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Qasim A, Morris SA, Belfort MA, Qureshi AM. Current Understanding of Indications, Technical Aspects and Outcomes of Fetal Cardiac Interventions. Interv Cardiol Clin 2024; 13:319-331. [PMID: 38839166 DOI: 10.1016/j.iccl.2024.03.005] [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: 06/07/2024]
Abstract
With the improvement in the detection of congenital heart disease in fetal life, fetal cardiac interventions are pushing the envelope in hopes of either altering the natural history of disease or improving survival in certain high-risk lesions. These interventions include fetal aortic valvuloplasty for evolving hypoplastic left heart syndrome, fetal atrial septoplasty with or without atrial septal stenting for hypoplastic left heart syndrome and variants with intact or severely restrictive atrial septum, and fetal pulmonary valvuloplasty for severe pulmonary stenosis or pulmonary atresia with intact ventricular septum. This review discusses their indications, technical aspects, and outcomes based on available literature.
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Affiliation(s)
- Amna Qasim
- Department of Cardiology, Arkansas Children's Hospital, University of Arkansas for Medical Sciences, Little Rock, AR, USA
| | - Shaine A Morris
- The Lillie Frank Abercrombie Division of Cardiology, Texas Children's Hospital, Baylor College of Medicine, Houston, TX, USA
| | - Michael A Belfort
- Department of Obstetrics and Gynecology, Texas Children's Hospital, Baylor College of Medicine
| | - Athar M Qureshi
- CE Mullins Cardiac Catheterization Laboratories, The Lillie Frank Abercrombie Division of Cardiology, Texas Children's Hospital, Baylor College of Medicine, Internal Medicine/Cardiology, Baylor St. Luke's Medical Center, 6651 Main Street, E 1920, Houston, TX 77030, USA.
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2
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Iliopoulos I, Mastropietro CW, Flores S, Cheung E, Amula V, Radman M, Kwiatkowski D, Puente BN, Buckley JR, Allen KY, Loomba R, Karki KB, Chiwane S, Cashen K, Piggott K, Kapileshwarkar Y, Gowda KMN, Badheka A, Raman R, Zang H, Costello JM. Pulmonary Atresia with Intact Ventricular Septum: Midterm Outcomes from a Multicenter Cohort. Pediatr Cardiol 2024; 45:847-857. [PMID: 35751685 DOI: 10.1007/s00246-022-02954-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/18/2022] [Accepted: 06/08/2022] [Indexed: 11/28/2022]
Abstract
Contemporary multicenter data regarding midterm outcomes for neonates with pulmonary atresia with intact ventricular septum are lacking. We sought to describe outcomes in a contemporary multicenter cohort, determine factors associated with end-states, and evaluate the effect of right ventricular coronary dependency and coronary atresia on transplant-free survival. Neonates treated during 2009-2019 in 19 United States centers were reviewed. Competing risks analysis was performed to determine cumulative risk of each end-state, and multivariable regression analyses were performed to identify factors associated with each end-state and transplant-free survival. We reviewed 295 patients. Median tricuspid valve Z-score was - 3.06 (25%, 75%: - 4.00, - 1.52). Final end-state was biventricular repair for 45 patients (15.2%), one-and-a half ventricle for 16 (5.4%), Fontan for 75 (25.4%), cardiac transplantation for 29 (9.8%), and death for 54 (18.3%). Seventy-six patients (25.7%) remained in mixed circulation. Cumulative risk estimate of death was 10.9%, 16.1%, 16.9%, and 18.8% at 1, 6 months, 1 year, and 5 years, respectively. Tricuspid valve Z-score was inversely, and coronary atresia positively associated with death or transplantation [odds ratio (OR) = 0.46, (95% confidence interval (CI) = 0.29-0.75, p < 0.001) and OR = 3.75 (95% CI 1.46-9.61, p = 0.011), respectively]. Right ventricular coronary dependency and left coronary atresia had a significant effect on transplant-free survival (log-rank p < 0.001). In a contemporary multicenter cohort of patients with PAIVS, consisting predominantly of patients with moderate-to-severe right ventricular hypoplasia, we observed favorable survival outcomes. Right ventricular coronary dependency and left, but not right, coronary atresia significantly worsens transplant-free survival.
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Affiliation(s)
- Ilias Iliopoulos
- The Heart Institute, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA.
- Cardiac Intensive Care, The Heart Institute, Cincinnati Children's Hospital Medical Center, 3333 Burnet Ave, MLC 2003, Cincinnati, OH, 45229, USA.
| | - Christopher W Mastropietro
- Division of Critical Care, Department of Pediatrics, Indiana University School of Medicine, Riley Hospital for Children, Indianapolis, IN, USA
| | - Saul Flores
- Department of Pediatrics, Baylor College of Medicine, Texas Children's Hospital, Houston, TX, USA
| | - Eva Cheung
- Department of Pediatrics, Columbia University College of Physicians and Surgeons, Morgan Stanley Children's Hospital of New York, New York, NY, USA
| | - Venugopal Amula
- Department of Pediatrics, University of Utah School of Medicine, Salt Lake City, UT, USA
| | - Monique Radman
- Division of Critical Care, Department of Pediatrics, University of Washington, Seattle Children's Hospital, Seattle, WA, USA
| | - David Kwiatkowski
- Division of Cardiology, Department of Pediatrics, Stanford University School of Medicine, Lucille Packard Children's Hospital, Palo Alto, CA, USA
| | - Bao Nguyen Puente
- Division of Cardiac Critical Care, Children's National Health System, Washington, DC, USA
| | - Jason R Buckley
- Division of Cardiology, Department of Pediatrics, Shawn Jenkins Children's Hospital, Medical University of South Carolina, Charleston, SC, USA
| | - Kiona Y Allen
- Division of Cardiology, Department of Pediatrics, Ann & Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Rohit Loomba
- Department of Pediatrics, Chicago Medical School, Advocate Children's Hospital, Chicago, IL, USA
| | - Karan B Karki
- Division of Cardiology, Department of Pediatrics, University of Tennessee Health Science Center, Le Bonheur Children's Hospital, Memphis, TN, USA
| | - Saurabh Chiwane
- Division of Pediatric Critical Care, Department of Pediatrics, Saint Louis University, Cardinal Glennon Children's Hospital, Saint Louis, MO, USA
| | - Katherine Cashen
- Department of Pediatrics, Central Michigan University, Children's Hospital of Michigan, Detroit, MI, USA
| | - Kurt Piggott
- Division of Critical Care, LSU Health Sciences, Children's Hospital, New Orleans, LA, USA
| | | | | | - Aditya Badheka
- Department of Pediatrics, University of Iowa Stead Family Children's Hospital, Iowa City, IA, USA
| | - Rahul Raman
- Department of Pediatrics, Mercy Medical Center, Des Moines, IA, USA
| | - Huaiyu Zang
- The Heart Institute, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - John M Costello
- Division of Cardiology, Department of Pediatrics, Shawn Jenkins Children's Hospital, Medical University of South Carolina, Charleston, SC, USA
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3
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Dalén M, Odermarsky M, Liuba P, Johansson Ramgren J, Synnergren M, Sunnegårdh J. Long-Term Survival After Single-Ventricle Palliation: A Swedish Nationwide Cohort Study. J Am Heart Assoc 2024; 13:e031722. [PMID: 38497454 PMCID: PMC11010024 DOI: 10.1161/jaha.123.031722] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/26/2023] [Accepted: 02/02/2024] [Indexed: 03/19/2024]
Abstract
BACKGROUND Long-term survival after single-ventricle palliation and the effect of dominant ventricle morphology in large, unselected series of patients are scarcely reported. METHODS AND RESULTS This nationwide cohort study included all children undergoing operation with single-ventricle palliation during their first year of life in Sweden between January 1994 and December 2019. Data were obtained from institutional records and assessment of underlying cardiac anomaly and dominant ventricular morphology was based on complete review of medical records, surgical reports, and echocardiographic examinations. Data on vital status and date of death were retrieved from the Swedish Cause of Death Register, allowing for complete data on survival. Among 766 included patients, 333 patients (43.5%) were classified as having left or biventricular dominance, and 432 patients (56.4%) as having right ventricular (RV) dominance (of whom 231 patients had hypoplastic left heart syndrome). Follow-up was 98.7% complete (10 patients emigrated). Mean follow-up was 11.3 years (maximum, 26.7 years). Long-term survival was significantly higher in patients with left ventricular compared with RV dominance (10-year survival: 91.0% [95% CI, 87.3%-93.6%] versus 71.1% [95% CI, 66.4%-75.2%]). RV dominance had a significant impact on outcomes after first-stage palliation but was also associated with impaired survival after completed total cavopulmonary connection. In total, 34 (4.4%) patients underwent heart transplantation. Of these 34 patients, 25 (73.5%) had predominant RV morphology. CONCLUSIONS This study provides clinically relevant knowledge about the long-term prognosis in patients with different underlying cardiac anomalies undergoing single-ventricle palliation. RV dominance had a significant impact on outcomes after initial surgical treatment but was also associated with impaired survival after completed Fontan circulation. REGISTRATION URL: https://www.clinicaltrials.gov; Unique identifier: NCT03356574.
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Affiliation(s)
- Magnus Dalén
- Department of Cardiothoracic Surgery Karolinska University Hospital Stockholm Sweden
- Department of Molecular Medicine and Surgery Karolinska Institutet Stockholm Sweden
| | - Michal Odermarsky
- Pediatric Heart Centre Skåne University Hospital Lund Sweden
- Department of Clinical Sciences Lund University Lund Sweden
| | - Petru Liuba
- Pediatric Heart Centre Skåne University Hospital Lund Sweden
- Department of Clinical Sciences Lund University Lund Sweden
| | - Jens Johansson Ramgren
- Pediatric Heart Centre Skåne University Hospital Lund Sweden
- Department of Clinical Sciences Lund University Lund Sweden
| | - Mats Synnergren
- Children's Heart Centre Sahlgrenska University Hospital Gothenburg Sweden
- Department of Pediatrics Institute of Clinical Sciences, Sahlgrenska Academy Gothenburg Sweden
| | - Jan Sunnegårdh
- Children's Heart Centre Sahlgrenska University Hospital Gothenburg Sweden
- Department of Pediatrics Institute of Clinical Sciences, Sahlgrenska Academy Gothenburg Sweden
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4
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Villalaín C, Moon-Grady AJ, Herberg U, Strainic J, Cohen JL, Shah A, Levi DS, Gómez-Montes E, Herraiz I, Galindo A. Prediction of postnatal circulation in pulmonary atresia/critical stenosis with intact ventricular septum: systematic review and external validation of models. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2023; 62:14-22. [PMID: 36776132 DOI: 10.1002/uog.26176] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/27/2022] [Revised: 01/12/2023] [Accepted: 01/23/2023] [Indexed: 06/06/2023]
Abstract
OBJECTIVE A favorable postnatal prognosis in cases of pulmonary atresia/critical stenosis with intact ventricular septum (PA/CS-IVS) is generally equated with the possibility of achieving biventricular (BV) repair. Identification of fetuses that will have postnatal univentricular (UV) circulation is key for prenatal counseling, optimization of perinatal care and decision-making regarding fetal therapy. We aimed to evaluate the accuracy of published models for predicting postnatal circulation in PA/CS-IVS using a large internationally derived validation cohort. METHODS This was a systematic review of published uni- and multiparametric models for the prediction of postnatal circulation based on echocardiographic findings at between 20 and 28 weeks of gestation. Models were externally validated using data from the International Fetal Cardiac Intervention Registry. Sensitivity, specificity, predictive values, area under the receiver-operating-characteristics curves (AUCs) and proportion of cases with true vs predicted outcome were calculated. RESULTS Eleven published studies that reported prognostic parameters of postnatal circulation were identified. Models varied widely in terms of the main outcome (UV (n = 3), non-BV (n = 3), BV (n = 3), right-ventricle-dependent coronary circulation (n = 1) or tricuspid valve size at birth (n = 1)) and in terms of the included predictors (single parameters only (n = 6), multiparametric score (n = 4) or both (n = 1)), and were developed on small sample sizes (range, 15-38). Nine models were validated externally given the availability of the required parameters in the validation cohort. Tricuspid valve diameter Z-score, tricuspid regurgitation, ratios between right and left cardiac structures and the presence of ventriculocoronary connections (VCC) were the most commonly evaluated parameters. Multiparametric models including up to four variables (ratios between right and left structures, right ventricular inflow duration, presence of VCC and tricuspid regurgitation) had the best performance (AUC, 0.80-0.89). Overall, the risk of UV outcome was underestimated and that of BV outcome was overestimated by most models. CONCLUSIONS Current prenatal models for the prediction of postnatal outcome in PA/CS-IVS are heterogeneous. Multiparametric models for predicting UV and non-BV circulation perform well in identifying BV patients but have low sensitivity, underestimating the rate of fetuses that will ultimately have UV circulation. Until better discrimination can be achieved, fetal interventions may need to be limited to only those cases in which non-BV postnatal circulation is certain. © 2023 The Authors. Ultrasound in Obstetrics & Gynecology published by John Wiley & Sons Ltd on behalf of International Society of Ultrasound in Obstetrics and Gynecology.
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Affiliation(s)
- C Villalaín
- Fetal Medicine Unit, Department of Obstetrics and Gynecology, University Hospital 12 de Octubre, Complutense University, Madrid, Spain
- Research Institute Hospital 12 de Octubre (imas12), Madrid, Spain
- Primary Care Interventions to Prevent Maternal and Child Chronic Diseases of Perinatal and Developmental Origin (RICORS network), RD21/0012/0024, Madrid, Spain
| | - A J Moon-Grady
- Department of Pediatrics, Division of Cardiology, University of California San Francisco, UCSF Benioff Children's Hospital, CA, USA
| | - U Herberg
- Klinik für Kinderkardiologie Universitätsklinikum, Aachen, Germany
| | - J Strainic
- Department of Pediatrics, Division of Pediatric Cardiology, The Congenital Heart Collaborative, Rainbow Babies and Children's Hospital, University Hospitals of Cleveland Medical Center, Case Western University, Cleveland, OH, USA
| | - J L Cohen
- Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - A Shah
- Division of Pediatric Cardiology, Morgan Stanley Children's Hospital of New York, Columbia University Irving Medical Center, New York, NY, USA
| | - D S Levi
- Division of Cardiology, UCLA Mattel Children's Hospital, University of California Los Angeles Medical School, Los Angeles, CA, USA
| | - E Gómez-Montes
- Fetal Medicine Unit, Department of Obstetrics and Gynecology, University Hospital 12 de Octubre, Complutense University, Madrid, Spain
- Research Institute Hospital 12 de Octubre (imas12), Madrid, Spain
- Primary Care Interventions to Prevent Maternal and Child Chronic Diseases of Perinatal and Developmental Origin (RICORS network), RD21/0012/0024, Madrid, Spain
| | - I Herraiz
- Fetal Medicine Unit, Department of Obstetrics and Gynecology, University Hospital 12 de Octubre, Complutense University, Madrid, Spain
- Research Institute Hospital 12 de Octubre (imas12), Madrid, Spain
- Primary Care Interventions to Prevent Maternal and Child Chronic Diseases of Perinatal and Developmental Origin (RICORS network), RD21/0012/0024, Madrid, Spain
| | - A Galindo
- Fetal Medicine Unit, Department of Obstetrics and Gynecology, University Hospital 12 de Octubre, Complutense University, Madrid, Spain
- Research Institute Hospital 12 de Octubre (imas12), Madrid, Spain
- Primary Care Interventions to Prevent Maternal and Child Chronic Diseases of Perinatal and Developmental Origin (RICORS network), RD21/0012/0024, Madrid, Spain
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5
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Konduri A, Sriram C, Mahadin D, Aggarwal S. Exercise Capacity in Patients with Pulmonary Atresia with Intact Ventricular Septum: Does the Type of Surgical Repair Matter? Pediatr Cardiol 2023; 44:556-563. [PMID: 35678826 DOI: 10.1007/s00246-022-02943-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/24/2022] [Accepted: 05/24/2022] [Indexed: 11/28/2022]
Abstract
Two standard surgical palliative options for neonates born with pulmonary atresia and intact ventricular septum (PA/IVS) include uni-or biventricular repair. Whenever feasible, the biventricular repair is considered to have better exercise capacity (XC) and outcomes. However, there is a paucity of data comparing objective XC between these two surgical techniques. Our aim was to compare XC, including longitudinal changes in patients with PA/IVS following uni-biventricular repair. We performed a single-center retrospective study of survivors with repaired PA/IVS who underwent comprehensive treadmill cardiopulmonary exercise testing. Initial and latest exercise parameters were compared for longitudinal analysis. Demographic and exercise parameters were collated. Peak oxygen uptake (VO2 in ml/kg/min), an indicator of maximal aerobic capacity, peak heart rate, and other measures of spirometry performed at the same time were collected. Recorded parameters included, (a) Percentage of predicted VO2 (% VO2) normalized for age, weight, height, and gender, (b) % oxygen (O2) pulse, (c) anaerobic threshold (AT), (d) Chronotropic index (CI), (e) % Breathing reserve, (f) Forced vital capacity (FVC), (g) % Forced Expiratory volume in 1 s (FEV1), (h) Maximum voluntary ventilation (MVV), and (i) VE/VCO2. Appropriate statistical tests were performed, and a p value < 0.05 was considered significant. A total of 35 patients (43% male, 57% univentricular repair) were included, with a mean (SD) age of 20.1(7.5) years. Patients with univentricular palliation demonstrated significantly impaired peak heart rate, chronotropic index (0.50 ± 0.2 vs. 0.90 ± 0.1, p = 0.02), VE/VCO2 (35.4 ± 5.0 vs. 30.2 ± 2.8, p = 0.001), and %FVC (78.3 ± 8.3 vs. 88.6 ± 15.1, p = 0.02). There was a trend towards reduction in % VO2 in the Fontan patients though it was statistically similar between the groups (68.4 ± 21.4 vs. 81.2 ± 18.9, p = 0.07). Longitudinal data were available for 11 patients in each group, and there was no longitudinal decline in their exercise parameters over similar intermediate follow-up duration [6.8 (UV) vs. 5.3 (BV) years]. We conclude that young survivors with PA/IVS with prior univentricular palliation demonstrated an objective impairment in their chronotropic parameters compared with the biventricular repair. However, this did not translate into a significant difference in their exercise capacity. There was no longitudinal decline in exercise capacity or other parameters over intermediate follow-up.
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Affiliation(s)
- Anusha Konduri
- Division of Pediatric Cardiology, Department of Pediatrics, Children's Hospital of Michigan, 3901 Beaubien Blvd, Detroit, MI, 48201, USA.
| | - Chenni Sriram
- Division of Pediatric Cardiology, Department of Pediatrics, Children's Hospital of Michigan, 3901 Beaubien Blvd, Detroit, MI, 48201, USA
| | - Deemah Mahadin
- Division of Pediatric Cardiology, Department of Pediatrics, Children's Hospital of Michigan, 3901 Beaubien Blvd, Detroit, MI, 48201, USA
| | - Sanjeev Aggarwal
- Division of Pediatric Cardiology, Department of Pediatrics, Children's Hospital of Michigan, 3901 Beaubien Blvd, Detroit, MI, 48201, USA
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6
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Olutoye OO, Joyeux L, King A, Belfort MA, Lee TC, Keswani SG. Minimally Invasive Fetal Surgery and the Next Frontier. Neoreviews 2023; 24:e67-e83. [PMID: 36720693 DOI: 10.1542/neo.24-2-e67] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
Most patients with congenital anomalies do not require prenatal intervention. Furthermore, many congenital anomalies requiring surgical intervention are treated adequately after birth. However, there is a subset of patients with congenital anomalies who will die before birth, shortly after birth, or experience severe postnatal complications without fetal surgery. Fetal surgery is unique in that an operation is performed on the fetus as well as the pregnant woman who does not receive any direct benefit from the surgery but rather lends herself to risks, such as hemorrhage, abruption, and preterm labor. The maternal risks involved with fetal surgery have limited the extent to which fetal interventions may be performed but have, in turn, led to technical innovations that have significantly advanced the field. This review will examine congenital abnormalities that can be treated with minimally invasive fetal surgery and introduce the next frontier of prenatal management of fetal surgical pathology.
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Affiliation(s)
- Oluyinka O Olutoye
- Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, TX
| | - Luc Joyeux
- Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, TX.,Texas Children's Fetal Center, Baylor College of Medicine, Houston, TX.,Division of Pediatric Surgery, Department of Surgery, Texas Children's Hospital, Houston, TX
| | - Alice King
- Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, TX.,Texas Children's Fetal Center, Baylor College of Medicine, Houston, TX.,Division of Pediatric Surgery, Department of Surgery, Texas Children's Hospital, Houston, TX
| | - Michael A Belfort
- Texas Children's Fetal Center, Baylor College of Medicine, Houston, TX.,Department of Obstetrics and Gynecology, Baylor College of Medicine, Texas Children's Hospital, Houston, TX
| | - Timothy C Lee
- Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, TX.,Texas Children's Fetal Center, Baylor College of Medicine, Houston, TX.,Division of Pediatric Surgery, Department of Surgery, Texas Children's Hospital, Houston, TX
| | - Sundeep G Keswani
- Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, TX.,Texas Children's Fetal Center, Baylor College of Medicine, Houston, TX.,Division of Pediatric Surgery, Department of Surgery, Texas Children's Hospital, Houston, TX
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7
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Cheung EW, Mastropietro CW, Flores S, Amula V, Radman M, Kwiatkowski D, Puente BN, Buckley JR, Allen K, Loomba R, Kakri K, Chiwane S, Cashen K, Piggott K, Kapileshwarkar Y, Gowda KMN, Badheka A, Raman R, Costello JM, Zang H, Iliopoulos I. Procedural Outcomes of Pulmonary Atresia Intact Ventricular Septum in Neonates: A Multicenter Study. Ann Thorac Surg 2022; 115:1470-1477. [PMID: 36070807 DOI: 10.1016/j.athoracsur.2022.07.055] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/04/2022] [Revised: 06/10/2022] [Accepted: 07/19/2022] [Indexed: 11/15/2022]
Abstract
BACKGROUND Multicenter contemporary data describing short-term outcomes following initial interventions of neonates with pulmonary atresia intact ventricular septum (PA-IVS) are limited. This multicenter study aims to describe characteristics and outcomes of PA-IVS neonates following their initial catheter or surgical intervention and identify factors associated with major adverse cardiac events (MACE). METHODS Neonates with PA-IVS who underwent surgical or catheter intervention between 2009-2019 in 19 centers were reviewed. Risk factors for MACE, defined as cardiopulmonary resuscitation, mechanical circulatory support, stroke, or in-hospital mortality, were analyzed using multivariable logistic regression model. RESULTS We reviewed 279 neonates: 79 (28%) underwent right ventricular decompression, 151 (54%) underwent systemic-to-pulmonary shunt or ductal stent placement only, 36 (13%) underwent right ventricular decompression with shunt or ductal stent placement, and 11 (4%) underwent transplantation. MACE occurred in 57 patients (20%): 26 (9%) received mechanical circulatory support, 37 (13%) received cardiopulmonary resuscitation, 16 (6%) suffered stroke, 23 (8%) died. The presence of two major coronary artery stenoses (adjusted OR: 4.99; 95% CI: 1.16-21.39) and lower weight at first intervention (adjusted OR: 1.52, 95% CI: 1.01-2.27) were significantly associated with MACE. Coronary ischemia was the most frequent presumed mechanism of death (n=10). CONCLUSIONS In a multicenter cohort, one in five neonates with PA-IVS experienced MACE following their initial intervention. Patients with two major coronary artery stenoses or lower weight at time of initial procedure were most likely to experience MACE and warrant vigilance during pre-intervention planning and post-intervention management.
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Affiliation(s)
- Eva W Cheung
- Division of Pediatric Critical Care & Hospital Medicine, Columbia University Irving Medical Center, New York, New York.
| | - Christopher W Mastropietro
- Division of Pediatric Critical Care, Indiana University School of Medicine, Riley Hospital for Children, Indianapolis, Indiana
| | - Saul Flores
- Department of Pediatrics, Baylor College of Medicine, Texas Children's Hospital, Houston, Texas
| | - Venugopal Amula
- Division of Pediatric Critical Care, University of Utah Health, Salt Lake City, Utah
| | - Monique Radman
- Division of Pediatric Critical Care, University of Washington, Seattle Children's Hospital, Seattle, Washington
| | - David Kwiatkowski
- Division of Pediatric Cardiology, Stanford University School of Medicine, Lucille Packard Children's Hospital, Palo Alto, California
| | - Bao Nguyen Puente
- Division of Cardiac Critical Care, Children's National Health System, Washington, District of Columbia
| | - Jason R Buckley
- Division of Pediatric Cardiology, Medical University of South Carolina, Charleston, South Carolina
| | - Kiona Allen
- Division of Pediatric Cardiology, Ann & Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Rohit Loomba
- Department of Pediatrics, Chicago Medical School, Advocate Children's Hospital, Chicago, Illinois
| | - Karan Kakri
- Division of Pediatric Cardiology, University of Tennessee Health Science Center, Le Bonheur Children's Hospital, Memphis, Tennessee
| | - Saurabh Chiwane
- Division of Pediatric Critical Care, Saint Louis University, Cardinal Glennon Children's Hospital, Saint Louis, Missouri
| | - Katherine Cashen
- Division of Critical Care Medicine, Duke University, Duke Children's Hospital, Durham, North Carolina
| | - Kurt Piggott
- Department of Pediatrics, LSU School of Medicine Children's Hospital, New Orleans, Louisiana
| | | | | | - Aditya Badheka
- Department of Pediatrics, University of Iowa Stead Family Children's Hospital, Iowa City, Iowa
| | - Rahul Raman
- Department of Pediatrics, Mercy Medical Center, Des Moines, Iowa
| | - John M Costello
- Division of Pediatric Cardiology, Medical University of South Carolina, Charleston, South Carolina
| | - Huaiyu Zang
- The Heart Institute, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Ilias Iliopoulos
- The Heart Institute, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
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8
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Sukhavasi A, McHugh-Grant S, Glatz AC, Mondal A, Griffis H, Burnham N, Chen JM, Mascio CE, Gaynor JW, Spray TL, Fuller SM. Pulmonary Atresia with Intact Ventricular Septum: Intended Strategies. J Thorac Cardiovasc Surg 2022; 164:1277-1288. [DOI: 10.1016/j.jtcvs.2021.11.104] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/13/2021] [Revised: 11/06/2021] [Accepted: 11/24/2021] [Indexed: 10/31/2022]
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9
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Manhem S, Hanséus K, Berggren H, Ekman-Joelsson BM. Survival With Respect to Morphology in Pulmonary Atresia and Intact Ventricular Septum in Sweden. World J Pediatr Congenit Heart Surg 2021; 12:27-34. [PMID: 33407024 DOI: 10.1177/2150135120958641] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Patients born with pulmonary atresia and intact ventricular septum represent a challenge to pediatric cardiologists. Our objective was to study changes in survival with respect to morphology in all children born with pulmonary atresia and intact ventricular septum in Sweden during 36 years. METHODS A retrospective, descriptive study based on medical reports and echocardiographic examinations consisting of those born between 1980 and 1998 (early group) and those born between 1999 and 2016 (late group). RESULTS The cohort consists of 171 patients (early group, n = 86 and late group, n = 85) yielding an incidence of 4.35 and 4.46 per 100,000 live births, respectively. One-year survival in the early group was 76% compared to 92% in the late group (P = .0004). For patients with membranous atresia, one-year survival increased from 78% to 98%, and for muscular pulmonary atresia, from 68% to 85%. In patients with muscular pulmonary atresia and ventriculocoronary arterial communications, there was no significant increase in survival. Risk factors for death were being born in the early time period hazard ratio (HR), 6; 95% CI (2.33-14.28) P = .0002, low birth weight HR, 1.26; 95% CI (1.14-1.4) P < .0001 and having muscular pulmonary atresia HR, 3.74; 95% CI (1.71-8.19) P = .0010. CONCLUSION The incidence of pulmonary atresia and intact ventricular septum remained unchanged during the study period. Survival has improved, especially for patients with membranous pulmonary atresia, while being born with muscular pulmonary atresia is still a risk factor for death. To further improve survival, greater focus on patients with muscular pulmonary atresia and ventriculocoronary arterial communications is required.
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Affiliation(s)
- Stina Manhem
- Department of Pediatrics, Institution for Clinical Sciences. Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Katarina Hanséus
- Department of Pediatric Cardiology, 59564Skåne University Hospital, Lund, Sweden
| | - Håkan Berggren
- Department of Pediatrics, Institution for Clinical Sciences. Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Britt-Marie Ekman-Joelsson
- Department of Pediatrics, Institution for Clinical Sciences. Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
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10
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Natural history of pulmonary atresia with intact ventricular septum (PAIVS) and critical pulmonary stenosis (CPS) and prediction of outcome. Arch Gynecol Obstet 2021; 304:81-90. [PMID: 33585987 PMCID: PMC8164597 DOI: 10.1007/s00404-020-05929-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2020] [Accepted: 11/27/2020] [Indexed: 11/16/2022]
Abstract
Objectives To analyse prenatal parameters predicting biventricular (BV) outcome in pulmonary atresia with intact ventricular septum/critical pulmonary stenosis (PAIVS/CPS). Methods We evaluated 82 foetuses from 01/08 to 10/18 in 3 centres in intervals 1 (< 24 weeks), 2 (24–30 weeks) and 3 (> 30 weeks). Results 61/82 (74.4%) were livebirths, 5 (8.2%) lost for follow-up, 3 (4.9%) had compassionate care leaving 53 (64.6% of the whole cohort and 86.9% of livebirths) with intention to treat. 9 died, 44/53 (83.0%) survived. 24/38 (63.2%) with information on postnatal outcome had BV outcome, 14 (36.8%) non-BV outcome (2 × 1.5 circulation). One with BV outcome had prenatal valvuloplasty. Best single parameter for BV outcome was tricuspid/mitral valve (TV/MV) ratio (AUC 0.93) in intervals 2 and 3 (AUC 0.92). Ventriculo-coronary-arterial communications (VCAC) were present in 11 (78.6%) in non-BV outcome group vs. 2 (8.3%) in BV outcome group (p < 0.001). Tricuspid insufficiency (TI)-Vmax > 2.5 m/s was present in BV outcome group in75.0% (18/24) vs. 14.3% (2/14) in non-BV outcome group. Including the most predictive markers (VCAC presence, TI- Vmax < 2.5 m/s, TV/MV ratio < cutoff) to a score, non-BV outcome was correctly predicted when > 1 criterion was fulfilled in all cases. After recently published criteria for foetal intervention, only 4/9 (44.4%) and 5/14 (35.7%) in our interval 2 + 3 with predicted non-BV outcome would have been candidates for intervention. Two (1 × intrauterine intervention) in interval 2, two in interval 3 reached BV outcome and one 1.5 circulation without intervention. Conclusion TV/MV ratio as simple parameter has high predictive value. After our score, non-BV outcome was correctly predicted in all cases. Criteria for foetal intervention must further be evaluated.
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11
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Kang SL, Jaeggi E, Ryan G, Chaturvedi RR. An Overview of Contemporary Outcomes in Fetal Cardiac Intervention: A Case for High-Volume Superspecialization? Pediatr Cardiol 2020; 41:479-485. [PMID: 32198586 DOI: 10.1007/s00246-020-02294-2] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/10/2020] [Accepted: 01/17/2020] [Indexed: 01/04/2023]
Abstract
Fetal cardiac interventions (FCI) offer the opportunity to rescue a fetus at risk of intrauterine death, or more ambitiously to alter disease progression. Most of these fetuses require multiple additional postnatal procedures, and it is difficult to disentangle the effect of the fetal procedure from that of the postnatal management sequence. The true clinical impact of FCI may only be discernible in large-volume institutions that can commit to a standardized postnatal approach and have sufficient case volume to overcome their FCI learning curve.
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Affiliation(s)
- Sok-Leng Kang
- Division of Cardiology, Labatt Heart Centre, The Hospital for Sick Children, Toronto, ON, M5G 1X8, Canada
| | - Edgar Jaeggi
- Division of Cardiology, Labatt Heart Centre, The Hospital for Sick Children, Toronto, ON, M5G 1X8, Canada
| | - Greg Ryan
- Fetal Medicine Unit, Department of Obstetrics and Gynecology, Mt Sinai Hospital, Toronto, ON, M5G 1X5, Canada
| | - Rajiv R Chaturvedi
- Division of Cardiology, Labatt Heart Centre, The Hospital for Sick Children, Toronto, ON, M5G 1X8, Canada. .,Fetal Medicine Unit, Department of Obstetrics and Gynecology, Mt Sinai Hospital, Toronto, ON, M5G 1X5, Canada.
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12
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An unusual association of sinus of Valsalva aneurysm with pulmonary atresia and intact ventricular septum. J Cardiovasc Comput Tomogr 2019; 14:e128-e129. [PMID: 31582351 DOI: 10.1016/j.jcct.2019.09.014] [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: 08/30/2019] [Revised: 09/14/2019] [Accepted: 09/21/2019] [Indexed: 11/23/2022]
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13
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Gottschalk I, Strizek B, Menzel T, Herberg U, Breuer J, Brockmeier K, Geipel A, Gembruch U, Berg C. Severe Pulmonary Stenosis or Atresia with Intact Ventricular Septum in the Fetus: The Natural History. Fetal Diagn Ther 2019; 47:420-428. [PMID: 31454806 DOI: 10.1159/000502178] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2019] [Accepted: 07/16/2019] [Indexed: 11/19/2022]
Abstract
PURPOSE To assess the intrauterine course, the outcome, and to establish a new prenatal echocardiographic scoring system to predict biventricular (BV) versus univentricular (UV) outcome of fetuses with severe pulmonary stenosis or atresia with intact ventricular septum (PSAIVS). METHODS All cases of PSAIVS diagnosed prenatally over a period of 14years were retrospectively collected in 2 tertiary referral centers. RESULTS Forty-nine fetuses with PSIVS (n = 11) or PAIVS (n = 38) were identified prenatally. Nineteen (38.8%) fetuses had additional ventriculocoronary connections (VCCs) and 21 (42.9%) fetuses had right ventricular hypoplasia. Four (8.2%) pregnancies were terminated, 2 (4.1%) ended in intrauterine fetal death, 4 (8.2%) in neonatal death, and 5 (10.2%) children died in infancy or childhood, including one case with compassionate care. Thirty-four of 44 (77.3%) fetuses with the intention-to-treat were alive at latest follow-up, 25 (73.5%) with BV, and 9 (26.5%) with UV circulation. Most significant predictive markers of UV circulation were Vmax of tricuspid regurgitation (TR) <2 m/s, right ventricle/left ventricle length ratio ≤0.6, and presence of VCC. A scoring system including these 3 markers had 100% sensitivity and 100% specificity predicting an UV outcome if more than one of these criteria was fulfilled. All 25 liveborn infants that were suitable for BV repair survived, whereas only 9 out of 14 candidates for UV repair survived. None of the 14 fetuses with predicted UV outcome would have met the inclusion criteria for fetal intervention, as 10 of them had VCC and the remaining 4 had absent TR or Vmax <2 m/s. CONCLUSION The prognosis of prenatally diagnosed PSAIVS is good if BV circulation can be achieved, while postnatal mortality in UV circulation is high within the first 4 months of life. Postnatal outcome can be predicted prenatally with high accuracy using a simple scoring system. This information is mandatory for parental counseling and may be useful in selecting fetuses for intrauterine valvuloplasty.
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Affiliation(s)
- Ingo Gottschalk
- Division of Prenatal Medicine, Department of Obstetrics and Gynecology, University of Cologne, Cologne, Germany,
| | - Brigitte Strizek
- Division of Fetal Surgery, Department of Obstetrics and Prenatal Medicine, University of Bonn, Bonn, Germany
| | - Tina Menzel
- Division of Prenatal Medicine, Department of Obstetrics and Gynecology, University of Cologne, Cologne, Germany
| | - Ulrike Herberg
- Department of Pediatric Cardiology, University of Bonn, Bonn, Germany
| | - Johannes Breuer
- Department of Pediatric Cardiology, University of Bonn, Bonn, Germany
| | - Konrad Brockmeier
- Department of Pediatric Cardiology, University of Cologne, Cologne, Germany
| | - Annegret Geipel
- Division of Fetal Surgery, Department of Obstetrics and Prenatal Medicine, University of Bonn, Bonn, Germany
| | - Ulrich Gembruch
- Division of Fetal Surgery, Department of Obstetrics and Prenatal Medicine, University of Bonn, Bonn, Germany
| | - Christoph Berg
- Division of Prenatal Medicine, Department of Obstetrics and Gynecology, University of Cologne, Cologne, Germany.,Division of Fetal Surgery, Department of Obstetrics and Prenatal Medicine, University of Bonn, Bonn, Germany
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14
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Wright LK, Knight JH, Thomas AS, Oster ME, St Louis JD, Kochilas LK. Long-term outcomes after intervention for pulmonary atresia with intact ventricular septum. Heart 2019; 105:1007-1013. [PMID: 30712000 DOI: 10.1136/heartjnl-2018-314124] [Citation(s) in RCA: 26] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/07/2018] [Revised: 12/14/2018] [Accepted: 12/19/2018] [Indexed: 11/04/2022] Open
Abstract
OBJECTIVE Pulmonary atresia with intact ventricular septum (PA/IVS) can be treated by various operative and catheter-based interventions. We aim to understand the long-term transplant-free survival of patients with PA/IVS by treatment strategy. METHODS Cohort study from the Pediatric Cardiac Care Consortium, a multi-institutional registry with prospectively acquired outcome data after linkage with the National Death Index and the Organ Procurement and Transplantation Network. RESULTS Eligible patients underwent neonatal surgery or catheter-based intervention for PA/IVS between 1982 and 2003 (median follow-up of 16.7 years, IQR: 12.6-22.7). Over the study period, 616 patients with PA/IVS underwent one of three initial interventions: aortopulmonary shunt, right ventricular decompression or both. Risk factors for death at initial intervention included earlier birth era (1982-1992), chromosomal abnormality and atresia of one or both coronary ostia. Among survivors of neonatal hospitalisation (n=491), there were 99 deaths (4 post-transplant) and 10 transplants (median age of death or transplant 0.7 years, IQR: 0.3-1.8 years). Definite repair or last-stage palliation was achieved in the form of completed two-ventricle repair (n=201), one-and-a-half ventricle (n=39) or Fontan (n=96). Overall 20-year survival was 66%, but for patients discharged alive after definitive repair, it reached 97.6% for single-ventricle patients, 90.9% for those with one-and-a-half ventricle and 98.0% for those with complete two-ventricle repair (log-rank p=0.052). CONCLUSIONS Transplant-free survival in PA/IVS is poor due to significant infantile and interstage mortality. Survival into early adulthood is excellent for patients reaching completion of their intended path independent of type of repair.
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Affiliation(s)
- Lydia K Wright
- Department of Pediatrics, Emory University School of Medicine, Atlanta, Georgia, USA.,Sibley Heart Center, Children's Healthcare of Atlanta, Atlanta, GA
| | - Jessica H Knight
- Department of Epidemiology and Biostatistics, University of Georgia School of Public Health, Athens, GA
| | - Amanda S Thomas
- Department of Pediatrics, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Matthew E Oster
- Department of Pediatrics, Emory University School of Medicine, Atlanta, Georgia, USA.,Sibley Heart Center, Children's Healthcare of Atlanta, Atlanta, GA
| | - James D St Louis
- Department of Pediatric Surgery, University of Missouri-Kansas City School of Medicine, Kansas City, Missouri, USA
| | - Lazaros K Kochilas
- Department of Pediatrics, Emory University School of Medicine, Atlanta, Georgia, USA.,Sibley Heart Center, Children's Healthcare of Atlanta, Atlanta, GA
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15
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LaPar DJ, Bacha E. Pulmonary Atresia With Intact Ventricular Septum With Borderline Tricuspid Valve: How Small Is Too Small. Semin Thorac Cardiovasc Surg Pediatr Card Surg Annu 2019; 22:27-31. [PMID: 31027561 DOI: 10.1053/j.pcsu.2019.02.007] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2019] [Accepted: 02/26/2019] [Indexed: 06/09/2023]
Abstract
PA/IVS is a rare, heterogenous congenital heart defect anatomically defined by complete obstruction to the right ventricular outflow tract with varying degrees of hypoplasia of the right ventricle and tricuspid valve. This lesion can have associated coronary artery anomalies and, in some cases, right ventricular-dependent coronary circulation. Due to the wide spectrum of presenting anatomic and clinical features, the treatment options are often dictated by the degree of development of the tricuspid valve and right ventricle. The purpose of this review is to discuss the spectrum of pulmonary atresia with intact ventricular septum morphologies and to evaluate the surgical decision-making process and approaches to surgical repair with respect to the impact of hypoplastic right-sided cardiac features.
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Affiliation(s)
- Damien J LaPar
- Congenital and Pediatric Cardiac Surgery, Morgan Stanley Children's Hospital of New York-Presbyterian, Columbia University, New York, New York.
| | - Emile Bacha
- Congenital and Pediatric Cardiac Surgery, Morgan Stanley Children's Hospital of New York-Presbyterian, Columbia University, New York, New York
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16
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Lopez C, Mertens L, Dragulescu A, Landeck B, Younoszai A, Friedberg MK, Hunter K, Di Maria MV. Strain and Rotational Mechanics in Children With Single Left Ventricles After Fontan. J Am Soc Echocardiogr 2018; 31:1297-1306. [PMID: 30344011 DOI: 10.1016/j.echo.2018.09.004] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/30/2017] [Indexed: 11/24/2022]
Abstract
BACKGROUND Left ventricular (LV) mechanics in patients with different single morphologic LV subtypes, including tricuspid atresia, double-inlet left ventricle, and pulmonary atresia with intact ventricular septum, remain poorly studied. Given that histologic studies indicate differences in LV myocardial fiber orientation, we hypothesized that this may result in altered LV mechanics. The aim of this study was to evaluate the influence of LV morphology on LV mechanics. METHODS Fifty-two children with single left ventricles after Fontan operation and age-matched control subjects were prospectively enrolled. Using two-dimensional speckle-tracking echocardiography, longitudinal strain was measured in the four-, three-, and two-chamber long-axis planes, and circumferential strain was measured at the basal, mid, and apical short-axis planes. Apical and basal rotation were measured, and twist and torsion were calculated. We compared strain and rotational mechanics in cases versus control subjects and among LV subtypes. RESULTS Compared with control subjects, subjects with single left ventricles had similar LV end-diastolic dimensions but significantly decreased ejection fractions. The single left ventricle cohort had normal global longitudinal strain (P = .20) but lower basal mean circumferential strain (P < .0001). Single left ventricle subjects had higher apical rotation (P = .0001) but decreased basal rotation (P = .0007); there was no difference in twist but increased torsion (P = .001). LV subtypes had different four-chamber (P = .01), two-chamber (P = .006), and global longitudinal strain (P = .01), lowest in the pulmonary atresia with intact ventricular septum subtype. CONCLUSIONS Longitudinal LV strain was preserved in children with single left ventricles after Fontan. A pattern of reduced basal circumferential strain and rotation with an increase in apical rotation and torsion in the single left ventricle cohort may be related to differences in myofiber orientation, increased fibrosis, and the impact of altered loading conditions throughout palliation. Decreased longitudinal strain in the pulmonary atresia with intact ventricular septum group may also reflect detrimental interventricular interactions.
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Affiliation(s)
- Carmen Lopez
- The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
| | - Luc Mertens
- The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
| | - Andreea Dragulescu
- The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
| | - Bruce Landeck
- Heart Institute, Section of Pediatric Cardiology, Department of Pediatrics, University of Colorado School of Medicine, Children's Hospital Colorado, Aurora, Colorado
| | - Adel Younoszai
- Heart Institute, Section of Pediatric Cardiology, Department of Pediatrics, University of Colorado School of Medicine, Children's Hospital Colorado, Aurora, Colorado
| | - Mark K Friedberg
- The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
| | - Kendall Hunter
- University of Colorado School of Bioengineering, Children's Hospital Colorado, Aurora, Colorado
| | - Michael V Di Maria
- Heart Institute, Section of Pediatric Cardiology, Department of Pediatrics, University of Colorado School of Medicine, Children's Hospital Colorado, Aurora, Colorado.
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17
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Tulzer A, Arzt W, Gitter R, Prandstetter C, Grohmann E, Mair R, Tulzer G. Immediate effects and outcome of in-utero pulmonary valvuloplasty in fetuses with pulmonary atresia with intact ventricular septum or critical pulmonary stenosis. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2018; 52:230-237. [PMID: 29569770 PMCID: PMC6100104 DOI: 10.1002/uog.19047] [Citation(s) in RCA: 31] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/04/2018] [Revised: 02/15/2018] [Accepted: 02/23/2018] [Indexed: 05/02/2023]
Abstract
OBJECTIVE To assess the immediate effects of fetal pulmonary valvuloplasty on right ventricular (RV) size and function as well as in-utero RV growth and postnatal outcome. METHODS Patients with pulmonary atresia with intact ventricular septum (PAIVS) or critical pulmonary stenosis (CPS) who underwent fetal pulmonary valvuloplasty at our center between October 2000 and July 2017 were included. Echocardiographic data obtained before and after the procedure were analyzed retrospectively (median interval after intervention, 1 (range, 1-3) days) for ventricular and valvular dimensions and ratios, RV filling time (duration of tricuspid valve (TV) inflow/cardiac cycle length), TV velocity time integral (TV-VTI) × heart rate (HR) and tricuspid regurgitation (TR) velocity. Longitudinal data were collected from only those fetuses followed up in our center. Outcome was assessed using the scoring system as described by Roman et al. for non-biventricular outcome. RESULTS Thirty-five pulmonary valvuloplasties were performed in our institution on 23 fetuses with PAIVS (n = 15) or CPS (n = 8). Median gestational age at intervention was 28 + 4 (range, 23 + 6 to 32 + 1) weeks. No fetal death occurred. Immediately after successful intervention, RV/left ventricular length (RV/LV) ratio (P ≤ 0.0001), TV/mitral valve annular diameter (TV/MV) ratio (P ≤ 0.001), RV filling time (P ≤ 0.00001) and TV-VTI × HR (P ≤ 0.001) increased significantly and TR velocity (P ≤ 0.001) decreased significantly. In fetuses followed longitudinally to delivery (n = 5), RV/LV and TV/MV ratios improved further or remained constant until birth. Fetuses with unsuccessful intervention (n = 2) became univentricular, all others had either a biventricular (n = 15), one-and-a-half ventricular (n = 3) or still undetermined (n = 3) outcome. Five of nine fetuses with a predicted non-biventricular outcome, in which the procedure was successful, became biventricular, while two of nine had an undetermined circulation. CONCLUSION In selected fetuses with PAIVS or CPS, in-utero pulmonary valvuloplasty led immediately to larger RV caused by reduced afterload and increased filling, thus improving the likelihood of biventricular outcome even in fetuses with a predicted non-biventricular circulation. © 2018 The Authors. Ultrasound in Obstetrics & Gynecology published by John Wiley & Sons Ltd on behalf of the International Society of Ultrasound in Obstetrics and Gynecology.
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Affiliation(s)
- A. Tulzer
- Children's Heart Center Linz, Department of Pediatric CardiologyKepler University HospitalLinzAustria
| | - W. Arzt
- Institute of Prenatal MedicineKepler University HospitalLinzAustria
| | - R. Gitter
- Children's Heart Center Linz, Department of Pediatric CardiologyKepler University HospitalLinzAustria
| | - C. Prandstetter
- Children's Heart Center Linz, Department of Pediatric CardiologyKepler University HospitalLinzAustria
| | - E. Grohmann
- Children's Heart Center Linz, Department of Pediatric CardiologyKepler University HospitalLinzAustria
| | - R. Mair
- Children's Heart Center Linz, Department of Pediatric Cardiac SurgeryKepler University HospitalLinzAustria
| | - G. Tulzer
- Children's Heart Center Linz, Department of Pediatric CardiologyKepler University HospitalLinzAustria
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18
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Predictors of Mortality in Children with Pulmonary Atresia with Intact Ventricular Septum. Pediatr Cardiol 2017; 38:1627-1632. [PMID: 28871366 DOI: 10.1007/s00246-017-1706-6] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/17/2017] [Accepted: 08/07/2017] [Indexed: 10/18/2022]
Abstract
Pulmonary atresia with intact ventricular septum (PA/IVS) is a rare cardiac congenital lesion characterized by imperforate pulmonary valve, intact ventricular septum, and atrial level shunt. Although different management strategies to establish a source of non-ductal dependent pulmonary blood flow have been described, studies have not assessed the relationship between the therapeutic approach, patient characteristics, and outcomes. The purpose of this study was to identify predictors of mortality for patients with PA/IVS. Neonates and children with PA/IVS were identified through analysis of the 2012 Kids' Inpatient Database of the Healthcare Cost and Utilization Project. Hospital admissions that included a cardiac catheterization and/or surgical procedure were analyzed to identify demographics, co-morbidities, and outcomes. We identified 508 patients with PA/IVS with hospital admissions that included cardiac catheterization (n = 165), surgical procedures (n = 273), or both (n = 70). The incidence of mortality in this cohort was 6.69% (34/508). Univariable analysis demonstrated that age less than 12 months (p < 0.001), non-elective admission (p < 0.001), AKI (p = 0.001), sepsis (p = 0.002), and the use of ECMO (p < 0.001) were associated with an increased risk of mortality, while no difference was observed for the type of therapeutic approach (p = 0.498). These variables were used in a multivariable logistic regression analysis to develop the predictive model for mortality. Age less than 12 months, non-elective admission, and the use of ECMO in children with PA/IVS were predictors for mortality. Interestingly, the type of therapeutic approach did not influence mortality, which suggests that patient characteristics other than the method chosen to provide pulmonary blood flow determine mortality.
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19
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Loomba RS, Pelech AN. Aortic perfusion score for pulmonary atresia with intact ventricular septum: An antegrade coronary perfusion scoring system that is predictive of need for transplant and mortality. CONGENIT HEART DIS 2017; 13:92-97. [PMID: 28653340 DOI: 10.1111/chd.12510] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/13/2017] [Revised: 05/20/2017] [Accepted: 05/26/2017] [Indexed: 11/28/2022]
Abstract
BACKGROUND Pulmonary atresia with intact ventricular septum is a unique congenital malformation of the heart in which patients may undergo single-, two- or 1½- ventricle repair. Size of the tricuspid valve annulus, morphology of the right ventricle and presence of ventriculocoronary connections can all impact the selection of appropriate palliative strategy. We developed the aortic perfusion score, a novel scoring system based on anterograde coronary perfusion with the aim of being able to identify patients at risk for death or transplant. METHODS A retrospective study was conducted. Patients were included if an initial catheterization was done prior to any intervention. Each patient was assigned an aortic perfusion score based on the amount of antegrade perfusion to the four main coronary arteries. Various characteristics, including aortic perfusion score, were compared between those who required transplant or died during follow-up vs those who did not. Receiver operator curve analysis was done to determine a cutoff point predictive of a composite endpoint of death or transplant. RESULTS A total of 64 patients were included in the analysis with 10 reaching the composite outcome. An aortic perfusion score of 227.5 predicted the endpoint with a sensitivity of 90% and a specificity of 83%. For each 1-point increase in the APS, the odds of death or transplant decreased by 1.7%. CONCLUSION The aortic perfusion score can be used to predict a composite endpoint of death or transplant and may be helpful in selecting patients that should be listed for transplant.
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Affiliation(s)
- Rohit S Loomba
- Division of Cardiology, Children's Hospital of Wisconsin, Milwaukee, Wisconsin, USA.,Division of Cardiology, UC-Davis Children's Hospital, Sacramento, California, USA
| | - Andrew N Pelech
- Division of Cardiology, Children's Hospital of Wisconsin, Milwaukee, Wisconsin, USA.,Division of Cardiology, UC-Davis Children's Hospital, Sacramento, California, USA
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20
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Awori MN, Mehta NP, Mitema FO, Kebba N. Optimal Z-Score Use in Surgical Decision-Making in Pulmonary Atresia With Intact Ventricular Septum. World J Pediatr Congenit Heart Surg 2017; 8:385-388. [DOI: 10.1177/2150135117701407] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Objectives: In the surgical treatment of pulmonary atresia with intact ventricular septum, the size of the tricuspid valve annulus (as measured by z-scores) has emerged as a significant factor in deciding which repair to perform. Various tricuspid valve annulus z-scores are reported as “cutoffs” for successful biventricular repair. We aimed to determine whether the use of different z-score data sets contributed to the gross variation in “cutoffs” for successful biventricular repair reported in the literature. Methods: A single search was made of PubMed using the “advanced” setting with the following search terms: pulmonary, atresia, intact, septum, z, and score. The filters “title” and “title/abstract” were used for the first four and last two terms, respectively; the instruction “AND” combined all terms. Articles that identified which z-score data set was used in patients with biventricular repairs were included. Results: From 13 articles, 1,392 patients were studied, 410 (29.5%) of which achieved biventricular repair. Three z-score data sets were quoted; mean tricuspid valve annulus z-scores in biventricular repair patients ranged between −0.53 and −5.1. After correcting for discrepancies between z-score data sets, no study reported a mean tricuspid valve annulus z-score <−2.8 in biventricular repair patients and 83.3% reported mean tricuspid valve annuli z-scores >−1.7. Conclusion: The use of varied tricuspid valve annuli z-score data sets may have contributed to gross variations in reported “cutoffs” for successful biventricular repair. This could lead to inappropriate surgical pathway allocation.
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Affiliation(s)
- Mark Nelson Awori
- Department of Surgery, School of Medicine, College of Health Sciences, University of Nairobi, Nairobi, Kenya
| | - Nikita P. Mehta
- Department of Surgery, School of Medicine, College of Health Sciences, University of Nairobi, Nairobi, Kenya
| | - Frederick O. Mitema
- Department of Surgery, School of Medicine, College of Health Sciences, University of Nairobi, Nairobi, Kenya
| | - Naomi Kebba
- Department of Surgery, School of Medicine, College of Health Sciences, University of Nairobi, Nairobi, Kenya
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21
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Agrawal H, Alkashkari W, Kenny D. Evolution of hybrid interventions for congenital heart disease. Expert Rev Cardiovasc Ther 2017; 15:257-266. [DOI: 10.1080/14779072.2017.1307733] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Affiliation(s)
- Hitesh Agrawal
- The Lillie Frank Abercrombie Section of Cardiology, Texas Children’s Hospital, Baylor College of Medicine, Houston, TX, USA
| | - Wail Alkashkari
- King Faisal Cardiac Center, King Saud Bin Abdulaziz University, King Abdulaziz Medical City, Jeddah, Saudi Arabia
| | - Damien Kenny
- Department of Cardiology, Our Lady’s Children’s Hospital, Crumlin, Dublin, Ireland
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22
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Intrauterine therapy for structural congenital heart disease: Contemporary results and Canadian experience. Trends Cardiovasc Med 2016; 26:639-46. [DOI: 10.1016/j.tcm.2016.04.006] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/13/2016] [Revised: 04/09/2016] [Accepted: 04/19/2016] [Indexed: 11/19/2022]
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Kotani Y, Kasahara S, Fujii Y, Eitoku T, Baba K, Otsuki SI, Kuroko Y, Arai S, Sano S. A staged decompression of right ventricle allows growth of right ventricle and subsequent biventricular repair in patients with pulmonary atresia and intact ventricular septum. Eur J Cardiothorac Surg 2016; 50:298-303. [DOI: 10.1093/ejcts/ezw124] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/05/2015] [Accepted: 12/29/2015] [Indexed: 11/15/2022] Open
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Li FF, Du XL, Chen S. Biventricular repair versus uni-ventricular repair for pulmonary atresia with intact ventrical septum: A systematic review. ACTA ACUST UNITED AC 2015; 35:656-661. [PMID: 26489617 DOI: 10.1007/s11596-015-1485-3] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2015] [Revised: 09/14/2015] [Indexed: 10/22/2022]
Abstract
The management of pulmonary atresia with intact ventricular septum (PA/IVS) remains controversial. The goal of separating systematic and pulmonary circulation can be achieved by biventricular or uni-ventricular (Fontan or one and a half ventricle repair) strategies. Although outcomes have been improved, these surgical procedures are still associated with high mortality and morbidity. An optimal strategy for definitive repair has yet to be defined. We searched databases for genetically randomized controlled trials (RCTs) comparing biventricular with uni-ventricular repair for patient with PA/IVS. Data extraction and quality assessment were performed following the guidelines of the Cochrane Collaboration. Primary outcome measures were overall survival, and secondary criteria included exercise function, arrhythmia-free survival and treatment-related mortality. A total number of 669 primary citations were screened for relevant studies. Detailed analysis revealed that no RCTs were found to adequately address the research question and no systematic meta-analysis would have been carried out. Nevertheless, several retrospective analyses and case series addressed the question of finding right balance between biventricular and uni-ventricular repair for patient with PA/IVS. In this review, we will discuss the currently available data.
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Affiliation(s)
- Fei-Fei Li
- Department of Cardiovascular Surgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430022, China
| | - Xin-Ling Du
- Department of Cardiovascular Surgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430022, China
| | - Shu Chen
- Department of Cardiovascular Surgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430022, China.
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Comparison of the offset distance of the tricuspid septal leaflet in neonates with Ebstein's anomaly and neonates with pulmonary atresia with intact ventricular septum. Cardiol Young 2015; 25:129-36. [PMID: 25022783 DOI: 10.1017/s1047951114001206] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
An indexed offset distance of the tricuspid septal leaflet ⩾8 mm/m2 is a quantitative criterion for the diagnosis of Ebstein's anomaly. The purpose of this study was to investigate the validity of this criterion for the discrimination of Ebstein's anomaly from pulmonary atresia with intact ventricular septum in neonatal patients. A total of 122 neonatal patients, 56 with Ebstein's anomaly and 66 with pulmonary atresia with intact ventricular septum, were enrolled. Diagnosis of each anomaly was based on typical morphologic features. Echocardiographic variables, including the offset distance of the tricuspid septal leaflet, were measured via an offline analysis of images recorded before 1 month of age. The offset distance of the tricuspid septal leaflet was indexed by the body surface area, and the indexed offset distances in the Ebstein's anomaly and pulmonary atresia with intact ventricular septum groups were 34.2 mm/m2 (7.1-119.1 mm/m2) and 7.2 mm/m2 (0.0-25.6 mm/m2), respectively. The indexed offset distance was ⩾8 mm/m2 in 29 (43.9%) of the patients with pulmonary atresia with intact ventricular septum; clinical and echocardiographic characteristics were comparable between these 29 patients and the remaining 37 patients with pulmonary atresia with intact ventricular septum. When an indexed offset distance ⩾8 mm/m2 was applied as a cut-off for the diagnosis of Ebstein's anomaly, the sensitivity was 0.963 and the specificity was 0.561. In conclusion, indexed offset distance ⩾8 mm/m2 cannot be used as a cut-off for the diagnosis of complicated Ebstein's anomaly in neonatal patients with pulmonary atresia with intact ventricular septum.
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Edwards A, Veldman A, Nitsos I, Chan Y, Brew N, Teoh M, Menahem S, Schranz D, Wong FY. A percutaneous fetal cardiac catheterization technique for pulmonary valvuloplasty and valvulotomy in a mid-gestation lamb model. Prenat Diagn 2014; 35:74-80. [DOI: 10.1002/pd.4486] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2013] [Revised: 08/13/2014] [Accepted: 08/18/2014] [Indexed: 11/10/2022]
Affiliation(s)
- Andrew Edwards
- The Ritchie Centre; Monash Institute of Medical Research-Prince Henry Institute; Melbourne Australia
- Perinatal Services; Monash Medical Centre; Melbourne Australia
- Fetal Cardiac Unit; Monash Medical Centre; Melbourne Australia
| | - Alex Veldman
- The Ritchie Centre; Monash Institute of Medical Research-Prince Henry Institute; Melbourne Australia
- Department of Paediatrics; Monash University; Melbourne Australia
- Pediatric Heart Center; Justus-Liebig University; Giessen Germany
| | - Ilias Nitsos
- The Ritchie Centre; Monash Institute of Medical Research-Prince Henry Institute; Melbourne Australia
| | - Yuen Chan
- Department of Pathology; Monash Medical Centre; Melbourne Australia
| | - Nadine Brew
- The Ritchie Centre; Monash Institute of Medical Research-Prince Henry Institute; Melbourne Australia
| | - Mark Teoh
- Perinatal Services; Monash Medical Centre; Melbourne Australia
- Fetal Cardiac Unit; Monash Medical Centre; Melbourne Australia
| | - Samuel Menahem
- The Ritchie Centre; Monash Institute of Medical Research-Prince Henry Institute; Melbourne Australia
- Department of Paediatrics; Monash University; Melbourne Australia
| | - Dietmar Schranz
- Pediatric Heart Center; Justus-Liebig University; Giessen Germany
| | - Flora Y. Wong
- The Ritchie Centre; Monash Institute of Medical Research-Prince Henry Institute; Melbourne Australia
- Department of Paediatrics; Monash University; Melbourne Australia
- Monash Newborn; Monash Medical Centre; Melbourne Australia
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Pulmonary atresia/intact ventricular septum: influence of coronary anatomy on single-ventricle outcome. Ann Thorac Surg 2014; 98:1371-7. [PMID: 25152382 DOI: 10.1016/j.athoracsur.2014.06.039] [Citation(s) in RCA: 52] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/02/2014] [Revised: 05/28/2014] [Accepted: 06/03/2014] [Indexed: 11/23/2022]
Abstract
BACKGROUND We investigated the influence of coronary artery abnormalities on outcome in patients with pulmonary atresia/intact ventricular septum (PA-IVS) for planned single-ventricle palliation. METHODS Catheterization and medical records were reviewed in patients with PA-IVS for planned single-ventricle palliation at our institution between 2000 and 2012. Primary outcome was death or transplantation. Patients with confirmed or strong suspicion of stenosis in 2 or more main coronary arteries or coronary ostial atresia were defined as having right ventricle-dependent coronary circulation (RVDCC); those with stenosis of 1 main vessel or normal anatomy were defined as having non-RVDCC. RESULTS Of 58 patients with PA-IVS, 17 (30%) underwent single-ventricle palliation. Ten (59%) had RVDCC (3 with ostial atresia) and 7 (41%) had non-RVDCC. Median follow-up time was 8.2 years (0 months-11.3 years), with 1 patient in each group lost to follow-up. Five patients with RVDCC died, including the 3 patients with ostial atresia, and 1 underwent transplantation at 6 months of life. No deaths occurred after second-stage palliation. Three of the 4 surviving patients with RVDCC completed a Fontan operation, and 2 of these patients had evidence of cardiac ischemia on follow-up. No deaths occurred among patients with non-RVDCC. Kaplan-Meier analysis demonstrated significantly better survival in patients with non-RVDCC (100%) than in patients with RVDCC (40%) (p = 0.026). CONCLUSIONS In patients with PA-IVS undergoing single-ventricle palliation, RVDCC is associated with high early mortality, especially with coronary ostial atresia. There should be early consideration of transplantation in neonates with RVDCC. Patients with non-RVDCC undergoing single-ventricle palliation have excellent long-term outcomes, with no mortality seen in this series.
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Atresia pulmonar con septo íntegro. CIRUGIA CARDIOVASCULAR 2014. [DOI: 10.1016/j.circv.2014.02.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
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Zampi JD, Hirsch-Romano JC, Goldstein BH, Shaya JA, Armstrong AK. Hybrid approach for pulmonary atresia with intact ventricular septum: Early single center results and comparison to the standard surgical approach. Catheter Cardiovasc Interv 2014; 83:753-61. [DOI: 10.1002/ccd.25181] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/24/2013] [Revised: 08/06/2013] [Accepted: 08/25/2013] [Indexed: 12/26/2022]
Affiliation(s)
- Jeffrey D. Zampi
- Division of Pediatric Cardiology; Department of Pediatrics; University of Michigan; Ann Arbor Michigan
| | - Jennifer C. Hirsch-Romano
- Division of Pediatric Cardiac Surgery; Department of Surgery; University of Michigan; Ann Arbor Michigan
| | - Bryan H. Goldstein
- The Heart Institute; Cincinnati Children's Hospital Medical Center; Cincinnati Ohio
| | | | - Aimee K. Armstrong
- Division of Pediatric Cardiology; Department of Pediatrics; University of Michigan; Ann Arbor Michigan
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Abstract
Fetal congenital heart disease may progress during pregnancy and may lead to irreversible myocardial or pulmonary damage. The rationale of fetal intracardiac interventions is to change fetal hemodynamics, prevent secondary damage and improve long-term outcome at an acceptable risk for mother and fetus. This review focuses on the current experience about patient selection, risks and benefits of this technique.
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Affiliation(s)
- Gerald Tulzer
- Children's Heart Centre Linz, Department of Pediatric Cardiology, Krankenhausstrasse 26-30, A-4020 Linz, Austria.
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31
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Karamlou T, Poynter JA, Walters HL, Rhodes J, Bondarenko I, Pasquali SK, Fuller SM, Lambert LM, Blackstone EH, Jacobs ML, Duncan K, Caldarone CA, Williams WG, McCrindle BW. Long-term functional health status and exercise test variables for patients with pulmonary atresia with intact ventricular septum: a Congenital Heart Surgeons Society study. J Thorac Cardiovasc Surg 2013; 145:1018-1027.e3. [PMID: 23374986 DOI: 10.1016/j.jtcvs.2012.11.092] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/24/2012] [Revised: 10/18/2012] [Accepted: 11/06/2012] [Indexed: 10/27/2022]
Abstract
BACKGROUND A bias favoring biventricular (BV) repair exists regarding choice of repair pathway for patients with pulmonary atresia with intact ventricular septum (PAIVS). We sought to determine the implications of moving borderline candidates down a BV route in terms of late functional health status (FHS) and exercise capacity (EC). METHODS Between 1987 and 1997, 448 neonates with PAIVS were enrolled in a multi-institutional study. Late EC and FHS were assessed following repair (mean 14 years) using standardized exercise testing and 3 validated FHS instruments. Relationships between FHS, EC, morphology, and 3 end states (ie, BV, univentricular [UV], or 1.5-ventricle repair [1.5V]) were evaluated. RESULTS One hundred two of 271 end state survivors participated (63 BV, 25 UV, and 14 1.5V). Participants had lower FHS scores in domains of physical functioning (P < .001) compared with age- and sex-matched normal controls, but scored significantly higher in nearly all psychosocial domains. EC was higher in 1.5V-repair patients (P = .02), whereas discrete FHS measures were higher in BV-repair patients. Peak oxygen consumption was low across all groups, and was positively correlated with larger initial tricuspid valve z-score (P < .001), with an enhanced effect within the BV-repair group. CONCLUSIONS Late patient-perceived physical FHS and measured EC are reduced, regardless of PAIVS repair pathway, with an important dichotomy whereby patients with PAIVS believe they are doing well despite important physical impediments. For those with smaller initial tricuspid valve z-score, achievement of survival with BV repair may be at a cost of late deficits in exercise capacity, emphasizing that better outcomes may be achieved for borderline patients with a 1.5V- or UV-repair strategy.
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Affiliation(s)
- Tara Karamlou
- Division of Pediatric Cardiac Surgery, Benioff Children's Hospital, University of California, San Francisco, San Francisco, Calif.
| | - Jeffrey A Poynter
- Division of Cardiovascular Surgery, The Hospital For Sick Children and the University of Toronto, Toronto, Ontario, Canada
| | - Henry L Walters
- Department of Cardiovascular Surgery, Children's Hospital of Michigan, Detroit, Mich
| | | | - Igor Bondarenko
- Department of Cardiovascular Surgery, Children's Hospital of Michigan, Detroit, Mich
| | - Sara K Pasquali
- Division of Cardiology, Department of Pediatrics and Communicable Diseases, C.S. Mott Children's Hospital, University of Michigan, Ann Arbor, Mich
| | - Stephanie M Fuller
- Division of Cardiovascular Surgery, The Children's Hospital of Philadelphia, Philadelphia, Pa
| | - Linda M Lambert
- Department of Pediatric Cardiovascular Surgery, Primary Children's Hospital, Salt Lake City, Utah
| | - Eugene H Blackstone
- Department of Quantitative Health Sciences, Research Institute, Cleveland Clinic, Cleveland, Ohio
| | - Marshall L Jacobs
- Department of Pediatric and Congenital Heart Surgery, Cleveland Clinic, Cleveland, Ohio
| | - Kim Duncan
- Division of Cardiothoracic Surgery, Children's Hospital and Medical Center, Omaha, Neb
| | - Christopher A Caldarone
- Division of Cardiovascular Surgery, The Hospital For Sick Children and the University of Toronto, Toronto, Ontario, Canada
| | - William G Williams
- Division of Cardiovascular Surgery, The Hospital For Sick Children and the University of Toronto, Toronto, Ontario, Canada
| | - Brian W McCrindle
- Division of Cardiology, The Hospital for Sick Children, Toronto, Ontario, Canada
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Fetal intervention in right outflow tract obstructive disease: selection of candidates and results. Cardiol Res Pract 2012; 2012:592403. [PMID: 22928144 PMCID: PMC3426214 DOI: 10.1155/2012/592403] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/24/2012] [Accepted: 06/26/2012] [Indexed: 11/29/2022] Open
Abstract
Objectives. To describe the process of selection of candidates for fetal cardiac intervention (FCI) in fetuses diagnosed with pulmonary atresia-critical stenosis with intact ventricular septum (PA/CS-IVS) and report our own experience with FCI for such disease. Methods. We searched our database for cases of PA/CS-IVS prenatally diagnosed in 2003–2012. Data of 38 fetuses were retrieved and analyzed. FCI were offered to 6 patients (2 refused). In the remaining it was not offered due to the presence of either favourable prognostic echocardiographic markers (n = 20) or poor prognostic indicators (n = 12). Results. The outcome of fetuses with PA/CS-IVS was accurately predicted with multiparametric scoring systems. Pulmonary valvuloplasty was technically successful in all 4 fetuses. The growth of the fetal right heart and hemodynamic parameters showed a Gaussian-like behaviour with an improvement in the first weeks and slow worsening as pregnancy advanced, probably indicating a restenosis. Conclusions. The most likely type of circulation after birth may be predicted in the second trimester of pregnancy by means of combining cardiac dimensions and functional parameters. Fetal pulmonary valvuloplasty in midgestation is technically feasible and in well-selected cases may improve right heart growth, fetal hemodynamics, and postnatal outcome.
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Alwi M, Choo KK, Radzi NA, Samion H, Pau KK, Hew CC. Concomitant stenting of the patent ductus arteriosus and radiofrequency valvotomy in pulmonary atresia with intact ventricular septum and intermediate right ventricle: Early in-hospital and medium-term outcomes. J Thorac Cardiovasc Surg 2011; 141:1355-61. [DOI: 10.1016/j.jtcvs.2010.08.085] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/14/2010] [Revised: 08/03/2010] [Accepted: 08/30/2010] [Indexed: 10/18/2022]
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Gómez-Montes E, Herraiz I, Mendoza A, Albert L, Hernández-García JM, Galindo A. Pulmonary atresia/critical stenosis with intact ventricular septum: prediction of outcome in the second trimester of pregnancy. Prenat Diagn 2011; 31:372-9. [DOI: 10.1002/pd.2698] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2010] [Revised: 12/06/2010] [Accepted: 12/07/2010] [Indexed: 11/05/2022]
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Abstract
Neonates born with hypoplastic left heart syndrome now have a remarkably improved prognosis compared with the situation existing before the development of the Norwood sequence of operative procedures. Some of those born with hypoplastic right ventricles in the setting of pulmonary atresia with an intact ventricular septum, however, still have a relatively poor prognosis. In part this reflects the presence of fistulous communication between the cavity of the right hypoplastic right ventricle and the coronary arterial tree. Such fistulous communications are now increasingly recognised as being important in the setting of hypoplastic left heart syndrome. In this brief review, we describe the anatomy of the communications. Those found with hypoplastic right ventricles are seen most frequently when the cavity of the ventricle effectively represents only the inlet, this in turn reflecting mural overgrowth of the apical trabecular and outlet components during foetal development. This almost certainly reflects an earlier appearance of the pulmonary valvar lesion that promotes the cavitary hypoplasia. In those with hypoplastic left ventricles, the key feature differentiating those with fistulous communications is the presence of a patent mitral valve, since the left ventricle is typically no more than a virtual slit in postero-inferior ventricular wall in the setting of mitral valvar atresia or absence of the left atrioventricular connection.
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Liang XC, Lam WWM, Cheung EWY, Wu AKP, Wong SJ, Cheung YF. Restrictive right ventricular physiology and right ventricular fibrosis as assessed by cardiac magnetic resonance and exercise capacity after biventricular repair of pulmonary atresia and intact ventricular septum. Clin Cardiol 2010; 33:104-10. [PMID: 20186992 DOI: 10.1002/clc.20711] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
Abstract
BACKGROUND The hypertrophic myocardium, myocardial fiber disarray, and endocardial fibroelastosis in pulmonary atresia and intact ventricular septum (PAIVS) may provide anatomic substrates for restrictive filling of the right ventricle. HYPOTHESIS Restrictive right ventricle (RV) physiology is related to RV fibrosis and exercise capacity in patients after biventricular repair of PAIVS. METHODS A total of 27 patients, age 16.5 +/- 5.6 years, were recruited after biventricular repair of PAIVS. Restrictive RV physiology was defined by the presence of antegrade diastolic pulmonary flow and RV fibrosis assessed by late gadolinium enhancement (LGE) cardiac magnetic resonance. Their RV function was compared with that of 27 healthy controls and related to RV LGE score and exercise capacity. RESULTS Compared with controls, PAIVS patients had lower tricuspid annular systolic and early diastolic velocities, RV global longitudinal systolic strain, systolic strain rate, and early and late diastolic strain rates (all P < 0.05). A total of 22 (81%, 95% confidence interval: 62%-94%) PAIVS patients demonstrated restrictive RV physiology. Compared to those without restrictive RV physiology (n = 5), these 22 patients had lower RV global systolic strain, lower RV systolic and early diastolic strain rates, higher RV LGE score, and a greater percent of predicted maximum oxygen consumption (all P < 0.05). CONCLUSION Restrictive RV physiology reflects RV diastolic dysfunction and is associated with more severe RV fibrosis but better exercise capacity in patients after biventricular repair of PAIVS.
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Affiliation(s)
- Xue-Cun Liang
- Division of Pediatric Cardiology, Department of Pediatrics and Adolescent Medicine, Queen Mary Hospital, University of Hong Kong, Hong Kong, China
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37
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Gardiner HM. The in-utero development and treatment of Pulmonary Atresia with intact septum. PROGRESS IN PEDIATRIC CARDIOLOGY 2010. [DOI: 10.1016/j.ppedcard.2010.02.003] [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] [Indexed: 11/29/2022]
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Pyles LA, Berry JM, Steinberger J, Foker JE. Initial, intra-operative, and post-operative evaluation of children with pulmonary atresia with intact ventricular septum with emphasis on the coronary connections to the right ventricle. PROGRESS IN PEDIATRIC CARDIOLOGY 2010. [DOI: 10.1016/j.ppedcard.2010.02.007] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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39
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The long-term consequences of the coronary artery lesions in pulmonary atresia with intact ventricular septum. PROGRESS IN PEDIATRIC CARDIOLOGY 2010. [DOI: 10.1016/j.ppedcard.2010.02.002] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
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Sekar P, Hornberger LK. The role of fetal echocardiography in fetal intervention: a symbiotic relationship. Clin Perinatol 2009; 36:301-27, ix. [PMID: 19559322 DOI: 10.1016/j.clp.2009.03.013] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
In this review, the authors explore the role of noninvasive and invasive fetal interventions in fetal cardiovascular disease guided by observations at fetal echocardiography. They first review fetal cardiac lesions that may be ameliorated by fetal intervention and then review noncardiac fetal pathologic findings for which fetal echocardiography can provide important insight into the pathophysiology and aid in patient selection for and timing of intervention and postintervention surveillance.
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Affiliation(s)
- Priya Sekar
- Department of Pediatrics, Division of Cardiology, Fetal and Neonatal Cardiology Program, WCMC 4C2 Stollery Children's Hospital, Alberta, Canada
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41
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Bryant R, Nowicki ER, Mee RBB, Rajeswaran J, Duncan BW, Rosenthal GL, Mohan U, Mumtaz M, Blackstone EH. Success and limitations of right ventricular sinus myectomy for pulmonary atresia with intact ventricular septum. J Thorac Cardiovasc Surg 2008; 136:735-42, 742.e1-2. [PMID: 18805279 DOI: 10.1016/j.jtcvs.2008.03.039] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/03/2007] [Revised: 02/27/2008] [Accepted: 03/30/2008] [Indexed: 11/18/2022]
Abstract
OBJECTIVES Right ventricular sinus myectomy has been proposed for pulmonary atresia with intact ventricular septum for morphology falling within the uncertain area for eventual biventricular repair. Our objective was to evaluate right ventricular sinus myectomy by characterizing the morphologic spectrum of these patients, determining whether biventricular repair was achieved, ascertaining growth of right-sided structures, and assessing survival. METHODS We evaluated medical records, all imaging studies, and follow-up data (complete in all but 1 patient) from 43 patients with pulmonary atresia with intact ventricular septum treated from October 1993 to July 2005, 16 of whom underwent right ventricular sinus myectomy. Serial echocardiographic measurements of right-sided cardiac structures were converted to Z values to estimate their growth relative to somatic growth. RESULTS Patients undergoing right ventricular sinus myectomy had mild-to-moderate right ventricular size diminution (grade -1.2 +/- 3.2) and a tricuspid valve Z value of -4.9 +/- 1.9. Thirteen (87%) of the 16 patients achieved biventricular repair. After right ventricular sinus myectomy, mean right ventricular cavity size grade increased to 1.4 +/- 0.66, but the tricuspid valve Z value did not change appreciably over time. Five-year survival after sinus myectomy was 85%; late deaths were in patients with the smallest tricuspid valves at presentation (Z value < -7). CONCLUSIONS Right ventricular sinus myectomy in the uncertain area for biventricular repair of pulmonary atresia with intact ventricular septum leads to immediate increase in right ventricular volume. It, in combination with establishing right ventricle-pulmonary trunk continuity, allowed early biventricular repair in 87% of patients. However, tricuspid valve growth in relation to somatic growth was minimal. Thus, small tricuspid valve size might limit the long-term success of biventricular repair achieved by means of right ventricular sinus myectomy.
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Affiliation(s)
- Roosevelt Bryant
- Department of Thoracic and Cardiovascular Surgery, Cleveland Clinic, Cleveland, Ohio 44195, USA
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42
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Abnormalities in myocardial perfusion after surgical correction of pulmonary atresia with intact ventricular septum. Cardiol Young 2008; 18:89-95. [PMID: 18197997 DOI: 10.1017/s1047951107001709] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
We describe the results of myocardial perfusion scintigraphy performed 4 to 15 years after surgery in 12 patients with pulmonary atresia and intact ventricular septum. We used single photon emission computed tomography after injection of technetium Tc-99m tetrofosmin at submaximal exercise test. The patients, 7 girls and 5 boys, with a mean age of 11 years, and a range from 6 to 19 years, had either undergone biventricular repair, in 5 cases, or univentricular palliation in the remaining 7. This second group included 4 patients with ventriculo-coronary arterial communications. Of the children, 3 with biventricular repair and 6 with univentricular palliation had perfusion defects. Children with biventricular repair had perfusion defects in the ventricular septum, while those having univentricular palliation also had defects located to the left ventricular free wall. All children with ventriculo-coronary arterial communications had perfusion defects both in the ventricular septum and in the left ventricular free wall.
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Nguyen TP, Srivastava S, Ko HH, Lai WW. Congenital muscular ventricular septal aneurysm: report of four cases and review of the literature. Pediatr Cardiol 2008; 29:40-4. [PMID: 17786376 DOI: 10.1007/s00246-007-9048-4] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/31/2007] [Revised: 07/29/2007] [Accepted: 08/09/2007] [Indexed: 10/22/2022]
Abstract
We describe a rare association between congenital muscular ventricular septal aneurysm (MuVSA) and right heart lesions, with emphasis on echocardiographic diagnosis, clinical presentation, and outcome. Our four cases of MuVSA occurred in combination with either pulmonary atresia with intact ventricular septum (PAIVS; three patients) or absent pulmonary valve syndrome with severe tricuspid stenosis (one patient). MuVSA and right heart lesions were detected in utero in three patients. The three patients with PAIVS and MuVSA survived with no significant morbidity from the septal aneurysm at 3- to 5-year follow-up. The presence of MuVSA did not negatively affect the outcome of our patients.
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Affiliation(s)
- Thieu P Nguyen
- Division of Pediatric Cardiology, Department of Pediatrics, The Mount Sinai Medical Center, New York, NY 10029, USA.
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Matsui H, Gardiner H. Fetal intervention for cardiac disease: the cutting edge of perinatal care. Semin Fetal Neonatal Med 2007; 12:482-9. [PMID: 17827079 DOI: 10.1016/j.siny.2007.06.003] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
Fetal cardiac valvuloplasty has been proposed for progressive cardiac disease with a poor prognosis, such as critical aortic stenosis and pulmonary atresia with intact ventricular septum and balloon atrial septostomy for hypoplastic left heart syndrome, or simple transposition of the great arteries with closed or restrictive inter-atrial communication. It is anticipated that early rescue of ventricles or the pulmonary veins from an unfavourable environment may promote healthier ventricular and vascular growth and improve postnatal outcomes. While close collaboration between the fetal medicine specialist and perinatal cardiologist may optimize the chances of technical success, obstacles to progress include the relative rarity of suitable cases and late referral for therapy. In common with other interventions in fetal medicine, there is a learning curve, and it would benefit progress if the procedures were initially concentrated in just a few centres to enable them to develop skills and experience. Following careful evaluation, it may then be desirable to train further centres and roll out best practice models.
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Affiliation(s)
- Hikoro Matsui
- Institute of Reproductive and Developmental Biology, Faculty of Medicine, Imperial College London, Queen Charlotte's and Chelsea Hospital, Hammersmith Campus, London W12 ONH, UK
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Abstract
The concept of fetal therapy is well established for many disorders diagnosed before birth but practical issues regarding its introduction into clinical practice are more difficult. Cardiac malformations are common, with major lesions affecting about 3.5 per thousand pregnancies; however, only a small proportion of these is likely to benefit from an intrauterine intervention. In addition, there are no good animal models of human cardiac disease and our knowledge of the underlying mechanisms is at best sketchy. This combination of factors has resulted in slow progress in developing effective therapies for the intrauterine management of cardiac disease. Recent research and clinical developments have included percutaneous valvuloplasty for severe aortic and pulmonary stenosis, perforation of the closed or restrictive inter-atrial septum and pacing for complete heart block. Progress in these endeavours has been variable but - overall - shows promise for treatment of the human fetus.
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Affiliation(s)
- Helena M Gardiner
- Institute of Reproductive and Developmental Biology, Faculty of Medicine, Imperial College, Queen Charlotte's and Chelsea Hospital, Du Cane Road, London, W12 ONN, UK.
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Calder AL, Peebles CR, Occleshaw CJ. The prevalence of coronary arterial abnormalities in pulmonary atresia with intact ventricular septum and their influence on surgical results. Cardiol Young 2007; 17:387-96. [PMID: 17572929 DOI: 10.1017/s1047951107000893] [Citation(s) in RCA: 36] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
BACKGROUND The relatively high mortality in patients with pulmonary atresia and intact ventricular septum may be related to the presence of significant coronary arterial anomalies. This retrospective review of cineangiocardiograms was undertaken to further elucidate the types and variety of such coronary arterial abnormalities, and to assess their effect on postoperative survival. MATERIAL AND RESULTS Details regarding coronary arterial anatomy and abnormalities were assessed in 116 patients. We noted the site and severity of lesions, and the presence of fistulous communications from the right ventricle to the coronary arteries, assessing the proportion of left ventricular myocardium affected by coronary arterial interruptions or significant stenoses, in other words, the amount dependent on coronary circulation from the right ventricle. We also measured diameters of the tricuspid and mitral valves. Fistulas were found in 87 patients (75%), interruptions of major coronary arteries in 40 patients (34%), lack of connections between the coronary arteries and the aorta in 18 patients (16%), and single origin of a coronary artery, with the right coronary artery arising from the left, in 6 patients (5%). We found increased mortality in 47 patients (40%) who had a right ventricular-dependent coronary arterial circulation. The presence of fistulas in itself was not associated with higher mortality, but the presence of coronary arterial interruptions (p = 0.05), and a higher myocardial score (p = 0.0009), were. CONCLUSION We encountered a higher prevalence of both coronary arterial abnormalities and right ventricular-dependent circulation than previously reported. Awareness of the severity of the coronary arterial abnormalities should assist in planning treatment.
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Affiliation(s)
- A Louise Calder
- Department of Paediatric Cardiology, Green Lane Hospital, Auckland, New Zealand.
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Roman KS, Fouron JC, Nii M, Smallhorn JF, Chaturvedi R, Jaeggi ET. Determinants of outcome in fetal pulmonary valve stenosis or atresia with intact ventricular septum. Am J Cardiol 2007; 99:699-703. [PMID: 17317375 DOI: 10.1016/j.amjcard.2006.09.120] [Citation(s) in RCA: 70] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/26/2006] [Revised: 09/19/2006] [Accepted: 09/19/2006] [Indexed: 12/24/2022]
Abstract
Pulmonary valve stenosis or atresia with intact ventricular septum represents a spectrum of severity. This study aimed to identify ultrasound markers of biventricular versus non-biventricular outcome. The fetal echocardiograms of 41 fetuses diagnosed with pulmonary stenosis or atresia and right ventricular (RV)/left ventricular (LV) length ratios >0.4 from 17 to 31 weeks of gestation were reviewed. Of 27 live-born patients with intention to treat, 8 had non-biventricular outcomes and 19 had biventricular circulation. At the time of diagnosis, poor RV function, flow reversal in the arterial duct, the degree of tricuspid valve (TV) regurgitation, and inferior vena cava Doppler flow pattern did not differ between the 2 outcome groups. However, RV sinusoids, the RV/LV length ratio, the TV/mitral valve ratio, and TV inflow duration were significantly different. Cut-off values derived from receiver-operating characteristic curves yielding the best sensitivity and specificity for a non-biventricular outcome were TV/mitral valve ratio <0.7, RV/LV length ratio <0.6, TV inflow duration <31.5% of cardiac cycle length, and the presence of RV sinusoids. If 3 of these 4 criteria were fulfilled, this predicted a non-biventricular outcome with sensitivity of 100% and specificity of 75%. In conclusion, in fetuses < or =31 weeks of gestation with pulmonary stenosis or atresia and intact ventricular septum, progression to a non-biventricular outcome can be predicted by a 4-criterion scoring system. The criteria may be useful in selecting fetuses for prenatal catheter intervention to prevent progressive RV hypoplasia.
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Affiliation(s)
- Kevin S Roman
- Division of Cardiology, Department of Pediatrics, The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
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Kawaraguchi Y, Taniguchi A, Otomo T, Ota C, Uchida N. Anesthetic management of bidirectional cavopulmonary shunt in a patient with pulmonary atresia with intact ventricular septum associated with sinusoidal communications. J Anesth 2006; 20:220-2. [PMID: 16897243 DOI: 10.1007/s00540-006-0395-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2005] [Accepted: 02/09/2006] [Indexed: 10/24/2022]
Abstract
Pulmonary atresia with intact ventricular septum (PAIVS) is sometimes associated with coronary artery anomalies, including right ventricle (RV)-to-coronary artery fistulas (sinusoidal communications), coronary artery stenoses, and coronary artery occlusions. In some cases, the coronary circulation depends entirely or partly on the desaturated systemic venous blood supply from the RV. Under these circumstances, decompression of the RV can result in fatal myocardial ischemia. A 6-month-old boy, diagnosed with PAIVS associated with sinusoidal communications, underwent a bidirectional cavopulmonary shunt procedure under venoarterial cardiopulmonary bypass (CPB). During CPB, to prevent RV decompression, we maintained right atrial pressure above 5 mmHg and used a pump perfusion rate of 30%-40% of the calculated value based on body surface area. Although electrocardiography showed slight ST depression and bradycardia, myocardial contractility after weaning from CPB was adequate to maintain the circulation with the administration of dobutamine and atrial pacing. In patients with PAIVS and RV-dependent coronary circulation, it is important to maintain coronary artery perfusion throughout the period of anesthesia.
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Affiliation(s)
- Yoshitaka Kawaraguchi
- Department of Anesthesia and Critical Care, Miyagi Children's Hospital, 4-3-17 Ochiai, Sendai 989-3126, Japan
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Anderson RH. Solving the disputes concerning the congenitally malformed heart. PROGRESS IN PEDIATRIC CARDIOLOGY 2006. [DOI: 10.1016/j.ppedcard.2006.07.002] [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: 10/24/2022]
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Salvin JW, McElhinney DB, Colan SD, Gauvreau K, del Nido PJ, Jenkins KJ, Lock JE, Tworetzky W. Fetal tricuspid valve size and growth as predictors of outcome in pulmonary atresia with intact ventricular septum. Pediatrics 2006; 118:e415-20. [PMID: 16882782 DOI: 10.1542/peds.2006-0428] [Citation(s) in RCA: 88] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
OBJECTIVE Pulmonary atresia with intact ventricular septum is a complex congenital cardiovascular anomaly that frequently requires single ventricle palliation. Fetal diagnosis of pulmonary atresia with intact ventricular septum is common, but the natural history of pulmonary atresia with intact ventricular septum diagnosed in midgestation, predictors of neonatal anatomy, and predictors of biventricular repair have not been determined. The objective of this study was to determine whether the size and rate of growth of the fetal tricuspid valve predict neonatal anatomy and biventricular repair. DESIGN AND RESULTS Twenty-three fetuses diagnosed with pulmonary atresia with intact ventricular septum between 1990 and 2004 were studied. Of 13 fetuses with a midgestation fetal tricuspid valve z score < or = -3, 1 achieved biventricular repair, compared with 5 of 5 with a tricuspid valve z score > -3. Of 13 fetuses with a midgestation fetal tricuspid valve z score < or = -3, 8 were diagnosed postnatally with a right ventricular dependent coronary circulation, compared with none with a tricuspid valve z score > -3. Midgestation and late gestation fetal tricuspid valve z scores correlated with neonatal tricuspid valve z score. The average rate of tricuspid valve growth between mid- and late fetal echocardiograms was significantly lower in patients who did not achieve biventricular repair than in those who did (0.012 +/- 0.008 cm per week vs 0.028 +/- 0.014 cm per week). CONCLUSIONS Fetal tricuspid valve z score and rate of growth predict postnatal outcome in pulmonary atresia with intact ventricular septum. These findings may have important implications for prenatal counseling and selection of patients for fetal pulmonary valve dilation.
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Affiliation(s)
- Joshua W Salvin
- Department of Cardiology, Cardiac ICU Office, Farley 6, Children's Hospital Boston, 300 Longwood Ave, Boston, Massachusetts 02115, USA.
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