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Pulmonary Vascular Sequelae of Palliated Single Ventricle Circulation: Arteriovenous Malformations and Aortopulmonary Collaterals. J Cardiovasc Dev Dis 2022; 9:jcdd9090309. [PMID: 36135454 PMCID: PMC9501802 DOI: 10.3390/jcdd9090309] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2022] [Revised: 09/12/2022] [Accepted: 09/14/2022] [Indexed: 11/16/2022] Open
Abstract
Children and adults with single ventricle congenital heart disease (CHD) develop many sequelae during staged surgical palliation. Universal pulmonary vascular sequelae in this patient population include two inter-related but distinct complications: pulmonary arteriovenous malformations (PAVMs) and aortopulmonary collaterals (APCs). This review highlights what is known and unknown about these vascular sequelae focusing on diagnostic testing, pathophysiology, and areas in need of further research.
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Spearman AD, Gupta A, Pan AY, Gronseth EI, Thirugnanam K, Gudausky TM, Foerster SR, Ramchandran R. Hepatic Vein Blood Increases Lung Microvascular Angiogenesis and Endothelial Cell Survival-Toward an Understanding of Univentricular Circulation. Semin Thorac Cardiovasc Surg 2020; 32:980-987. [PMID: 32387780 DOI: 10.1053/j.semtcvs.2020.03.004] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2020] [Accepted: 03/25/2020] [Indexed: 11/11/2022]
Abstract
To improve our understanding of pulmonary arteriovenous malformations in univentricular congenital heart disease, our objective was to identify the effects of hepatic vein and superior vena cava constituents on lung microvascular endothelial cells independent of blood flow. Paired blood samples were collected from the hepatic vein and superior vena cava in children 0-10 years old undergoing cardiac catheterization. Isolated serum was subsequently used for in vitro endothelial cell assays. Angiogenic activity was assessed using tube formation and scratch migration. Endothelial cell survival was assessed using proliferation (BrdU incorporation, cell cycle analysis) and apoptosis (caspase 3/7 activity, Annexin-V labeling). Data were analyzed using Wilcoxon signed-rank test and repeated measures analysis. Upon incubating lung microvascular endothelial cells with 10% patient serum, hepatic vein serum increases angiogenic activity (tube formation, P = 0.04, n = 24; migration, P< 0.001, n = 18), increases proliferation (BrdU, P < 0.001, n = 32; S-phase, P = 0.04, n = 13), and decreases apoptosis (caspase 3/7, P < 0.001, n = 32; Annexin-V, P = 0.04, n = 12) compared to superior vena cava serum. Hepatic vein serum regulates lung microvascular endothelial cells by increasing angiogenesis and survival in vitro. Loss of hepatic vein serum signaling in the lung microvasculature may promote maladaptive lung microvascular remodeling and pulmonary arteriovenous malformations.
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Affiliation(s)
- Andrew D Spearman
- Division of Cardiology, Department of Pediatrics, Medical College of Wisconsin, Children's Hospital of Wisconsin, Herma Heart Institute, Milwaukee, Wisconsin.
| | - Ankan Gupta
- Division of Neonatology, Department of Pediatrics, Medical College of Wisconsin, Children's Hospital of Wisconsin, Milwaukee, Wisconsin
| | - Amy Y Pan
- Division of Quantitative Health Sciences, Department of Pediatrics, Children's Hospital of Wisconsin, Milwaukee, Wisconsin
| | - Emily I Gronseth
- Division of Neonatology, Department of Pediatrics, Medical College of Wisconsin, Children's Hospital of Wisconsin, Milwaukee, Wisconsin
| | - Karthikeyan Thirugnanam
- Division of Neonatology, Department of Pediatrics, Medical College of Wisconsin, Children's Hospital of Wisconsin, Milwaukee, Wisconsin
| | - Todd M Gudausky
- Division of Cardiology, Department of Pediatrics, Medical College of Wisconsin, Children's Hospital of Wisconsin, Herma Heart Institute, Milwaukee, Wisconsin
| | - Susan R Foerster
- Division of Cardiology, Department of Pediatrics, Medical College of Wisconsin, Children's Hospital of Wisconsin, Herma Heart Institute, Milwaukee, Wisconsin
| | - Ramani Ramchandran
- Division of Neonatology, Department of Pediatrics, Medical College of Wisconsin, Children's Hospital of Wisconsin, Milwaukee, Wisconsin; Department of Obstetrics and Gynecology, Medical College of Wisconsin, Milwaukee, Wisconsin
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Kritharis A, Al-Samkari H, Kuter DJ. Hereditary hemorrhagic telangiectasia: diagnosis and management from the hematologist's perspective. Haematologica 2018; 103:1433-1443. [PMID: 29794143 PMCID: PMC6119150 DOI: 10.3324/haematol.2018.193003] [Citation(s) in RCA: 107] [Impact Index Per Article: 17.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2018] [Accepted: 05/14/2018] [Indexed: 12/11/2022] Open
Abstract
Hereditary hemorrhagic telangiectasia (HHT), also known as Osler-Weber-Rendu syndrome, is an autosomal dominant disorder that causes abnormal blood vessel formation. The diagnosis of hereditary hemorrhagic telangiectasia is clinical, based on the Curaçao criteria. Genetic mutations that have been identified include ENG, ACVRL1/ALK1, and MADH4/SMAD4, among others. Patients with HHT may have telangiectasias and arteriovenous malformations in various organs and suffer from many complications including bleeding, anemia, iron deficiency, and high-output heart failure. Families with the same mutation exhibit considerable phenotypic variation. Optimal treatment is best delivered via a multidisciplinary approach with appropriate diagnosis, screening and local and/or systemic management of lesions. Anti-angiogenic agents such as bevacizumab have emerged as a promising systemic therapy in reducing bleeding complications but are not curative. Other pharmacological agents include iron supplementation, antifibrinolytics and hormonal treatment. This review discusses the biology of HHT, management issues that face the practising hematologist, and considerations of future directions in HHT treatment.
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Affiliation(s)
- Athena Kritharis
- Division of Blood Disorders, Rutgers Cancer Institute of New Jersey, New Brunswick, NJ, USA
| | - Hanny Al-Samkari
- Hematology Division, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - David J Kuter
- Hematology Division, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
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Wisotzkey BL, Magyar DL, Jones TK, Boucek RJ, Permut LC, Kemna MS, Law YM. A tale of two cases of pulmonary arteriovenous malformation: How they fared after cardiac transplantation. Clin Transplant 2017; 32. [PMID: 29277952 DOI: 10.1111/ctr.13183] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/19/2017] [Indexed: 12/01/2022]
Abstract
BACKGROUND In single ventricle patients, aortopulmonary collaterals (APCs) and pulmonary arteriovenous malformations (PAVMs) following superior cavopulmonary shunt (CPS) can complicate orthotopic heart transplant (OHT) by cyanosis and hemoptysis. Although PAVMs can regress with the restoration of hepatic venous flow to the pulmonary circulation, the effects of hypoxemia on the "unconditioned" allograft are not known. CASES Two patients with significant PAVMs after CPS were cyanotic following OHT. One patient with predominantly unilateral left PAVMs had arterial saturation levels less than 70% despite pulmonary vasodilators and ventilation. A custom flow restrictor-covered stent was deployed in the pulmonary artery of the affected side, redirecting the blood flow to the contralateral lung, immediately improving cyanosis. When the PAVMs regressed, the flow restrictor stent was dilated to eliminate the constriction. The second patient with PAVMs had cyanosis and severe hemoptysis from APCs post-OHT. The APCs required an extensive coil embolization, while the cyanosis responded to oxygen and pulmonary vasodilators. Both recipients did well with gradual resolution of PAVMs within 8 months. CONCLUSIONS Despite cyanosis from right-to-left intrapulmonary shunting, allograft function recovered. Novel transcatheter interventions can play a role in patients with significant APCs or PAVM following cardiac transplantation.
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Affiliation(s)
- Bethany L Wisotzkey
- Department of Pediatrics, Division of Pediatric Cardiology, Johns Hopkins All Children's Hospital, Saint Petersburg, FL, USA
| | - Dari L Magyar
- Department of Pediatrics, Seattle Children's Hospital, Seattle, WA, USA
| | - Thomas K Jones
- Department of Pediatrics, Division of Pediatric Cardiology, Seattle Children's Hospital, Seattle, WA, USA
| | - Robert J Boucek
- Department of Pediatrics, Division of Pediatric Cardiology, Seattle Children's Hospital, Seattle, WA, USA
| | - Lester C Permut
- Department of Pediatrics, Division of Pediatric Cardiothoracic Surgery, Seattle Children's Hospital, Seattle, WA, USA
| | - Mariska S Kemna
- Department of Pediatrics, Division of Pediatric Cardiology, Seattle Children's Hospital, Seattle, WA, USA
| | - Yuk M Law
- Department of Pediatrics, Division of Pediatric Cardiology, Seattle Children's Hospital, Seattle, WA, USA
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Histologic evidence of intrapulmonary anastomoses by three-dimensional reconstruction in severe bronchopulmonary dysplasia. Ann Am Thorac Soc 2014; 10:474-81. [PMID: 23987309 DOI: 10.1513/annalsats.201305-124oc] [Citation(s) in RCA: 57] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
RATIONALE Bronchopulmonary dysplasia (BPD) is the chronic lung disease of infancy that occurs in premature infants after oxygen and ventilator therapy for acute respiratory disease at birth. Despite improvement in current therapies, the clinical course of infants with BPD is often characterized by marked hypoxemia that can become refractory to therapy. Preacinar anatomic and functional communications between systemic and pulmonary vascular systems has been established in fetal lungs, but whether increased intrapulmonary anastomotic vessels or their failure to regress after birth contributes to hypoxemia in preterm infants with BPD is unknown. OBJECTIVES We sought to find histologic evidence of intrapulmonary anastomotic vessels in lungs of patients who died of severe BPD. METHODS We collected lung tissues from fatal BPD cases and performed histology, immunohistochemistry, and high-precision three-dimensional reconstruction techniques. MEASUREMENTS AND MAIN RESULTS We report histologic evidence of intrapulmonary vessels that bridge pulmonary arteries and veins in the distal lungs of infants dying with severe BPD. These prominent vessels appear similar to "misaligned pulmonary veins" described in the lethal form of congenital lung disorder, alveolar capillary dysplasia. CONCLUSIONS We found striking histological evidence of precapillary arteriovenous anastomotic vessels in the lungs of infants with severe bronchopulmonary dysplasia. We propose that persistence or expansion of these vessels after premature birth provides the anatomic basis for intrapulmonary shunt and hypoxemia in neonates with severe bronchopulmonary dysplasia and may play a significant role in the morbidity and mortality of BPD.
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Abstract
Severe cyanosis due to pulmonary arteriovenous fistulas occurs often after a bidirectional superior cavopulmonary anastomosis (Glenn operation) and also in some congenital anomalies in which hepatic venous blood bypasses the lungs in the first passage. Relocation of hepatic flow into the lungs usually causes these fistulas to disappear. Similar pulmonary arteriovenous fistulas are observed in hereditary haemorrhagic telangiectasia, and in liver disease (hepatopulmonary syndrome). There is no convincing identification yet of a responsible hepatic factor that produces these lesions. Candidates for such a factor are reviewed, and the possibility of angiotensin or bradykinin contributing to the fistulas is discussed.
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Larsen SH, Emmertsen K, Bjerre J, Hjortdal VE. Progressive cyanosis following Kawashima operation: slow resolution after redirection of hepatic veins. J Cardiothorac Surg 2013; 8:67. [PMID: 23561447 PMCID: PMC3622568 DOI: 10.1186/1749-8090-8-67] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2013] [Accepted: 03/21/2013] [Indexed: 11/12/2022] Open
Abstract
Progressive cyanosis often develops following Kawashima operation in patients with left atrial isomerism, interrupted inferior vena cava and hepatic veins draining to the atria. Knowledge on the timing and extend of resolution following hepatic venous redirection is sparse. A girl developed progressing cyanosis following Kawashima operation at the age of ten months. Arterial oxygen saturations at rest dropped to 60-65%. Surgical redirection of hepatic veins into the cavopulmonary circulation at the age of three years had no immediate effect. However, arterial oxygen saturations increased gradually over nine months to 90-93% and 95-100% after three years.
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Affiliation(s)
- Signe Holm Larsen
- Department of Cardiology, Aarhus University Hospital, Brendstrupgaardsvej, 8200 Aarhus N, Denmark.
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Krieger EV, Valente AM, Landzberg MJ, Stout KK. Acute dyspnea in a young man with an old sternotomy. CONGENIT HEART DIS 2012; 7:E73-7. [PMID: 22471669 DOI: 10.1111/j.1747-0803.2012.00641.x] [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] [Indexed: 01/19/2023]
Abstract
Described is a 42-year-old man with complex congenital heart disease with single-ventricle physiology who underwent a Fontan operation at 27 years of age. He presented with sudden-onset chest pain and dyspnea and was initially misdiagnosed with a pulmonary embolism. This case is described in order to highlight the challenges in the evaluation of common presentations in adults with congenital heart disease.
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Affiliation(s)
- Eric V Krieger
- Division of Cardiology, Department of Medicine, University of Washington Medical Center, Seattle, WA 98195, USA.
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Baghdady Y, Hussein Y, Shehata M. Vascular endothelial growth factor in children with cyanotic and acyanotic and congenital heart disease. Arch Med Sci 2010; 6:221-5. [PMID: 22371751 PMCID: PMC3281344 DOI: 10.5114/aoms.2010.13899] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/16/2008] [Revised: 01/22/2009] [Accepted: 02/15/2009] [Indexed: 11/17/2022] Open
Abstract
INTRODUCTION Vascular endothelial growth factor is a potent stimulator of angiogenesis. Children with cyanotic congenital heart disease often experience the development of widespread formation of collateral blood vessels, which may represent a form of abnormal angiogenesis resulting in increased morbidity and mortality. We undertook the present study to determine whether children with cyanotic congenital heart disease have elevated serum levels of vascular endothelial growth factor compared to children with acyanotic heart disease. MATERIAL AND METHODS Serum was obtained from 35 children with cyanotic congenital heart disease and 30 children with acyanotic heart disease. Vascular endothelial growth factor levels were measured in the serum of these patients by sandwich enzyme immunoassay. RESULTS Vascular endothelial growth factor was significantly elevated in children with cyanotic congenital heart disease compared to children with acyanotic heart disease (150.3 ±48.1 vs. 85.4 ±18.7 pg/ml, respectively, p < 0.001). In the cyanotic group, oxygen saturation (SaO(2)) was negatively correlated with VEGF (r=-0.631, p < 0.001) while haemoglobin was positively correlated (r=0.781, p = 0.007). No significant correlations were found in the acyanotic group. CONCLUSIONS Children with cyanotic congenital heart disease have elevated systemic levels of vascular endothelial growth factor directly related to the degree of cyanosis (SaO(2) and haemoglobin levels). These findings suggest that the widespread formation of collateral vessels in these children may be mediated by vascular endothelial growth factor.
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Affiliation(s)
- Yasser Baghdady
- Cardiology Department, Faculty of Medicine, Cairo University, Egypt
| | - Yasser Hussein
- Paediatric Department, Faculty of Medicine, Cairo University, Egypt
| | - Mohamed Shehata
- Clinical Pathology Departments, Faculty of Medicine, Cairo University, Egypt
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Invited Commentary. Ann Thorac Surg 2009; 87:553-4. [DOI: 10.1016/j.athoracsur.2008.11.046] [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: 11/16/2008] [Revised: 11/16/2008] [Accepted: 11/20/2008] [Indexed: 11/19/2022]
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Tipps RS, Mumtaz M, Leahy P, Duncan BW. Gene array analysis of a rat model of pulmonary arteriovenous malformations after superior cavopulmonary anastomosis. J Thorac Cardiovasc Surg 2008; 136:283-9. [PMID: 18692629 DOI: 10.1016/j.jtcvs.2008.02.011] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/22/2007] [Revised: 11/21/2007] [Accepted: 02/12/2008] [Indexed: 11/27/2022]
Abstract
OBJECTIVE Pulmonary arteriovenous malformations commonly develop in children who have undergone a cavopulmonary anastomosis as part of the palliative sequence for single-ventricle physiology. METHODS We developed a rat model of cavopulmonary anastomosis that results in pulmonary arteriovenous malformations that are angiographically and histologically similar to the human condition. We used this model to analyze the gene expression profile associated with pulmonary arteriovenous malformations developing after cavopulmonary anastomosis. RESULTS Six Sprague-Dawley rats underwent right superior cavopulmonary anastomosis, allowing the left lung to serve as a control. Total RNA was isolated from each lung at death 8 months postoperatively and compared by using the Affymetrix Rat Microarray RAE230 2.0 GeneChip (Affymetrix, Santa Clara, Calif). One hundred thirty-seven genes demonstrated altered expression in the lungs after cavopulmonary anastomosis compared with that seen in the control lungs: 55 (40%) genes demonstrated increased expression, and 82 (60%) genes demonstrated decreased expression. Modulation of genes associated with angiogenesis and vascular remodeling was found, including angiopoietin-2, placental growth factor, several matrix metalloproteases, and several collagen subtypes. Genes with vasoactive properties, including endothelin 1 and endothelin receptor type B, demonstrated altered gene expression. Several members of the transforming growth factor beta superfamily signaling pathway also demonstrated altered expression. CONCLUSIONS These changes in gene expression might have causative implications for pulmonary arteriovenous malformations that develop after cavopulmonary anastomosis.
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Affiliation(s)
- Russell S Tipps
- Department of Pediatric and Congenital Heart Surgery, Children's Hospital, Cleveland Clinic, Cleveland, Ohio 44195, USA
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Bradley SM. Morphological studies of pulmonary arteriovenous shunting in a lamb model of superior cavopulmonary anastomosis. Pediatr Cardiol 2008; 29:701-3. [PMID: 18385920 DOI: 10.1007/s00246-008-9219-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Hamada H, Ebata R, Higashi K, Tateno S, Niwa K, Honda T, Yasukawa K, Terai M. Serum vascular endothelial growth factor in cyanotic congenital heart disease functionally contributes to endothelial cell kinetics in vitro. Int J Cardiol 2006; 120:66-71. [PMID: 17126928 DOI: 10.1016/j.ijcard.2006.08.106] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/06/2006] [Revised: 08/03/2006] [Accepted: 08/10/2006] [Indexed: 01/19/2023]
Abstract
BACKGROUND Remarkable amounts of neovascularization develop in patients with cyanotic congenital heart disease who have low pulmonary blood flow and systemic cyanosis, but the factors functionally responsible for angiogenesis in cyanotic congenital heart disease have not been determined. METHODS AND RESULTS To investigate the functional angiogenic molecules in serum from these patients, serum angiogenic activity was studied in 21 patients (systemic oxygen saturation: 82+/-1.9%) and in 17 healthy controls. Patient serum was more active in stimulating the tube formation of human umbilical vein endothelial cells (HUVECs) into capillary-like structures than control serum (150% vs 104% of internal control; p<0.001). This increased serum angiogenic activity normalized after total cardiac repair (p<0.001). The migration activity of HUVECs was also accelerated in patient serum (p=0.007). To identify the molecules in patient serum affecting tube formation of HUVECs, we examined the effects of an inhibitor or a neutralizing antibody against various angiogenic molecules on in vitro angiogenesis. Both the soluble vascular endothelial growth factor (VEGF) receptor 1 and the VEGF receptor 2 tyrosine kinase inhibitor SU5416 reduced the basal serum angiogenic activity of patients and this was reversed by a supplement of recombinant human VEGF. CONCLUSION Our results indicate that serum VEGF functionally contributes to vascular endothelial cell kinetics in patients with cyanotic congenital heart disease.
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Affiliation(s)
- Hiromichi Hamada
- Department of Pediatrics, Graduate School of Medicine, Chiba University, 1-8-1 Inohana, Chuo-ku, Chiba-shi, Chiba 260-8670, Japan
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Urcelay GE, Borzutzky AJ, Becker PA, Castillo ME. Nitric Oxide in Pulmonary Arteriovenous Malformations and Fontan Procedure. Ann Thorac Surg 2005; 80:338-40. [PMID: 15975403 DOI: 10.1016/j.athoracsur.2003.12.095] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 12/29/2003] [Indexed: 11/26/2022]
Abstract
Pulmonary arteriovenous malformations are a well documented complication of superior cavopulmonary (Glenn) connections. We report the successful management of a case of severe hypoxemia in the early postoperative period of a patient who underwent the Fontan operation. The patient had previously been diagnosed with pulmonary arteriovenous malformations; the use of inhaled nitric oxide was followed up with reversal of life-threatening hypoxemia. At 6-month postoperative follow-up, the patient was asymptomatic with near normal aortic saturation.
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Affiliation(s)
- Gonzalo E Urcelay
- Department of Pediatrics, Pontificial Catholic University of Chile, Santiago, Chile.
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Mumtaz MA, Fraga CH, Nicholls CM, Desai S, Vasilyev N, Joshi R, Mee RBB, Duncan BW. Increased expression of vascular endothelial growth factor messenger RNA in lungs of rats after cavopulmonary anastomosis. J Thorac Cardiovasc Surg 2005; 129:209-10. [PMID: 15632845 DOI: 10.1016/j.jtcvs.2004.04.006] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Affiliation(s)
- Muhammad A Mumtaz
- Department of Pediatric and Congenital Heart Surgery, The Children's Hospital at The Cleveland Clinic, Ohio, USA
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Ikai A, Riemer RK, Ma X, Reinhartz O, Hanley FL, Reddy VM. Pulmonary expression of the hepatocyte growth factor receptor c-Met shifts from medial to intimal layer after cavopulmonary anastomosis. J Thorac Cardiovasc Surg 2004; 127:1442-9. [PMID: 15116006 DOI: 10.1016/j.jtcvs.2003.09.009] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
OBJECTIVE Pulmonary arteriovenous malformations occur in up to 60% of patients after cavopulmonary anastomosis. We compared the effects of cavopulmonary anastomosis and pulmonary artery banding on lung gene expression in an ovine model to study the abnormal pulmonary vascular remodeling after the exclusion of inferior vena caval blood independent of reduced pulmonary blood flow. We previously demonstrated by contrast echocardiography that pulmonary arteriovenous malformations develop by 8 weeks after cavopulmonary anastomosis but not after pulmonary artery banding. Hepatocyte growth factor, a pleiotropic factor with morphogenic, mitogenic, and angiogenic activities, signals via its specific receptor c-Met to induce the antiapoptotic factor Bcl-2. In this study, we examined pulmonary artery expression of these factors and their potential role in pulmonary artery remodeling after cavopulmonary anastomosis and pulmonary artery banding. METHODS Eighteen lambs aged 35 to 45 days were placed into 3 groups: cavopulmonary anastomosis, pulmonary artery banding, and control (n = 6/group). In the cavopulmonary anastomosis group, the superior vena cava was anastomosed to the right pulmonary artery in an end-to-end fashion. In the pulmonary artery banding group, the left pulmonary artery was banded to reduce blood flow to 20% of control. The control group had a simple right pulmonary artery clamp for 30 minutes. Lung was harvested for Western blot, reverse transcriptase-polymerase chain reaction, and immunostaining at 2 weeks (n = 3/group) and 5 weeks (n = 3/group) after surgery. RESULTS The expression of c-Met mRNA after cavopulmonary anastomosis was increased by twofold compared with the control or pulmonary artery banding group. The total lung expression of c-Met by Western blot was also up regulated at 2 weeks (P <.05). However, total lung expression of hepatocyte growth factor and Bcl-2 by Western and reverse transcriptase-polymerase chain reaction was not different from the control and pulmonary artery banding groups at both 2 and 5 weeks after surgery. Immunohistochemical analysis revealed that c-Met expression was localized to the intimal layer of the pulmonary artery in the cavopulmonary anastomosis, while its expression in the control and pulmonary artery banding lungs was localized to the medial layer. Localization of Bcl-2 on the intimal layer in lambs with cavopulmonary anastomosis followed the same pattern as c-Met. CONCLUSIONS After cavopulmonary anastomosis, pulmonary artery expression of the hepatocyte growth factor receptor c-Met and one of its downstream effectors, Bcl-2, had increased in the intimal layer and decreased in the medial layer. Because the hepatocyte growth factor signaling promotes increased endothelial cell survival, it may have a role in pulmonary artery remodeling following cavopulmonary anastomosis. In addition, the change of c-Met expression in the medial layer after cavopulmonary anastomosis suggests a possible mechanism for the smooth muscle cell alteration related to abnormal angiogenesis.
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Affiliation(s)
- Akio Ikai
- Department of Cardiothoracic Surgery, Division of Pediatric Cardiac Surgery, Stanford University, Palo Alto, CA 94305-5407, USA
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Ikai A, Shirai M, Nishimura K, Ikeda T, Kameyama T, Ueyama K, Komeda M. Hypoxic pulmonary vasoconstriction disappears in a rabbit model of cavopulmonary shunt. J Thorac Cardiovasc Surg 2004; 127:1450-7. [PMID: 15116007 DOI: 10.1016/s0022-5223(03)01191-7] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
BACKGROUND Cavopulmonary shunt is widely known as an interim staging procedure in patients with single-ventricle physiology. However, the physiologic characteristics of the pulmonary arterial system after cavopulmonary shunt are not clearly understood. In this article, we developed a rabbit cavopulmonary shunt model and studied the morphologic changes and physiologic characteristics (namely, hypoxic pulmonary vasoconstriction) of pulmonary arteries after cavopulmonary shunt. METHODS Male Japanese white rabbits aged 12 to 16 weeks were used for the study. In 5 rabbits, the superior vena cava was anastomosed to the right pulmonary artery in an end-to-side fashion, followed by a proximal side ligation of the right pulmonary artery (cavopulmonary shunt group). In 4 rabbits, the superior vena cava and the right pulmonary artery were dissected and clamped for 10 minutes without making a cavopulmonary shunt (sham group). Two weeks after the operation, we then measured the internal diameter of the acinar (internal diameter, 164 +/- 7 microm), the lobular (305 +/- 13 microm), and the segmental (669 +/- 16 microm) pulmonary arteries in both controlled and hypoxic conditions by using a specially designed x-ray television system. Also, morphometric measurements were made in the pulmonary arteries around the terminal bronchioles. RESULTS Two weeks after the operation, the arterial oxygen tension under room air conditions was significantly lower in the cavopulmonary shunt group than in the sham group (68.2 +/- 2.2 mm Hg vs 91.1 +/- 1.9 mm Hg; P =.01). The baseline internal diameters in the acinar and the lobular (resistance), but not the segmental (conduit), pulmonary arteries on the anastomosed side of the cavopulmonary shunt group were significantly larger than those of pulmonary arteries on the nonanastomosed side of the cavopulmonary shunt group and the sham group. Moreover, the pulmonary arteries on the anastomosed side of the cavopulmonary shunt group did not respond to hypoxia, whereas those on the nonanastomosed side of the cavopulmonary shunt and sham groups did have local internal diameter reductions in the acinar and lobular arteries (-1.1% +/- 1.0% in the anastomosed side vs -17.7% +/- 3.5% in the nonanastomosed side vs -20.9% +/- 6.1% in the sham group; P =.03). In the morphometric studies, the internal diameter of the pulmonary artery accompanying the terminal bronchiole in the anastomosed side of the cavopulmonary shunt group was significantly larger, and the ratio of medial thickness relative to the outer diameter was smaller compared with ratios in the nonanastomosed side of the cavopulmonary shunt group and the sham group. CONCLUSIONS We developed a rabbit cavopulmonary shunt model. In the anastomosed side of the cavopulmonary shunt group, the peripheral pulmonary arteries, which contributed greatly in regulating the pulmonary vascular resistance, had a local reduction in the basal vascular tone and no hypoxic vasoconstriction 2 weeks after the operation.
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Affiliation(s)
- Akio Ikai
- Department of Cardiovascular Surgery, Graduate School of Medicine, Kyoto University, Kyoto, Japan
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Friehs I, del Nido PJ. Invited commentary. Ann Thorac Surg 2004. [DOI: 10.1016/j.athoracsur.2003.12.001] [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: 11/27/2022]
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19
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Sidwell RU, Daubeney PEF, Porter W, Roberts NM. Neonatal hemangiomatosis and atrial septal defect: a rare cause of right heart failure in infancy. Pediatr Dermatol 2004; 21:66-9. [PMID: 14871331 DOI: 10.1111/j.0736-8046.2004.21115.x] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
Neonatal hemangiomatosis is a well-recognized cause of left ventricular failure. We describe an infant with neonatal hemangiomatosis and an ostium secundum atrial septal defect who developed severe right heart failure. This was due to the combination of increased flow through the right heart as a result of the atrial septal defect, and the background high cardiac output from the massive arteriovenous shunting and multiple hemangiomas. In addition, the multiple hepatic hemangiomas may exert a vasoactive influence on the pulmonary vasculature.
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Affiliation(s)
- Rachel U Sidwell
- Department of Pediatric Dermatology, Chelsea and Westminster Hospital, London, United Kingdom
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20
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Abstract
Pulmonary arteriovenous malformations (PAVMs) are a cause of progressive cyanosis after cavopulmonary anastomosis in children with single ventricle physiology who are on the pathway leading to a Fontan procedure. Investigations into possible mechanisms for the etiology of PAVMs are ongoing and suggest that the liver might play a key regulatory role in the development of these lesions.
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Affiliation(s)
- Brian W Duncan
- Pediatric and Congenital Heart Surgery, The Children's Hospital at The Cleveland Clinic, The Cleveland Clinic Foundation, Cleveland, Ohio, USA.
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21
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Starnes SL, Duncan BW, Fraga CH, Desai SY, Jones TK, Mathur SK, Rosenthal GL, Lupinetti FM. Rat model of pulmonary arteriovenous malformations after right superior cavopulmonary anastomosis. Am J Physiol Heart Circ Physiol 2002; 283:H2151-6. [PMID: 12384493 DOI: 10.1152/ajpheart.00368.2002] [Citation(s) in RCA: 17] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
We developed a rat model of pulmonary arteriovenous malformations after cavopulmonary anastomosis. We sought to determine whether this model reproduces the angiographic and histologic features seen in the human condition. Eight Sprague-Dawley rats underwent a right superior cavopulmonary anastomosis with the use of microsurgical techniques. Between 2 and 13 mo, pulmonary angiography was performed, the animals were euthanized, and the lungs were removed. Microscopic sections of the lung were stained with an endothelial-specific antibody (von Willebrand factor). Microvessel density was determined by counting vessels staining positively for von Willebrand factor, and the shunted and nonshunted (control) lungs were compared for each animal. Pulmonary angiography revealed time-dependent development of arteriovenous malformations. Microvessel density demonstrated a time-dependent increase in the shunted lung compared with the control lung (simple linear regression of the ratio of the microvessel density of the shunted lung divided by the microvessel density of the control lung on time; R(2) = 0.79, P = 0.003). This animal model reproduces the same angiographic and microscopic features of pulmonary arteriovenous malformations that develop in humans after cavopulmonary anastomosis. This appears to be a valid model that may be used to further study etiologic mechanisms for this phenomenon.
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Affiliation(s)
- Sandra L Starnes
- Division of Cardiac Surgery, Children's Hospital and Regional Medical Center, Seattle, WA 98105, USA
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22
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Malhotra SP, Reddy VM, Thelitz S, He YP, McMullan DM, Hanley FL, Riemer RK. The role of oxidative stress in the development of pulmonary arteriovenous malformations after cavopulmonary anastomosis. J Thorac Cardiovasc Surg 2002; 124:479-85. [PMID: 12202863 DOI: 10.1067/mtc.2002.120346] [Citation(s) in RCA: 17] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
BACKGROUND Cavopulmonary anastomosis is used for palliation of cyanotic heart disease. Clinically significant pulmonary arteriovenous malformations occur in up to 25% of patients after surgical intervention. Cavopulmonary anastomosis creates several modifications to pulmonary physiology that may contribute to the development of pulmonary arteriovenous malformations, including reduced pulmonary blood flow and the exclusion of inferior vena caval effluent. OBJECTIVE By comparing the expression of angiogenic and stress-related proteins after cavopulmonary anastomosis and pulmonary artery banding, we sought to determine which genes were upregulated independent of reduced pulmonary blood flow. METHODS Lambs aged 35 to 45 days were placed into 1 of 3 groups: cavopulmonary anastomosis (n = 6), pulmonary artery banding (n = 6), and sham control (n = 6) animals. In our model pulmonary arteriovenous malformations are detectable by means of bubble-contrast echocardiography 8 weeks after cavopulmonary anastomosis. Lung tissue was harvested for Western blotting at 2 and 5 weeks after surgery. RESULTS Cavopulmonary anastomosis and pulmonary artery banding both increased angiogenic gene expression, but only cavopulmonary anastomosis induced the expression of endothelial stress-related genes. Vascular endothelial growth factor was upregulated 2.5-fold after both cavopulmonary anastomosis (P =.002) and pulmonary artery banding (P =.007). Only cavopulmonary anastomosis upregulated 2 stress-related genes, HO1 and GLUT1, 2.7-fold (P =.002) and 3.8-fold (P =.03), respectively. Hypoxia-inducible factor was upregulated 4-fold (P =.003) after cavopulmonary anastomosis. Pulmonary artery banding failed to induce the increased expression of any of these proteins. CONCLUSIONS Reduced pulmonary blood flow induces a pulmonary angiogenic response but not an endothelial stress response. These results suggest that oxidative stress is more relevant to the formation of pulmonary arteriovenous malformations than angiogenic signaling alone because pulmonary artery banding does not result in pulmonary arteriovenous malformations. Oxidative stress of the pulmonary endothelium resulting from cavopulmonary anastomosis may predispose the affected vasculature to arteriovenous shunting.
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Affiliation(s)
- Sunil P Malhotra
- Division of Cardiothoracic Surgery, University of California, San Francisco, Calif. 94305-5407, USA
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23
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Jacobs ML. Complications associated with heterotaxy syndrome in Fontan patients. Semin Thorac Cardiovasc Surg Pediatr Card Surg Annu 2002; 5:25-35. [PMID: 11994862 DOI: 10.1053/pcsu.2002.31500] [Citation(s) in RCA: 18] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/18/2023]
Abstract
Enormous progress has been made in the last decade toward decreasing the risk of the Fontan operation and optimizing early and intermediate outcomes. Heterotaxy syndrome patients, with their extensive constellation of anatomic abnormalities, constitute a challenging group to manage surgically. Palliative procedures early in life are directed at creation of a satisfactory balance between pulmonary and systemic blood flow and at the same time assurance of unobstructed pulmonary venous return. For heterotaxy patients who survive beyond the newborn period, and are considered to have nonseptatable hearts, early reduction of the volume load of the functional single ventricle is extremely important. Early conversion from parallel pulmonary and systemic circulations to a superior cavopulmonary anastomosis (bidirectional Glenn or hemi-Fontan) is the preferred strategy. Traditionally, those patients with heterotaxy who survive initial surgical management have been considered a very high-risk population with respect to an eventual Fontan procedure. In heterotaxy patients it is particularly important to understand the unique and variable anatomy of the sinus node and conduction system, the potential for occult pulmonary venous obstruction, the tendency for development of atrioventricular valve regurgitation in volume loaded ventricles, and the potential for recurrent or persistent cyanosis because of intrahepatic shunting or pulmonary arteriovenous malformations.
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Affiliation(s)
- Marshall L Jacobs
- Section of Cardiothoracic Surgery, St. Christopher's Hospital for Children, Philadelphia, PA 19134, USA
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24
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Parolin MB, Coelho JCU, Puccinelli V, Schulz GJ, de Souza AM, de Barros JA. [Hepatopulmonary syndrome in liver transplantation candidates]. ARQUIVOS DE GASTROENTEROLOGIA 2002; 39:11-6. [PMID: 12184159 DOI: 10.1590/s0004-28032002000100003] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
BACKGROUND Hepatopulmonary syndrome is an important clinical problem associated with chronic liver disease. Liver transplantation can result in complete resolution of the arterial hypoxemia associated with this syndrome, even in its most severe presentation. AIM To determine the prevalence of hepatopulmonary syndrome in adult liver transplant candidates. PATIENTS AND METHODS Fifty-four consecutives adult patients (> or = 18 years) with severe liver disease waiting for liver transplant were screened for arterial hypoxemia (PaO2 < 70 mm Hg) while they were seated, at rest, and breathing room air. Patients with arterial hypoxemia underwent contrast-enhanced two-dimensional echocardiography and pulmonary function testing. Hypoxemia (PaO2 < 70 mm Hg) was present in 7 of 54 patients (12.9%), although only 1 of them complained of dyspnea. The Child's classification of the patients were: A = 1, B = 4, and C = 1. All seven hypoxemic patients had positive contrast-enhanced two-dimensional echocardiography, consistent with hepatopulmonary syndrome. CONCLUSION The prevalence of hepatopulmonary syndrome in adult liver transplant candidates is elevated. The screening for hepatopulmonary syndrome should be part of the routine evaluation of liver transplant candidates even in the absence of pulmonary symptoms.
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Affiliation(s)
- Mônica Beatriz Parolin
- Serviço de Transplante Hepático, Laboratório de Provas de Funçào Pumonar, Hospital de Clínicas, Universidade Federal do Paraná, Curitiba, PR.
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25
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Walker PG, Oweis GF, Watterson KG. Distribution of hepatic venous blood in the total cavo pulmonary connection: an in vitro study into the effects of connection geometry. J Biomech Eng 2001; 123:558-64. [PMID: 11783726 DOI: 10.1115/1.1407827] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
The total cavo pulmonary connection, or TCPC, is a surgical correction to congenital heart defects. The geometry of this connection has been shown to determine the fluid power loss as well as the distribution of hepatic fluid that enters through the inferior vena cava. In vitro studies were performed to measure the power loss and hepatic fluid distribution in models of the TCPC with four different geometries. It was found that a zero offset straight geometry provided good hepatic fluid distribution but large power loss. A zero offset flared geometry provided low power loss but poor hepatic fluid distribution. The optimal geometry from those tested was found to be the zero offset cowl geometry whereby an enlargement was made on one side of the inferior and superior vena cava. So long as the cowl was directed toward the pulmonary artery of lowest flow rate, low power loss and relatively good distribution of hepatic flow could be obtained.
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Affiliation(s)
- P G Walker
- School of Mechanical Engineering, University of Leeds, United Kingdom.
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26
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Chu JM, Wu QY, Wang WM. Pulmonary Blood Distribution after Total Cavopulmonary Connection. Asian Cardiovasc Thorac Ann 2001. [DOI: 10.1177/021849230100900408] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
From July 1998 to December 2000, the distribution of pulmonary blood flow was evaluated in 34 consecutive surviving patients who had been randomly assigned to one of 4 different modes of total cavopulmonary connection. All patients underwent radionuclide lung perfusion imaging with 99mTc-macroaggregated albumin to determine the distribution of blood from the superior and inferior venae cavae and the total pulmonary flow to each lung. The most physiological distribution of blood between the right and left lungs was obtained when the inferior vena cava anastomosis was widened and slightly offset towards the right pulmonary artery in patients without persistent left superior vena cava. This type of anastomosis should also reduce the incidence of arteriovenous malformations in the lung caused by exclusion of hepatic venous return.
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Affiliation(s)
| | | | - Wen Ming Wang
- Department of Nuclear Medicine Cardiovascular Institute and Fuwai Hospital Chinese Academy of Medical Sciences and Peking Union Medical College Beijing, People's Republic of China
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27
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Abstract
Acute heart failure is unusual in the pediatric population, but in many situations it justifies aggressive therapy. For example, children with lymphocytic myocarditis have an overall survival rate of nearly 90%, with complete myocardial recovery for the majority. Pharmacologic agents traditionally have been the mainstay of medical therapy for acute heart failure, but, in recent years, there has been increasing interest in using measures that reduce the myocardial workload. This article highlights nonpharmacologic approaches to the management of severe heart failure in the critically ill child. It also concentrates on physiologic approaches that address the balance between oxygen demand and delivery; the manipulation of cardiopulmonary interactions to optimize ventricular function; and the use of mechanical circulatory support as a method of achieving ultimate myocardial rest.
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Affiliation(s)
- L Shekerdemian
- Cardiac Intensive Care Unit, Great Ormond Street Hospital, London, UK.
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28
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Lee JH, Lee DH, Zo JH, Kim TH, Lee KL, Chung HS, Kim CH, Han SK, Sim YS, Lee HS, Yoon YB, Song IS, Kim CY. Hepatopulmonary syndrome in poorly compensated postnecrotic liver cirrhosis by hepatitis B virus in Korea. Korean J Intern Med 2001; 16:56-61. [PMID: 11590902 PMCID: PMC4531714 DOI: 10.3904/kjim.2001.16.2.56] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/22/2023] Open
Abstract
BACKGROUND Hepatopulmonary syndrome (HPS) refers to the association of hypoxemia, intrapulmonary shunting and chronic liver disease. But there is no clear data about the prevalence of HPS in postnecrotic liver cirrhosis by hepatitis B virus (HBV), the most common cause of liver disease in Korea. The aim of this study was to investigate the prevalence of HPS in poorly compensated postnecrotic liver cirrhosis by HBV, and the correlation of the hepatopulmonary syndrome with clinical aspects of postnecrotic liver cirrhosis by HBV. METHODS Thirty-five patients underwent pulmonary function test, arterial blood gas analysis and contrast-enhanced echocardiography. All patients were diagnosed as HBV-induced Child class C liver cirrhosis and had no evidence of intrinsic cardiopulmonary disease. RESULTS Intrapulmonary shunt was detected in 6/35 (17.1%) by contrast-enhanced echocardiography. Two of six patients with intrahepatic shunts had significant hypoxemia (PaO2 < 70 mmHg) and four showed increased alveolar-arterial oxygen gradient over 20 mmHg. Only cyanosis could reliably distinguish between shunt positive and negative patients. CONCLUSIONS The prevalence of intrapulmonary shunt in poorly compensated postnecrotic liver cirrhosis by HBV was 17.1% and the frequency of hepatopulmonary syndrome was relatively low (5.7%). 'Subclinical' hepatopulmonary syndrome (echocardiographically positive intrapulmonary shunt but without profound hypoxemia) exists in 11.4% of cases with poorly compensated postnecrotic liver cirrhosis by HBV. Cyanosis is the only reliable clinical indicator of HPS of HBV-induced poorly compensated liver cirrhosis. Further studies are required to determine if the prevalence and clinical manifestations of HPS varies with etiology or with geographical and racial differences.
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Affiliation(s)
- J H Lee
- Department of Internal Medicine, Liver Research Institute, Seoul Municipal Boramae Hospital, Seoul, Korea
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29
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Starnes SL, Duncan BW, Kneebone JM, Fraga CH, States S, Rosenthal GL, Lupinetti FM. Pulmonary microvessel density is a marker of angiogenesis in children after cavopulmonary anastomosis. J Thorac Cardiovasc Surg 2000; 120:902-7. [PMID: 11044316 DOI: 10.1067/mtc.2000.110248] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
OBJECTIVE Pulmonary arteriovenous malformations cause progressive cyanosis in children after cavopulmonary anastomosis and may be due to abnormal angiogenesis. We determined the microvessel density, a marker of angiogenesis, in the lungs of children after cavopulmonary anastomosis. METHODS Lung biopsy specimens were obtained from 8 children after cavopulmonary anastomosis and from 4 control patients. Three of the 8 children undergoing cavopulmonary anastomosis had clinical and angiographic evidence of pulmonary arteriovenous malformations, whereas the other 5 were free of symptoms. Routine histologic and immunohistologic stains were performed with a primary antibody to von Willebrand factor. Microvessel staining for von Willebrand factor was determined for 10 fields (200x) per patient. RESULTS Patients with and without pulmonary arteriovenous malformations after cavopulmonary anastomosis demonstrated significantly increased microvessel density compared with control subjects (32.7 +/- 2.8 vs 9.3 +/- 4.6, P =.02, and 31.5 +/- 15.7 vs 9.3 +/- 4.6, P =.01, respectively). There was no difference in microvessel density in children with and without clinically apparent pulmonary arteriovenous malformations after cavopulmonary anastomosis (P =.9). The children with pulmonary arteriovenous malformations had numerous greatly dilated vessels that were absent in the asymptomatic children after cavopulmonary anastomosis. CONCLUSIONS After cavopulmonary anastomosis, pulmonary microvessel density is increased even in the absence of clinically apparent pulmonary arteriovenous malformations, supporting the presence of a constant angiogenic stimulus. Children with clinically apparent pulmonary arteriovenous malformations possess large numbers of greatly dilated pulmonary microvessels, which are absent in asymptomatic children after cavopulmonary anastomosis. These results suggest that the transition to clinically apparent pulmonary arteriovenous malformations may be due to mechanisms that lead to vessel dilation and remodeling.
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Affiliation(s)
- S L Starnes
- Divisions of Cardiac Surgery and Cardiology, Children's Hospital and Regional Medical Center, Seattle, Washington, USA
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30
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Freedom RM, Hamilton R, Yoo SJ, Mikailian H, Benson L, McCrindle B, Justino H, Williams WG. The Fontan procedure: analysis of cohorts and late complications. Cardiol Young 2000; 10:307-31. [PMID: 10950328 DOI: 10.1017/s1047951100009616] [Citation(s) in RCA: 56] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Affiliation(s)
- R M Freedom
- Department of Pathology and Laboratory Medicine, the Hospital for Sick Children, Toronto, Canada.
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31
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Walker PG, Howe TT, Davies RL, Fisher J, Watterson KG. Distribution of hepatic venous blood in the total cavo-pulmonary connection: an in vitro study. Eur J Cardiothorac Surg 2000; 17:658-65. [PMID: 10856856 DOI: 10.1016/s1010-7940(00)00425-5] [Citation(s) in RCA: 19] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
OBJECTIVES The objective of this project was to quantify the effects of geometry on the distribution of hepatic blood to the lungs in patients with a total cavo-pulmonary connection. The basis for this work is the supposition that hepatic blood is necessary for proper lung function. METHODS Plastic models of these connections were made with varying degrees of offset between the inferior and superior vena cava and attached to an in vitro flow loop. Dye was injected into the inferior vena cava and its concentration quantified in each pulmonary artery. These data were converted to percentage concentration and distribution of hepatic blood to each lung. RESULTS With no offset between the vena cava, hepatic blood distribution and concentration to each lung was similar to normal. For an offset of one or more diameters, hepatic blood tended to flow preferentially towards the nearest pulmonary artery with the opposite pulmonary artery exhibiting a deficit (<10% of normal). CONCLUSIONS Distribution of hepatic blood to each lung was found to be a function of vena cava offset and pulmonary artery flow split. Under normal conditions, 60% of blood towards the right pulmonary artery, the hepatic blood distribution to both lungs could be maintained above 50% of normal if the inferior vena cava was offset towards the left pulmonary artery. Offsetting the inferior vena cava towards the right pulmonary artery jeopardized the delivery of hepatic blood to one lung.
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Affiliation(s)
- P G Walker
- School of Mechanical Engineering, University of Leeds, LS2 9JT, Leeds, UK.
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32
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Abstract
Pediatric cardiac intensive care has emerged as a distinct clinical entity to meet the unique needs of pediatric patients with congenital and acquired heart disease. This new subspecialty demands expertise and experience in the pediatric subspecialties of cardiology, intensive care, cardiac surgery, cardiac anesthesia, neonatology, and others. Ten recent developments will have an impact on pediatric cardiac intensive care for the coming decades: 1) emergence of new patient populations; 2) new clinical methodologies in the treatment of pulmonary hypertension; 3) innovations in techniques of respiratory support; 4) expanding research of single ventricle physiology; 5) advances in the treatment of heart failure; 6) improved noninvasive imaging; 7) new directions in interventional cardiac catheterization; 8) new techniques in pediatric cardiac surgery; 9) use of computer technology and intensive care monitoring; and 10) appreciation for global economics of intensive care. Finally, a multidisciplinary approach with a team esprit de corps remains vital to a successful pediatric cardiac intensive care program.
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Affiliation(s)
- A C Chang
- Pediatric Cardiac Intensive Care Program, Miami Children's Hospital, Florida 33155-4069, USA.
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