1
|
Lynch A, Jeewa A, Minn S, Arathoon K, Honjo O, Floh A, Hassan A, Jean-St-Michel E. Outcomes of Children With Hypoplastic Left Heart Syndrome and Heart Failure on Medical Therapy. JACC. ADVANCES 2024; 3:100811. [PMID: 38939382 PMCID: PMC11198231 DOI: 10.1016/j.jacadv.2023.100811] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/02/2023] [Revised: 09/05/2023] [Accepted: 11/09/2023] [Indexed: 06/29/2024]
Abstract
Background Systemic right ventricle (RV) dysfunction is associated with lower transplant-free survival (TFS) in hypoplastic left heart syndrome (HLHS), but the likelihood of functional improvement and utility of heart failure (HF) medications is not understood. Objectives The authors aimed to describe TFS, HF medication use, and surgical interventions in HLHS patients with RV dysfunction with and without subsequent improvement in function. Methods The SickKids HF Database is a retrospective cohort that includes all pediatric HLHS patients with RV dysfunction lasting >30 days. We compared TFS, HF medications, and surgical interventions in HLHS patients with and without functional normalization. Results Of 99 patients with HLHS and RV dysfunction, 52% had normalized function for ≥30 days. TFS at 2 years after dysfunction onset was lower in those without normalization (14% vs 78%, P < 0.001). Patients without normalization were less likely to reach target dosing (TD) of HF medications (27% vs 47% on 1 medication at TD, P < 0.001) and undergo Fontan completion (7% vs 53%, P < 0.001). Clinical factors associated with improved TFS were normalization of function for ≥30 days, onset of dysfunction after bidirectional Glenn, and exposure to ACE inhibition. Conclusions Our cohort of HLHS patients with systemic RV dysfunction demonstrated a novel finding of improved TFS in those with functional normalization for ≥30 days. Achieving TD of HF medications was associated with improved outcomes. This may reflect patient stability and tolerance for HF medication more than its therapeutic effect, but it can help inform decisions to proceed with surgical palliation or list for transplant.
Collapse
Affiliation(s)
- Aine Lynch
- Division of Cardiology, The Hospital for Sick Children, Toronto, Ontario, Canada
- University of Toronto, Toronto, Ontario, Canada
| | - Aamir Jeewa
- Division of Cardiology, The Hospital for Sick Children, Toronto, Ontario, Canada
- University of Toronto, Toronto, Ontario, Canada
| | - Sunghoon Minn
- Division of Cardiology, The Hospital for Sick Children, Toronto, Ontario, Canada
- University of Toronto, Toronto, Ontario, Canada
| | - Katelyn Arathoon
- Division of Cardiology, The Hospital for Sick Children, Toronto, Ontario, Canada
- University of Toronto, Toronto, Ontario, Canada
| | - Osami Honjo
- University of Toronto, Toronto, Ontario, Canada
- Division of Cardiovascular Surgery, The Labatt Family Heart Centre, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Alejandro Floh
- University of Toronto, Toronto, Ontario, Canada
- Division of Critical Care Medicine, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Ahmed Hassan
- Division of Cardiology, The Hospital for Sick Children, Toronto, Ontario, Canada
- University of Toronto, Toronto, Ontario, Canada
| | - Emilie Jean-St-Michel
- Division of Cardiology, The Hospital for Sick Children, Toronto, Ontario, Canada
- University of Toronto, Toronto, Ontario, Canada
| |
Collapse
|
2
|
Jacobs JP, DeCampli WM, Karamlou T, Najm HK, Marino BS, Blackstone EH, McCrindle BW, Jegatheeswaran A, St Louis JD, Austin EH, Caldarone CA, Mavroudis C, Overman DM, Dearani JA, Jacobs ML, Tchervenkov CI, Svensson LG, Barron D, Kirklin JK, Williams WG. The Academic Impact of Congenital Heart Surgeons' Society (CHSS) Studies. World J Pediatr Congenit Heart Surg 2023; 14:602-619. [PMID: 37737599 DOI: 10.1177/21501351231190916] [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: 09/23/2023]
Abstract
PURPOSE We reviewed all 64 articles ever published by The Congenital Heart Surgeons' Society (CHSS) Data Center to estimate the academic impact of these peer-reviewed articles. MATERIALS AND METHODS The Congenital Heart Surgeons' Society has performed research based on 12 Diagnostic Inception Cohorts. The first cohort (Transposition) began enrolling patients on January 1, 1985. We queried PubMed to determine the number of publications that referenced each of the 64 journal articles generated by the datasets of the 12 Diagnostic Inception Cohorts that comprise the CHSS Database. Descriptive summaries of the data were tabulated using mean with standard deviation and median with range. RESULTS Sixty-four peer-reviewed papers have been published based on the CHSS Database. Fifty-nine peer-reviewed articles have been published based on the 12 Diagnostic Inception Cohorts, and five additional articles have been published based on Data Science. Excluding the recently established Diagnostic Inception Cohort for patients with Ebstein malformation of tricuspid valve, the number of papers published per cohort ranged from 1 for coarctation to 11 for transposition of the great arteries. The 11 articles generated from the CHSS Transposition Cohort were referenced by a total of 111 articles (median number of references per journal article = 9 [range = 0-22, mean = 10.1]). Overall, individual articles were cited by an average of 11 (mean), and a maximum of 41 PubMed-listed publications. Overall, these 64 peer-reviewed articles based on the CHSS Database were cited 692 times in PubMed-listed publications. The first CHSS peer-reviewed article was published in 1987, and during the 35 years from 1987 to 2022, inclusive, the annual number of CHSS publications has ranged from 0 to 7, with a mean of 1.8 publications per year (median = 1, mode = 1). CONCLUSION Congenital Heart Surgeons' Society studies are widely referenced in the pediatric cardiac surgical literature, with over 10 citations per published article. These cohorts provide unique information unavailable in other sources of data. A tool to access this analysis is available at: [https://data-center.chss.org/multimedia/files/2022/CAI.pdf].
Collapse
Affiliation(s)
- Jeffrey Phillip Jacobs
- Congenital Heart Center, Division of Cardiovascular Surgery, Departments of Surgery and Pediatrics, University of Florida, Gainesville, FL, USA
| | - William M DeCampli
- Division of Pediatric Cardiac Surgery, Arnold Palmer Hospital for Children, Orlando, FL, USA
| | - Tara Karamlou
- Pediatric and Adult Congenital Heart Center, Cleveland Clinic, Cleveland, OH, USA
| | - Hani K Najm
- Pediatric and Adult Congenital Heart Center, Cleveland Clinic, Cleveland, OH, USA
| | - Bradley S Marino
- Pediatric and Adult Congenital Heart Center, Cleveland Clinic, Cleveland, OH, USA
| | - Eugene H Blackstone
- Pediatric and Adult Congenital Heart Center, Cleveland Clinic, Cleveland, OH, USA
| | - Brian W McCrindle
- Division of Pediatric Cardiology, Hospital for Sick Children, Toronto, Ontario, Canada
| | | | - James D St Louis
- Department of Cardiac Surgery, Inova Fairfax Hospital and Inova L.J Murphy Children's Hospital, Fairfax, VA, USA
- Departments of Surgery and Pediatrics, Children's Hospital of Georgia, Augusta University, Augusta, GA, USA
| | - Erle H Austin
- Department of Cardiovascular and Thoracic Surgery, University of Louisville, Louisville, KY, USA
- Norton Children's Hospital, Louisville, KY, USA
| | | | - Constantine Mavroudis
- Pediatric Cardiothoracic Surgery, Peyton Manning Children's Hospital, Indianapolis, IN, USA
- Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - David M Overman
- Division of Cardiovascular Surgery, Mayo Clinic-Children's Minnesota Cardiovascular Collaborative, Minneapolis, MN, USA
| | - Joseph A Dearani
- Division of Cardiovascular Surgery, Mayo Clinic-Children's Minnesota Cardiovascular Collaborative, Minneapolis, MN, USA
| | - Marshall L Jacobs
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Christo I Tchervenkov
- Division of Cardiovascular Surgery, The Montreal Children's Hospital, McGill University Health Centre, Montreal, Québec, Canada
| | - Lars G Svensson
- Pediatric and Adult Congenital Heart Center, Cleveland Clinic, Cleveland, OH, USA
| | - David Barron
- Division of Cardiovascular Surgery, Hospital for Sick Children, Toronto, Ontario, Canada
| | - James K Kirklin
- Kirklin Institute for Research in Surgical Outcomes, Birmingham, AL, USA
| | - William G Williams
- Division of Cardiovascular Surgery, Hospital for Sick Children, Toronto, Ontario, Canada
| |
Collapse
|
3
|
Jegatheeswaran A, Argo MB, Devlin PJ, Callahan CP, Meza JM, Wilder TJ, Hickey EJ, Karamlou T. The Congenital Heart Surgeons' Society Kirklin/Ashburn Fellowship: The Fellows' Perspective. World J Pediatr Congenit Heart Surg 2023; 14:575-586. [PMID: 37737596 DOI: 10.1177/21501351231190087] [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: 09/23/2023]
Abstract
Since its establishment in 2001, the Congenital Heart Surgeons' Society John W. Kirklin/David Ashburn Fellowship has contributed substantially to the field of congenital heart surgery research while simultaneously training the next generation of surgeon- scientists. To date, ten fellows (and counting) have successfully completed this rigorous training, producing over 40 published articles focused on longitudinal outcomes from the various Congenital Heart Surgeons' Society cohorts. As the Kirklin/Ashburn Fellowship expands and additional fellows matriculate, its legacy, the network of support, and the contribution to congenital heart surgery research will undoubtedly hold strong.
Collapse
Affiliation(s)
- Anusha Jegatheeswaran
- Department of Cardiothoracic Surgery, Great Ormond Street Hospital for Children, London, UK
- Children's Cardiovascular Disease, Institute of Cardiovascular Science, University College London, London, UK
| | - Madison B Argo
- Department of Surgery, University of Wisconsin Hospital and Clinics, Madison, WI, USA
- Division of Cardiovascular Surgery, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Paul J Devlin
- Division of Cardiac Surgery and Bluhm Cardiovascular Institute, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Connor P Callahan
- Division of Pediatric Cardiothoracic Surgery, University Hospitals Rainbow Babies and Children's, Cleveland, OH, USA
| | - James M Meza
- Division of Cardiovascular and Thoracic Surgery, Duke University Medical Center, Durham, NC, USA
| | - Travis J Wilder
- Department of Surgery, Washington University School of Medicine, St. Louis, MO, USA
| | - Edward J Hickey
- Department of Cardiothoracic Surgery, Texas Children's Hospital, Houston, TX, USA
- Baylor College of Medicine, Houston, TX, USA
| | - Tara Karamlou
- Division of Pediatric Cardiac Surgery and the Heart, Vascular, and Thoracic Institute, Cleveland Clinic, Cleveland, OH, USA
| |
Collapse
|
4
|
Das A, Hameed M, Prather R, Farias M, Divo E, Kassab A, Nykanen D, DeCampli W. In-Silico and In-Vitro Analysis of the Novel Hybrid Comprehensive Stage II Operation for Single Ventricle Circulation. Bioengineering (Basel) 2023; 10:bioengineering10020135. [PMID: 36829630 PMCID: PMC9952694 DOI: 10.3390/bioengineering10020135] [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] [Received: 08/26/2022] [Revised: 12/22/2022] [Accepted: 01/05/2023] [Indexed: 01/20/2023] Open
Abstract
Single ventricle (SV) anomalies account for one-fourth of all congenital heart disease cases. The existing palliative treatment for this anomaly achieves a survival rate of only 50%. To reduce the trauma associated with surgical management, the hybrid comprehensive stage II (HCSII) operation was designed as an alternative for a select subset of SV patients with the adequate antegrade aortic flow. This study aims to provide better insight into the hemodynamics of HCSII patients utilizing a multiscale Computational Fluid Dynamics (CFD) model and a mock flow loop (MFL). Both 3D-0D loosely coupled CFD and MFL models have been tuned to match baseline hemodynamic parameters obtained from patient-specific catheterization data. The hemodynamic findings from clinical data closely match the in-vitro and in-silico measurements and show a strong correlation (r = 0.9). The geometrical modification applied to the models had little effect on the oxygen delivery. Similarly, the particle residence time study reveals that particles injected in the main pulmonary artery (MPA) have successfully ejected within one cardiac cycle, and no pathological flows were observed.
Collapse
Affiliation(s)
- Arka Das
- Department of Mechanical Engineering, Embry-Riddle Aeronautical University, Daytona Beach, FL 32114, USA
- Correspondence: ; Tel.: +1-386-241-1457
| | - Marwan Hameed
- Department of Mechanical Engineering, American University of Bahrain, Riffa 942, Bahrain
| | - Ray Prather
- Department of Mechanical Engineering, Embry-Riddle Aeronautical University, Daytona Beach, FL 32114, USA
- Department of Mechanical and Aerospace Engineering, University of Central Florida, Orlando, FL 32816, USA
- The Heart Center at Orlando Health Arnold Palmer Hospital for Children, Orlando, FL 32806, USA
| | - Michael Farias
- The Heart Center at Orlando Health Arnold Palmer Hospital for Children, Orlando, FL 32806, USA
- Department of Clinical Sciences, College of Medicine, University of Central Florida, Orlando, FL 32816, USA
| | - Eduardo Divo
- Department of Mechanical Engineering, Embry-Riddle Aeronautical University, Daytona Beach, FL 32114, USA
| | - Alain Kassab
- Department of Mechanical and Aerospace Engineering, University of Central Florida, Orlando, FL 32816, USA
| | - David Nykanen
- The Heart Center at Orlando Health Arnold Palmer Hospital for Children, Orlando, FL 32806, USA
- Department of Clinical Sciences, College of Medicine, University of Central Florida, Orlando, FL 32816, USA
| | - William DeCampli
- The Heart Center at Orlando Health Arnold Palmer Hospital for Children, Orlando, FL 32806, USA
- Department of Clinical Sciences, College of Medicine, University of Central Florida, Orlando, FL 32816, USA
| |
Collapse
|
5
|
Dolgner SJ, Tjoeng YL, Chan T. Analysis of the Single Ventricle Reconstruction Trial Using Restricted Mean Survival Time and Shunt Type Received. J Am Heart Assoc 2022; 11:e025978. [PMID: 36073629 PMCID: PMC9683638 DOI: 10.1161/jaha.122.025978] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Affiliation(s)
- Stephen J. Dolgner
- Pediatric Cardiology, Heart CenterTexas Children’s Hospital, Baylor College of MedicineHoustonTX
| | - Yuen L. Tjoeng
- The Heart CenterSeattle Children’s Hospital, University of WashingtonSeattleWA
| | - Titus Chan
- The Heart CenterSeattle Children’s Hospital, University of WashingtonSeattleWA
| |
Collapse
|
6
|
Wald R, Mertens L. Hypoplastic Left Heart Syndrome Across the Lifespan: Clinical Considerations for Care of the Fetus, Child, and Adult. Can J Cardiol 2022; 38:930-945. [PMID: 35568266 DOI: 10.1016/j.cjca.2022.04.028] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2022] [Revised: 04/22/2022] [Accepted: 04/24/2022] [Indexed: 12/14/2022] Open
Abstract
Hypoplastic left heart syndrome (HLHS) is the most common anatomic lesion in children born with single ventricle physiology and is characterized by the presence of a dominant right ventricle and a hypoplastic left ventricle along with small left-sided heart structures. Diagnostic subgroups of HLHS reflect the extent of inflow and outflow obstruction at the aortic and mitral valves, specifically stenosis or atresia. If left unpalliated, HLHS is a uniformly fatal lesion in infancy. Following introduction of the Norwood operation, early survival has steadily improved over the past four decades, mirroring advances in operative and peri-operative management as well as reflecting refinements in patient surveillance and interstage clinical care. Notably, survival following staged palliation has increased from 0% to a 5-year survival of 60-65% for children in some centres. Despite the prevalence of HLHS in childhood with relatively favourable surgical outcomes in contemporary series, this cohort is only now reaching early adult life and longer-term outcomes have yet to be elucidated. In this article we focus on contemporary clinical management strategies for patients with HLHS across the lifespan, from fetal to adult life. Nomenclature and diagnostic considerations are discussed and current literature pertaining to putative genetic etiologies is reviewed. The spectrum of fetal and pediatric interventional strategies, both percutaneous and surgical, are described. Clinical, patient-reported and neurodevelopmental outcomes of HLHS are delineated. Finally, note is made of current areas of clinical uncertainty and suggested directions for future research are highlighted.
Collapse
Affiliation(s)
- Rachel Wald
- Labatt Family Heart Centre, Division of Cardiology, Hospital for Sick Children, Department of Pediatrics, University of Toronto, Toronto, Ontario, Canada; Peter Munk Cardiac Centre, Division of Cardiology, University Health Network, Department of Medicine,University of Toronto, Toronto, Ontario, Canada
| | - Luc Mertens
- Labatt Family Heart Centre, Division of Cardiology, Hospital for Sick Children, Department of Pediatrics, University of Toronto, Toronto, Ontario, Canada; Peter Munk Cardiac Centre, Division of Cardiology, University Health Network, Department of Medicine,University of Toronto, Toronto, Ontario, Canada
| |
Collapse
|
7
|
Surgical Strategies in Single Ventricle Management of Neonates and Infants. Can J Cardiol 2022; 38:909-920. [PMID: 35513174 DOI: 10.1016/j.cjca.2022.04.021] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2022] [Revised: 04/25/2022] [Accepted: 04/26/2022] [Indexed: 12/17/2022] Open
Abstract
No area of congenital heart disease has undergone greater change and innovation than Single Ventricle management over the past 20 years. Surgical and catheter lab interventions have transformed outcomes such that in some subgroups more than 80% of these patients can survive into adulthood. Driven by parallel development in diagnostic imaging and cardiac intensive care, surgical management is focused on the neonatal period as the key time to creating a balanced circulation and limiting pulmonary blood-flow. Different configurations of the circulation including new types of surgical shunts and the role of 'hybrid' circulations provide greater options and better physiology. This overview will focus on these changes in surgical management and timing but also look at the exciting areas of regenerative therapies to improve ventricular function, and the concept of ventricular rehabilitation to achieve biventricular circulations in certain groups of patients. The importance of early (neonatal) intervention and multidisciplinary approach to management is emphasised, as well as looking beyond simply survival but also improving neurodevelopmental outcomes.
Collapse
|
8
|
Winlaw DS, Hill GD, Heydarian HC, Shahanavaz S. Invited Commentary: What Do We Achieve With Expedited Left Atrial Decompression? World J Pediatr Congenit Heart Surg 2022; 13:321-323. [PMID: 35446212 DOI: 10.1177/21501351221089924] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- David S Winlaw
- Cardiothoracic Surgery, The Heart Institute, 2518Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - Garick D Hill
- Cardiology, The Heart Institute, 2518Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - Haleh C Heydarian
- Cardiology, The Heart Institute, 2518Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - Shabana Shahanavaz
- Cardiology, The Heart Institute, 2518Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| |
Collapse
|
9
|
Fricke K, Mellander M, Hanséus K, Tran P, Synnergren M, Johansson Ramgren J, Rydberg A, Sunnegårdh J, Dalén M, Sjöberg G, Weismann CG, Liuba, P. Impact of Left Ventricular Morphology on Adverse Outcomes Following Stage 1 Palliation for Hypoplastic Left Heart Syndrome: 20 Years of National Data From Sweden. J Am Heart Assoc 2022; 11:e022929. [PMID: 35348003 PMCID: PMC9075443 DOI: 10.1161/jaha.121.022929] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background
Hypoplastic left heart syndrome is associated with significant morbidity and mortality. We aimed to assess the influence of left ventricular morphology and choice of shunt on adverse outcome in patients with hypoplastic left heart syndrome and stage 1 palliation.
Methods and Results
This was a retrospective analysis of patients with hypoplastic left heart syndrome with stage 1 palliation between 1999 and 2018 in Sweden. Patients (n=167) were grouped based on the anatomic subtypes aortic‐mitral atresia, aortic atresia‐mitral stenosis (AA‐MS), and aortic‐mitral stenosis. The left ventricular phenotypes including globular left ventricle (Glob‐LV), miniaturized and slit‐like left ventricle (LV), and the incidence of major adverse events (MAEs) including mortality were assessed. The overall mortality and MAEs were 31% and 41%, respectively. AA‐MS (35%) was associated with both mortality (all other subtypes versus AA‐MS: interstage‐I: hazard ratio [HR], 2.7;
P
=0.006; overall: HR, 2.2;
P
=0.005) and MAEs (HR, 2.4;
P
=0.0009). Glob‐LV (57%), noticed in all patients with AA‐MS, 61% of patients with aortic stenosis‐mitral stenosis, and 19% of patients with aortic atresia‐mitral atresia, was associated with both mortality (all other left ventricular phenotypes versus Glob‐LV: interstage‐I: HR, 4.5;
P
=0.004; overall: HR, 3.4;
P
=0.0007) and MAEs (HR, 2.7;
P
=0.0007). There was no difference in mortality and MAEs between patients with AA‐MS and without AA‐MS with Glob‐LV (
P
>0.15). Patients with AA‐MS (35%) or Glob‐LV (38%) palliated with a Blalock‐Taussig shunt had higher overall mortality compared with those palliated with Sano shunts, irrespective of the stage 1 palliation year (AA‐MS: HR, 2.6;
P
=0.04; Glob‐ LV: HR, 2.1;
P
=0.03).
Conclusions
Glob‐LV and AA‐MS are independent morphological risk factors for adverse short‐ and long‐ term outcome, especially if a Blalock‐Taussig shunt is used as part of stage 1 palliation. These findings are important for the clinical management of patients with hypoplastic left heart syndrome.
Collapse
Affiliation(s)
- Katrin Fricke
- Cardiology Pediatric Heart Centre Skåne University Hospital Lund Sweden
- Pediatrics Department of Clinical Sciences Lund University Lund Sweden
| | - Mats Mellander
- Department of Pediatrics Institute of Clinical SciencesSahlgrenska Academy Gothenburg Sweden
- Children´s Heart Centre Sahlgrenska University Hospital Gothenburg Sweden
| | - Katarina Hanséus
- Cardiology Pediatric Heart Centre Skåne University Hospital Lund Sweden
- Pediatrics Department of Clinical Sciences Lund University Lund Sweden
| | - Phan‐Kiet Tran
- Pediatrics Department of Clinical Sciences Lund University Lund Sweden
- Cardiac Surgery Pediatric Heart Centre Skåne University Hospital Lund Sweden
| | - Mats Synnergren
- Department of Pediatrics Institute of Clinical SciencesSahlgrenska Academy Gothenburg Sweden
- Children´s Heart Centre Sahlgrenska University Hospital Gothenburg Sweden
| | - Jens Johansson Ramgren
- Pediatrics Department of Clinical Sciences Lund University Lund Sweden
- Cardiac Surgery Pediatric Heart Centre Skåne University Hospital Lund Sweden
| | - Annika Rydberg
- Department of Clinical Sciences, Pediatrics Umeå University Umeå Sweden
| | - Jan Sunnegårdh
- Department of Pediatrics Institute of Clinical SciencesSahlgrenska Academy Gothenburg Sweden
- Children´s Heart Centre Sahlgrenska University Hospital Gothenburg Sweden
| | - Magnus Dalén
- Department of Cardiothoracic Surgery Karolinska University Hospital Stockholm Sweden
- Department of Molecular Medicine and Surgery Karolinska Institute Stockholm Sweden
| | - Gunnar Sjöberg
- Department of Women's and Children's Health Karolinska Institute Stockholm Sweden
| | - Constance G. Weismann
- Cardiology Pediatric Heart Centre Skåne University Hospital Lund Sweden
- Pediatrics Department of Clinical Sciences Lund University Lund Sweden
| | - Petru Liuba,
- Cardiology Pediatric Heart Centre Skåne University Hospital Lund Sweden
- Pediatrics Department of Clinical Sciences Lund University Lund Sweden
| |
Collapse
|
10
|
Wirth SH, Heydarian HC, Marcuccio E, Tepe BE, Stein LH, Hill GD. Increasing Use of the Right Ventricle to Pulmonary Artery Shunt for Stage 1 Palliation. Ann Thorac Surg 2022; 115:1229-1236. [PMID: 35033509 DOI: 10.1016/j.athoracsur.2021.12.040] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/06/2021] [Revised: 11/14/2021] [Accepted: 12/10/2021] [Indexed: 11/30/2022]
Abstract
BACKGROUND Stage 1 palliation of hypoplastic left heart syndrome entails use of the Norwood operation with either a modified Blalock-Taussig shunt or a right ventricle-to-pulmonary artery shunt, or the Hybrid procedure. Utilization trends and factors influencing palliation selection remain unclear. We aimed to evaluate these questions and to compare outcomes between types of stage 1 palliation. METHODS The National Pediatric Cardiology Quality Improvement Collaborative phase 1 (6/2008-8/2016) and phase 2 (8/2016-9/2019) databases were used. Procedure type was assessed by operation year. Baseline characteristics and annual hospital volume were evaluated. Post-surgical admission duration and outcomes were compared. RESULTS 3,497 patients were included, 30.8% with modified Blalock-Taussig shunt, 59.7% with right-ventricle-to-pulmonary-artery shunt, and 9.5% with Hybrid. Use of the right-ventricle-to-pulmonary-artery shunt increased over time (p=0.02). This increase was similar among all hospital volumes. Higher hospital volume (OR 1.2 [95% CI 1.1-1.4], p=0.003), male sex (OR 1.3 [95% CI 1.1-1.6], p=0.01), and isolated cardiac disease (OR 1.33 [95% CI 1.01-1.55], p=0.05) were associated with relatively higher likelihoods of a modified Blalock-Taussig shunt. Mortality/transplant rates before stage 2 palliation were higher with the modified Blalock-Taussig shunt than the right-ventricle-to-pulmonary-artery shunt (12.3% vs 9.6%, p=0.03). CONCLUSIONS In stage one palliation, use of right-ventricle-to-pulmonary-artery shunts has increased over time, use of modified Blalock-Taussig shunts has decreased, and use of Hybrids was unchanged. The modified Blalock-Taussig shunt has a higher likelihood of use in higher volume centers, males, and less complex patients, but is associated with longer hospitalizations and lower transplant-free survival to stage 2 palliation.
Collapse
Affiliation(s)
- Scott H Wirth
- Heart Institute, Cincinnati Children's Hospital Medical Center, 3333 Burnet Avenue, MLC 2003, Cincinnati, OH 45229.
| | - Haleh C Heydarian
- Heart Institute, Cincinnati Children's Hospital Medical Center, 3333 Burnet Avenue, MLC 2003, Cincinnati, OH 45229
| | - Elisa Marcuccio
- Heart Institute, Cincinnati Children's Hospital Medical Center, 3333 Burnet Avenue, MLC 2003, Cincinnati, OH 45229
| | - Brooke E Tepe
- Heart Institute, Cincinnati Children's Hospital Medical Center, 3333 Burnet Avenue, MLC 2003, Cincinnati, OH 45229
| | - Laurel H Stein
- Heart Institute, Cincinnati Children's Hospital Medical Center, 3333 Burnet Avenue, MLC 2003, Cincinnati, OH 45229
| | - Garick D Hill
- Heart Institute, Cincinnati Children's Hospital Medical Center, 3333 Burnet Avenue, MLC 2003, Cincinnati, OH 45229
| |
Collapse
|
11
|
Piber N, Ono M, Palm J, Kido T, Burri M, Röhlig C, Strbad M, Cleuziou J, Lemmer J, Dilber D, Klawonn F, Ewert P, Hager A, Hörer J. Influence of Shunt Type on Survival and Right Heart Function after the Norwood Procedure for Aortic Atresia. Semin Thorac Cardiovasc Surg 2021; 34:1300-1310. [PMID: 34838954 DOI: 10.1053/j.semtcvs.2021.11.012] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2021] [Accepted: 11/18/2021] [Indexed: 12/28/2022]
Abstract
The study objective was to compare the results after Norwood procedure between modified Blalock-Taussig shunt (MBTS) and right ventricle-to-pulmonary artery conduit (RVPAC) according to Sano in patients with hypoplastic left heart syndrome (HLHS) and aortic atresia (AA). A total of 146 neonates with HLHS and AA who underwent the Norwood procedure at our institution between 2001 and 2020 were divided into 2 groups according to shunt type (MBTS or RVPAC). Survival after the Norwood procedure was compared between the groups. Longitudinal right ventricular and tricuspid valve function in each group were evaluated using cubic splines method. RVPAC was performed in 103 patients and MBTS in 43 according to surgeon preference. There were no differences in the 30-day mortality rates (16.5% vs 16.3%, P = 0.973). Survival at 0.5, 1 and 3 years was 79.6%, 74.6%, and 68.9% in RVPAC and 66.8%, 64.3%, and 58.5% in MBTS (P = 0.293). Among 23 patients undergoing tricuspid valve procedure, different mechanisms of tricuspid regurgitation were observed between the groups. Longitudinal analysis revealed greater prevalence of late right ventricular dysfunction in RVPAC patients. In 77 patients who completed Fontan procedure, the postoperative N-terminal pro B-type natriuretic peptide value was significantly higher in RVPAC vs MBTS (554 vs 276 ng/L, P = 0.007). No survival advantage of RVPAC over MBTS was observed in neonates with HLHS and AA undergoing the Norwood procedure. Longitudinal analysis demonstrated a greater prevalence of right ventricular dysfunction and higher N-terminal pro B-type natriuretic peptide values during late follow-up in patients with RVPAC.
Collapse
Affiliation(s)
- Nicole Piber
- Department of Congenital and Pediatric Heart Surgery, German Heart Center Munich, Technische Universität München, Division of Congenital and Pediatric Heart Surgery, University Hospital of Munich, Ludwig-Maximilians-Universität, Munich, Germany
| | - Masamichi Ono
- Department of Congenital and Pediatric Heart Surgery, German Heart Center Munich, Technische Universität München, Division of Congenital and Pediatric Heart Surgery, University Hospital of Munich, Ludwig-Maximilians-Universität, Munich, Germany.
| | - Jonas Palm
- Department of Pediatric Cardiology and Congenital Heart Disease, German Heart Center Munich Technische Universität München, Munich, Germany
| | - Takashi Kido
- Department of Congenital and Pediatric Heart Surgery, German Heart Center Munich, Technische Universität München, Division of Congenital and Pediatric Heart Surgery, University Hospital of Munich, Ludwig-Maximilians-Universität, Munich, Germany
| | - Melchior Burri
- Department of Cardiovascular Surgery, German Heart Center Munich, Technische Universität München, Munich, Germany
| | - Christoph Röhlig
- Department of Pediatric Cardiology and Congenital Heart Disease, German Heart Center Munich Technische Universität München, Munich, Germany
| | - Martina Strbad
- Department of Congenital and Pediatric Heart Surgery, German Heart Center Munich, Technische Universität München, Division of Congenital and Pediatric Heart Surgery, University Hospital of Munich, Ludwig-Maximilians-Universität, Munich, Germany
| | - Julie Cleuziou
- Department of Congenital and Pediatric Heart Surgery, German Heart Center Munich, Technische Universität München, Division of Congenital and Pediatric Heart Surgery, University Hospital of Munich, Ludwig-Maximilians-Universität, Munich, Germany
| | - Julia Lemmer
- Department of Pediatric Cardiology and Congenital Heart Disease, German Heart Center Munich Technische Universität München, Munich, Germany
| | - Daniel Dilber
- Department of Pediatrics, University Hospital Centre Zagreb, School of medicine Zagreb, Zagreb, Croatia
| | - Frank Klawonn
- Biostatistics, Helmholtz Center for Infection Research, Braunschweig, Germany; Department of Computer Science, Ostfalia University, Wolfenbüttel, Germany
| | - Peter Ewert
- Department of Pediatric Cardiology and Congenital Heart Disease, German Heart Center Munich Technische Universität München, Munich, Germany
| | - Alfred Hager
- Department of Pediatric Cardiology and Congenital Heart Disease, German Heart Center Munich Technische Universität München, Munich, Germany
| | - Jürgen Hörer
- Department of Congenital and Pediatric Heart Surgery, German Heart Center Munich, Technische Universität München, Division of Congenital and Pediatric Heart Surgery, University Hospital of Munich, Ludwig-Maximilians-Universität, Munich, Germany
| |
Collapse
|
12
|
Balasubramanian S, Smith SN, Srinivasan P, Tacy TA, Hanley FL, Chen S, Wright GE, Peng LF, Punn R. Longitudinal Assessment of Right Ventricular Function in Hypoplastic Left Heart Syndrome. Pediatr Cardiol 2021; 42:1394-1404. [PMID: 33987707 DOI: 10.1007/s00246-021-02624-y] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/23/2020] [Accepted: 04/21/2021] [Indexed: 12/31/2022]
Abstract
Overall survival of patients with hypoplastic left heart syndrome (HLHS) has shown continued improvement. Right ventricular (RV) dysfunction, in the long term, adversely affects prognosis in these patients. This study examines changes in echocardiographic markers of RV function in a longitudinal cohort. We retrospectively reviewed patients with HLHS managed at our institution from 7/1994 to 1/2016. Follow-up included surgical and clinical data, and echocardiographic measures. Measures of RV function preceding and following all three stages of single ventricular palliation were collected. Freedom from transplant-free survival was assessed by Kaplan-Meier analysis. Multivariable associations with time to death or transplant were explored using the Cox proportional hazards model. A total of 120 patients with HLHS were identified. Norwood operation was performed in all patients. The probability of survival for the cohort was 71 ± 4.4%, 69 ± 4.5% and 66 ± 4.7% at 1, 2 and 5 years respectively after stage I Norwood operation. RV fractional area change (FAC), compared to post-Norwood was decreased at all subsequent stages with the greatest change noted post-superior cavo-pulmonary shunt from 40.7 ± 9.3% to 31.1 ± 8.3% (p < 0.001). Similarly, tricuspid valve annular systolic excursion (TAPSE) Z-score declined from -2.9 ± 1.3 to -9.7 ± 1.3 (p < 0.001) with a decrement at every stage of evaluation. In comparison to patients with post-Norwood RV FAC >35% and TAPSE Z-score > -5, patients with RV FAC ≤ 35% and TAPSE Z-score ≤ -5 had a significantly lower transplant-free survival (p < 0.0001). In patients with HLHS undergoing staged palliation, decrement in RV function manifests longitudinally. Post-Norwood RV FAC and TAPSE Z-score appear to be early markers of poor outcome in this population.
Collapse
Affiliation(s)
- Sowmya Balasubramanian
- Division of Cardiology, Department of Pediatrics, Stanford Medical School, 750 Welch Road, Stanford, CA, USA. .,Division of Pediatric Cardiology, 1540 East Hospital Drive, Ann Arbor, MI, 48109, USA.
| | - Shea N Smith
- Division of Cardiology, Department of Pediatrics, Stanford Medical School, 750 Welch Road, Stanford, CA, USA
| | | | - Theresa A Tacy
- Division of Cardiology, Department of Pediatrics, Stanford Medical School, 750 Welch Road, Stanford, CA, USA
| | - Frank L Hanley
- Division of Cardiology, Department of Pediatrics, Stanford Medical School, 750 Welch Road, Stanford, CA, USA
| | - Sharon Chen
- Division of Cardiology, Department of Pediatrics, Stanford Medical School, 750 Welch Road, Stanford, CA, USA
| | - Gail E Wright
- Division of Cardiology, Department of Pediatrics, Stanford Medical School, 750 Welch Road, Stanford, CA, USA
| | - Lynn F Peng
- Division of Cardiology, Department of Pediatrics, Stanford Medical School, 750 Welch Road, Stanford, CA, USA
| | - Rajesh Punn
- Division of Cardiology, Department of Pediatrics, Stanford Medical School, 750 Welch Road, Stanford, CA, USA
| |
Collapse
|
13
|
Kelly TJ, Zannino D, Brink J, Konstantinov IE, Cheung MM, d'Udekem Y, Brizard CP. A shunt decision-making protocol in the surgical palliation of hypoplastic left heart syndrome from 2004 to 2016. Eur J Cardiothorac Surg 2021; 58:153-162. [PMID: 32034901 DOI: 10.1093/ejcts/ezz382] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/06/2019] [Revised: 12/15/2019] [Accepted: 12/22/2019] [Indexed: 11/13/2022] Open
Abstract
OBJECTIVES The aim of this study was to study the impact of a decision-making protocol for shunt type in the Norwood procedure for hypoplastic left heart syndrome. Our cohort extends from 2004 to 2016. In era 1 (pre-2008), there was no policy for the choice of Norwood shunt. In era 2 (post-2008), a standard protocol was implemented. The right ventricle (RV)-to-pulmonary artery conduit was utilized for low-birth weight patients (<2.5 kg). The right modified Blalock-Taussig Shunt (RBTS) was constructed for normal birth weight patients. METHODS The records of 133 consecutive operative patients with hypoplastic left heart syndrome anatomy between 2004 and 2016 were retrospectively reviewed. Survival risk factors were analysed using the Cox proportional hazards risk model. RESULTS The Norwood procedure was performed at a mean age of 2.9 ± 1.9 days. Bidirectional cavopulmonary shunt was performed at a median age of 99 days (interquartile range 91-107). In era 1, 38.6% (22/57) of patients received the RBTS and 61.4% (35/57) of patients received the RV-to-pulmonary artery conduit. In era 2, 86.8% (66/76) of patients received the RBTS and 13.2% (10/76) of patients received the RV-to-pulmonary artery conduit. The actuarial survival to Fontan was 72.2% (96/133). Era 1 patients were more likely to die within the 1st year (hazard ratio = 2.310, P = 0.025). CONCLUSIONS The shunt protocol may improve outcomes in high-risk patients, and we have demonstrated the reliability of the RBTS in low-risk patients. The short- and mid-term outcomes of our Norwood population justify the continued efforts to improve surgical and perioperative management.
Collapse
Affiliation(s)
- Thomas John Kelly
- Department of Pediatrics, University of Melbourne, Melbourne, VIC, Australia
| | - Diana Zannino
- The Heart Research Group, Murdoch Children's Research Institute (MCRI), Melbourne, VIC, Australia
| | - Johann Brink
- Cardiac Surgery Department, Royal Children's Hospital, Melbourne, VIC, Australia
| | - Igor E Konstantinov
- Department of Pediatrics, University of Melbourne, Melbourne, VIC, Australia.,The Heart Research Group, Murdoch Children's Research Institute (MCRI), Melbourne, VIC, Australia.,Cardiac Surgery Department, Royal Children's Hospital, Melbourne, VIC, Australia
| | - Michael M Cheung
- Department of Pediatrics, University of Melbourne, Melbourne, VIC, Australia.,Cardiac Surgery Department, Royal Children's Hospital, Melbourne, VIC, Australia.,Cardiology Department, Royal Children's Hospital, Melbourne, VIC, Australia
| | - Yves d'Udekem
- Department of Pediatrics, University of Melbourne, Melbourne, VIC, Australia.,The Heart Research Group, Murdoch Children's Research Institute (MCRI), Melbourne, VIC, Australia.,Cardiac Surgery Department, Royal Children's Hospital, Melbourne, VIC, Australia
| | - Christian Pierre Brizard
- Department of Pediatrics, University of Melbourne, Melbourne, VIC, Australia.,The Heart Research Group, Murdoch Children's Research Institute (MCRI), Melbourne, VIC, Australia.,Cardiac Surgery Department, Royal Children's Hospital, Melbourne, VIC, Australia
| |
Collapse
|
14
|
Ono M, Kido T, Wallner M, Burri M, Lemmer J, Ewert P, Strbad M, Cleuziou J, Hager A, Hörer J. Comparison of shunt types in the neonatal Norwood procedure for single ventricle. Eur J Cardiothorac Surg 2021; 60:1084-1091. [PMID: 34050665 DOI: 10.1093/ejcts/ezab163] [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: 09/15/2020] [Revised: 02/01/2021] [Accepted: 02/22/2021] [Indexed: 11/14/2022] Open
Abstract
OBJECTIVES The ideal shunt for pulmonary blood flow, modified Blalock-Taussig shunt (MBTS) or right ventricular-pulmonary artery conduit (RVPAC) is yet to be determined. This study aimed to evaluate outcomes after the Norwood procedure according to the type of shunt. METHODS A total of 322 neonates with hypoplastic left heart syndrome and related anomalies who underwent the Norwood procedure at our institution between 2001 and 2019 were divided into MBTS and RVPAC groups and the outcomes after the Norwood procedure were compared between the groups with respect to mortality after each staged procedure. RESULTS We identified 322 consequent patients who underwent neonatal Norwood procedure for hypoplastic left heart syndrome (271 patients, 84.2%) and its variant (51 patients, 15.8%). RVPAC was performed in 163 (50.6%) patients and MBTS was performed in 159 (49.4%). There were no differences in the rate of early death (11.0% vs 12.6%, P = 0.69) or late death (7.4% vs 6.9%, P = 0.87) between the 2 groups after the Norwood procedure, and no significant difference in the number of patients who reached bidirectional cavopulmonary shunt (77.9% vs 76.1%, P = 0.69), and there was no difference in mortality after bidirectional cavopulmonary shunt (12.3% vs 7.5%, P = 0.15) or Fontan completion rate (54.0% vs 52.2%, P = 0.42) between the 2 groups. Survival at 0.5, 1, 3 and 6 years after the Norwood procedure was 81.0%, 73.8%, 67.9% and 67.0% in patients with RVPAC and 77.1%, 73.3%, 69.1% and 67.9% in patients with MBTS. There was no significant difference in the survival between the 2 groups during the median follow-up of 2.6 (interquartile ranges: 0.3-8.4, maximal 18.8) years (P = 0.97). CONCLUSIONS In neonates undergoing the Norwood procedure, our available data of maximal 18.8 years follow-up showed no significant difference in early mortality, inter-stage attritions, or overall survival, between MBTS and RVPAC.
Collapse
Affiliation(s)
- Masamichi Ono
- Department of Congenital and Pediatric Heart Surgery, German Heart Center Munich, Technische Universität München, Munich, Germany.,Division of Congenital and Pediatric Heart Surgery, University Hospital of Munich, Ludwig-Maximilians-Universität, Munich, Germany
| | - Takashi Kido
- Department of Congenital and Pediatric Heart Surgery, German Heart Center Munich, Technische Universität München, Munich, Germany.,Division of Congenital and Pediatric Heart Surgery, University Hospital of Munich, Ludwig-Maximilians-Universität, Munich, Germany
| | - Marie Wallner
- Department of Congenital and Pediatric Heart Surgery, German Heart Center Munich, Technische Universität München, Munich, Germany.,Division of Congenital and Pediatric Heart Surgery, University Hospital of Munich, Ludwig-Maximilians-Universität, Munich, Germany
| | - Melchior Burri
- Department of Cardiovascular Surgery, German Heart Center Munich, Technische Universität München, Munich, Germany
| | - Julia Lemmer
- Department of Pediatric Cardiology and Congenital Heart Disease, German Heart Center Munich, Technical University of Munich, Munich, Germany
| | - Peter Ewert
- Department of Pediatric Cardiology and Congenital Heart Disease, German Heart Center Munich, Technical University of Munich, Munich, Germany
| | - Martina Strbad
- Department of Congenital and Pediatric Heart Surgery, German Heart Center Munich, Technische Universität München, Munich, Germany.,Division of Congenital and Pediatric Heart Surgery, University Hospital of Munich, Ludwig-Maximilians-Universität, Munich, Germany
| | - Julie Cleuziou
- Department of Congenital and Pediatric Heart Surgery, German Heart Center Munich, Technische Universität München, Munich, Germany.,Division of Congenital and Pediatric Heart Surgery, University Hospital of Munich, Ludwig-Maximilians-Universität, Munich, Germany
| | - Alfred Hager
- Department of Pediatric Cardiology and Congenital Heart Disease, German Heart Center Munich, Technical University of Munich, Munich, Germany
| | - Jürgen Hörer
- Department of Congenital and Pediatric Heart Surgery, German Heart Center Munich, Technische Universität München, Munich, Germany.,Division of Congenital and Pediatric Heart Surgery, University Hospital of Munich, Ludwig-Maximilians-Universität, Munich, Germany
| |
Collapse
|
15
|
John MJ, Wilder TJ. Commentary: Form improves function: The importance of a well-constructed neoaortic arch. J Thorac Cardiovasc Surg 2021; 162:1807-1808. [PMID: 33814178 DOI: 10.1016/j.jtcvs.2021.03.019] [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: 03/05/2021] [Revised: 03/05/2021] [Accepted: 03/05/2021] [Indexed: 11/25/2022]
Affiliation(s)
- Mohan J John
- Division of Congenital Heart Surgery, Texas Children's Hospital, Baylor College of Medicine, Houston, Tex
| | - Travis J Wilder
- Division of Congenital Heart Surgery, Texas Children's Hospital, Baylor College of Medicine, Houston, Tex.
| |
Collapse
|
16
|
Sinha R, Altin HF, McCracken C, Well A, Rosenblum J, Kanter K, Kogon B, Alsoufi B. Effect of Atrioventricular Valve Repair on Multistage Palliation Results of Single-Ventricle Defects. Ann Thorac Surg 2021; 111:662-670. [DOI: 10.1016/j.athoracsur.2020.03.126] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/09/2019] [Revised: 03/17/2020] [Accepted: 03/30/2020] [Indexed: 11/30/2022]
|
17
|
Wilder TJ, Caldarone CA. Apples to oranges: Making sense of hybrid palliation for hypoplastic left heart syndrome. JTCVS OPEN 2020; 4:47-54. [PMID: 36004289 PMCID: PMC9390685 DOI: 10.1016/j.xjon.2020.10.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/25/2020] [Accepted: 10/06/2020] [Indexed: 11/29/2022]
Affiliation(s)
- Travis J. Wilder
- Address for reprints: Travis J. Wilder, MD, Legacy Tower, Floor 19, 6651 Main St, Mail Code 19345H, Houston, TX 77030.
| | | |
Collapse
|
18
|
Barron DJ, Jegatheeswaran A. Commentary: Late attrition in Norwood populations: Kicking the can down the road? J Thorac Cardiovasc Surg 2020; 162:398-399. [PMID: 33341269 DOI: 10.1016/j.jtcvs.2020.11.070] [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: 11/16/2020] [Revised: 11/16/2020] [Accepted: 11/17/2020] [Indexed: 11/28/2022]
Affiliation(s)
- David J Barron
- Division of Cardiovascular Surgery, Department of Surgery, Hospital for Sick Children, Toronto, Ontario, Canada.
| | - Anusha Jegatheeswaran
- Division of Cardiovascular Surgery, Department of Surgery, Hospital for Sick Children, Toronto, Ontario, Canada
| |
Collapse
|
19
|
Alsoufi B. Commentary: Attrition after superior cavopulmonary connection; we don't have to be perfect but better than yesterday. J Thorac Cardiovasc Surg 2020; 162:394-395. [PMID: 33339603 DOI: 10.1016/j.jtcvs.2020.11.037] [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: 11/08/2020] [Revised: 11/08/2020] [Accepted: 11/11/2020] [Indexed: 12/01/2022]
Affiliation(s)
- Bahaaldin Alsoufi
- Department of Cardiovascular and Thoracic Surgery, University of Louisville School of Medicine, Louisville, Ky.
| |
Collapse
|
20
|
Alphonso N, Angelini A, Barron DJ, Bellsham-Revell H, Blom NA, Brown K, Davis D, Duncan D, Fedrigo M, Galletti L, Hehir D, Herberg U, Jacobs JP, Januszewska K, Karl TR, Malec E, Maruszewski B, Montgomerie J, Pizzaro C, Schranz D, Shillingford AJ, Simpson JM. Guidelines for the management of neonates and infants with hypoplastic left heart syndrome: The European Association for Cardio-Thoracic Surgery (EACTS) and the Association for European Paediatric and Congenital Cardiology (AEPC) Hypoplastic Left Heart Syndrome Guidelines Task Force. Eur J Cardiothorac Surg 2020; 58:416-499. [DOI: 10.1093/ejcts/ezaa188] [Citation(s) in RCA: 24] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Affiliation(s)
- Nelson Alphonso
- Queensland Pediatric Cardiac Service, Queensland Children’s Hospital, University of Queensland, Brisbane, QLD, Australia
| | - Annalisa Angelini
- Department of Cardiac, Thoracic Vascular Sciences and Public health, University of Padua Medical School, Padua, Italy
| | - David J Barron
- Department of Cardiovascular Surgery, Hospital for Sick Children, University of Toronto, Toronto, ON, Canada
| | | | - Nico A Blom
- Division of Pediatric Cardiology, Department of Pediatrics, Leiden University Medical Center, Leiden, Netherlands
| | - Katherine Brown
- Paediatric Intensive Care, Heart and Lung Division, Great Ormond Street Hospital NHS Foundation Trust, London, UK
| | - Deborah Davis
- Department of Anesthesiology, Thomas Jefferson University, Philadelphia, PA, USA
- Nemours Cardiac Center, A.I. Du Pont Hospital for Children, Wilmington, DE, USA
| | - Daniel Duncan
- Nemours Cardiac Center, A.I. Du Pont Hospital for Children, Wilmington, DE, USA
| | - Marny Fedrigo
- Department of Cardiac, Thoracic Vascular Sciences and Public Health, University of Padua Medical School, Padua, Italy
| | - Lorenzo Galletti
- Unit of Pediatric Cardiac Surgery, Bambino Gesù Children's Hospital, Rome, Italy
| | - David Hehir
- Division of Cardiology, Children’s Hospital of Philadelphia, Philadelphia, PA, USA
| | - Ulrike Herberg
- Department of Pediatric Cardiology, University Hospital Bonn, Bonn, Germany
| | | | - Katarzyna Januszewska
- Division of Pediatric Cardiac Surgery, University Hospital Muenster, Westphalian-Wilhelm’s-University, Muenster, Germany
| | | | - Edward Malec
- Division of Pediatric Cardiac Surgery, University Hospital Muenster, Westphalian-Wilhelm’s-University, Muenster, Germany
| | - Bohdan Maruszewski
- Department for Pediatric Cardiothoracic Surgery, Children's Memorial Health Institute, Warsaw, Poland
| | - James Montgomerie
- Department of Anesthesia, Birmingham Children’s Hospital, Birmingham, UK
| | - Christian Pizzaro
- Nemours Cardiac Center, A.I. Du Pont Hospital for Children, Wilmington, DE, USA
- Department of Surgery, Thomas Jefferson University, Philadelphia, PA, USA
| | - Dietmar Schranz
- Pediatric Heart Center, Justus-Liebig University, Giessen, Germany
| | - Amanda J Shillingford
- Division of Cardiology, Children's Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
| | | | | |
Collapse
|
21
|
Najm HK, Karamlou T, Ahmad M, Hassan S, Yaman M, Stewart R, Pettersson G. Biventricular Conversion in Unseptatable Hearts: "Ventricular Switch". Semin Thorac Cardiovasc Surg 2020; 33:172-180. [PMID: 32858218 DOI: 10.1053/j.semtcvs.2020.08.010] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2020] [Accepted: 08/20/2020] [Indexed: 11/11/2022]
Abstract
Patients with complex systemic and pulmonary venous anatomy, common atrioventricular canal defects and conotruncal anomalies have traditionally been routed to univentricular palliation and labeled as "unseptatable." This report describes our initial experience in septation/biventricular conversion ("ventricular switch"), utilizing the left ventricle (LV) as the subpulmonary ventricle, essentially recapitulating the physiology of congenitally corrected transposition of the great arteries. Five consecutive patients with challenging anatomic configuration underwent septation. All patients were severely cyanotic and had important functional limitations. All patients required complex atrial septation. Ventricular septation was precluded by fixed pulmonary vascular resistance in 2 patients. Systemic venous return was diverted to the morphologic LV as part of physiological 2V (n = 4) or 1.5 V repair (n = 1). Median conversion age was 9 years (range 11 months-46 years). Four patients had 12 previous cardiac surgical procedures in preparation for univentricular repair elsewhere. Three dimensional-printed heart models evaluated feasibility of septation. All patients are alive at a median follow-up of 0.6 years (range 0.08-2.7 years). Median hospital stay was 13 (range 10-60) days. LV recruitment improved functional status and significantly increased systemic oxygen saturation in all patients (79 ± 7% vs 95 ± 5%, P = 0.003). We report a novel paradigm for successfully utilizing both ventricles with the morphologic LV as the subpulmonary ventricle, in a complex population thought to be unseptatable. This approach is versatile and can likely be extrapolated to other complex anatomic configurations. Although we utilized this strategy in patients of variable age, earlier ventricular switch may yield the best results.
Collapse
Affiliation(s)
- Hani K Najm
- Division of Pediatric Cardiac Surgery, Heart Vascular Institute, Cleveland Clinic, Cleveland, Ohio.
| | - Tara Karamlou
- Division of Pediatric Cardiac Surgery, Heart Vascular Institute, Cleveland Clinic, Cleveland, Ohio
| | - Munir Ahmad
- Division of Pediatric Cardiac Surgery, Heart Vascular Institute, Cleveland Clinic, Cleveland, Ohio
| | - Saad Hassan
- Division of adult Cardiothoracic Surgery, Heart Vascular Institute, Cleveland Clinic, Cleveland, Ohio
| | - Malek Yaman
- Division of adult Cardiothoracic Surgery, Heart Vascular Institute, Cleveland Clinic, Cleveland, Ohio
| | - Robert Stewart
- Division of Pediatric Cardiac Surgery, Heart Vascular Institute, Cleveland Clinic, Cleveland, Ohio; Pediatric Cardiac Surgery, Congenital Heart Center, Akron Children's Hospital, Akron, Ohio
| | - Gosta Pettersson
- Division of Pediatric Cardiac Surgery, Heart Vascular Institute, Cleveland Clinic, Cleveland, Ohio; Department of Pediatrics and Pediatric Cardiology, Pediatric Institute, Cleveland Clinic, Cleveland, Ohio
| |
Collapse
|
22
|
Kobayashi Y, Kotani Y, Kuroko Y, Kawabata T, Sano S, Kasahara S. Norwood procedure with right ventricle to pulmonary artery conduit: a single-centre 20-year experience. Eur J Cardiothorac Surg 2020; 58:230-236. [DOI: 10.1093/ejcts/ezaa041] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/18/2019] [Revised: 01/13/2020] [Accepted: 01/17/2020] [Indexed: 11/13/2022] Open
Abstract
Abstract
OBJECTIVES
The aim of this study was to evaluate the long-term outcomes of the Norwood procedure with right ventricle–pulmonary artery (RV–PA) conduit for hypoplastic left heart complex.
METHODS
A retrospective observational study was performed in 136 patients with hypoplastic left heart complex who underwent a Norwood procedure with RV–PA conduit between 1998 and 2017. The probabilities of survival, reintervention and Fontan completion were analysed.
RESULTS
Stage 1 survival was 91.9% (125/136). Reintervention for PA stenosis was needed for 22% and 30% at stages 2 and 3, respectively, while 15% underwent reintervention for aortic arch recoarctation. Among 106 bidirectional Glenn survivors, 93 (68% of the total number of patients) had a Fontan completion, while 4 were not considered to be Fontan candidates. Risk factors for overall mortality included weighing <2.5 kg at the time of the Norwood procedure, intact atrium septum, total anomalous pulmonary vein connection and more than mild atrioventricular regurgitation at the time of the Norwood procedure. Overall survival was 80.9%, 72.3% and 62.8% at 1, 5 and 20 years, respectively.
CONCLUSIONS
Probabilities of survival and Fontan completion were acceptable under the current surgical strategy incorporating RV–PA Norwood procedure as the first palliation. Incorporating a strategy to maintain PA growth and ventricular function through the staged repair is of prime importance. Further studies are necessary to observe changes in atrioventricular regurgitation as well as in right ventricular function, in patients who require atrioventricular valve interventions during the staged Fontan completion.
Collapse
Affiliation(s)
- Yasuyuki Kobayashi
- Department of Cardiovascular Surgery, Okayama University Hospital, Okayama, Japan
| | - Yasuhiro Kotani
- Department of Cardiovascular Surgery, Okayama University Hospital, Okayama, Japan
| | - Yosuke Kuroko
- Department of Cardiovascular Surgery, Okayama University Hospital, Okayama, Japan
| | - Takuya Kawabata
- Department of Cardiovascular Surgery, Okayama University Hospital, Okayama, Japan
| | - Shunji Sano
- Department of Pediatric Cardiothoracic Surgery, University of California, San Francisco, CA, USA
| | - Shingo Kasahara
- Department of Cardiovascular Surgery, Okayama University Hospital, Okayama, Japan
| |
Collapse
|
23
|
Evolution of the Norwood operation outcomes in patients with late presentation. J Thorac Cardiovasc Surg 2020; 159:1040-1048. [DOI: 10.1016/j.jtcvs.2019.07.154] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/13/2019] [Revised: 07/05/2019] [Accepted: 07/11/2019] [Indexed: 11/23/2022]
|
24
|
Karamlou T, Najm HK. Evolution of care pathways for babies with hypoplastic left heart syndrome: integrating mechanistic and clinical process investigation, standardization, and collaborative study. J Thorac Dis 2020; 12:1174-1183. [PMID: 32274198 PMCID: PMC7139006 DOI: 10.21037/jtd.2019.10.75] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Since initial descriptions of staged palliation for hypoplastic left heart syndrome (HLHS) in the 1980’s, much has been learned about the pathophysiology of the single ventricle circulation. New therapies that leverage systems biology and clinical derivatives have been developed. While in-hospital mortality and morbidity for babies with HLHS have continued to improve, there remains a long (and daresay winding) road ahead to achieve ideal outcomes. Important variation in even these abbreviated in-hospital metrics persists among institutions and currently utilized prediction models explain only a small amount of this variation. Moreover, long-term survival and neurodevelopmental health for patients with HLHS are infrequently reported and remain suboptimal despite improved in-hospital outcomes. This focused review will describe the evolution of national outcomes for HLHS over time and the potential factors motivating improved time-related mortality. Emerging modifiable risk-factors that hold promise in terms of moving the needle for long-term success, including social determinants of health and the delineation of genetic profiles, will be discussed. Specifically, this review will integrate contemporary data based on the first murine HLHS models that suggest a genetically elicited modular phenotype with environmental factors known to impact the initial durability of surgical therapies. A comprehensive approach to the management of HLHS, which leverages both proactive transplantation and hybrid palliation, in addition to traditional Norwood palliation, will be emphasized to extend and match management to the complete spectrum of patient risk-profiles. Finally, we will explore the critical role that national collaboratives and quality reporting initiatives have played in improving outcomes and shifting the focus to more meaningful long-term survival and neurodevelopment.
Collapse
Affiliation(s)
- Tara Karamlou
- Division of Pediatric Cardiac Surgery, Cleveland Clinic Heart Vascular Institute, Cleveland, OH, USA
| | - Hani K Najm
- Division of Pediatric Cardiac Surgery, Cleveland Clinic Heart Vascular Institute, Cleveland, OH, USA
| |
Collapse
|
25
|
Fujita S, Yamagishi M, Maeda Y, Itatani K, Asada S, Hongu H, Yamashita E, Takayanagi Y, Nakatsuji H, Yaku H. The effect of a valved small conduit on systemic ventricle–pulmonary artery shunt in the Norwood-type palliation. Eur J Cardiothorac Surg 2020; 57:1105-1112. [DOI: 10.1093/ejcts/ezz377] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/29/2019] [Revised: 12/17/2019] [Accepted: 12/22/2019] [Indexed: 11/14/2022] Open
Abstract
Abstract
OBJECTIVES
The aim of this study was to clarify the impact of valved systemic ventricle–pulmonary artery (SV–PA) shunt on outcomes after stage-1 Norwood-type palliation (NP) compared with the modified Blalock–Taussig shunt.
METHODS
Consecutive patients who underwent NP between 2003 and 2019 were enrolled. SV–PA shunts using the expanded polytetrafluoroethylene valved conduit were implanted in 18 patients (valved SV–PA group), and another 18 patients underwent modified Blalock–Taussig shunt during NP (modified Blalock–Taussig shunt group). All valved conduits were made in our institution in advance.
RESULTS
No differences in baseline characteristics were found between the groups, except for shunt size. During a median 2.9 (interquartile range 0.4–6.4, maximum 14.2) years of follow-up, 8 (22.2%) patients died across both groups. There were no statistically significant differences in early mortality (5.5% vs 11.1%, P = 0.55) and overall survival rates at 5 years (80.8% vs 71.4%, P = 0.48) in the valved SV–PA and modified Blalock–Taussig shunt groups. No statistically significant difference was observed in the frequency of interventions between the groups (31% vs 33%, P = 1.0). At the time of the bidirectional Glenn procedure, the systemic ventricular end-diastolic volume index was significantly lower (84 ± 24 vs 106 ± 31 ml/m2, P = 0.05) and the ejection fraction was significantly greater (62 ± 8% vs 55 ± 9%, P = 0.03) in the valved SV–PA group. There was no statistically significant difference in the pulmonary artery index (228 ± 85 vs 226 ± 60 mm2/m2, P = 0.92).
CONCLUSIONS
A valved SV–PA shunt using an expanded polytetrafluoroethylene valved conduit was associated with preserved ventricular function after NP and did not impair pulmonary artery growth by controlling pulmonary regurgitation.
Collapse
Affiliation(s)
- Shuhei Fujita
- Department of Pediatric Cardiovascular Surgery, Children’s Medical Center, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - Masaaki Yamagishi
- Department of Pediatric Cardiovascular Surgery, Children’s Medical Center, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - Yoshinobu Maeda
- Department of Pediatric Cardiovascular Surgery, Children’s Medical Center, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - Keiichi Itatani
- Division of Cardiovascular Surgery, Department of Surgery, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - Satoshi Asada
- Department of Pediatric Cardiovascular Surgery, Children’s Medical Center, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - Hisayuki Hongu
- Department of Pediatric Cardiovascular Surgery, Children’s Medical Center, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - Eijiro Yamashita
- Department of Pediatric Cardiovascular Surgery, Children’s Medical Center, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - Yuji Takayanagi
- Department of Pediatric Cardiovascular Surgery, Children’s Medical Center, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - Hiroki Nakatsuji
- Department of Pediatric Cardiovascular Surgery, Children’s Medical Center, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - Hitoshi Yaku
- Division of Cardiovascular Surgery, Department of Surgery, Kyoto Prefectural University of Medicine, Kyoto, Japan
| |
Collapse
|
26
|
Lodge AJ. Commentary: Another look at stage I Norwood outcomes from a different perspective. J Thorac Cardiovasc Surg 2019; 159:1049-1050. [PMID: 31677888 DOI: 10.1016/j.jtcvs.2019.07.145] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/30/2019] [Revised: 07/30/2019] [Accepted: 07/31/2019] [Indexed: 11/18/2022]
Affiliation(s)
- Andrew J Lodge
- Pediatric and Congenital Heart Center, Division of Cardiovascular and Thoracic Surgery, Department of Surgery, Duke University Medical Center, Durham, NC.
| |
Collapse
|
27
|
Salve GG, Datar GM, Perumal G, Singh AAV, Ayer JG, Roberts P, Sholler GF, Cole AD, Pigott N, Loughran-Fowlds A, Weatherall A, Alahakoon TI, Orr Y, Nicholson IA, Winlaw DS. Impact of High-Risk Characteristics in Hypoplastic Left Heart Syndrome. World J Pediatr Congenit Heart Surg 2019; 10:475-484. [PMID: 31307299 DOI: 10.1177/2150135119852319] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND Management of hypoplastic left heart syndrome (HLHS) presents many challenges. We describe our institutional outcomes for management of patients with HLHS over the past 12 years and highlight our strategy for those with highly restrictive/intact interatrial septum (R/I-IAS). METHODS Eighty-eight neonates with HLHS underwent surgical treatment, divided equally into Era-I (n = 44, April 2006 to February 2013) and Era-II (n = 44, March 2013 to June 2018). Up to 2013, all patients with R/I-IAS were delivered at an adjacent adult hospital and then moved to our hospital for intensive care and management. From 2014, these patients were delivered at a co-located theatre in our hospital with immediate atrial septectomy. The hybrid approach was occasionally used with preference for the Norwood procedure for suitable candidates. RESULTS One-year survival after Norwood procedure was 62.5% and 80% for Era-I and Era-II (P = not significant (ns)), respectively, and 41% of patients were categorized as high risk using conventional criteria. Survival at 1 year differed significantly between high-risk and standard-risk patients (P = 0.01). For high-risk patients, survival increased from 42% to 65% between eras (P = ns). In the R/I-IAS subgroup (n = 15), 11 underwent Norwood procedure after emergency atrial septectomy. Of these, seven born at the adjacent adult hospital had 40% survival to stage II versus 60% for the four born at the colocated theatre. Delivery in a colocated theatre reduced the birth-to-cardiopulmonary bypass median time from 445 (150-660) to 62 (52-71) minutes. CONCLUSION Reported surgical outcomes are comparable to multicenter reports and international databases. Proactive management for risk factors such as R/I-IAS may contribute to improved overall outcomes.
Collapse
Affiliation(s)
- Gananjay G Salve
- 1 Heart Centre for Children, The Children's Hospital at Westmead, Westmead, New South Wales, Australia
| | - Gauri M Datar
- 1 Heart Centre for Children, The Children's Hospital at Westmead, Westmead, New South Wales, Australia
| | - Gopinath Perumal
- 1 Heart Centre for Children, The Children's Hospital at Westmead, Westmead, New South Wales, Australia
| | - Aakansha Ajay Vir Singh
- 1 Heart Centre for Children, The Children's Hospital at Westmead, Westmead, New South Wales, Australia
| | - Julian G Ayer
- 1 Heart Centre for Children, The Children's Hospital at Westmead, Westmead, New South Wales, Australia.,2 Faculty of Medicine and Health, The University of Sydney, Sydney, New South Wales, Australia
| | - Philip Roberts
- 1 Heart Centre for Children, The Children's Hospital at Westmead, Westmead, New South Wales, Australia
| | - Gary F Sholler
- 1 Heart Centre for Children, The Children's Hospital at Westmead, Westmead, New South Wales, Australia.,2 Faculty of Medicine and Health, The University of Sydney, Sydney, New South Wales, Australia
| | - Andrew D Cole
- 1 Heart Centre for Children, The Children's Hospital at Westmead, Westmead, New South Wales, Australia
| | - Nick Pigott
- 3 Paediatric Intensive Care, The Children's Hospital at Westmead, Westmead, New South Wales, Australia
| | - Alison Loughran-Fowlds
- 2 Faculty of Medicine and Health, The University of Sydney, Sydney, New South Wales, Australia.,4 Grace Centre for Newborn Intensive Care, The Children's Hospital at Westmead, Westmead, New South Wales, Australia
| | - Andrew Weatherall
- 2 Faculty of Medicine and Health, The University of Sydney, Sydney, New South Wales, Australia.,5 Department of Anaesthetics, The Children's Hospital at Westmead, Westmead, New South Wales, Australia
| | - T Indika Alahakoon
- 2 Faculty of Medicine and Health, The University of Sydney, Sydney, New South Wales, Australia.,6 Department of Maternal Fetal Medicine, Westmead Hospital, Westmead, New South Wales, Australia
| | - Yishay Orr
- 1 Heart Centre for Children, The Children's Hospital at Westmead, Westmead, New South Wales, Australia.,2 Faculty of Medicine and Health, The University of Sydney, Sydney, New South Wales, Australia
| | - Ian A Nicholson
- 1 Heart Centre for Children, The Children's Hospital at Westmead, Westmead, New South Wales, Australia.,2 Faculty of Medicine and Health, The University of Sydney, Sydney, New South Wales, Australia
| | - David S Winlaw
- 1 Heart Centre for Children, The Children's Hospital at Westmead, Westmead, New South Wales, Australia.,2 Faculty of Medicine and Health, The University of Sydney, Sydney, New South Wales, Australia
| |
Collapse
|
28
|
Karamlou T, Najm HK. Commentary: Black or white: The false dichotomy argument inherent in comparing biventricular repair versus Fontan completion. J Thorac Cardiovasc Surg 2019; 158:1168-1170. [PMID: 31301896 DOI: 10.1016/j.jtcvs.2019.05.074] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/27/2019] [Accepted: 05/29/2019] [Indexed: 11/19/2022]
Affiliation(s)
- Tara Karamlou
- Division of Pediatric Cardiac Surgery, Heart Vascular Institute, Cleveland Clinic, Cleveland, Ohio.
| | - Hani K Najm
- Division of Pediatric Cardiac Surgery, Heart Vascular Institute, Cleveland Clinic, Cleveland, Ohio
| |
Collapse
|
29
|
Affiliation(s)
- David Bichell
- 1 Monroe Carell Jr. Children's Hospital, Vanderbilt University Medical Center, Nashville, TN, USA
| |
Collapse
|
30
|
Karamlou T, Meza JM, Najm HK, Nigro JJ, Hill KD. Single-ventricle reconstruction 2.0: A closer look at our understanding of care for infants undergoing the Norwood procedure. J Thorac Cardiovasc Surg 2019; 158:837-842.e5. [PMID: 31101343 DOI: 10.1016/j.jtcvs.2018.12.121] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/02/2018] [Revised: 12/06/2018] [Accepted: 12/13/2018] [Indexed: 10/27/2022]
Affiliation(s)
- Tara Karamlou
- Division of Pediatric Cardiac Surgery and the Heart Vascular Institute, Cleveland Clinic, Cleveland, Ohio.
| | - James M Meza
- Department of Surgery, Duke University Medical Center, Durham, NC
| | - Hani K Najm
- Division of Pediatric Cardiac Surgery and the Heart Vascular Institute, Cleveland Clinic, Cleveland, Ohio
| | - John J Nigro
- Division of Pediatric Cardiac Surgery, Rady Children's Hospital and the University of California, San Diego, San Diego, Calif
| | - Kevin D Hill
- Division of Pediatric Cardiology, Duke University Medical Center and the Duke Clinical Research Institute, Durham, NC
| |
Collapse
|
31
|
Rai V, Gładki M, Dudyńska M, Skalski J. Hypoplastic left heart syndrome [HLHS]: treatment options in present era. Indian J Thorac Cardiovasc Surg 2019; 35:196-202. [PMID: 33061005 PMCID: PMC7525540 DOI: 10.1007/s12055-018-0742-z] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2018] [Revised: 09/02/2018] [Accepted: 09/07/2018] [Indexed: 11/29/2022] Open
Abstract
Hypoplastic left heart syndrome (HLHS) is the most severe form of congenital heart defect (CHD). The first successful intervention for it was undertaken by Norwood in 1983. Since then, there have been much development in the pre, intra, and postoperative treatment option in staged palliative surgical procedures. Early diagnostic management, prenatal interventions, innovative diagnostic methods, constantly modified surgical techniques, and hybridization contribute to a significant progress in treatment options. This will allow for defining an optimal strategy of improving survival and quality of life in HLHS patients. The development of intervention cardiology makes possible the stepwise treatment of the defect with one operation only. The first and third stage may be done by hybrid or interventional methods, then only the second stage of treatment needs to be done surgically. The world experience and all the available literature says that the 1st-stage procedure could be done now safely either directly or with a bridge to Norwood followed by the stage 2 with a Glen or Hemi-Fontan and followed by a Fontan down the lane surgically.
Collapse
Affiliation(s)
- Vivek Rai
- Department of Pediatric Cardiac Surgery, Jagiellonian University Children’s Hospital, Ul. Wielicka 265, 30-663 Krakow, Poland
| | - Marcin Gładki
- Department of Pediatric Cardiac Surgery, Jagiellonian University Children’s Hospital, Ul. Wielicka 265, 30-663 Krakow, Poland
| | - Mirosława Dudyńska
- Department of Pediatric Cardiac Surgery, Jagiellonian University Children’s Hospital, Ul. Wielicka 265, 30-663 Krakow, Poland
| | - Janusz Skalski
- Department of Pediatric Cardiac Surgery, Jagiellonian University Children’s Hospital, Ul. Wielicka 265, 30-663 Krakow, Poland
| |
Collapse
|
32
|
Kutty S, Danford DA. Shunts and the Single Right Ventricle. Circ Cardiovasc Imaging 2019; 12:e008711. [DOI: 10.1161/circimaging.118.008711] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Shelby Kutty
- The Helen B. Taussig Heart Center, Johns Hopkins Hospital and School of Medicine, Baltimore, MD (S.K.)
| | - David A. Danford
- Division of Pediatric Cardiology, University of Nebraska College of Medicine and Children’s Hospital and Medical Center, Omaha, NE (D.A.D.)
| |
Collapse
|
33
|
Cleveland D, Adam Banks C, Hara H, Carlo WF, Mauchley DC, Cooper DKC. The Case for Cardiac Xenotransplantation in Neonates: Is Now the Time to Reconsider Xenotransplantation for Hypoplastic Left Heart Syndrome? Pediatr Cardiol 2019; 40:437-444. [PMID: 30302505 DOI: 10.1007/s00246-018-1998-1] [Citation(s) in RCA: 29] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/14/2018] [Accepted: 09/28/2018] [Indexed: 01/06/2023]
Abstract
Neonatal cardiac transplantation for hypoplastic left heart syndrome (HLHS) is associated with excellent long-term survival compared to older recipients. However, heart transplantation for neonates is greatly limited by the critical shortage of donor hearts, and by the associated mortality of the long pre-transplant waiting period. This led to the development of staged surgical palliation as the first-line surgical therapy for HLHS. Recent advances in genetic engineering and xenotransplantation have provided the potential to replicate the excellent results of neonatal cardiac allotransplantation while eliminating wait-list-associated mortality through genetically modified pig-to-human neonatal cardiac xenotransplantation. The elimination of the major pig antigens in addition to the immature B-cell response in neonates allows for the potential to induce B-cell tolerance. Additionally, the relatively mature neonatal T-cell response could be reduced by thymectomy at the time of operation combined with donor-specific pig thymus transplantation to "reprogram" the host's T-cells to recognize the xenograft as host tissue. In light of the recent significantly increased graft survival of genetically-engineered pig-to-baboon cardiac xenotransplantation, we propose that now is the time to consider devoting research to advance the potential clinical application of cardiac xenotransplantation as a treatment option for patients with HLHS. Employing cardiac xenotransplantation could revolutionize therapy for complex congenital heart defects and open a new chapter in the field of pediatric cardiac transplantation.
Collapse
Affiliation(s)
- David Cleveland
- Division of Pediatric Cardiovascular Surgery, University of Alabama at Birmingham, Birmingham, AL, USA.
| | - C Adam Banks
- Division of Pediatric Cardiovascular Surgery, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Hidetaka Hara
- Xenotransplantation Program, Department of Surgery, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Waldemar F Carlo
- Section of Pediatric Cardiology, University of Alabama at Birmingham, Birmingham, AL, USA
| | - David C Mauchley
- Division of Pediatric Cardiovascular Surgery, University of Alabama at Birmingham, Birmingham, AL, USA
| | - David K C Cooper
- Xenotransplantation Program, Department of Surgery, University of Alabama at Birmingham, Birmingham, AL, USA
| |
Collapse
|
34
|
Alsoufi B, McCracken C, Kochilas LK, Clabby M, Kanter K. Factors Associated With Interstage Mortality Following Neonatal Single Ventricle Palliation. World J Pediatr Congenit Heart Surg 2018; 9:616-623. [DOI: 10.1177/2150135118787723] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
Background: Several advances have led to improved hospital survival following neonatal palliation (NP) of single ventricle (SV) anomalies. Nonetheless, a number of patients continue to suffer from interstage mortality (ISM) prior to subsequent Glenn. We aim to study patients’ characteristics and anatomic, surgical, and clinical details associated with ISM. Methods: A total of 453 SV neonates survived to hospital discharge following NP. Competing risk analysis modeled events after NP (Glenn, transplantation, or death) and examined variables associated with ISM. Results: Competing risk analysis showed that one year following NP, 10% of patients had died, 87% had progressed to Glenn, 1% had received heart transplantation, and 2% were alive without subsequent surgery. On multivariable analysis, factors associated with ISM were as follows: weight ≤2.5 kg (hazard ratio, HR = 2.4 [1.2-4.6], P = .013), premature birth ≤36 weeks (HR = 2.0 [1.0-4.0], P = .05), genetic syndromes (HR = 3.2 [1.7-6.1], P < .001), unplanned cardiac reoperation (HR = 2.1 [1.0-4.4], P = .05), and prolonged intensive care unit (ICU) stay >30 days following NP (HR = 2.5 [1.4-4.5], P < .001). Palliative surgery type (shunt, Norwood, band) was not associated with ISM, although aortopulmonary shunt circulation after Norwood was (HR = 5.4 [1.5-19.2] P = .01). Of interest, underlying SV anatomy was not associated with ISM (HR = 1.1 [0.6-2.2], P = .749). Conclusions: In our series, ISM following NP occurred in 10% of hospital survivors. As opposed to hospital death, underlying SV anomaly was not associated with ISM. Conversely, several patient factors (prematurity, low weight, and genetic syndromes) and clinical factors (unplanned reoperation and prolonged ICU stay following NP) were associated with ISM. Vigilant outpatient management that is individualized to specific clinical and social needs, taking into account all associated factors, is warranted to improve survival in high-risk patients.
Collapse
Affiliation(s)
- Bahaaldin Alsoufi
- Division of Cardiothoracic Surgery, Children’s Healthcare of Atlanta, Emory University School of Medicine, Atlanta, GA, USA
| | - Courtney McCracken
- Sibley Heart Center, Children’s Healthcare of Atlanta, Emory University School of Medicine, Atlanta, GA, USA
| | - Lazaros K. Kochilas
- Sibley Heart Center, Children’s Healthcare of Atlanta, Emory University School of Medicine, Atlanta, GA, USA
| | - Martha Clabby
- Sibley Heart Center, Children’s Healthcare of Atlanta, Emory University School of Medicine, Atlanta, GA, USA
| | - Kirk Kanter
- Division of Cardiothoracic Surgery, Children’s Healthcare of Atlanta, Emory University School of Medicine, Atlanta, GA, USA
| |
Collapse
|
35
|
Mavroudis C, Kirklin JK, DeCampli WM. Incremental History of the Congenital Heart Surgeons’ Society (2014-2018). World J Pediatr Congenit Heart Surg 2018; 9:668-676. [DOI: 10.1177/2150135118800305] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
The history of the first 41 years of the Congenital Heart Surgeons Society (CHSS) was recorded in 2015 which chronicled the metamorphosis of a small informal meeting into a mature organization with bylaws, officers, committees, funded research, the Kirklin-Ashburn Fellowship, and a vision to become the premier organization of congenital heart surgery in North America. Chief among these transformations was the implementation and development of the CHSS Data Center. Member participation, fellowship education, and significant outcomes research have been the hallmark of the CHSS. This incremental historical review highlights continued CHSS sentinel advances. Fifty-three CHSS Data Center manuscripts have been published. Citation scores (number of literature citations that each manuscript has accrued) have been collated and analyzed by cohort study. The average citation score for all manuscripts was 75.4 ± 76.3 (range: 1-333). The Kirklin/Ashburn Fellowship continues to thrive with academic achievements and generous contributions to the endowment. The World Journal of Pediatric and Congenital Heart Surgery has been adopted as the official organ of the CHSS. A Past President’s Dinner has been inaugurated serving as a senior advisory committee to the Executive Council. Toronto Work Weekends continue. Congenital Heart Surgeons Society growth has accrued to 159 active members and 82 institutional members. Future considerations include the size, content, and duration of the annual meeting; the potential for increased membership; and political penetrance into national cardiothoracic governing organizations regarding committee appointments, executive council representation, and education initiatives. Congenital Heart Surgeons Society has achieved numerous advances during this incremental period.
Collapse
Affiliation(s)
- Constantine Mavroudis
- Johns Hopkins University School of Medicine, Florida Hospital for Children, Orlando, FL, USA
| | - James K. Kirklin
- Department of Surgery, University of Alabama, Birmingham, AL, USA
| | - William M. DeCampli
- Congenital Heart Surgery, Arnold Palmer Children’s Hospital, Orlando, FL, USA
| |
Collapse
|
36
|
Ono M, Beran E, Burri M, Cleuziou J, Pabst von Ohain J, Strbad M, Röhlig C, Hager A, Hörer J, Schreiber C, Lange R. Long-term outcome of preadolescents, adolescents, and adult patients undergoing total cavopulmonary connection. J Thorac Cardiovasc Surg 2018; 156:1166-1176.e4. [DOI: 10.1016/j.jtcvs.2018.03.155] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/15/2017] [Revised: 03/15/2018] [Accepted: 03/22/2018] [Indexed: 10/17/2022]
|
37
|
Jean-St-Michel E, Meza JM, Maguire J, Coles J, McCrindle BW. Survival to Stage II with Ventricular Dysfunction: Secondary Analysis of the Single Ventricle Reconstruction Trial. Pediatr Cardiol 2018. [PMID: 29520465 DOI: 10.1007/s00246-018-1845-4] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Ventricular dysfunction affects survival in patients with single right ventricle (RV), and remains one of the primary indications for heart transplantation. Since it is challenging to predict the capacity of patients with ventricular dysfunction to proceed to the stage II procedure, we sought to identify factors that would be associated with death or heart transplantation without achieving stage II for single RV patients with ventricular dysfunction after Norwood procedure. The Single Ventricle Reconstruction (SVR) trial public-use database was used. Patients with a RV ejection fraction less than 44% or a RV fractional area of change less than 35% on the post-Norwood echocardiogram were included. Parametric risk hazard analysis was used to identify risk factors for death or transplantation without achieving stage II. Of 365 patients with ventricular function measurements on the post-Norwood echocardiogram, 123 (34%) patients had RV dysfunction. The transplantation-free survival was significantly lower for those with ventricular dysfunction compared to those with normal function (log rank Chi-square = 4.23, p = 0.04). Furthermore, having a Blalock-Taussig (BT) shunt, a large RV, a post-Norwood infectious complication, and a surgeon who performs five or less Norwood per year were independent risk factors for death or transplantation without achieving stage II. The predicted 6-month transplantation-free survival for patients with all four identified risk factors was 1% (70% CI 0-13%). Early heart transplantation referral might be considered for post-Norwood patients with BT shunt and RV dysfunction, especially if other high-risk features are present.
Collapse
Affiliation(s)
- Emilie Jean-St-Michel
- Division of Cardiology, The Labatt Family Heart Centre, Department of Pediatrics, The Hospital for Sick Children, University of Toronto, 555 University Avenue, Toronto, ON, M5G 1X8, Canada.
| | - James M Meza
- Division of Cardiovascular Surgery, The Labatt Family Heart Centre, Department of Surgery, The Hospital for Sick Children, University of Toronto, 555 University Avenue, Toronto, ON, M5G 1X8, Canada
| | - Jonathon Maguire
- Li Ka Shing Knowledge Institute of St. Michael's hospital, Department of Pediatrics, St. Michael's Hospital, University of Toronto, 30 Bond St, Toronto, ON, M5B1W8, Canada
| | - John Coles
- Division of Cardiovascular Surgery, The Labatt Family Heart Centre, Department of Surgery, The Hospital for Sick Children, University of Toronto, 555 University Avenue, Toronto, ON, M5G 1X8, Canada
| | - Brian W McCrindle
- Division of Cardiology, The Labatt Family Heart Centre, Department of Pediatrics, The Hospital for Sick Children, University of Toronto, 555 University Avenue, Toronto, ON, M5G 1X8, Canada
| |
Collapse
|
38
|
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.
Collapse
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
| |
Collapse
|
39
|
Alsoufi B, Sinha R, McCracken C, Figueroa J, Altin F, Kanter K. Outcomes and risk factors associated with tricuspid valve repair in children with hypoplastic left heart syndrome†. Eur J Cardiothorac Surg 2018; 54:993-1000. [DOI: 10.1093/ejcts/ezy198] [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: 10/29/2017] [Accepted: 04/19/2018] [Indexed: 11/15/2022] Open
Affiliation(s)
- Bahaaldin Alsoufi
- Division of Cardiothoracic Surgery, Children’s Healthcare of Atlanta, Emory University School of Medicine, Atlanta, GA, USA
| | - Raina Sinha
- Division of Cardiothoracic Surgery, Children’s Healthcare of Atlanta, Emory University School of Medicine, Atlanta, GA, USA
| | - Courtney McCracken
- Division of Cardiothoracic Surgery, Children’s Healthcare of Atlanta, Emory University School of Medicine, Atlanta, GA, USA
| | - Janet Figueroa
- Division of Cardiothoracic Surgery, Children’s Healthcare of Atlanta, Emory University School of Medicine, Atlanta, GA, USA
| | - Firat Altin
- Division of Cardiothoracic Surgery, Children’s Healthcare of Atlanta, Emory University School of Medicine, Atlanta, GA, USA
| | - Kirk Kanter
- Division of Cardiothoracic Surgery, Children’s Healthcare of Atlanta, Emory University School of Medicine, Atlanta, GA, USA
| |
Collapse
|
40
|
Ambastha C, Bittle GJ, Morales D, Parchment N, Saha P, Mishra R, Sharma S, Vasilenko A, Gunasekaran M, Al-Suqi MT, Li D, Yang P, Kaushal S. Regenerative medicine therapy for single ventricle congenital heart disease. Transl Pediatr 2018; 7:176-187. [PMID: 29770299 PMCID: PMC5938254 DOI: 10.21037/tp.2018.04.01] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/14/2023] Open
Abstract
One of the most complex forms of congenital heart disease (CHD) involving single ventricle physiology is hypoplastic left heart syndrome (HLHS), characterized by underdevelopment of the left ventricle (LV), mitral and aortic valves, and narrowing of the ascending aorta. The underdeveloped LV is incapable of providing long-term systemic flow, and if left untreated, the condition is fatal. Current treatment for this condition consists of three consecutive staged palliative operations: the first is conducted within the first few weeks of birth, the second between 4 to 6 months, and the third and final surgery within the first 4 years. At the conclusion of the third surgery, systemic perfusion is provided by the right ventricle (RV), and deoxygenated blood flows passively to the pulmonary vasculature. Despite these palliative interventions, the RV, which is ill suited to provide long-term systemic perfusion, is prone to eventual failure. In the absence of satisfying curative treatments, stem cell therapy may represent one innovative approach to the management of RV dysfunction in HLHS patients. Several stem cell populations from different tissues (cardiac and non-cardiac), different age groups (adult- vs. neonate-derived), and different donors (autologous vs. allogeneic), are under active investigation. Preclinical trials in small and large animal models have elucidated several mechanisms by which these stem cells affect the injured myocardium, and are driving the shift from a paradigm based upon cellular engraftment and differentiation to one based primarily on paracrine effects. Recent studies have comprehensively evaluated the individual components of the stem cells' secretomes, shedding new light on the intracellular and extracellular pathways at the center of their therapeutic effects. This research has laid the groundwork for clinical application, and there are now several trials of stem cell therapies in pediatric populations that will provide important insights into the value of this therapeutic strategy in the management of HLHS and other forms of CHD. This article reviews the many stem cell types applied to CHD, their preclinical investigation and the mechanisms by which they might affect RV dysfunction in HLHS patients, and finally, the completed and ongoing clinical trials of stem cell therapy in patients with CHD.
Collapse
Affiliation(s)
- Chetan Ambastha
- Division of Cardiac Surgery, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Gregory J Bittle
- Division of Cardiac Surgery, University of Maryland School of Medicine, Baltimore, MD, USA
| | - David Morales
- Division of Cardiac Surgery, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Nathaniel Parchment
- Division of Cardiac Surgery, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Progyaparamita Saha
- Division of Cardiac Surgery, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Rachana Mishra
- Division of Cardiac Surgery, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Sudhish Sharma
- Division of Cardiac Surgery, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Alexander Vasilenko
- Division of Cardiac Surgery, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Muthukumar Gunasekaran
- Division of Cardiac Surgery, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Manal T Al-Suqi
- Division of Cardiac Surgery, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Deqiang Li
- Division of Cardiac Surgery, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Peixin Yang
- Division of Cardiac Surgery, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Sunjay Kaushal
- Division of Cardiac Surgery, University of Maryland School of Medicine, Baltimore, MD, USA
| |
Collapse
|
41
|
Wilder TJ. Redefining Successful Outcomes in the Hybrid Era. World J Pediatr Congenit Heart Surg 2018; 9:234-235. [PMID: 29544425 DOI: 10.1177/2150135118761029] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Travis J Wilder
- 1 Division of Cardiothoracic Surgery, University of Utah, Salt Lake City, UT, USA
| |
Collapse
|
42
|
|
43
|
Cao JY, Phan K, Ayer J, Celermajer DS, Winlaw DS. Long term survival of hypoplastic left heart syndrome infants: Meta-analysis comparing outcomes from the modified Blalock-Taussig shunt and the right ventricle to pulmonary artery shunt. Int J Cardiol 2018; 254:107-116. [PMID: 29407078 DOI: 10.1016/j.ijcard.2017.10.040] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/13/2017] [Revised: 10/09/2017] [Accepted: 10/12/2017] [Indexed: 12/29/2022]
Abstract
BACKGROUND Stage 1 palliation of hypoplastic left heart syndrome (HLHS) involves the Norwood procedure combined with a modified Blalock-Taussig shunt (mBTS) or right ventricle to pulmonary artery shunt (RVPAS). Short-term survival has been described previously, whereas longer-term outcomes remain a subject of debate. This meta-analysis aimed to describe the short and long-term survival outcomes of these two shunts, and explore factors that might influence survival. METHODS Medline, Cochrane Libraries and EMBASE were systematically searched, and 32 studies were included for statistical synthesis, comprising 1348 mBTS and 1258 RVPAS patients. RESULTS While early in-hospital survival was superior in the RVPAS group (RR=1.5, p<0.05, 95% CI: 1.21-1.85), this difference was lost from 2years post-stage 1 palliation (RR=0.91, p>0.05, 95% CI: 0.79-1.04), and maintained unchanged up to 6years. This shift in survival was also reflected in inter-stage survival, with superior RVPAS outcomes between stage 1 and 2 (RR=1.62, p<0.05, 95% CI: 1.39-1.88), and equivalent outcomes between stage 2 and 3. Potential contributors to this included a significantly higher rate of pulmonary artery stenosis in the RVPAS group and an increased requirement for shunt re-intervention in this group prior to stage 2. CONCLUSIONS Despite early advantages, RVPAS and mBTS for palliation of hypoplastic left heart syndrome produced comparable long-term survival. The RVPAS patients experienced more pulmonary artery stenosis and requirement for shunt re-intervention. The impact of shunt type on quality and survival with a Fontan is yet to be assessed.
Collapse
Affiliation(s)
- Jacob Y Cao
- Sydney Medical School, University of Sydney, Sydney, Australia
| | - Kevin Phan
- Sydney Medical School, University of Sydney, Sydney, Australia; NeuroSpine Surgery Research Group (NSURG), Prince of Wales Private Hospital, Sydney, Australia
| | - Julian Ayer
- Sydney Medical School, University of Sydney, Sydney, Australia; The Heart Centre for Children, The Children's Hospital at Westmead, Sydney, NSW, Australia
| | - David S Celermajer
- Sydney Medical School, University of Sydney, Sydney, Australia; Cardiology, Royal Prince Alfred Hospital, Sydney, NSW, Australia
| | - David S Winlaw
- Sydney Medical School, University of Sydney, Sydney, Australia; The Heart Centre for Children, The Children's Hospital at Westmead, Sydney, NSW, Australia.
| |
Collapse
|
44
|
Burkhart HM, Mir A, Thompson JL. Hypoplastic left heart syndrome and the allure of a valved conduit. J Thorac Cardiovasc Surg 2018; 155:1745-1746. [PMID: 29370913 DOI: 10.1016/j.jtcvs.2017.12.074] [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: 12/01/2017] [Accepted: 12/18/2017] [Indexed: 10/18/2022]
Affiliation(s)
- Harold M Burkhart
- Division of Cardiovascular and Thoracic Surgery, University of Oklahoma Health Sciences Center, Oklahoma City, Okla.
| | - Arshid Mir
- Section of Pediatric Cardiology, University of Oklahoma Health Sciences Center, Oklahoma City, Okla
| | - Jess L Thompson
- Division of Cardiovascular and Thoracic Surgery, University of Oklahoma Health Sciences Center, Oklahoma City, Okla
| |
Collapse
|
45
|
Rogers L, Pagel C, Sullivan ID, Mustafa M, Tsang V, Utley M, Bull C, Franklin RC, Brown KL. Interventional treatments and risk factors in patients born with hypoplastic left heart syndrome in England and Wales from 2000 to 2015. Heart 2018; 104:1500-1507. [DOI: 10.1136/heartjnl-2017-312448] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/19/2017] [Revised: 12/18/2017] [Accepted: 12/19/2017] [Indexed: 01/25/2023] Open
Abstract
ObjectiveTo describe the long-term outcomes, treatment pathways and risk factors for patients diagnosed with hypoplastic left heart syndrome (HLHS) in England and Wales.MethodsThe UK’s national audit database captures every procedure undertaken for congenital heart disease and updated life status for resident patients in England and Wales. Patients with HLHS born between 2000 and 2015 were identified using codes from the International Paediatric and Congenital Cardiac Code.ResultsThere were 976 patients with HLHS. Of these, 9.6% had a prepathway intervention, 89.5% underwent a traditional pathway of staged palliation and 6.4% of infants underwent a hybrid pathway. Patients undergoing prepathway procedures or the hybrid pathway were more complex, exhibiting higher rates of prematurity and acquired comorbidity. Prepathway intervention was associated with the highest in-hospital mortality (34.0%).44.6% of patients had an off-pathway procedure after their primary procedure, most frequently stenting or dilation of residual or recoarctation and most commonly occurring between stage 1 and stage 2.The survival rate at 1 year and 5 years was 60.7% (95% CI 57.5 to 63.7) and 56.3% (95% CI 53.0 to 59.5), respectively. Patients with an antenatal diagnosis (multivariable HR (MHR) 1.63 (95% CI 1.12 to 2.38)), low weight (<2.5 kg) (MHR 1.49 (95% CI 1.05 to 2.11)) or the presence of an acquired comorbidity (MHR 2.04 (95% CI 1.30 to 3.19)) were less likely to survive.ConclusionTreatment pathways among patients with HLHS are complex and variable. It is essential that the long-term outcomes of conditions like HLHS that require serial interventions are studied to provide a fuller picture and to inform quality assurance and improvement.
Collapse
|
46
|
Interstage evaluation of homograft-valved right ventricle to pulmonary artery conduits for palliation of hypoplastic left heart syndrome. J Thorac Cardiovasc Surg 2017; 155:1747-1755.e1. [PMID: 29223842 DOI: 10.1016/j.jtcvs.2017.11.001] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/04/2017] [Revised: 10/18/2017] [Accepted: 11/01/2017] [Indexed: 11/22/2022]
Abstract
OBJECTIVE Palliation of hypoplastic left heart syndrome with a standard nonvalved right ventricle to pulmonary artery conduit results in an inefficient circulation in part due to diastolic regurgitation. A composite right ventricle pulmonary artery conduit with a homograft valve has a hypothetical advantage of reducing regurgitation, but may differ in the propensity for stenosis because of valve remodeling. METHODS This retrospective cohort study included 130 patients with hypoplastic left heart syndrome who underwent a modified stage 1 procedure with a right ventricle to pulmonary artery conduit from 2002 to 2015. A composite valved conduit (cryopreserved homograft valve anastomosed to a polytetrafluoroethylene tube) was placed in 100 patients (47 aortic, 32 pulmonary, 13 femoral/saphenous vein, 8 unknown), and a nonvalved conduit was used in 30 patients. Echocardiographic functional parameters were evaluated before and after stage 1 palliation and before the bidirectional Glenn procedure, and interstage interventions were assessed. RESULTS On competing risk analysis, survival over time was better in the valved conduit group (P = .040), but this difference was no longer significant after adjustment for surgical era. There was no significant difference between groups in the cumulative incidence of bidirectional Glenn completion (P = .15). Patients with a valved conduit underwent more interventions for conduit obstruction in the interstage period, but this difference did not reach significance (P = .16). There were no differences between groups in echocardiographic parameters of right ventricle function at baseline or pre-Glenn. CONCLUSIONS In this cohort of patients with hypoplastic left heart syndrome, inclusion of a valved right ventricle to pulmonary artery conduit was not associated with any difference in survival on adjusted analysis and did not confer an identifiable benefit on right ventricle function.
Collapse
|
47
|
Karamlou T, Velez DA, Nigro JJ. Encrypted prediction: A hacker's perspective. J Thorac Cardiovasc Surg 2017; 154:2038-2040. [DOI: 10.1016/j.jtcvs.2017.08.112] [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: 08/27/2017] [Accepted: 08/30/2017] [Indexed: 11/26/2022]
|
48
|
Meza JM, Hickey E, McCrindle B, Blackstone E, Anderson B, Overman D, Kirklin JK, Karamlou T, Caldarone C, Kim R, DeCampli W, Jacobs M, Guleserian K, Jacobs JP, Jaquiss R. The Optimal Timing of Stage-2-Palliation After the Norwood Operation. Ann Thorac Surg 2017; 105:193-199. [PMID: 28847537 DOI: 10.1016/j.athoracsur.2017.05.041] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/20/2017] [Revised: 05/11/2017] [Accepted: 05/12/2017] [Indexed: 11/18/2022]
Abstract
BACKGROUND The effect of the timing of stage-2-palliation (S2P) on survival through single ventricle palliation remains unknown. This study investigated the optimal timing of S2P that minimizes pre-S2P attrition and maximizes post-S2P survival. METHODS The Congenital Heart Surgeons' Society's critical left ventricular outflow tract obstruction cohort was used. Survival analysis was performed using multiphase parametric hazard analysis. Separate risk factors for death after the Norwood and after S2P were identified. Based on the multivariable models, infants were stratified as low, intermediate, or high risk. Cumulative 2-year, post-Norwood survival was predicted. Optimal timing was determined using conditional survival analysis and plotted as 2-year, post-Norwood survival versus age at S2P. RESULTS A Norwood operation was performed in 534 neonates from 21 institutions. The S2P was performed in 71%, at a median age of 5.1 months (IQR: 4.3 to 6.0), and 22% died after Norwood. By 5 years after S2P, 10% of infants had died. For low- and intermediate-risk infants, performing S2P after age 3 months was associated with 89% ± 3% and 82% ± 3% 2-year survival, respectively. Undergoing an interval cardiac reoperation or moderate-severe right ventricular dysfunction before S2P were high-risk features. Among high-risk infants, 2-year survival was 63% ± 5%, and even lower when S2P was performed before age 6 months. CONCLUSIONS Performing S2P after age 3 months may optimize survival of low- and intermediate-risk infants. High-risk infants are unlikely to complete three-stage palliation, and early S2P may increase their risk of mortality. We infer that early referral for cardiac transplantation may increase their chance of survival.
Collapse
Affiliation(s)
- James M Meza
- Division of Cardiovascular Surgery, The Hospital for Sick Children, Toronto, Ontario
| | - Edward Hickey
- Division of Cardiovascular Surgery, The Hospital for Sick Children, Toronto, Ontario
| | - Brian McCrindle
- Division of Pediatric Cardiology, The Hospital for Sick Children, Toronto, Ontario
| | - Eugene Blackstone
- Division of Thoracic and Cardiovascular Surgery and Quantitative Health Sciences, Cleveland Clinic, Cleveland, Ohio
| | - Brett Anderson
- Division of Cardiology, Morgan-Stanley Children's Hospital/New York Presbyterian Hospital, New York, New York
| | - David Overman
- Division of Pediatric Cardiovascular Surgery, Children's Hospitals and Clinics of Minnesota, Minneapolis, Minnesota
| | - James K Kirklin
- Division of Cardiothoracic Surgery, University of Alabama at Birmingham, Birmingham, Alabama
| | - Tara Karamlou
- Division of Thoracic and Cardiovascular Surgery, Phoenix Children's Hospital, Phoenix, Arizona
| | - Christopher Caldarone
- Division of Cardiovascular Surgery, The Hospital for Sick Children, Toronto, Ontario
| | - Richard Kim
- Division of Cardiothoracic Surgery, Los Angeles Children's Hospital, Los Angeles, California
| | - William DeCampli
- Division of Pediatric Cardiac Surgery, Arnold Palmer Hospital for Children, Orlando, Florida
| | - Marshall Jacobs
- Division of Cardiac Surgery, Johns Hopkins Heart and Vascular Institute, Baltimore, Maryland
| | - Kristine Guleserian
- Division of Cardiovascular Surgery, Niklaus Children's Hospital, Miami, Florida
| | - Jeffrey P Jacobs
- Division of Cardiovascular Surgery, Johns Hopkins All Children's Hospital, St. Petersburg, Florida
| | - Robert Jaquiss
- Division of Pediatric Cardiothoracic Surgery, Children's Medical Center, Dallas, Texas.
| |
Collapse
|
49
|
Pagel C, Rogers L, Brown K, Ambler G, Anderson D, Barron D, Blackshaw E, Crowe S, English K, Franklin R, Jesper E, Meagher L, Pearson M, Rakow T, Salamonowicz M, Spiegelhalter D, Stickley J, Thomas J, Tibby S, Tsang V, Utley M, Witter T. Improving risk adjustment in the PRAiS (Partial Risk Adjustment in Surgery) model for mortality after paediatric cardiac surgery and improving public understanding of its use in monitoring outcomes. HEALTH SERVICES AND DELIVERY RESEARCH 2017. [DOI: 10.3310/hsdr05230] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
BackgroundIn 2011, we developed a risk model for 30-day mortality after children’s heart surgery. The PRAiS (Partial Risk Adjustment in Surgery) model uses data on the procedure performed, diagnosis, age, weight and comorbidity. Our treatment of comorbidity was simplistic because of data quality. Software that implements PRAiS is used by the National Congenital Heart Disease Audit (NCHDA) in its audit work. The use of PRAiS triggered the temporary suspension of surgery at one unit in 2013. The public anger that surrounded this illustrated the need for public resources around outcomes monitoring.Objectives(1) To improve the PRAiS risk model by incorporating more information about comorbidities. (2) To develop online resources for the public to help them to understand published mortality data.DesignObjective 1 The outcome measure was death within 30 days of the start of each surgical episode of care. The analysts worked with an expert panel of clinical and data management representatives. Model development followed an iterative process of clinical discussion of risk factors, development of regression models and assessment of model performance under cross-validation. Performance was measured using the area under the receiving operator characteristic (AUROC) curve and calibration in the cross-validation test sets. The final model was further assessed in a 2014–15 validation data set.Objective 2 We developed draft website material that we iteratively tested through four sets of two workshops (one workshop for parents of children who had undergone heart surgery and one workshop for other interested users). Each workshop recruited new participants. The academic psychologists ran two sets of three experiments to explore further understanding of the web content.DataWe used pseudonymised NCHDA data from April 2009 to April 2014. We later unexpectedly received a further year of data (2014–15), which became a prospective validation set.ResultsObjective 1The cleaned 2009–14 data comprised 21,838 30-day surgical episodes, with 539 deaths. The 2014–15 data contained 4207 episodes, with 97 deaths. The final regression model included four new comorbidity groupings. Under cross-validation, the model had a median AUROC curve of 0.83 (total range 0.82 to 0.83), a median calibration slope of 0.92 (total range 0.64 to 1.25) and a median intercept of –0.23 (range –1.08 to 0.85). In the validation set, the AUROC curve was 0.86 [95% confidence interval (CI) 0.83 to 0.89], and its calibration slope and intercept were 1.01 (95% CI 0.83 to 1.18) and 0.11 (95% CI –0.45 to 0.67), respectively. We recalibrated the final model on 2009–15 data and updated the PRAiS software.Objective 2We coproduced a website (http://childrensheartsurgery.info/) that provides interactive exploration of the data, two animations and background information. It was launched in June 2016 and was very well received.LimitationsWe needed to use discharge status as a proxy for 30-day life status for the 14% of overseas patients without a NHS number. We did not have sufficient time or resources to extensively test the usability and take-up of the website following its launch.ConclusionsThe project successfully achieved its stated aims. A key theme throughout has been the importance of collaboration and coproduction. In particular for aim 2, we generated a great deal of generalisable learning about how to communicate complex clinical and mathematical information.Further workExtending our codevelopment approach to cover many other aspects of quality measurement across congenital heart disease and other specialised NHS services.FundingThe National Institute for Health Research Health Services and Delivery Research programme.
Collapse
Affiliation(s)
- Christina Pagel
- Clinical Operational Research Unit, University College London, London, UK
| | - Libby Rogers
- Clinical Operational Research Unit, University College London, London, UK
| | - Katherine Brown
- Cardiac, Critical Care and Respiratory Division, Great Ormond Street Hospital for Children NHS Foundation Trust, London, UK
| | - Gareth Ambler
- Department of Statistical Science, University College London, London, UK
| | - David Anderson
- Cardiology and Critical Care, Evelina London Children’s Hospital, Guy’s and St Thomas’ NHS Foundation Trust, London, UK
| | - David Barron
- Cardiothoracic Surgery, Birmingham Children’s Hospital, Birmingham, UK
| | | | - Sonya Crowe
- Clinical Operational Research Unit, University College London, London, UK
| | - Kate English
- Cardiology, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - Rodney Franklin
- Paediatric Cardiology, Royal Brompton & Harefield NHS Foundation Trust, London, UK
| | | | | | - Mike Pearson
- Statistical Laboratory, Centre for Mathematical Sciences, University of Cambridge, Cambridge, UK
| | - Tim Rakow
- Department of Psychology, King’s College London, London, UK
| | | | - David Spiegelhalter
- Statistical Laboratory, Centre for Mathematical Sciences, University of Cambridge, Cambridge, UK
| | - John Stickley
- Cardiothoracic Surgery, Birmingham Children’s Hospital, Birmingham, UK
| | | | - Shane Tibby
- Cardiology and Critical Care, Evelina London Children’s Hospital, Guy’s and St Thomas’ NHS Foundation Trust, London, UK
| | - Victor Tsang
- Cardiac, Critical Care and Respiratory Division, Great Ormond Street Hospital for Children NHS Foundation Trust, London, UK
| | - Martin Utley
- Clinical Operational Research Unit, University College London, London, UK
| | - Thomas Witter
- Cardiology and Critical Care, Evelina London Children’s Hospital, Guy’s and St Thomas’ NHS Foundation Trust, London, UK
| |
Collapse
|
50
|
Barron DJ, Haq IU, Crucean A, Stickley J, Botha P, Khan N, Jones TJ, Brawn WJ. The importance of age and weight on cavopulmonary shunt (stage II) outcomes after the Norwood procedure: Planned versus unplanned surgery. J Thorac Cardiovasc Surg 2017; 154:228-238. [DOI: 10.1016/j.jtcvs.2016.12.036] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/19/2016] [Revised: 12/20/2016] [Accepted: 12/30/2016] [Indexed: 10/20/2022]
|