, Eskişehir, Turkey
| | - Muhammet Dural
- Department of Cardiology, Faculty of Medicine, Eskişehir Osmangazi University, Eskişehir, Turkey
| | - Emre Şener
- Department of Cardiology, Faculty of Medicine, Eskişehir Osmangazi University, Eskişehir, Turkey
| | - Pelin Meşe
- Department of Cardiology, Faculty of Medicine, Eskişehir Osmangazi University, Eskişehir, Turkey
| | - Emel Kurt
- Department of Chest Diseases, Faculty of Medicine, Eskişehir Osmangazi University, Eskişehir, Turkey
| | - Nevin Aydın
- 3 Department of Radiology, Faculty of Medicine, Eskişehir Osmangazi University, Eskişehir, Turkey
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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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26
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Elmowafy E, Soliman ME. Losartan-chitosan/dextran sulfate microplex as a carrier to lung therapeutics: Dry powder inhalation, aerodynamic profile and pulmonary tolerability. Int J Biol Macromol 2019; 136:220-229. [PMID: 31195046 DOI: 10.1016/j.ijbiomac.2019.06.058] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2019] [Revised: 05/19/2019] [Accepted: 06/09/2019] [Indexed: 12/25/2022]
Abstract
This study aims to obtain an inhalation powder with meaningful aerodynamic and safety profiles for the lung delivery of losartan (LS). For this, the capacity of self-assembly of chitosan (CS) and dextran sulfate (DS) to form CS/DS microplex (MC), incorporating high payload of hydrophilic LS was harnessed. Dry powder inhaler (LS-MC-DPI), prepared via spray drying of the best achieved LS-MC, was proposed to impart precise engineered inhalation characteristics. Micrometric robust CS/DS MC was revealed to offer the opportunity to heighten LS encapsulation, accounting for ~75%. LS-MC-DPI was successfully developed with high yield, flowability, respirable aerodynamic size and morphology which formed swellable and mucoadhesive network, facilitating intra-pulmonary delivery. Moreover, sustained release pattern, augmented deep lung deposition and safe histological profile were realized. Overall, the newly developed LS-MC DPI shows promises as an inhalation system. The aerodynamic performance and safety of LS-MC-DPI verify its suitability for further in vivo lung therapeutics.
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Affiliation(s)
- Enas Elmowafy
- Department of Pharmaceutics and Industrial Pharmacy, Faculty of Pharmacy, Ain Shams University, Cairo, Egypt, Monazzamet Elwehda Elafrikeya Street, Abbaseyya, Cairo P.O. 11566, Egypt.
| | - Mahmoud E Soliman
- Department of Pharmaceutics and Industrial Pharmacy, Faculty of Pharmacy, Ain Shams University, Cairo, Egypt, Monazzamet Elwehda Elafrikeya Street, Abbaseyya, Cairo P.O. 11566, Egypt
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27
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Backes CH, Nealon E, Armstrong AK, Cua CL, Mitchell C, Krishnan U, Vanderlaan RD, Song MK, Viola N, Smith CV, McConnell PI, Rivera BK, Bridge J. Pulmonary Vein Stenosis in Infants: A Systematic Review, Meta-Analysis, and Meta-Regression. J Pediatr 2018; 198:36-45.e3. [PMID: 29650415 DOI: 10.1016/j.jpeds.2018.02.030] [Citation(s) in RCA: 26] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/07/2017] [Revised: 01/08/2018] [Accepted: 02/13/2018] [Indexed: 12/22/2022]
Abstract
OBJECTIVE To quantify outcomes of infants (<1 year of age) diagnosed with pulmonary vein stenosis (PVS). STUDY DESIGN MEDLINE (PubMed), Scopus, and Web of Science were searched through February 1, 2017, with no language restrictions. Publications including infants diagnosed with primary PVS, defined as the absence of preceding intervention(s), were considered. The study was performed according to Meta-analysis of Observational Studies in Epidemiology guidelines, the Systematic Reviews, and Meta-Analysis checklist, and registered prospectively. The quality of selected reports was critically examined. Data extraction was independently performed by multiple observers with outcomes agreed upon a priori. Data were pooled using an inverse variance heterogeneity model with incidence of mortality the primary outcome of interest. RESULTS Forty-eight studies of 185 infants were included. Studies were highly diverse with regards to the participants, interventions, and outcomes reported. The median (range) age at diagnosis was 5.0 (0.1-11.6) months. Pooled mortality was 58.5% (95% CI 49.8%-67.0%, I2 = 21.4%). We observed greater mortality incidence among infants with 3 or 4 vein stenoses than in those with 1 or 2 vein stenoses (83.3% vs 36.1%; P < .01). We observed greater mortality among infants with bilateral than unilateral disease (78.7% vs 26.0%; P < .01). CONCLUSIONS Studies of primary PVS during infancy are highly variable in their methodological quality and estimates of clinical outcomes; therefore, estimates of prognosis remain uncertain. Multicenter, interdisciplinary collaborations, including alignment of key outcome measurements, are needed to answer questions beyond the scope of available data.
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Affiliation(s)
- Carl H Backes
- Department of Pediatrics, Nationwide Children's Hospital and The Ohio State University, Columbus, OH; The Heart Center, Nationwide Children's Hospital, Columbus, OH; Department of Obstetrics and Gynecology, The Ohio State University, Columbus, OH; Center for Perinatal Research, The Research Institute at Nationwide Children's Hospital, Columbus, OH.
| | - Erin Nealon
- Department of Pediatrics, Nationwide Children's Hospital and The Ohio State University, Columbus, OH
| | - Aimee K Armstrong
- Department of Pediatrics, Nationwide Children's Hospital and The Ohio State University, Columbus, OH; The Heart Center, Nationwide Children's Hospital, Columbus, OH
| | - Clifford L Cua
- Department of Pediatrics, Nationwide Children's Hospital and The Ohio State University, Columbus, OH; The Heart Center, Nationwide Children's Hospital, Columbus, OH
| | - Courtney Mitchell
- Center for Perinatal Research, The Research Institute at Nationwide Children's Hospital, Columbus, OH
| | - Usha Krishnan
- Department of Pediatric Cardiology, Columbia University, New York, NY
| | - Rachel D Vanderlaan
- Division of Cardiac Surgery, University of Toronto, Hospital for Sick Children, Toronto, Ontario, Canada
| | - Mi Kyoung Song
- Department of Pediatrics, Seoul National University Children's Hospital, Seoul, Republic of Korea
| | - Nicola Viola
- Department of Thoracic and Cardiovascular Surgery, University Hospital of Southampton, Southampton, United Kingdom; Department of Cardiothoracic Surgery, Children's Hospital of Southampton, Southampton, United Kingdom
| | - Charles V Smith
- Center for Developmental Therapeutics, Seattle Children's Research Institute, University of Washington School of Medicine, Seattle, WA
| | - Patrick I McConnell
- Department of Surgery, The Ohio State University, College of Medicine, Columbus, OH; Center for Pediatric Transplant Research, Nationwide Children's Hospital, Columbus, OH; Department of Cardiothoracic Surgery, Nationwide Children's Hospital, Columbus, OH
| | - Brian K Rivera
- Center for Perinatal Research, The Research Institute at Nationwide Children's Hospital, Columbus, OH
| | - Jeffrey Bridge
- Center for Innovation in Pediatric Practice, The Research Institute at Nationwide Children's Hospital, Columbus, OH
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Domingo L, Magdo HS, Day RW. Acute Pulmonary Vasodilator Testing and Long-Term Clinical Course in Segmental Pulmonary Vascular Disease. Pediatr Cardiol 2018; 39:501-508. [PMID: 29196781 DOI: 10.1007/s00246-017-1780-9] [Citation(s) in RCA: 6] [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] [Received: 07/11/2017] [Accepted: 11/21/2017] [Indexed: 10/18/2022]
Abstract
Results of acute pulmonary vasodilator testing (AVT) and the outcome of medical therapy have not been described in patients with segmental pulmonary vascular disease (SPVD). We sought to compare the pulmonary vasodilatory effects of oxygen, oxygen with nitric oxide, and diltiazem, and to describe the clinical course of patients with SPVD and pulmonary hypertension. A retrospective review of 16 patients with pulmonary hypertension and SPVD involving 2-3 major lung segments who underwent AVT between January 2000 and December 2015 was performed. Baseline hemodynamic measurements were obtained with patients breathing ≤ 30% oxygen. AVT was performed using 100% oxygen, 100% oxygen with 20 ppm nitric oxide, 21-35% oxygen, and 21-35% oxygen with intravenous diltiazem. The events associated with their long-term care were described. Nine of 16 patients were acutely responsive during AVT using the Sitbon criteria. The change in mean pulmonary artery pressure with oxygen or oxygen with nitric oxide (19 ± 12 mmHg) was significantly greater than the change with diltiazem (7 ± 5 mmHg). Pulmonary vasodilator therapy was initiated or escalated after AVT in 12 patients. Five patients subsequently experienced a decrease in mean pulmonary artery pressure or normalization in B-type natriuretic peptide. Three patients experienced adverse events associated with therapy. The actuarial survival was 94% over a period of 1-20 years. This study suggests that AVT can be used to identify patients with SPVD who are reactive to oxygen, oxygen with nitric oxide, and diltiazem. Clinical improvement was temporally associated with pulmonary vasodilator therapy in some patients with few adverse effects.
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Affiliation(s)
- Liezl Domingo
- Division of Pediatric Cardiology, Primary Children's Hospital, University of Utah, 81 North Mario Capecchi Drive, Salt Lake City, UT, 84113, USA.
| | - H Sonali Magdo
- Division of Pediatric Cardiology, Primary Children's Hospital, University of Utah, 81 North Mario Capecchi Drive, Salt Lake City, UT, 84113, USA
| | - Ronald W Day
- Division of Pediatric Cardiology, Primary Children's Hospital, University of Utah, 81 North Mario Capecchi Drive, Salt Lake City, UT, 84113, USA
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Alsoufi B. Lost in translation. J Thorac Cardiovasc Surg 2017; 154:1754-1755. [PMID: 28780182 DOI: 10.1016/j.jtcvs.2017.07.010] [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: 07/04/2017] [Accepted: 07/10/2017] [Indexed: 10/19/2022]
Affiliation(s)
- Bahaaldin Alsoufi
- Division of Cardiothoracic Surgery, Emory University School of Medicine, Children's Healthcare of Atlanta, Atlanta, Ga.
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Prosnitz AR, Leopold J, Irons M, Jenkins K, Roberts AE. Pulmonary vein stenosis in patients with Smith-Lemli-Opitz syndrome. CONGENIT HEART DIS 2017; 12:475-483. [PMID: 28719049 DOI: 10.1111/chd.12471] [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: 12/05/2016] [Revised: 03/16/2017] [Accepted: 04/14/2017] [Indexed: 12/13/2022]
Abstract
OBJECTIVE To describe a group of children with co-incident pulmonary vein stenosis and Smith-Lemli-Opitz syndrome and to generate hypotheses as to the shared pathogenesis of these disorders. DESIGN Retrospective case series. PATIENTS Five subjects in a pulmonary vein stenosis cohort of 170 subjects were diagnosed with Smith-Lemli-Opitz syndrome soon after birth. RESULTS All five cases were diagnosed with Smith-Lemli-Opitz syndrome within 6 weeks of life, with no family history of either disorder. All cases had pathologically elevated 7-dehydrocholesterol levels and two of the five cases had previously reported pathogenic 7-dehydrocholesterol reductase mutations. Smith-Lemli-Opitz syndrome severity scores ranged from mild to classical (2-7). Gestational age at birth ranged from 35 to 39 weeks. Four of the cases were male by karyotype. Pulmonary vein stenosis was diagnosed in all cases within 2 months of life, earlier than most published cohorts. All cases progressed to bilateral disease and three cases developed atresia of at least one vein. Despite catheter and surgical interventions, all subjects' pulmonary vein stenosis rapidly recurred and progressed. Three of the subjects died, at 2 months, 3 months, and 11 months. Survival at 16 months after diagnosis was 43%. CONCLUSIONS Patients with pulmonary vein stenosis who have a suggestive syndromic presentation should be screened for Smith-Lemli-Opitz syndrome with easily obtainable serum sterol tests. Echocardiograms should be obtained in all newly diagnosed patients with Smith-Lemli-Opitz syndrome, with a low threshold for repeating the study if new respiratory symptoms of uncertain etiology arise. Further studies into the pathophysiology of pulmonary vein stenosis should consider the role of cholesterol-based signaling pathways in the promotion of intimal proliferation.
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Affiliation(s)
- Aaron R Prosnitz
- Department of Cardiology, Boston Children's Hospital, Boston, Massachusetts, USA
| | - Jane Leopold
- Division of Cardiovascular Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Mira Irons
- American Board of Medical Specialties, Chicago, Illinois, USA
| | - Kathy Jenkins
- Department of Cardiology, Boston Children's Hospital, Boston, Massachusetts, USA
| | - Amy E Roberts
- Department of Cardiology, Boston Children's Hospital, Boston, Massachusetts, USA
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Kalfa D, Belli E, Bacha E, Lambert V, di Carlo D, Kostolny M, Salminen J, Nosal M, Poncelet A, Horer J, Berggren H, Yemets I, Hazekamp M, Maruszewski B, Sarris G, Pozzi M, Ebels T, Lacour-Gayet F. Primary Pulmonary Vein Stenosis: Outcomes, Risk Factors, and Severity Score in a Multicentric Study. Ann Thorac Surg 2017. [DOI: 10.1016/j.athoracsur.2017.03.022] [Citation(s) in RCA: 45] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Pulmonary vein stenosis: Severity and location predict survival after surgical repair. J Thorac Cardiovasc Surg 2016; 151:657-666.e2. [DOI: 10.1016/j.jtcvs.2015.08.121] [Citation(s) in RCA: 48] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/21/2015] [Revised: 08/25/2015] [Accepted: 08/29/2015] [Indexed: 11/22/2022]
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Pulmonary vein stenosis—novel strategies for a challenging and resistant condition? J Thorac Cardiovasc Surg 2016; 151:618-620. [DOI: 10.1016/j.jtcvs.2015.11.040] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/20/2015] [Accepted: 11/20/2015] [Indexed: 11/19/2022]
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Pulmonary Vein Stenosis in a Newborn: A Commonly Overlooked Diagnosis. Case Rep Cardiol 2015; 2015:870257. [PMID: 26457207 PMCID: PMC4592733 DOI: 10.1155/2015/870257] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2015] [Accepted: 09/09/2015] [Indexed: 12/01/2022] Open
Abstract
The diagnosis of primary pulmonary vein stenosis is often overlooked because its symptoms overlap lung diseases and pulmonary arterial hypertension. Its diagnosis may be difficult because the condition is progressive and associated with other defects. We present a case of pulmonary vein stenosis in a newborn with stenosis of the left-sided common pulmonary vein, diffuse hypoplasia of the superior right pulmonary vein, and atresia of the inferior right pulmonary vein.
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Tsang VT, Tran PK. Pulmonary vein stenosis: Challenges ahead. J Thorac Cardiovasc Surg 2015; 150:776. [PMID: 26277464 DOI: 10.1016/j.jtcvs.2015.07.024] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/07/2015] [Accepted: 07/07/2015] [Indexed: 11/28/2022]
Affiliation(s)
- Victor T Tsang
- Department of Cardiothoracic Surgery, Great Ormond Street Hospital for Children NHS Trust, London, United Kingdom.
| | - Phan-Kiet Tran
- Department of Cardiothoracic Surgery, Great Ormond Street Hospital for Children NHS Trust, London, United Kingdom
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Shi G, Zhu Z, Chen H, Zhang H, Zheng J, Liu J. Surgical repair for primary pulmonary vein stenosis: Single-institution, midterm follow-up. J Thorac Cardiovasc Surg 2015; 150:181-8. [DOI: 10.1016/j.jtcvs.2015.03.032] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/21/2014] [Revised: 03/11/2015] [Accepted: 03/20/2015] [Indexed: 12/15/2022]
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Abstract
Congenital cardiac anesthesiology is a rapidly expanding field at both ends of the life spectrum. The care of the unborn child with congenital heart disease is becoming highly specialized in regional centers that offer advanced imaging techniques, coordinated specialist care, and potentially fetal interventions. As more children with congenital heart disease survive to adulthood, patients and their health care providers are facing new challenges. The growing volume of publications reflects this expanding field of congenital cardiac anesthesiology. This year in review article highlights some developing trends in the literature.
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Losartan for progressive pulmonary vein stenosis: A possible solution? J Thorac Cardiovasc Surg 2014; 148:2559. [DOI: 10.1016/j.jtcvs.2014.10.007] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/02/2014] [Accepted: 10/02/2014] [Indexed: 11/19/2022]
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