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Greenberg JW, Guzman-Gomez A, Kulshrestha K, Dani A, Lehenbauer DG, Chin C, Zafar F, Morales DLS. Contemporary Outcomes of Heart Transplantation in Children with Heterotaxy Syndrome: Sub-Optimal Pre-Transplant Optimization Translates into Early Post-Transplant Mortality. Pediatr Cardiol 2024; 45:1343-1352. [PMID: 36811659 DOI: 10.1007/s00246-023-03122-z] [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: 12/05/2022] [Accepted: 02/02/2023] [Indexed: 02/24/2023]
Abstract
Patients with heterotaxy syndrome and congenital heart disease (CHD) experience inferior cardiac surgical outcomes. Heart transplantation outcomes are understudied, however, particularly compared to non-CHD patients. Data from UNOS and PHIS were used to identify 4803 children (< 18 years) undergoing first-time heart transplant between 2003 and 2022 with diagnoses of heterotaxy (n = 278), other-CHD (n = 2236), and non-CHD cardiomyopathy (n = 2289). Heterotaxy patients were older (median 5 yr) and heavier (median 17 kg) at transplant than other-CHD (median 2 yr and 12 kg), and younger and lighter than cardiomyopathy (median 7 yr and 24 kg) (all p < 0.001). UNOS status 1A/1 at listing was not different between groups (65-67%; p = 0.683). At transplant, heterotaxy and other-CHD patients had similar rates of renal dysfunction (12 and 17%), inotropes (10% and 11%), and ventilator-dependence (19 and 18%). Compared to cardiomyopathy, heterotaxy patients had comparable renal dysfunction (9%, p = 0.058) and inotropes (46%, p = 0.097) but more hepatic dysfunction (17%, p < 0.001) and ventilator-dependence (12%, p = 0.003). Rates of ventricular assist device (VAD) were: heterotaxy-10%, other-CHD-11% (p = 0.839 vs. heterotaxy), cardiomyopathy-37% (p < 0.001 vs. heterotaxy). The 1-year incidence of acute rejection post-transplant was comparable between heterotaxy and others (p > 0.05). While overall post-transplant survival was significantly worse for heterotaxy than others (p < 0.05 vs. both), conditional 1-year survival was comparable (p > 0.3 vs. both). Children with heterotaxy syndrome experience inferior post-heart transplant survival, although early mortality appears to influence this trend, with 1-year survivors having equivalent outcomes. Given similar pre-transplant clinical status to others, heterotaxy patients are potentially under risk-stratified. Increased VAD utilization and pre-transplant end-organ function optimization may portend improved outcomes.
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Affiliation(s)
- Jason W Greenberg
- Cincinnati Children's Hospital Medical Center, The Heart Institute, University of Cincinnati School of Medicine, 3333 Burnet Ave, Cincinnati, OH, 45229, USA.
| | - Amalia Guzman-Gomez
- Cincinnati Children's Hospital Medical Center, The Heart Institute, University of Cincinnati School of Medicine, 3333 Burnet Ave, Cincinnati, OH, 45229, USA
| | - Kevin Kulshrestha
- Cincinnati Children's Hospital Medical Center, The Heart Institute, University of Cincinnati School of Medicine, 3333 Burnet Ave, Cincinnati, OH, 45229, USA
| | - Alia Dani
- Cincinnati Children's Hospital Medical Center, The Heart Institute, University of Cincinnati School of Medicine, 3333 Burnet Ave, Cincinnati, OH, 45229, USA
| | - David G Lehenbauer
- Cincinnati Children's Hospital Medical Center, The Heart Institute, University of Cincinnati School of Medicine, 3333 Burnet Ave, Cincinnati, OH, 45229, USA
| | - Clifford Chin
- Cincinnati Children's Hospital Medical Center, The Heart Institute, University of Cincinnati School of Medicine, 3333 Burnet Ave, Cincinnati, OH, 45229, USA
| | - Farhan Zafar
- Cincinnati Children's Hospital Medical Center, The Heart Institute, University of Cincinnati School of Medicine, 3333 Burnet Ave, Cincinnati, OH, 45229, USA
| | - David L S Morales
- Cincinnati Children's Hospital Medical Center, The Heart Institute, University of Cincinnati School of Medicine, 3333 Burnet Ave, Cincinnati, OH, 45229, USA
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Durbin MD, Helvaty LR, Posorske A, Zhang S, Huang M, Li M, Abreu D, Fairman K, Geddes GC, Helm BM, Landis BJ, McEntire A, Mitchell DK, Ware SM. Rapid Genome Sequencing Shows Diagnostic Utility In Infants With Congenital Heart Defects. RESEARCH SQUARE 2024:rs.3.rs-3976548. [PMID: 38562732 PMCID: PMC10984023 DOI: 10.21203/rs.3.rs-3976548/v1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 04/04/2024]
Abstract
Congenital heart disease (CHD) is the most common birth defect and a leading cause of infant mortality. CHD often has a genetic etiology and recent studies demonstrate utility in genetic testing. In clinical practice, decisions around genetic testing choices continue to evolve, and the incorporation of rapid genome sequencing (rGS) in CHD has not been well studied. Though smaller studies demonstrate the value of rGS, they also highlight the burden of results interpretation. We analyze genetic testing in CHD at two time-points, in 2018 and 2022-2023, across a change in clinical testing guidelines from chromosome microarray (CMA) to rGS. Analysis of 421 hospitalized infants with CHD demonstrated consistent genetic testing across time. Overall, after incorporation of rGS in 2022-2023, the diagnostic yield was 6.8% higher compared to 2018, and this pattern was consistent across all patient subtypes analyzed. In 2018, CMA was the most common test performed, with diagnostic results for CHD in 14.3%, while in 2022-2023, rGS was the most frequent test performed, with results diagnostic for CHD in 16.9%. Additionally, rGS identified 44% more unique genetic diagnoses than CMA. This is the largest study to highlight the value of rGS in CHD and has important implications for management.
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Affiliation(s)
- Matthew D Durbin
- Indiana University School of Medicine, Indianapolis, IN
- Herman B Wells Center for Pediatric Research, Indianapolis, IN
| | | | - Alyx Posorske
- Indiana University School of Medicine, Indianapolis, IN
| | - Samuel Zhang
- Indiana University School of Medicine, Indianapolis, IN
| | - Manyan Huang
- Indiana University Bloomington School of Public Health, Bloomington, IN
| | - Ming Li
- Indiana University Bloomington School of Public Health, Bloomington, IN
| | - Daniel Abreu
- Indiana University School of Medicine, Indianapolis, IN
| | | | | | | | - Benjamin J Landis
- Indiana University School of Medicine, Indianapolis, IN
- Herman B Wells Center for Pediatric Research, Indianapolis, IN
| | | | | | - Stephanie M Ware
- Indiana University School of Medicine, Indianapolis, IN
- Herman B Wells Center for Pediatric Research, Indianapolis, IN
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Durbin MD, Fairman K, Helvaty LR, Huang M, Li M, Abreu D, Geddes GC, Helm BM, Landis BJ, McEntire A, Mitchell DK, Ware SM. Genetic Testing Guidelines Impact Care in Newborns with Congenital Heart Defects. J Pediatr 2023; 260:113495. [PMID: 37211210 PMCID: PMC10660555 DOI: 10.1016/j.jpeds.2023.113495] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/30/2022] [Revised: 05/11/2023] [Accepted: 05/14/2023] [Indexed: 05/23/2023]
Abstract
OBJECTIVE To evaluate genetic evaluation practices in newborns with the most common birth defect, congenital heart defects (CHD), we determined the prevalence and the yield of genetic evaluation across time and across patient subtypes, before and after implementation of institutional genetic testing guidelines. STUDY DESIGN This was a retrospective, cross-sectional study of 664 hospitalized newborns with CHD using multivariate analyses of genetic evaluation practices across time and patient subtypes. RESULTS Genetic testing guidelines for hospitalized newborns with CHD were implemented in 2014, and subsequently genetic testing increased (40% in 2013 and 75% in 2018, OR 5.02, 95% CI 2.84-8.88, P < .001) as did medical geneticists' involvement (24% in 2013 and 64% in 2018, P < .001). In 2018, there was an increased use of chromosomal microarray (P < .001), gene panels (P = .016), and exome sequencing (P = .001). The testing yield was high (42%) and consistent across years and patient subtypes analyzed. Increased testing prevalence (P < .001) concomitant with consistent testing yield (P = .139) added an estimated 10 additional genetic diagnoses per year, reflecting a 29% increase. CONCLUSIONS In patients with CHD, yield of genetic testing was high. After implementing guidelines, genetic testing increased significantly and shifted to newer sequence-based methods. Increased use of genetic testing identified more patients with clinically important results with potential to impact patient care.
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Affiliation(s)
- Matthew D Durbin
- Division of Neonatal-Perinatal Medicine, Department of Pediatrics, Riley Hospital for Children, Indiana University School of Medicine, Indianapolis, IN
| | - Korre Fairman
- Division of Neonatal-Perinatal Medicine, Department of Pediatrics, Washington University School of Medicine, St. Louis, MO
| | - Lindsey R Helvaty
- Department of Pediatrics, Indiana University School of Medicine, Indianapolis, IN
| | - Manyan Huang
- Department of Epidemiology and Biostatistics, Indiana University Bloomington School of Public Health, Bloomington, IN
| | - Ming Li
- Department of Epidemiology and Biostatistics, Indiana University Bloomington School of Public Health, Bloomington, IN
| | - Daniel Abreu
- Indiana University School of Medicine, Indianapolis, IN
| | - Gabrielle C Geddes
- Department of Medical and Molecular Genetics, Indiana University School of Medicine, Indianapolis, IN
| | - Benjamin M Helm
- Department of Medical and Molecular Genetics, Indiana University School of Medicine, Indianapolis, IN
| | - Benjamin J Landis
- Department of Medical and Molecular Genetics, Indiana University School of Medicine, Indianapolis, IN; Division of Pediatric Cardiology, Department of Pediatrics, Riley Hospital for Children, Indiana University School of Medicine, Indianapolis, IN
| | - Alexis McEntire
- Department of Medical and Molecular Genetics, Indiana University School of Medicine, Indianapolis, IN
| | - Dana K Mitchell
- Department of Pediatrics, Indiana University School of Medicine, Indianapolis, IN
| | - Stephanie M Ware
- Department of Pediatrics, Indiana University School of Medicine, Indianapolis, IN; Department of Medical and Molecular Genetics, Indiana University School of Medicine, Indianapolis, IN.
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Vassar R, Peyvandi S, Gano D, Cox S, Zetino Y, Miller S, McQuillen P. Critical congenital heart disease beyond HLHS and TGA: neonatal brain injury and early neurodevelopment. Pediatr Res 2023; 94:691-698. [PMID: 36782067 PMCID: PMC10403377 DOI: 10.1038/s41390-023-02490-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/30/2022] [Revised: 01/12/2023] [Accepted: 01/15/2023] [Indexed: 02/15/2023]
Abstract
BACKGROUND Characterization of brain injury and neurodevelopmental (ND) outcomes in critical congenital heart disease (cCHD) has primarily focused on hypoplastic left heart syndrome (HLHS) and transposition of the great arteries (TGA). This study reports brain injury and ND outcomes among patients with heterogeneous cCHD diagnoses beyond HLHS and TGA. METHODS This prospective cohort study included infants with HLHS, TGA, or heterogenous "Other cCHD" including left- or right-sided obstructive lesions, anomalous pulmonary venous return, and truncus arteriosus. Brain injury on perioperative brain MRI and ND outcomes on the Bayley-II at 30 months were compared. RESULTS A total of 218 participants were included (HLHS = 60; TGA = 118; "Other cCHD" = 40, including 8 with genetic syndromes). Pre-operative (n = 209) and post-operative (n = 189) MRI showed similarly high brain injury rates across groups, regardless of cardiopulmonary bypass exposure. At 30 months, participants with "Other cCHD" had lower cognitive scores (p = 0.035) compared to those with HLHS and TGA, though worse ND outcome in this group was driven by those with genetic disorders. CONCLUSIONS Frequency of brain injury and neurodevelopmental delay among patients with "Other cCHD" is similar to those with HLHS or TGA. Patients with all cCHD lesions are at risk for impaired outcomes; developmental and genetic screening is indicated. IMPACT This study adds to literature on risk of brain injury in patients with critical congenital heart disease (cCHD) diagnoses other than hypoplastic left heart syndrome (HLHS) and transposition of the great arteries (TGA), a heterogenous cohort of patients that has often been excluded from imaging studies. Children with cCHD beyond HLHS and TGA have similarly high rates of acquired brain injury. The high rate of neurodevelopmental impairment in this heterogenous group of cCHD diagnoses beyond HLHS and TGA is primarily driven by patients with comorbid genetic syndromes such as 22q11.2 deletion syndrome.
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Affiliation(s)
- Rachel Vassar
- Division of Pediatric Neurology, Department of Neurology, Benioff Children's Hospital, University of California, San Francisco, CA, USA.
| | - Shabnam Peyvandi
- Division of Pediatric Cardiology, Department of Pediatrics, Benioff Children's Hospital, University of California, San Francisco, CA, USA
| | - Dawn Gano
- Division of Pediatric Neurology, Department of Neurology, Benioff Children's Hospital, University of California, San Francisco, CA, USA
| | - Stephany Cox
- Division of Pediatric Cardiology, Department of Pediatrics, Benioff Children's Hospital, University of California, San Francisco, CA, USA
- Division of Developmental Medicine, Department of Pediatrics, Benioff Children's Hospital, University of California, San Francisco, CA, USA
| | - Yensy Zetino
- Division of Pediatric Cardiology, Department of Pediatrics, Benioff Children's Hospital, University of California, San Francisco, CA, USA
| | - Steven Miller
- Department of Neurology, Hospital for Sick Children, University of Toronto, Toronto, ON, Canada
| | - Patrick McQuillen
- Division of Critical Care, Department of Pediatrics, Benioff Children's Hospital, University of California, San Francisco, CA, USA
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DNMT3B rs2424913 as a Risk Factor for Congenital Heart Defects in Down Syndrome. Genes (Basel) 2023; 14:genes14030576. [PMID: 36980848 PMCID: PMC10048502 DOI: 10.3390/genes14030576] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2023] [Revised: 02/21/2023] [Accepted: 02/23/2023] [Indexed: 03/03/2023] Open
Abstract
Impairments of the genes that encode enzymes that are involved in one-carbon metabolism because of the presence of gene polymorphisms can affect the methylation pattern. The altered methylation profiles of the genes involved in cardiogenesis may result in congenital heart defects (CHDs). The aim of this study was to investigate the association between the MTHFR rs1801133, MTHFR rs1801131, MTRR rs1801394, DNMT1 rs2228611, DNMT3A rs1550117, DNMT3B rs1569686, and DNMT3B rs2424913 gene polymorphisms and congenital heart defects in Down syndrome (DS) individuals. The study was conducted on 350 participants, including 134 DS individuals with CHDs (DSCHD+), 124 DS individuals without CHDs (DSCHD−), and 92 individuals with non-syndromic CHD. The genotyping was performed using the PCR–RFLP method. A statistically significant higher frequency of the DNMT3B rs2424913 TT in the DSCHD+ individuals was observed. The DNMT3B rs2424913 TT genotype, as well as the T allele, had significantly higher frequencies in the individuals with DS and atrial septal defects (ASDs) in comparison with the individuals with DS and other CHDs. Furthermore, our results indicate a statistically significant effect of the DNMT3B rs1569686 TT genotype in individuals with non-syndromic CHDs. The results of the study suggest that the DNMT3B rs2424913 TT genotypes may be a possible predisposing factor for CHDs in DS individuals, and especially those with ASDs.
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Ma J, Gu Y, Liu J, Song J, Zhou T, Jiang M, Wen Y, Guo X, Zhou Z, Sha J, He J, Hu Z, Luo L, Liu M. Functional screening of congenital heart disease risk loci identifies 5 genes essential for heart development in zebrafish. Cell Mol Life Sci 2022; 80:19. [PMID: 36574072 PMCID: PMC11073085 DOI: 10.1007/s00018-022-04669-5] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2022] [Revised: 12/09/2022] [Accepted: 12/10/2022] [Indexed: 12/28/2022]
Abstract
Congenital heart disease (CHD) is the most common birth defect worldwide and a main cause of perinatal and infant mortality. Our previous genome-wide association study identified 53 SNPs that associated with CHD in the Han Chinese population. Here, we performed functional screening of 27 orthologous genes in zebrafish using injection of antisense morpholino oligos. From this screen, 5 genes were identified as essential for heart development, including iqgap2, ptprt, ptpn22, tbck and maml3. Presumptive roles of the novel CHD-related genes include heart chamber formation (iqgap2 and ptprt) and atrioventricular canal formation (ptpn22 and tbck). While deficiency of maml3 led to defective cardiac trabeculation and consequent heart failure in zebrafish embryos. Furthermore, we found that maml3 mutants showed decreased cardiomyocyte proliferation which caused a reduction in cardiac trabeculae due to inhibition of Notch signaling. Together, our study identifies 5 novel CHD-related genes that are essential for heart development in zebrafish and first demonstrates that maml3 is required for Notch signaling in vivo.
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Affiliation(s)
- Jianlong Ma
- Institute of Developmental Biology and Regenerative Medicine, Southwest University, Chongqing, 400715, China
| | - Yayun Gu
- State Key Laboratory of Reproductive Medicine, Nanjing Medical University, Nanjing, 211100, China
- Department of Epidemiology and Biostatistics, School of Public Health, Nanjing Medical University, Nanjing, 211100, China
| | - Juanjuan Liu
- State Key Laboratory of Reproductive Medicine, Nanjing Medical University, Nanjing, 211100, China
- Department of Histology and Embryology, Nanjing Medical University, Nanjing, 211100, China
| | - Jingmei Song
- Institute of Developmental Biology and Regenerative Medicine, Southwest University, Chongqing, 400715, China
| | - Tao Zhou
- State Key Laboratory of Reproductive Medicine, Nanjing Medical University, Nanjing, 211100, China
- Department of Histology and Embryology, Nanjing Medical University, Nanjing, 211100, China
| | - Min Jiang
- State Key Laboratory of Reproductive Medicine, Nanjing Medical University, Nanjing, 211100, China
- Department of Histology and Embryology, Nanjing Medical University, Nanjing, 211100, China
| | - Yang Wen
- State Key Laboratory of Reproductive Medicine, Nanjing Medical University, Nanjing, 211100, China
- Department of Epidemiology and Biostatistics, School of Public Health, Nanjing Medical University, Nanjing, 211100, China
| | - Xuejiang Guo
- State Key Laboratory of Reproductive Medicine, Nanjing Medical University, Nanjing, 211100, China
- Department of Histology and Embryology, Nanjing Medical University, Nanjing, 211100, China
| | - Zuomin Zhou
- State Key Laboratory of Reproductive Medicine, Nanjing Medical University, Nanjing, 211100, China
- Department of Histology and Embryology, Nanjing Medical University, Nanjing, 211100, China
| | - Jiahao Sha
- State Key Laboratory of Reproductive Medicine, Nanjing Medical University, Nanjing, 211100, China
- Department of Histology and Embryology, Nanjing Medical University, Nanjing, 211100, China
| | - Jianbo He
- Institute of Developmental Biology and Regenerative Medicine, Southwest University, Chongqing, 400715, China
| | - Zhibin Hu
- State Key Laboratory of Reproductive Medicine, Nanjing Medical University, Nanjing, 211100, China
- Department of Epidemiology and Biostatistics, School of Public Health, Nanjing Medical University, Nanjing, 211100, China
- Key Laboratory of Targeted Intervention of Cardiovascular Disease, Collaborative Innovation Center for Cardiovascular Disease Translational Medicine, Nanjing Medical University, Nanjing, 211100, China
| | - Lingfei Luo
- Institute of Developmental Biology and Regenerative Medicine, Southwest University, Chongqing, 400715, China.
| | - Mingxi Liu
- State Key Laboratory of Reproductive Medicine, The Affiliated Taizhou People's Hospital of Nanjing Medical University, Taizhou School of Clinical Medicine, Nanjing Medical University, Nanjing, 211100, China.
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Landis BJ, Helm BM, Herrmann JL, Hoover MC, Durbin MD, Elmore LR, Huang M, Johansen M, Li M, Przybylowski LF, Geddes GC, Ware SM. Learning to Crawl: Determining the Role of Genetic Abnormalities on Postoperative Outcomes in Congenital Heart Disease. J Am Heart Assoc 2022; 11:e026369. [PMID: 36172937 PMCID: PMC9673727 DOI: 10.1161/jaha.122.026369] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/05/2022] [Accepted: 07/27/2022] [Indexed: 11/16/2022]
Abstract
Background Our cardiac center established a systematic approach for inpatient cardiovascular genetics evaluations of infants with congenital heart disease, including routine chromosomal microarray (CMA) testing. This provides a new opportunity to investigate correlation between genetic abnormalities and postoperative course. Methods and Results Infants who underwent congenital heart disease surgery as neonates (aged ≤28 days) from 2015 to 2020 were identified. Cases with trisomy 21 or 18 were excluded. Diagnostic genetic results or CMA with variant of uncertain significance were considered abnormal. We compared postoperative outcomes following initial congenital heart disease surgery in patients found to have genetic abnormality to those who had negative CMA. Among 355 eligible patients, genetics consultations or CMA were completed in 88%. A genetic abnormality was identified in 73 patients (21%), whereas 221 had negative CMA results. Genetic abnormality was associated with prematurity, extracardiac anomaly, and lower weight at surgery. Operative mortality rate was 9.6% in patients with a genetic abnormality versus 4.1% in patients without an identified genetic abnormality (P=0.080). Mortality was similar when genetic evaluations were diagnostic (9.3%) or identified a variant of uncertain significance on CMA (10.0%). Among 14 patients with 22q11.2 deletion, the 2 mortality cases had additional CMA findings. In patients without extracardiac anomaly, genetic abnormality was independently associated with increased mortality (P=0.019). CMA abnormality was not associated with postoperative length of hospitalization, extracorporeal membrane oxygenation, or >7 days to initial extubation. Conclusions Routine genetic evaluations and CMA may help to stratify mortality risk in severe congenital heart disease with syndromic or nonsyndromic presentations.
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Affiliation(s)
- Benjamin J. Landis
- Division of Pediatric Cardiology, Department of Pediatrics, Riley Hospital for ChildrenIndiana University School of MedicineIndianapolisIN
- Department of Medical and Molecular GeneticsIndiana University School of MedicineIndianapolisIN
| | - Benjamin M. Helm
- Department of Medical and Molecular GeneticsIndiana University School of MedicineIndianapolisIN
| | - Jeremy L. Herrmann
- Division of Thoracic and Cardiovascular SurgeryIndiana University School of MedicineIndianapolisIN
| | - Madeline C. Hoover
- Division of Pediatric Cardiology, Department of Pediatrics, Riley Hospital for ChildrenIndiana University School of MedicineIndianapolisIN
| | - Matthew D. Durbin
- Division of Neonatal‐Perinatal Medicine, Riley Hospital for ChildrenIndiana University School of MedicineIndianapolisIN
| | - Lindsey R. Elmore
- Department of PediatricsIndiana University School of MedicineIndianapolisIN
| | - Manyan Huang
- Department of Epidemiology and BiostatisticsIndiana University Bloomington School of Public HealthBloomingtonIN
| | - Michael Johansen
- Division of Pediatric Cardiology, Department of Pediatrics, Riley Hospital for ChildrenIndiana University School of MedicineIndianapolisIN
| | - Ming Li
- Department of Epidemiology and BiostatisticsIndiana University Bloomington School of Public HealthBloomingtonIN
| | - Leon F. Przybylowski
- Division of Pediatric Cardiology, Department of Pediatrics, Riley Hospital for ChildrenIndiana University School of MedicineIndianapolisIN
| | - Gabrielle C. Geddes
- Department of Medical and Molecular GeneticsIndiana University School of MedicineIndianapolisIN
| | - Stephanie M. Ware
- Department of Medical and Molecular GeneticsIndiana University School of MedicineIndianapolisIN
- Department of PediatricsIndiana University School of MedicineIndianapolisIN
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Bhatt AB, Lantin-Hermoso MR, Daniels CJ, Jaquiss R, Landis BJ, Marino BS, Rathod RH, Vincent RN, Keller BB, Villafane J. Isolated Coarctation of the Aorta: Current Concepts and Perspectives. Front Cardiovasc Med 2022; 9:817866. [PMID: 35694677 PMCID: PMC9174545 DOI: 10.3389/fcvm.2022.817866] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2021] [Accepted: 03/21/2022] [Indexed: 12/02/2022] Open
Abstract
Current management of isolated CoA, localized narrowing of the aortic arch in the absence of other congenital heart disease, is a success story with improved prenatal diagnosis, high survival and improved understanding of long-term complication. Isolated CoA has heterogenous presentations, complex etiologic mechanisms, and progressive pathophysiologic changes that influence outcome. End-to-end or extended end-to-end anastomosis are the favored surgical approaches for isolated CoA in infants and transcatheter intervention is favored for children and adults. Primary stent placement is the procedure of choice in larger children and adults. Most adults with treated isolated CoA thrive, have normal daily activities, and undergo successful childbirth. Fetal echocardiography is the cornerstone of prenatal counseling and genetic testing is recommended. Advanced 3D imaging identifies aortic complications and myocardial dysfunction and guides individualized therapies including re-intervention. Adult CHD program enrollment is recommended. Longer follow-up data are needed to determine the frequency and severity of aneurysm formation, myocardial dysfunction, and whether childhood lifestyle modifications reduce late-onset complications.
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Affiliation(s)
- Ami B. Bhatt
- Departments of Internal Medicine and Pediatrics and Division of Cardiology, Harvard Medical School, Boston, MA, United States
| | - Maria R. Lantin-Hermoso
- Section of Cardiology, Department of Pediatrics, Baylor College of Medicine, Houston, TX, United States
| | - Curt J. Daniels
- Departments of Pediatrics and Internal Medicine, The Ohio State University Medical Center, Columbus, OH, United States
| | - Robert Jaquiss
- Department of Cardiovascular and Thoracic Surgery and Department of Pediatrics, UT Southwestern Medical Center, Dallas, TX, United States
| | - Benjamin John Landis
- Department of Pediatrics and Department of Medical and Molecular Genetics, Indiana University School of Medicine, Indianapolis, IN, United States
| | - Bradley S. Marino
- Department of Pediatric Cardiology, Cleveland Clinic Children's, Cleveland, OH, United States
| | - Rahul H. Rathod
- Department of Pediatrics, Harvard Medical School, Boston, MA, United States
| | - Robert N. Vincent
- Department of Pediatrics, New York Medical College, Valhalla, NY, United States
| | - Bradley B. Keller
- Cincinnati Children's Heart Institute and the Department of Pediatrics, University of Cincinnati, Cincinnati, OH, United States
| | - Juan Villafane
- Cincinnati Children's Heart Institute and the Department of Pediatrics, University of Cincinnati, Cincinnati, OH, United States
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Patients requiring pediatric palliative care for advanced heart disease in France: A descriptive study. Arch Pediatr 2021; 28:548-552. [PMID: 34400053 DOI: 10.1016/j.arcped.2021.06.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2021] [Revised: 04/10/2021] [Accepted: 06/13/2021] [Indexed: 11/21/2022]
Abstract
INTRODUCTION Pediatric palliative care (PPC) teams address unmet needs and improve the quality of life of patients with life-limiting conditions across pediatric subspecialties. However, little is known about the timing, reasons, and nature of PPC team interventions in advanced heart diseases (AHD). OBJECTIVES Here we describe how, when, and why PPC teams interact with referred teams of children suffering from AHD. METHODS We conducted a retrospective nationwide survey among PPC teams in France. All patients referred to participating PPC teams for a cardiologic disease in 2019 were studied. RESULTS Among six PPC teams, 18 patients with AHD had a PPC consultation in 2019. Six of these patients had cardiomyopathy and 12 had congenital heart disease (CHD). The median age at referral was 0.9 months for CHD and 72 months for cardiomyopathy. An antenatal diagnosis had been made for six families with CHD, and two of them were referred to PPC before birth allowing for a prenatal palliative care plan. The main reason for referral was ethical considerations (50%) followed by organization for home-based palliative care (28%). PPC teams participated in ethical discussions when asked to but also provided family support (12/18), home-based PPC (9/18), coordination of care (5/18), support of the referred team (4/18), and symptoms management (3/18) CONCLUSION: The main reason for referral to PPC was ethical considerations, but PPC interventions followed a holistic model of care. Prospective outcomes measurement and partnerships should be further developed.
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The role of DNA methylation in syndromic and non-syndromic congenital heart disease. Clin Epigenetics 2021; 13:93. [PMID: 33902696 PMCID: PMC8077695 DOI: 10.1186/s13148-021-01077-7] [Citation(s) in RCA: 24] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2021] [Accepted: 04/13/2021] [Indexed: 02/07/2023] Open
Abstract
Congenital heart disease (CHD) is a common structural birth defect worldwide, and defects typically occur in the walls and valves of the heart or enlarged blood vessels. Chromosomal abnormalities and genetic mutations only account for a small portion of the pathogenic mechanisms of CHD, and the etiology of most cases remains unknown. The role of epigenetics in various diseases, including CHD, has attracted increased attention. The contributions of DNA methylation, one of the most important epigenetic modifications, to CHD have not been illuminated. Increasing evidence suggests that aberrant DNA methylation is related to CHD. Here, we briefly introduce DNA methylation and CHD and then review the DNA methylation profiles during cardiac development and in CHD, abnormalities in maternal genome-wide DNA methylation patterns are also described. Whole genome methylation profile and important differentially methylated genes identified in recent years are summarized and clustered according to the sample type and methodologies. Finally, we discuss the novel technology for and prospects of CHD-related DNA methylation.
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Shikany AR, Landis BJ, Parrott A, Miller EM, Coyan A, Walters L, Hinton RB, Goldenberg P, Ware SM. A Comprehensive Clinical Genetics Approach to Critical Congenital Heart Disease in Infancy. J Pediatr 2020; 227:231-238.e14. [PMID: 32717230 PMCID: PMC8424561 DOI: 10.1016/j.jpeds.2020.07.065] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/28/2020] [Revised: 07/17/2020] [Accepted: 07/21/2020] [Indexed: 12/25/2022]
Abstract
OBJECTIVE To investigate the frequency of genetic diagnoses among infants with critical congenital heart disease (CHD) using a comprehensive cardiovascular genetics approach and to identify genotype-phenotype correlations. STUDY DESIGN A retrospective chart review of patients evaluated by cardiovascular genetics in a pediatric cardiac intensive care unit from 2010 to 2015 was performed. Infants with CHD who were <1 month of age were included. CHD was classified using structured phenotype definitions. Cardiac and noncardiac phenotypes were tested for associations with abnormal genetic testing using χ1 and Fisher exact tests. RESULTS Genetic evaluation was completed in 293 infants with CHD, of whom 213 had isolated congenital heart disease (iCHD) and 80 had multiple congenital anomalies. Overall, the yield of abnormal genetic testing was 26%. The multiple congenital anomalies cohort had a greater yield of genetic testing (39%) than the iCHD cohort (20%) (OR 2.7). Using a non-hierarchical CHD classification and excluding 22q11.2 deletion and common aneuploidies, right ventricular obstructive defects were associated with abnormal genetic testing (P = .0005). Extracardiac features associated with abnormal genetic testing included ear, nose, and throat (P = .003) and brain (P = .0001) abnormalities. A diagnosis of small for gestational age or intrauterine growth retardation also was associated with abnormal genetic testing (P = .0061), as was presence of dysmorphic features (P = .0033, OR 3.5). Infants without dysmorphia with iCHD or multiple congenital anomalies had similar frequencies of abnormal genetic testing. CONCLUSIONS The present study provides evidence to support a comprehensive cardiovascular genetics approach in evaluating infants with critical CHD while also identifying important genotype-phenotype considerations.
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Affiliation(s)
- Amy R Shikany
- The Heart Institute, Cincinnati Children's Hospital Medical Center, Cincinnati, OH.
| | - Benjamin J Landis
- Department of Medical and Molecular Genetics, Indiana University School of Medicine, Indianapolis, IN; Department of Pediatrics, Indiana University School of Medicine, Indianapolis, IN
| | | | - Erin M Miller
- The Heart Institute, Cincinnati Children's Hospital Medical Center, Cincinnati, OH; Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH
| | - Alyxis Coyan
- Division of Human Genetics, Cincinnati Children's Hospital Medical Center, Cincinnati, OH
| | | | - Robert B Hinton
- The Heart Institute, Cincinnati Children's Hospital Medical Center, Cincinnati, OH; Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH
| | - Paula Goldenberg
- Massachusetts General Hospital, Medical Genetics, Boston, MA; Department of Pediatrics, Harvard Medical School, Boston, MA
| | - Stephanie M Ware
- Department of Medical and Molecular Genetics, Indiana University School of Medicine, Indianapolis, IN; Department of Pediatrics, Indiana University School of Medicine, Indianapolis, IN
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12
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Abstract
PURPOSE OF REVIEW This article reviews the current understanding and limitations in knowledge of the effect genetics and genetic diagnoses have on perioperative and postoperative surgical outcomes in patients with congenital heart disease (CHD). RECENT FINDINGS Presence of a known genetic diagnosis seems to effect multiple significant outcome metrics in CHD surgery including length of stay, need for extracorporeal membrane oxygenation, mortality, bleeding, and heart failure. Data regarding the effects of genetics in CHD is complicated by lack of standard genetic assessment resulting in inaccurate risk stratification of patients when analyzing data. Only 30% of variation in CHD surgical outcomes are explained by currently measured variables, with 2.5% being attributed to diagnosed genetic disorders, it is thought a significant amount of the remaining outcome variation is because of unmeasured genetic factors. SUMMARY Genetic diagnoses clearly have a significant effect on surgical outcomes in patients with CHD. Our current understanding is limited by lack of consistent genetic evaluation and assessment as well as evolving knowledge and discovery regarding the genetics of CHD. Standardizing genetic assessment of patients with CHD will allow for the best risk stratification and ultimate understanding of these effects.
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13
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Nees SN, Chung WK. Genetic Basis of Human Congenital Heart Disease. Cold Spring Harb Perspect Biol 2020; 12:cshperspect.a036749. [PMID: 31818857 DOI: 10.1101/cshperspect.a036749] [Citation(s) in RCA: 35] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Congenital heart disease (CHD) is the most common major congenital anomaly with an incidence of ∼1% of live births and is a significant cause of birth defect-related mortality. The genetic mechanisms underlying the development of CHD are complex and remain incompletely understood. Known genetic causes include all classes of genetic variation including chromosomal aneuploidies, copy number variants, and rare and common single-nucleotide variants, which can be either de novo or inherited. Among patients with CHD, ∼8%-12% have a chromosomal abnormality or aneuploidy, between 3% and 25% have a copy number variation, and 3%-5% have a single-gene defect in an established CHD gene with higher likelihood of identifying a genetic cause in patients with nonisolated CHD. These genetic variants disrupt or alter genes that play an important role in normal cardiac development and in some cases have pleiotropic effects on other organs. This work reviews some of the most common genetic causes of CHD as well as what is currently known about the underlying mechanisms.
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Affiliation(s)
| | - Wendy K Chung
- Department of Pediatrics.,Department of Medicine, Columbia University Irving Medical Center, New York, New York 10032, USA
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14
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Nasirov T, Dykes JC, Bruzoni M, Maeda K. Combined pediatric heart transplant and Nuss procedure in a patient with Marfan syndrome. JTCVS Tech 2020. [DOI: 10.1016/j.xjtc.2019.11.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
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15
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Abstract
Heterotaxy is a generalized term for patients who have an abnormality of laterality that cannot be described as situs inversus. Infants with heterotaxy can have significant anatomic and medical complexity and require personalized, specialized care, including comprehensive anatomic assessment. Common and rare anatomic findings are reviewed by system to help guide a thorough phenotypic evaluation. General care guidelines and considerations unique to this patient population are included. Future directions for this unique patient population, particularly in light of improved neonatal survival, are discussed.
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Affiliation(s)
- Gabrielle C Geddes
- Department of Pediatrics, Medical College of Wisconsin, Milwaukee, WI, USA; Herma Heart Institute, Children's Hospital of Wisconsin, 9000 West Wisconsin Avenue, MS#716, Milwaukee, WI 53226, USA.
| | - Sai-Suma Samudrala
- Department of Cell Biology, Neurobiology and Anatomy, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Michael G Earing
- Department of Pediatrics, Medical College of Wisconsin, Milwaukee, WI, USA; Herma Heart Institute, Children's Hospital of Wisconsin, 9000 West Wisconsin Avenue, MS#716, Milwaukee, WI 53226, USA; Section of Adult Cardiovascular Medicine, Department of Internal Medicine, Medical College of Wisconsin, Milwaukee, WI, USA
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16
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Meisner JK, Martin DM. Congenital heart defects in CHARGE: The molecular role of CHD7 and effects on cardiac phenotype and clinical outcomes. AMERICAN JOURNAL OF MEDICAL GENETICS PART C-SEMINARS IN MEDICAL GENETICS 2019; 184:81-89. [PMID: 31833191 DOI: 10.1002/ajmg.c.31761] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/08/2019] [Accepted: 12/02/2019] [Indexed: 02/06/2023]
Abstract
CHARGE syndrome is characterized by a pattern of congenital anomalies (Coloboma of the eye, Heart defects, Atresia of the choanae, Retardation of growth, Genital abnormalities, and Ear abnormalities). De novo mutations of chromodomain helicase DNA binding protein 7 (CHD7) are the primary cause of CHARGE syndrome. The clinical phenotype is highly variable including a wide spectrum of congenital heart defects. Here, we review the range of congenital heart defects and the molecular effects of CHD7 on cardiovascular development that lead to an over-representation of atrioventricular septal, conotruncal, and aortic arch defects in CHARGE syndrome. Further, we review the overlap of cardiovascular and noncardiovascular comorbidities present in CHARGE and their impact on the peri-operative morbidity and mortality in individuals with CHARGE syndrome.
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Affiliation(s)
- Joshua K Meisner
- Department of Pediatrics, University of Michigan, Ann Arbor, Michigan
| | - Donna M Martin
- Department of Pediatrics, University of Michigan, Ann Arbor, Michigan.,Department of Human Genetics, University of Michigan, Ann Arbor, Michigan
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Purifoy ET, Spray BJ, Riley JS, Prodhan P, Bolin EH. Effect of Trisomy 21 on Postoperative Length of Stay and Non-cardiac Surgery After Complete Repair of Tetralogy of Fallot. Pediatr Cardiol 2019; 40:1627-1632. [PMID: 31494702 DOI: 10.1007/s00246-019-02196-y] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/18/2019] [Accepted: 08/23/2019] [Indexed: 12/14/2022]
Abstract
Trisomy 21 (T21) is the most common chromosomal abnormality, and is frequently associated with congenital heart disease. Results of previous studies evaluating the effect of T21 on postoperative outcomes and complications following heart surgery have been mixed. Our goal was to determine if T21 is associated with higher frequency of adverse postoperative outcomes following repair of tetralogy of Fallot (TOF). A query of the Pediatric Health Information System was performed for patients who underwent complete repair of TOF from 2004 to 2015. Patients with a genetic syndrome other than T21 and tracheostomy and/or gastrostomy prior to heart surgery were excluded. Two groups were created on the basis of whether patients received a diagnostic code for T21. The adverse outcomes of interest were postoperative mortality, postoperative length of stay (LOS), postoperative gastrostomy, and postoperative tracheostomy. Univariate and Kaplan-Meier analysis were performed to evaluate outcomes. There were a total of 4790 patients; 430 (9%) patients had T21, and 4360 (91%) patients without a genetic diagnosis. There was no significant difference in mortality before discharge between those with and without T21 (2.3% vs 1.4%; p = 0.155). Patients with T21 had longer postoperative LOS (mean of 19.8 days vs 12.4 days; p < 0.001), and higher rates of postoperative gastrostomy (13.3% vs 5.3%; p < 0.02). There was no significant difference between groups for rates of postoperative tracheostomy (1.9% vs 1.2%; p = 0.276). Kaplan-Meier analysis confirmed that patients with T21 had longer postoperative LOS and greater incidence of gastrostomy.
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Affiliation(s)
- Eric T Purifoy
- Department of Pediatrics, Section of Pediatric Cardiology, University of Arkansas for Medical Sciences and Arkansas Children's Research Institute, 1 Children's Way, Slot 512-3, Little Rock, AR, 72202-3591, USA.
| | - Beverly J Spray
- Biostatistics Core, Arkansas Children's Research Institute, 13 Children's Way, Little Rock, AR, 72202-3591, USA
| | - Joe S Riley
- Biostatistics Core, Arkansas Children's Research Institute, 13 Children's Way, Little Rock, AR, 72202-3591, USA
| | - Parthak Prodhan
- Department of Pediatrics, Section of Pediatric Cardiology, University of Arkansas for Medical Sciences and Arkansas Children's Research Institute, 1 Children's Way, Slot 512-3, Little Rock, AR, 72202-3591, USA
| | - Elijah H Bolin
- Department of Pediatrics, Section of Pediatric Cardiology, University of Arkansas for Medical Sciences and Arkansas Children's Research Institute, 1 Children's Way, Slot 512-3, Little Rock, AR, 72202-3591, USA
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18
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Peyvandi S, Baer RJ, Moon-Grady AJ, Oltman SP, Chambers CD, Norton ME, Rajagopal S, Ryckman KK, Jelliffe-Pawlowski LL, Steurer MA. Socioeconomic Mediators of Racial and Ethnic Disparities in Congenital Heart Disease Outcomes: A Population-Based Study in California. J Am Heart Assoc 2019; 7:e010342. [PMID: 30371284 PMCID: PMC6474947 DOI: 10.1161/jaha.118.010342] [Citation(s) in RCA: 100] [Impact Index Per Article: 20.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
Background Racial/ethnic and socioeconomic disparities exist in outcomes for children with congenital heart disease. We sought to determine the influence of race/ethnicity and mediating socioeconomic factors on 1‐year outcomes for live‐born infants with hypoplastic left heart syndrome and dextro‐Transposition of the great arteries. Methods and Results The authors performed a population‐based cohort study using the California Office of Statewide Health Planning and Development database. Live‐born infants without chromosomal anomalies were included. The outcome was a composite measure of mortality or unexpected hospital readmissions within the first year of life defined as >3 (hypoplastic left heart syndrome) or >1 readmissions (dextro‐Transposition of the great arteries). Hispanic ethnicity was compared with non‐Hispanic white ethnicity. Mediation analyses determined the percent contribution to outcome for each mediator on the pathway between race/ethnicity and outcome. A total of 1796 patients comprised the cohort (n=964 [hypoplastic left heart syndrome], n=832 [dextro‐Transposition of the great arteries]) and 1315 were included in the analysis (n=477 non‐Hispanic white, n=838 Hispanic). Hispanic ethnicity was associated with a poor outcome (crude odds ratio, 1.72; 95% confidence interval [CI], 1.37–2.17). Higher maternal education (crude odds ratio 0.5; 95% CI, 0.38–0.65) and private insurance (crude odds ratio, 0.65; 95% CI, 0.45–0.71) were protective. In the mediation analysis, maternal education and insurance status explained 33.2% (95% CI, 7–66.4) and 27.6% (95% CI, 6.5–63.1) of the relationship between race/ethnicity and poor outcome, while infant characteristics played a minimal role. Conclusions Socioeconomic factors explain a significant portion of the association between Hispanic ethnicity and poor outcome in neonates with critical congenital heart disease. These findings identify vulnerable populations that would benefit from resources to lessen health disparities.
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Affiliation(s)
- Shabnam Peyvandi
- 1 Divisions of Cardiology and Critical Care Department of Pediatrics University of California San Francisco Benioff Children's Hospital San Francisco CA
| | - Rebecca J Baer
- 2 Department of Epidemiology & Biostatistics and the California Preterm Birth Initiative University of California San Francisco Benioff Children's Hospital San Francisco CA.,4 Department of Pediatrics University of California San Diego La Jolla California
| | - Anita J Moon-Grady
- 1 Divisions of Cardiology and Critical Care Department of Pediatrics University of California San Francisco Benioff Children's Hospital San Francisco CA
| | - Scott P Oltman
- 2 Department of Epidemiology & Biostatistics and the California Preterm Birth Initiative University of California San Francisco Benioff Children's Hospital San Francisco CA
| | - Christina D Chambers
- 4 Department of Pediatrics University of California San Diego La Jolla California
| | - Mary E Norton
- 3 Department of Obstetrics, Gynecology, and Reproductive Sciences University of California San Francisco Benioff Children's Hospital San Francisco CA
| | - Satish Rajagopal
- 1 Divisions of Cardiology and Critical Care Department of Pediatrics University of California San Francisco Benioff Children's Hospital San Francisco CA
| | - Kelli K Ryckman
- 5 Department of Epidemiology College of Public Health, University of Iowa Iowa City Iowa
| | - Laura L Jelliffe-Pawlowski
- 2 Department of Epidemiology & Biostatistics and the California Preterm Birth Initiative University of California San Francisco Benioff Children's Hospital San Francisco CA
| | - Martina A Steurer
- 1 Divisions of Cardiology and Critical Care Department of Pediatrics University of California San Francisco Benioff Children's Hospital San Francisco CA.,2 Department of Epidemiology & Biostatistics and the California Preterm Birth Initiative University of California San Francisco Benioff Children's Hospital San Francisco CA
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19
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Lahiri S, Gil W, Daria S, Joshua G, Parul J, Redmond B, Elizabeth W. Genetic abnormalities/syndromes significantly impact perioperative outcomes of conotruncal heart defects. Ann Pediatr Cardiol 2019; 13:38-45. [PMID: 32030034 PMCID: PMC6979035 DOI: 10.4103/apc.apc_51_19] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/15/2019] [Revised: 06/05/2019] [Accepted: 07/23/2019] [Indexed: 12/13/2022] Open
Abstract
Objectives: The main objective of the study is to characterize the effects of genetic abnormalities/syndromes (GA/S) on perioperative outcomes of cardiac surgeries involving repair of conotruncal heart defects (CTHD). Design: The study involves a single-center retrospective analysis of patients who underwent complete repair of CTHDs (tetralogy of Fallot [TOF], truncus arteriosus, interrupted aortic arch, and ventricular septal defect with coarctation) between January 2000 and December 2015. The primary outcome was the post operative length of stay (PLOS). The secondary outcomes were mortality, cardiac complications, hematologic complications, infections, and number of medications-at-discharge. Setting: Cardiac intensive care unit in a tertiary pediatric hospital in South Florida that performs around 300 open-heart surgeries a year. Subjects: A total of 177 patients with CTHDs who underwent cardiac surgeries in the stated time period were included in the final study cohort. Measurements and Main Results: Majority of patients had TOF (72.5%) and 46 (26%) had GA/S. The most common GA/S was 22q11 deletion (37%). PLOS was significantly increased in patients with GA/S (P < 0.05). Patients with GA/S were 4.5 times more likely to have a postoperative cardiac complication, 4.2 times more likely to have a postoperative infection, and received 1.6 times more medications at discharge than those without GA/S. However, GA/S was not associated with increased perioperative mortality. Black patients were three times more likely to have a longer PLOS than White patients. Conclusions: Perioperative outcomes in patients with GA/S suggested an increased residual cardiovascular disease and increased resource usage. Notably, this is the first study demonstrating the effect of race and ethnicity on PLOS in CTHD patients.
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Affiliation(s)
- Subhrajit Lahiri
- Pediatric Cardiology, Texas Children's Hospital, Houston, Texas, USA
| | - Wernovsky Gil
- Pediatric Cardiology, Children's National Health System, Washington, DC, USA
| | - Salyakina Daria
- Heart Center, Nicklaus Children's Hospital, Miami, Florida, USA
| | - Gruber Joshua
- Heart Center, Nicklaus Children's Hospital, Miami, Florida, USA
| | - Jayakar Parul
- Heart Center, Nicklaus Children's Hospital, Miami, Florida, USA
| | - Burke Redmond
- Heart Center, Nicklaus Children's Hospital, Miami, Florida, USA
| | - Welch Elizabeth
- Heart Center, Nicklaus Children's Hospital, Miami, Florida, USA
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20
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Pierpont ME, Brueckner M, Chung WK, Garg V, Lacro RV, McGuire AL, Mital S, Priest JR, Pu WT, Roberts A, Ware SM, Gelb BD, Russell MW. Genetic Basis for Congenital Heart Disease: Revisited: A Scientific Statement From the American Heart Association. Circulation 2019; 138:e653-e711. [PMID: 30571578 DOI: 10.1161/cir.0000000000000606] [Citation(s) in RCA: 344] [Impact Index Per Article: 68.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
This review provides an updated summary of the state of our knowledge of the genetic contributions to the pathogenesis of congenital heart disease. Since 2007, when the initial American Heart Association scientific statement on the genetic basis of congenital heart disease was published, new genomic techniques have become widely available that have dramatically changed our understanding of the causes of congenital heart disease and, clinically, have allowed more accurate definition of the pathogeneses of congenital heart disease in patients of all ages and even prenatally. Information is presented on new molecular testing techniques and their application to congenital heart disease, both isolated and associated with other congenital anomalies or syndromes. Recent advances in the understanding of copy number variants, syndromes, RASopathies, and heterotaxy/ciliopathies are provided. Insights into new research with congenital heart disease models, including genetically manipulated animals such as mice, chicks, and zebrafish, as well as human induced pluripotent stem cell-based approaches are provided to allow an understanding of how future research breakthroughs for congenital heart disease are likely to happen. It is anticipated that this review will provide a large range of health care-related personnel, including pediatric cardiologists, pediatricians, adult cardiologists, thoracic surgeons, obstetricians, geneticists, genetic counselors, and other related clinicians, timely information on the genetic aspects of congenital heart disease. The objective is to provide a comprehensive basis for interdisciplinary care for those with congenital heart disease.
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21
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Morell E, Moynihan K, Wolfe J, Blume ED. Palliative care and paediatric cardiology: current evidence and future directions. THE LANCET CHILD & ADOLESCENT HEALTH 2019; 3:502-510. [PMID: 31126897 DOI: 10.1016/s2352-4642(19)30121-x] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/31/2018] [Revised: 01/20/2019] [Accepted: 02/27/2019] [Indexed: 12/24/2022]
Abstract
Although outcomes for children with heart disease have improved substantially over the past several decades, heart disease remains one of the leading causes of paediatric mortality. For children who progress to advanced heart disease, disease morbidity is high, with many children requiring multiple surgical interventions and long-term intensive care hospitalisations. Care for children with advanced heart disease requires a multidisciplinary approach, and opportunities for earlier integration of palliative care are being explored. This Viewpoint summarises the relevant literature over the past decade. We also identify gaps in parent and provider understanding of prognosis and communication, propose indications for palliative care consultation in paediatric advanced heart disease, and summarise attitudes and perceived barriers to palliative care consultation. Areas for additional research that we identify include paediatric cardiologist education, parental distress, socioeconomic disparities, and patient-reported outcomes. Interdisciplinary clinical and research efforts are required to further advance the field and improve integration of palliative care in the care of children with heart disease.
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Affiliation(s)
- Emily Morell
- Division of Pediatric Critical Care, UCSF Benioff Children's Hospitals, San Francisco, CA, USA
| | - Katie Moynihan
- Department of Cardiology, Boston Children's Hospital, Boston, MA, USA
| | - Joanne Wolfe
- Pediatric Palliative Care, Boston Children's Hospital, Boston, MA, USA
| | - Elizabeth D Blume
- Department of Cardiology, Boston Children's Hospital, Boston, MA, USA.
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22
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Duong SQ, Godown J, Soslow JH, Thurm C, Hall M, Sainathan S, Morell VO, Dodd DA, Feingold B. Increased mortality, morbidities, and costs after heart transplantation in heterotaxy syndrome and other complex situs arrangements. J Thorac Cardiovasc Surg 2019; 157:730-740.e11. [PMID: 30669235 PMCID: PMC6865268 DOI: 10.1016/j.jtcvs.2018.11.022] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/11/2018] [Revised: 10/22/2018] [Accepted: 11/04/2018] [Indexed: 12/16/2022]
Abstract
OBJECTIVES Identify pediatric heart transplant (HT) recipients with heterotaxy and other complex arrangements of cardiac situs (heterotaxy/situs anomaly) and compare mortality, morbidities, length of stay (LOS), and costs to recipients with congenital heart disease without heterotaxy/situs anomaly. METHODS Using linked registry data (2001-2016), we identified 186 HT recipients with heterotaxy/situs anomaly and 1254 with congenital heart disease without heterotaxy/situs anomaly. We compared post-HT outcomes in univariable and multivariable time-to-event analyses. LOS and cost from HT to discharge were compared using Wilcoxon rank-sum tests. Sensitivity analyses were performed using stricter heterotaxy/situs anomaly group inclusion criteria and through propensity matching. RESULTS HT recipients with heterotaxy/situs anomaly were older (median age, 5.1 vs 1.6 years; P < .001) and more often black, Asian, Hispanic, or "other" nonwhite (54% vs 32%; P < .001). Heterotaxy/situs anomaly was independently associated with increased mortality (hazard ratio, 1.58; 95% confidence interval, 1.19-2.09; P = .002), even among 6-month survivors (hazard ratio, 1.86; 95% confidence interval, 1.09-3.16; P = .021). Heterotaxy/situs anomaly recipients more commonly required dialysis (odds ratio, 2.58; 95% confidence interval, 1.51-4.42; P = .001) and cardiac reoperation (odds ratio, 1.91; 95% confidence interval, 1.17-3.11; P = .010) before discharge. They had longer ischemic times (19.2 additional minutes [range, 10.9-27.5 minutes]; P < .001), post-HT intensive care unit LOS (16 vs 13 days; P = .012), and hospital LOS (26 vs 23 days; P = .005). Post-HT hospitalization costs were also greater ($447,604 vs $379,357; P = .001). CONCLUSIONS Heterotaxy and other complex arrangements of cardiac situs are associated with increased mortality, postoperative complications, LOS, and costs after HT. Although increased surgical complexity can account for many of these differences, inferior late survival is not well explained and deserves further study.
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Affiliation(s)
- Son Q Duong
- Department of Pediatrics, University of Pittsburgh School of Medicine, Pittsburgh, Pa
| | - Justin Godown
- Division of Pediatric Cardiology, Monroe Carell Jr. Children's Hospital at Vanderbilt, Nashville, Tenn
| | - Jonathan H Soslow
- Division of Pediatric Cardiology, Monroe Carell Jr. Children's Hospital at Vanderbilt, Nashville, Tenn
| | - Cary Thurm
- Children's Hospital Association, Lenexa, Kan
| | - Matt Hall
- Children's Hospital Association, Lenexa, Kan
| | - Sandeep Sainathan
- Department of Cardiothoracic Surgery, University of Pittsburgh School of Medicine, Pittsburgh, Pa
| | - Victor O Morell
- Department of Cardiothoracic Surgery, University of Pittsburgh School of Medicine, Pittsburgh, Pa
| | - Debra A Dodd
- Division of Pediatric Cardiology, Monroe Carell Jr. Children's Hospital at Vanderbilt, Nashville, Tenn
| | - Brian Feingold
- Department of Pediatrics, University of Pittsburgh School of Medicine, Pittsburgh, Pa; Department of Clinical and Translational Science, University of Pittsburgh School of Medicine, Pittsburgh, Pa.
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Thoraco-Abdominal Abnormalities in Bardet-Biedl Syndrome: Situs Inversus and Heterotaxy. J Pediatr 2019; 204:31-37. [PMID: 30293640 DOI: 10.1016/j.jpeds.2018.08.068] [Citation(s) in RCA: 25] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/02/2018] [Revised: 07/16/2018] [Accepted: 08/28/2018] [Indexed: 12/19/2022]
Abstract
OBJECTIVES To characterize the diversity and prevalence of thoraco-abdominal abnormalities in Bardet-Biedl syndrome (BBS), a model ciliopathy for understanding the role of cilia in human health. STUDY DESIGN The Clinical Registry Investigating BBS, a worldwide registry exploring the phenotype and natural history of BBS, was used to conduct the study. Protected health information was obtained by subject or family interview and Health Insurance Portability and Accountability Act-approved release of data including imaging studies and genetic testing. Echocardiography and imaging findings were independently confirmed by 2 cardiologists. RESULTS Thoraco-abdominal abnormalities were identified in 6 of 368 (1.6%) subjects with a minimum prevalence of 1 in 60 Clinical Registry Investigating BBS participants. Diverse laterality defects were observed suggesting that the underlying ciliopathy randomly alters embryonic left-right axis orientation. Congenital heart disease, common in heterotaxy, was present in 2 subjects. Additional defects, uncommonly reported in BBS, were observed in the central nervous, genitourinary, gastrointestinal, and musculoskeletal systems in the subjects. No BBS genotype was favored in the cohort. One subject had genetic and clinical phenotype diagnostic of both primary ciliary dyskinesia and BBS. CONCLUSIONS The variety of thoraco-abdominal abnormalities in BBS suggests the pleiotropic nature of these anomalies is not confined to a single pattern or genotype. Clinicians providing care to individuals with BBS should consider the increased prevalence of thoraco-abdominal anomalies in BBS. Individuals with features suggestive of other ciliopathies, such as primary ciliary dyskinesia, should undergo further evaluation for additional genetic disorders. TRIAL REGISTRATION ClinicalTrials.gov: NCT02329210.
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Furlong-Dillard J, Bailly D, Amula V, Wilkes J, Bratton S. Resource Use and Morbidities in Pediatric Cardiac Surgery Patients with Genetic Conditions. J Pediatr 2018; 193:139-146.e1. [PMID: 29246465 DOI: 10.1016/j.jpeds.2017.09.085] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/14/2017] [Revised: 08/24/2017] [Accepted: 09/29/2017] [Indexed: 01/21/2023]
Abstract
OBJECTIVE To evaluate and describe resource use and perioperative morbidities among those patients with genetic conditions undergoing cardiac surgery. STUDY DESIGN Using the Pediatric Health Information System database, we identified patients ≤18 years old with cardiac surgery classified by Risk Adjustment for Congenital Heart Surgery (RACHS) during 2003-2014. A total of 95 253 patients met study criteria and included no genetic conditions (84.6%), trisomy 21 (9.9%), trisomy 13 or 18 (0.2%), 22q11 deletion (0.8%), Turner syndrome (0.4%), and "other" genetic conditions (4.2%). We compared perioperative complications and procedures in each genetic condition with patients without genetic conditions using regression analysis. RESULTS All groups with genetic conditions, excluding trisomy 21 RACHS 3-5, experienced increased length of stay and cost among survivors. Complications varied by genetic condition, with patients with trisomy 21 having increased odds of pulmonary hypertension and nosocomial infections. Patients with 22q11 only had increased odds of infection. Patients with Turner syndrome had increased odds of acute renal failure (OR 2.35). Patients with trisomy 13 or 18 had increased odds of pulmonary hypertension (OR 3.13), acute renal failure (OR 2.93), cardiac arrest (OR 2.84), and nosocomial infections (OR 3.53), and those with "other" genetic conditions had increased odds of all complications. CONCLUSIONS Children with congenital heart disease and genetic conditions, except trisomy 21 RACHS 3-5, had increased costs and length of stay. Perioperative morbidities were more common and differed across genetic condition subgroups. Patient-specific risk factors are important for risk stratification, benchmarking, and counseling with families.
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Affiliation(s)
- Jamie Furlong-Dillard
- Department of Pediatrics, Division Critical Care, University of Utah School of Medicine, Salt Lake City, UT
| | - David Bailly
- Department of Pediatrics, Division Critical Care, University of Utah School of Medicine, Salt Lake City, UT
| | - Venugopal Amula
- Department of Pediatrics, Division Critical Care, University of Utah School of Medicine, Salt Lake City, UT
| | - Jacob Wilkes
- Quality and Informatics, Intermountain Healthcare, Salt Lake City, UT
| | - Susan Bratton
- Department of Pediatrics, Division Critical Care, University of Utah School of Medicine, Salt Lake City, UT
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Blue GM, Kirk EP, Giannoulatou E, Sholler GF, Dunwoodie SL, Harvey RP, Winlaw DS. Advances in the Genetics of Congenital Heart Disease: A Clinician's Guide. J Am Coll Cardiol 2017; 69:859-870. [PMID: 28209227 DOI: 10.1016/j.jacc.2016.11.060] [Citation(s) in RCA: 88] [Impact Index Per Article: 12.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/26/2016] [Revised: 11/15/2016] [Accepted: 11/17/2016] [Indexed: 11/18/2022]
Abstract
Our understanding of the genetics of congenital heart disease (CHD) is rapidly expanding; however, many questions, particularly those relating to sporadic forms of disease, remain unanswered. Massively parallel sequencing technology has made significant contributions to the field, both from a diagnostic perspective for patients and, importantly, also from the perspective of disease mechanism. The importance of de novo variation in sporadic disease is a recent highlight, and the genetic link between heart and brain development has been established. Furthermore, evidence of an underlying burden of genetic variation contributing to sporadic and familial forms of CHD has been identified. Although we are still unable to identify the cause of CHD for most patients, recent findings have provided us with a much clearer understanding of the types of variants and their individual contributions and collectively mark an important milestone in our understanding of both familial and sporadic forms of disease.
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Affiliation(s)
- Gillian M Blue
- Kids Heart Research, The Children's Hospital at Westmead, Sydney, Australia; Heart Centre for Children, The Children's Hospital at Westmead, Sydney, Australia; Sydney Medical School, University of Sydney, Australia
| | - Edwin P Kirk
- Department of Medical Genetics, Sydney Children's Hospital, Sydney, Australia; School of Women's and Children's Health, Faculty of Medicine, University of New South Wales, Sydney, Australia
| | - Eleni Giannoulatou
- Victor Chang Cardiac Research Institute, Darlinghurst, Sydney, Australia; St Vincent's Clinical School, Faculty of Medicine, University of New South Wales, Sydney, Australia; School of Biotechnology and Biomolecular Sciences, University of New South Wales, Sydney
| | - Gary F Sholler
- Kids Heart Research, The Children's Hospital at Westmead, Sydney, Australia; Heart Centre for Children, The Children's Hospital at Westmead, Sydney, Australia; Sydney Medical School, University of Sydney, Australia
| | - Sally L Dunwoodie
- Victor Chang Cardiac Research Institute, Darlinghurst, Sydney, Australia; St Vincent's Clinical School, Faculty of Medicine, University of New South Wales, Sydney, Australia; School of Biotechnology and Biomolecular Sciences, University of New South Wales, Sydney
| | - Richard P Harvey
- Victor Chang Cardiac Research Institute, Darlinghurst, Sydney, Australia; St Vincent's Clinical School, Faculty of Medicine, University of New South Wales, Sydney, Australia; School of Biotechnology and Biomolecular Sciences, University of New South Wales, Sydney
| | - David S Winlaw
- Kids Heart Research, The Children's Hospital at Westmead, Sydney, Australia; Heart Centre for Children, The Children's Hospital at Westmead, Sydney, Australia; Sydney Medical School, University of Sydney, Australia.
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Jernigan EG, Strassle PD, Stebbins RC, Meyer RE, Nelson JS. Effect of Concomitant Birth Defects and Genetic Anomalies on Infant Mortality in Tetralogy of Fallot. Birth Defects Res 2017. [PMID: 28627098 DOI: 10.1002/bdr2.1057] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
BACKGROUND A substantial proportion of infants born with tetralogy of Fallot (TOF) die in infancy. A better understanding of the heterogeneity associated with TOF, including extracardiac malformations and chromosomal anomalies is vital to stratifying risk and optimizing outcomes during infancy. METHODS Using the North Carolina Birth Defects Monitoring Program, infants diagnosed with TOF and born between 2003 and 2012 were included. Kaplan-Meier survival curves were used to estimate cumulative 1-year mortality, stratified by the presence of concomitant birth defects (BDs) and chromosomal anomalies. Multivariable logistic regression was used to estimate the direct effect of each concomitant BD, after adjusting for all others. RESULTS A total of 496 infants with TOF were included, and 15% (n = 76) died. The number of concomitant BD systems was significantly associated with the risk of death at 1-year, p < 0.0001. Specifically, the risk of mortality was 8% among infants with TOF with or without additional cardiac defects, 16% among infants with TOF and 1 extracardiac BD system, 19% among infants with 2 extracardiac BD systems, and 39% among infants with ≥ 3 extracardiac BD systems. After adjustment, concomitant eye and gastrointestinal defects were significantly associated increased with 1-year mortality, odds ratio 2.83 (95% confidence interval, 1.08-7.32) and odds ratio 4.43 (95% confidence interval, 1.57, 12.45), respectively. Infants with trisomy 13 or trisomy 18 were also significantly more likely to die, p < 0.0001. CONCLUSION Both concomitant BDs and genetic anomalies increase the risk of mortality among infants with TOF. Future studies are needed to identify the underlying genetic and socioeconomic risk factors for high-risk TOF infants. Birth Defects Research 109:1154-1165, 2017. © 2017 Wiley Periodicals, Inc.
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Affiliation(s)
- Eric G Jernigan
- University of North Carolina School of Medicine, Chapel Hill, North Carolina
| | - Paula D Strassle
- Department of Epidemiology, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina.,Department of Surgery, University of North Carolina School of Medicine, Chapel Hill, North Carolina
| | - Rebecca C Stebbins
- Department of Epidemiology, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Robert E Meyer
- North Carolina State Center for Health Statistics Birth Defects Monitoring Program, Raleigh, North Carolina.,Department of Maternal and Child Health, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Jennifer S Nelson
- Department of Epidemiology, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina.,Department of Surgery, University of North Carolina School of Medicine, Chapel Hill, North Carolina.,Department of Cardiothoracic, Surgery Nemours Children's Hospital, Orlando, FL, USA
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Landis BJ, Ware SM. The Current Landscape of Genetic Testing in Cardiovascular Malformations: Opportunities and Challenges. Front Cardiovasc Med 2016; 3:22. [PMID: 27504451 PMCID: PMC4959014 DOI: 10.3389/fcvm.2016.00022] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2016] [Accepted: 06/30/2016] [Indexed: 12/21/2022] Open
Abstract
Human cardiovascular malformations (CVMs) frequently have a genetic contribution. Through the application of novel technologies, such as next-generation sequencing, DNA sequence variants associated with CVMs are being identified at a rapid pace. While clinicians are now able to offer testing with NGS gene panels or whole exome sequencing to any patient with a CVM, the interpretation of genetic variation remains problematic. Variable phenotypic expression, reduced penetrance, inconsistent phenotyping methods, and the lack of high-throughput functional testing of variants contribute to these challenges. This article elaborates critical issues that impact the decision to broadly implement clinical molecular genetic testing in CVMs. Major benefits of testing include establishing a genetic diagnosis, facilitating cost-effective screening of family members who may have subclinical disease, predicting recurrence risk in offsprings, enabling early diagnosis and anticipatory management of CV and non-CV disease phenotypes, predicting long-term outcomes, and facilitating the development of novel therapies aimed at disease improvement or prevention. Limitations include financial cost, psychosocial cost, and ambiguity of interpretation of results. Multiplex families and patients with syndromic features are two groups where disease causation could potentially be firmly established. However, these account for the minority of the overall CVM population, and there is increasing recognition that genotypes previously associated with syndromes also exist in patients who lack non-CV findings. In all circumstances, ongoing dialog between cardiologists and clinical geneticists will be needed to accurately interpret genetic testing and improve these patients’ health. This may be most effectively implemented by the creation and support of CV genetics services at centers committed to pursuing testing for patients.
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Affiliation(s)
- Benjamin J Landis
- Department of Pediatrics, Indiana University School of Medicine, Indianapolis, IN, USA; Department of Medical and Molecular Genetics, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Stephanie M Ware
- Department of Pediatrics, Indiana University School of Medicine, Indianapolis, IN, USA; Department of Medical and Molecular Genetics, Indiana University School of Medicine, Indianapolis, IN, USA
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