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Jalal Z, Langouet E, Dib N, Le-Quellenec S, Mostefa-Kara M, Martin A, Roubertie F, Thambo JB. Role and Applications of Experimental Animal Models of Fontan Circulation. J Clin Med 2024; 13:2601. [PMID: 38731130 PMCID: PMC11084605 DOI: 10.3390/jcm13092601] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/29/2024] [Revised: 04/17/2024] [Accepted: 04/26/2024] [Indexed: 05/13/2024] Open
Abstract
Over the last four decades, the Fontan operation has been the treatment of choice for children born with complex congenital heart diseases and a single-ventricle physiology. However, therapeutic options remain limited and despite ongoing improvements in initial surgical repair, patients still experience a multiplicity of cardiovascular complications. The causes for cardiovascular failure are multifactorial and include systemic ventricular dysfunction, pulmonary vascular resistance, atrioventricular valve regurgitation, arrhythmia, development of collaterals, protein-losing enteropathy, hepatic dysfunction, and plastic bronchitis, among others. The mechanisms leading to these late complications remain to be fully elucidated. Experimental animal models have been developed as preclinical steps that enable a better understanding of the underlying pathophysiology. They furthermore play a key role in the evaluation of the efficacy and safety of new medical devices prior to their use in human clinical studies. However, these experimental models have several limitations. In this review, we aim to provide an overview of the evolution and progress of the various types of experimental animal models used in the Fontan procedure published to date in the literature. A special focus is placed on experimental studies performed on animal models of the Fontan procedure with or without mechanical circulatory support as well as a description of their impact in the evolution of the Fontan design. We also highlight the contribution of animal models to our understanding of the pathophysiology and assess forthcoming developments that may improve the contribution of animal models for the testing of new therapeutic solutions.
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Affiliation(s)
- Zakaria Jalal
- Department of Pediatric and Adult Congenital Cardiology, University Hospital of Bordeaux, 33600 Pessac, France; (N.D.); (F.R.); (J.-B.T.)
- LIRYC Electrophysiology and Heart Modeling Institute, Fondation Bordeaux Université, 33600 Pessac, France
- Centre de Recherche Cardio-Thoracique de Bordeaux, INSERM U1045, 33600 Pessac, France
| | - Elise Langouet
- Department of Pediatric and Adult Congenital Cardiology Anesthesiology, University Hospital of Bordeaux, 33600 Pessac, France;
| | - Nabil Dib
- Department of Pediatric and Adult Congenital Cardiology, University Hospital of Bordeaux, 33600 Pessac, France; (N.D.); (F.R.); (J.-B.T.)
- LIRYC Electrophysiology and Heart Modeling Institute, Fondation Bordeaux Université, 33600 Pessac, France
- Centre de Recherche Cardio-Thoracique de Bordeaux, INSERM U1045, 33600 Pessac, France
| | | | - Mansour Mostefa-Kara
- Adult Congenital Heart Disease Medico-Surgical Unit, European Georges Pompidou Hospital, 75015 Paris, France;
| | - Amandine Martin
- Department of Cardiac Surgery, University Hospital, 97400 Saint-Denis, France;
| | - François Roubertie
- Department of Pediatric and Adult Congenital Cardiology, University Hospital of Bordeaux, 33600 Pessac, France; (N.D.); (F.R.); (J.-B.T.)
- LIRYC Electrophysiology and Heart Modeling Institute, Fondation Bordeaux Université, 33600 Pessac, France
- Centre de Recherche Cardio-Thoracique de Bordeaux, INSERM U1045, 33600 Pessac, France
| | - Jean-Benoît Thambo
- Department of Pediatric and Adult Congenital Cardiology, University Hospital of Bordeaux, 33600 Pessac, France; (N.D.); (F.R.); (J.-B.T.)
- LIRYC Electrophysiology and Heart Modeling Institute, Fondation Bordeaux Université, 33600 Pessac, France
- Centre de Recherche Cardio-Thoracique de Bordeaux, INSERM U1045, 33600 Pessac, France
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Fernandes JF, Bellsham-Revell H, Wong J, Salih C, Pushparajah K, Lamata P, de Vecchi A. Hemodynamic inefficiencies during stress hold key for comprehensive assessment after Fontan operation. JTCVS Tech 2024; 23:81-85. [PMID: 38352014 PMCID: PMC10859639 DOI: 10.1016/j.xjtc.2023.11.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2023] [Revised: 10/24/2023] [Accepted: 10/25/2023] [Indexed: 02/16/2024] Open
Affiliation(s)
- Joao F. Fernandes
- School of Biomedical Engineering and Imaging Sciences, King's College London, London, United Kingdom
| | - Hannah Bellsham-Revell
- Department of Congenital Heart Disease, Evelina London Children's Hospital, Guy's & St Thomas' Hospital, London, United Kingdom
| | - James Wong
- Department of Congenital Heart Disease, Evelina London Children's Hospital, Guy's & St Thomas' Hospital, London, United Kingdom
| | - Caner Salih
- Department of Congenital Heart Disease, Evelina London Children's Hospital, Guy's & St Thomas' Hospital, London, United Kingdom
| | - Kuberan Pushparajah
- School of Biomedical Engineering and Imaging Sciences, King's College London, London, United Kingdom
- Department of Congenital Heart Disease, Evelina London Children's Hospital, Guy's & St Thomas' Hospital, London, United Kingdom
| | - Pablo Lamata
- School of Biomedical Engineering and Imaging Sciences, King's College London, London, United Kingdom
| | - Adelaide de Vecchi
- School of Biomedical Engineering and Imaging Sciences, King's College London, London, United Kingdom
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Laohachai K, Ayer J. Impairments in Pulmonary Function in Fontan Patients: Their Causes and Consequences. Front Pediatr 2022; 10:825841. [PMID: 35498782 PMCID: PMC9051243 DOI: 10.3389/fped.2022.825841] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/30/2021] [Accepted: 02/23/2022] [Indexed: 11/26/2022] Open
Abstract
Patients with a Fontan circulation lack a sub-pulmonary ventricle with pulmonary blood flow passively redirected to the lungs. In the Fontan circulation, ventilation has a significant influence on pulmonary blood flow and cardiac output both at rest and with exercise. Children and adults with a Fontan circulation have abnormalities in lung function. In particular, restrictive ventilatory patterns, as measured by spirometry, and impaired gas transfer, as measured by the diffusing capacity of carbon monoxide, have been frequently observed. These abnormalities in lung function are associated with reduced exercise capacity and quality of life. Moderate to severe impairment in lung volumes is independently associated with reduced survival in adults with congenital heart disease. Skeletal and inspiratory muscle weakness has also been reported in patients with a Fontan circulation, with the prospect of improving respiratory muscle function through exercise training programs. In this review, we will present data on cardiopulmonary interactions in the Fontan circulation, the prevalence and severity of impaired lung function, and respiratory muscle function in this population. We will discuss potential causes for and consequence of respiratory impairments, and their impact on exercise capacity and longer-term Fontan outcome. We aim to shed light on possible strategies to reduce morbidity by improving respiratory function in this growing population of patients.
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Affiliation(s)
- Karina Laohachai
- Cardiology Department, Women's and Children's Hospital, Adelaide, SA, Australia.,Faculty of Medicine and Health, The University of Sydney, Sydney, NSW, Australia
| | - Julian Ayer
- Faculty of Medicine and Health, The University of Sydney, Sydney, NSW, Australia.,The Heart Centre for Children, Children's Hospital at Westmead, Sydney, NSW, Australia
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Zhong SW, Zhang YQ, Chen LJ, Zhang ZF, Wu LP, Hong WJ. Ventricular function and dyssynchrony in children with a functional single right ventricle using real time three-dimensional echocardiography after fontan operation. Echocardiography 2021; 38:1218-1227. [PMID: 34156720 DOI: 10.1111/echo.15148] [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: 03/23/2021] [Revised: 06/06/2021] [Accepted: 06/11/2021] [Indexed: 11/29/2022] Open
Abstract
BACKGROUND This study aimed to evaluate the feasibility and clinical value of real time three-dimensional echocardiography (RT-3DE) for assessing ventricular systolic dysfunction and dyssynchrony in children with an functional single right ventricle (FSRV) having undergone the Fontan procedure. METHODS Twenty-five children with an FSRV and 25 healthy children were enrolled in our study. RV volume analysis was performed compared with magnetic resonance imaging (MRI) as the reference standard in FSRV patients. The patients were divided into wide and narrow QRS interval groups. Global and regional functions of the RV in three compartments (inflow, body, and outflow) were compared between FSRV and control subjects, including RV systolic dyssynchrony indices of maximal difference of time to minimal volume (Tmsv-Dif), standard deviation of time to minimal volume (Tmsv-SD), maximal difference of time to minimal volume corrected by R-R interval (Tmsv-Dif%), and standard deviation of time to minimal volume corrected by R-R interval (Tmsv-SD%). RESULTS RT-3DE measurements were significantly lower than MRI measurements for RV-EDV, RV-ESV, RV-SV, and RVEF (p < 0.01).Compared with controls, patients with an FRSV had significantly higher dyssynchrony indices and significantly lower global EF in both narrow QRS interval and wide QRS interval groups. Tmsv-SD% was shown to be most strongly correlated with MRI-RVEF (r = -.570, p = 0.003). CONCLUSIONS RT-3DE tended to underestimate RV ventricular volume in children with FSRV. Children with an FSRV and either a wide or narrow QRS interval had reduced ventricular function and higher dyssynchrony than normal subjects. Worsening RV dyssynchrony is associated with overall decline in function after the Fontan operation.
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Affiliation(s)
- Shu-Wen Zhong
- International Department, Shanghai Children's Medical Center, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
| | - Yu-Qi Zhang
- Department of Pediatric Cardiology, Shanghai Children's Medical Center, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
| | - Li-Jun Chen
- Department of Pediatric Cardiology, Shanghai Children's Medical Center, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
| | - Zhi-Fang Zhang
- Department of Pediatric Cardiology, Shanghai Children's Medical Center, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
| | - Lan-Ping Wu
- Department of Pediatric Cardiology, Shanghai Children's Medical Center, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
| | - Wen-Jing Hong
- Department of Pediatric Cardiology, Shanghai Children's Medical Center, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
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Vaiyani D, Matsuo K, Kanaan U, Patel B, Akintoye O, Travers CD, Kelleman M, Sachdeva R, Petit CJ. Total vascular resistance increases during volume-unloading in asymptomatic single ventricle patients. Am Heart J 2021; 236:69-79. [PMID: 33640333 DOI: 10.1016/j.ahj.2021.02.019] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/21/2020] [Accepted: 02/23/2021] [Indexed: 11/19/2022]
Abstract
OBJECTIVE While the surgical stages of single ventricle (SV) palliation serve to separate pulmonary venous and systemic venous return, and to volume-unload the SV, staged palliation also results in transition from parallel to series circulation, increasing total vascular resistance. How this transition affects pressure loading of the SV is as yet unreported. METHODS We performed a retrospective chart review of Stage I, II, and III cardiac catheterization (CC) and echocardiographic data from 2001-2017 in all SV pts, with focus on systemic, pulmonary, and total vascular resistance (SVR, PVR, TVR respectively). Longitudinal analyses were performed with log-transformed variables. Effects of SVR-lowering medications were analyzed using Wilcoxon rank-sum testing. RESULTS There were 372 total patients who underwent CC at a Stage I (median age of 4.4 months, n=310), Stage II (median age 2.7 years, n = 244), and Stage III (median age 7.3 years, n = 113). Total volume loading decreases with progression to Stage III (P< 0.001). While PVR gradually increases from Stage II to Stage III, and SVR increases from Stage I to Stage III, TVR dramatically increases with progress towards series circulation. TVR was not affected by use of systemic vasodilator therapy. TVR, PVR, SVR, and CI did not correlate with indices of SV function at Stage III. CONCLUSIONS TVR steadily increases with an increasing contribution from SVR over progressive stages. TVR was not affected by systemic vasodilator agents. TVR did not correlate with echo-based indices of SV function. Further studies are needed to see if modulating TVR can improve exercise tolerance and outcomes.
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Affiliation(s)
- Danish Vaiyani
- Division of Cardiology, Children's Healthcare of Atlanta, Atlanta, GA; Division of Pediatrics, Emory University, Atlanta, GA.
| | | | - Usama Kanaan
- Division of Cardiology, Children's Healthcare of Atlanta, Atlanta, GA; Division of Pediatrics, Emory University, Atlanta, GA
| | | | - Ololade Akintoye
- Division of Cardiology, Children's Healthcare of Atlanta, Atlanta, GA; Division of Pediatrics, Emory University, Atlanta, GA
| | | | | | - Ritu Sachdeva
- Division of Cardiology, Children's Healthcare of Atlanta, Atlanta, GA; Division of Pediatrics, Emory University, Atlanta, GA
| | - Christopher J Petit
- Division of Cardiology, Columbia University Vagelos College of Physicians and Surgeons, Columbia University, New York, NY
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Schäfer M, Frank BS, Jacobsen R, Rausch CM, Mitchell MB, Jaggers J, Stone ML, Morgan GJ, Browne LP, Barker AJ, Hunter KS, Ivy DD, Younoszai A, Di Maria MV. Patients with Fontan circulation have abnormal aortic wave propagation patterns: A wave intensity analysis study. Int J Cardiol 2020; 322:158-167. [PMID: 32853667 DOI: 10.1016/j.ijcard.2020.08.063] [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: 05/21/2020] [Revised: 07/17/2020] [Accepted: 08/17/2020] [Indexed: 01/09/2023]
Abstract
BACKGROUND Elevated systemic afterload in patients with Fontan circulation may lead to impaired single ventricular function. Wave intensity analysis (WIA) enables evaluation of compression and expansion waves traveling through vasculature. We aimed to investigate the unfavorable wave propagation causing excessive afterload may be an important contributor to the overall single ventricle function and to the limited functional capacity in this patient population. METHODS Patients with hypoplastic left heart syndrome (HLHS) (n = 25), single left ventricle (SLV) (n = 24), and normal controls (n = 10) underwent phase-contrast MRI based WIA analysis evaluated in the ascending aorta. Forward compression wave (FCW) representing dP/dt, backward compression wave (BCW) reflecting vascular stiffness, and forward decompression wave (FDW) representing LV relaxation were recorded and indexed to each other. RESULTS FCW was lowest in HLHS patients (1098 mm5/s), and higher in the SLV group (1457 mm5/s), and controls (6457 mm5/s) (P < 0.001). BCW/FCW was increased in HLHS (0.22) and SLV (0.14) groups compared to controls (0.08) (P = 0.003). Peak VO2 correlated with FCW (R = 0.50, P = 0.015), stroke volume (R = 0.72, P < 0.001), and cardiac output (R = 0.44, P = 0.034). CONCLUSIONS Patients with HLHS and SLV have unfavorable aortic WIA patterns with increased BCW/FCW ratio indicating increased systemic afterload due to retrograde compression waves. Reduced FCW and systolic MRI indices correlated with peak VO2 suggesting that abnormal systolic wave propagation may play a role in exercise intolerance for Fontan patients.
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Affiliation(s)
- Michal Schäfer
- Heart Institute, Children's Hospital Colorado, University of Colorado - Denver, Anschutz Medical Campus, USA.
| | - Benjamin S Frank
- Heart Institute, Children's Hospital Colorado, University of Colorado - Denver, Anschutz Medical Campus, USA
| | - Roni Jacobsen
- Heart Institute, Children's Hospital Colorado, University of Colorado - Denver, Anschutz Medical Campus, USA
| | - Christopher M Rausch
- Heart Institute, Children's Hospital Colorado, University of Colorado - Denver, Anschutz Medical Campus, USA
| | - Max B Mitchell
- Division of Pediatric Cardiothoracic Surgery, Department of Surgery, University of Colorado - Denver, Anschutz Medical Campus, USA
| | - James Jaggers
- Division of Pediatric Cardiothoracic Surgery, Department of Surgery, University of Colorado - Denver, Anschutz Medical Campus, USA
| | - Matthew L Stone
- Division of Pediatric Cardiothoracic Surgery, Department of Surgery, University of Colorado - Denver, Anschutz Medical Campus, USA
| | - Gareth J Morgan
- Heart Institute, Children's Hospital Colorado, University of Colorado - Denver, Anschutz Medical Campus, USA
| | - Lorna P Browne
- Department of Radiology, Children's Hospital Colorado, University of Colorado - Denver, Anschutz Medical Campus, USA
| | - Alex J Barker
- Department of Radiology, Children's Hospital Colorado, University of Colorado - Denver, Anschutz Medical Campus, USA; Department of Bioengineering, University of Colorado - Denver, Anschutz Medical Campus, USA
| | - Kendall S Hunter
- Heart Institute, Children's Hospital Colorado, University of Colorado - Denver, Anschutz Medical Campus, USA; Department of Bioengineering, University of Colorado - Denver, Anschutz Medical Campus, USA
| | - D Dunbar Ivy
- Heart Institute, Children's Hospital Colorado, University of Colorado - Denver, Anschutz Medical Campus, USA
| | - Adel Younoszai
- Heart Institute, Children's Hospital Colorado, University of Colorado - Denver, Anschutz Medical Campus, USA
| | - Michael V Di Maria
- Heart Institute, Children's Hospital Colorado, University of Colorado - Denver, Anschutz Medical Campus, USA
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Winkler C, Neidlin M, Sonntag SJ, Grünwald A, Groß-Hardt S, Breuer J, Linden K, Herberg U. Estimation of left ventricular stroke work based on a large cohort of healthy children. Comput Biol Med 2020; 123:103908. [PMID: 32768048 DOI: 10.1016/j.compbiomed.2020.103908] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2020] [Revised: 07/04/2020] [Accepted: 07/04/2020] [Indexed: 11/19/2022]
Abstract
Left ventricular stroke work is an important prognostic marker to analyze cardiac function. Standard values for children are, however, missing. For clinicians, standards can help to improve the treatment decision of heart failures. For engineers, they can help to optimize medical devices. In this study, we estimated the left ventricular stroke work for children based on modeled pressure-volume loops. A lumped parameter model was fitted to clinical data of 340 healthy children. Reference curves for standard values were created over age, weight, and height. Left ventricular volume was measured with 3D echocardiography, while maximal ventricular pressure was approximated with a regression model from the literature. For validation of this method, we used 18 measurements acquired by a conductance catheter in 11 patients. The method demonstrated a low absolute mean difference of 0.033 J (SD: 0.031 J) for stroke work between measurement and estimation, while the percentage error was 21.66 %. According to the resulting reference curves, left ventricular stroke work of newborns has a median of 0.06 J and increases to 1.15 J at the age of 18 years. Stroke work increases over weight and height in a similar trend. The percentile curves depict the distribution. We demonstrate how reference curves can be used for quantification of differences and comparison in patients.
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Affiliation(s)
- Christian Winkler
- Department of Pediatric Cardiology, University Hospital of Bonn, Germany.
| | - Michael Neidlin
- Department of Mechanical Engineering, National Technical University of Athens, Greece; Department of Cardiovascular Engineering, Institute of Applied Medical Engineering, Helmholtz Institute, Medical Faculty, RWTH Aachen University, Germany
| | | | - Anna Grünwald
- Department of Cardiovascular Engineering, Institute of Applied Medical Engineering, Helmholtz Institute, Medical Faculty, RWTH Aachen University, Germany
| | - Sascha Groß-Hardt
- Department of Cardiovascular Engineering, Institute of Applied Medical Engineering, Helmholtz Institute, Medical Faculty, RWTH Aachen University, Germany
| | - Johannes Breuer
- Department of Pediatric Cardiology, University Hospital of Bonn, Germany
| | - Katharina Linden
- Department of Pediatric Cardiology, University Hospital of Bonn, Germany
| | - Ulrike Herberg
- Department of Pediatric Cardiology, University Hospital of Bonn, Germany
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Ing RJ, Mclennan D, Twite MD, DiMaria M. Anesthetic Considerations for Fontan-Associated Liver Disease and the Failing Fontan Circuit. J Cardiothorac Vasc Anesth 2020; 34:2224-2233. [PMID: 32249074 DOI: 10.1053/j.jvca.2020.02.040] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/16/2018] [Revised: 02/19/2020] [Accepted: 02/23/2020] [Indexed: 12/13/2022]
Affiliation(s)
- Richard J Ing
- Department of Anesthesiology, Children's Hospital Colorado, Anschutz Medical Campus, Aurora, CO; School of Medicine, University of Colorado, Aurora, CO.
| | - Daniel Mclennan
- Stead Family Children's Hospital, University of Iowa, Iowa City, IA
| | - Mark D Twite
- Department of Anesthesiology, Children's Hospital Colorado, Anschutz Medical Campus, Aurora, CO; School of Medicine, University of Colorado, Aurora, CO
| | - Michael DiMaria
- Department of Anesthesiology, Children's Hospital Colorado, Anschutz Medical Campus, Aurora, CO; School of Medicine, University of Colorado, Aurora, CO
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Saiki H, Kuwata S, Iwamoto Y, Ishido H, Taketazu M, Masutani S, Nishida T, Senzaki H. Fenestration in the Fontan circulation as a strategy for chronic cardioprotection. Heart 2019; 105:1266-1272. [DOI: 10.1136/heartjnl-2018-314183] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/23/2018] [Revised: 01/10/2019] [Accepted: 02/08/2019] [Indexed: 12/13/2022] Open
Abstract
BackgroundFenestration in the Fontan circulation potentially liberates patients from factors leading to cardiovascular remodelling, through stable haemodynamics with attenuated venous congestion. We hypothesised that a fenestrated Fontan procedure would possess chronic haemodynamic advantages beyond the preload preservation.MethodsWe enrolled 35 patients with fenestrated Fontan with a constructed pressure–volume relationship under dobutamine (DOB) infusion and/or transient fenestration occlusion (TFO). Despite the use of antiplatelets and anticoagulants, natural closure of fenestration was confirmed in 11 patients. Cardiovascular properties in patients with patent fenestration (P-F) were compared with those in patients with naturally closed fenestration (NC-F). To further delineate the roles of fenestration, paired analysis in patients with P-F was performed under DOB or rapid atrial pacing with/without TFO.ResultsAs compared with P-F, patients with NC-F had a higher heart rate (HR), smaller ventricular end-diastolic area, better ejection fraction and higher central venous pressure, with higher pulmonary resistance. While this was similarly observed after DOB infusion, DOB markedly augmented diastolic and systolic ventricular stiffness in patients with NC-F compared with patients with P-F. As a mirror image of the relationship between patients with P-F and NC-F, TFO markedly reduced preload, suppressed cardiac output, and augmented afterload and diastolic stiffness. Importantly, rapid atrial pacing compromised these haemodynamic advantages of fenestration.ConclusionsAs compared with patients with NC-F, patients with P-F had robust haemodynamics with secured preload reserve, reduced afterload and a suppressed beta-adrenergic response, along with a lower HR at baseline, although these advantages had been overshadowed, or worsened, by an increased HR.
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Van Puyvelde J, Rega F, Minami T, Claus P, Cools B, Gewillig M, Meyns B. Creation of the Fontan circulation in sheep: a survival model. Interact Cardiovasc Thorac Surg 2019; 29:15-21. [DOI: 10.1093/icvts/ivz022] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2018] [Revised: 12/30/2018] [Accepted: 01/13/2019] [Indexed: 11/13/2022] Open
Affiliation(s)
- Joeri Van Puyvelde
- Department of Cardiac Surgery, University Hospitals Leuven, Leuven, Belgium
| | - Filip Rega
- Department of Cardiac Surgery, University Hospitals Leuven, Leuven, Belgium
| | - Tomoyuki Minami
- Department of Cardiac Surgery, University Hospitals Leuven, Leuven, Belgium
| | - Piet Claus
- Department of Cardiovascular Imaging and Dynamics, University Hospitals Leuven, Leuven, Belgium
| | - Bjorn Cools
- Department of Paediatric Cardiology, University Hospitals Leuven, Leuven, Belgium
| | - Marc Gewillig
- Department of Paediatric Cardiology, University Hospitals Leuven, Leuven, Belgium
| | - Bart Meyns
- Department of Cardiac Surgery, University Hospitals Leuven, Leuven, Belgium
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11
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Tominaga Y, Kawata H, Iwai S, Yamauchi S, Kugo Y, Hasegawa M, Kayatani F, Takahashi K, Aoki H. Left ventricular function after a Fontan operation in patients with pulmonary atresia with an intact ventricular septum. Interact Cardiovasc Thorac Surg 2019; 28:273-278. [PMID: 30085069 DOI: 10.1093/icvts/ivy229] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2017] [Accepted: 06/10/2018] [Indexed: 11/12/2022] Open
Abstract
OBJECTIVES In patients with pulmonary atresia with an intact ventricular septum (PA/IVS), there are no reports about the impact of sinusoidal communication (SC) on left ventricular (LV) performance after a Fontan operation; therefore, the purpose of this study was to fill this gap in the literature. METHODS We performed a single-centre, retrospective study of 46 patients with PA/IVS. Nineteen patients who underwent the Fontan procedure were enrolled and divided into 2 groups: those with SC (SC group) and those without SC (N group). The 2 groups were compared in terms of postoperative cardiac function. RESULTS Thirteen patients were in the SC group (4 patients with right ventricle-dependent coronary circulation) and 6, in the N group. Although 2 of the patients with right ventricular (RV)-dependent coronary circulation showed focal asynergy of the LV wall, others showed no findings of myocardial infarction. The patients' preoperative age and age during the observation period after the Fontan operation did not differ. There was no difference in LV ejection fraction, cardiac index and RV and pulmonary artery pressure before and after the Fontan operation. Preoperative RV volume in the N group was greater than that in the SC group. Brain natriuretic peptide levels were higher in the SC group after the Fontan operation. On ventricular efficacy analysis, contractility was lower (1.8 ± 0.32 vs 2.5 ± 0.40 mmHg/ml/m2, P = 0.001) and ventricular efficacy was worse (1.0 ± 0.15 vs 0.86 ± 0.11, P = 0.046) in the SC group during the postoperative period. CONCLUSIONS Compared to patients with PA/IVS without SC, patients with PA/IVS with SC had a low cardiac contractility and decreased cardiac output efficiency after the Fontan procedure.
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Affiliation(s)
- Yuji Tominaga
- Department of Cardiovascular Surgery, Osaka Women's and Children's Hospital, Izumi, Osaka, Japan
| | - Hiroaki Kawata
- Department of Cardiovascular Surgery, Osaka Women's and Children's Hospital, Izumi, Osaka, Japan
| | - Shigemitsu Iwai
- Department of Cardiovascular Surgery, Osaka Women's and Children's Hospital, Izumi, Osaka, Japan
| | - Sanae Yamauchi
- Department of Cardiovascular Surgery, Osaka Women's and Children's Hospital, Izumi, Osaka, Japan
| | - Yosuke Kugo
- Department of Cardiovascular Surgery, Osaka Women's and Children's Hospital, Izumi, Osaka, Japan
| | - Moyu Hasegawa
- Department of Cardiovascular Surgery, Osaka Women's and Children's Hospital, Izumi, Osaka, Japan
| | - Futoshi Kayatani
- Department of Pediatric Cardiology, Osaka Women's and Children's Hospital, Izumi, Osaka, Japan
| | - Kunihiko Takahashi
- Department of Pediatric Cardiology, Osaka Women's and Children's Hospital, Izumi, Osaka, Japan
| | - Hisaaki Aoki
- Department of Pediatric Cardiology, Osaka Women's and Children's Hospital, Izumi, Osaka, Japan
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Chen LJ, Zhang YQ, Bao SF, Zhong SW, Sun AM, Zhang ZF. Velocity vector imaging for the assessment of segmental ventricular function in children with a single right ventricle after cavopulmonary anastomosis. Curr Med Res Opin 2019; 35:203-210. [PMID: 29611724 DOI: 10.1080/03007995.2018.1460337] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
Abstract
OBJECTIVE Ventricular function assessment is very important for the treatment and prognostic classification of children with a single right ventricle (SRV) after cavopulmonary anastomosis (CPA). However, unusual ventricular shapes can result in inaccurate measurements. The aim of this study was to evaluate velocity vector imaging (VVI) for assessing segmental ventricular function in children with SRV after CPA. METHODS Twenty-one children with SRV after CPA and 21 age- and sex-matched children with normal biventricular anatomy and function were included. The longitudinal velocity, displacement, strain and strain rate were measured in the two groups in six segments by VVI. The velocity, displacement, strain and strain rate of the SRVs were compared with max(dp/dt) measured during simultaneous cardiac catheterization in the SRV subjects. RESULTS The control group consisted of 13 males and 8 females (69% males) with a mean age of 6.7 ± 3.5 years and mean weight of 20.5 ± 6.5 kg, and the study group consisted of 13 males and 8 females with a mean age 6.7 ± 3.7 years and mean weight of 20.6 ± 6.8 kg. Age, weight and sex distribution were similar between the groups (all, p > .05). Strain and strain rate values in all six segments were significantly lower in the study group than in the control group (all, p < .05). The max(dp/dt) of the SRV was 522.84 ± 158.32 mmHg/s, and the strain rate of the basal segment at the rudimentary chamber correlated best with max(dp/dt) (r = 0.74, p < .01). CONCLUSIONS Segmental ventricular dysfunction was present in children with SRV after CPA, and it could be assessed using VVI.
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Affiliation(s)
- Li-Jun Chen
- a Department of Pediatric Cardiology , Shanghai Children's Medical Center, Shanghai Jiao Tong University School of Medicine , Shanghai , China
| | - Yu-Qi Zhang
- a Department of Pediatric Cardiology , Shanghai Children's Medical Center, Shanghai Jiao Tong University School of Medicine , Shanghai , China
| | - Sheng-Fang Bao
- a Department of Pediatric Cardiology , Shanghai Children's Medical Center, Shanghai Jiao Tong University School of Medicine , Shanghai , China
| | - Shu-Wen Zhong
- a Department of Pediatric Cardiology , Shanghai Children's Medical Center, Shanghai Jiao Tong University School of Medicine , Shanghai , China
| | - Ai-Min Sun
- b Department of Medical Imaging , Shanghai Children's Medical Center, Shanghai Jiao Tong University School of Medicine , Shanghai , China
| | - Zhi-Fang Zhang
- a Department of Pediatric Cardiology , Shanghai Children's Medical Center, Shanghai Jiao Tong University School of Medicine , Shanghai , China
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13
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Granegger M, Valencia A, Quandt D, Dave H, Kretschmar O, Hübler M, Schweiger M. Approaches to Establish Extracardiac Total Cavopulmonary Connections in Animal Models—A Review. World J Pediatr Congenit Heart Surg 2019; 10:81-89. [DOI: 10.1177/2150135118802788] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Background: Long-term survival of patients with a single ventricle palliated with a Fontan procedure is still limited. No curative treatment options are available. To investigate the pathophysiology and potential treatment options, such as mechanical circulatory support (MCS), appropriate large animal models are required. The aim of this review was to analyze all full-text manuscripts presenting approaches for an extracardiac total cavopulmonary connection (TCPC) animal model to identify the feasibility and limitations in the acute and chronic setting. Methods: A literature search was performed for full-text publications presenting large animal models with extracardiac TCPCs on Pubmed and Embase. Out of 454 reviewed papers, 23 manuscripts fulfilled the inclusion criteria. Surgical procedures were categorized and hemodynamic changes at the transition from the biventricular to the univentricular condition analyzed. Results: Surgical procedures varied especially regarding coronary venous flow handling and anatomic shape of the TCPC. In most studies (n = 14), the main pulmonary artery was clamped and the coronary venous flow redirected by additional surgical interventions. Only in five reports, the caval veins were connected to the right pulmonary artery to create a true TCPC shape, whereas in all others (n = 18), the veins were connected to the main pulmonary artery. An elevated pulmonary vascular resistance was identified as a limiting hemodynamic factor for TCPC completion in healthy animals. Conclusions: A variety of acute TCPC animal models were successfully established with and without MCS, reflecting the most important hemodynamic features of a Fontan circulation; however, chronic animal models were not reported.
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Affiliation(s)
- Marcus Granegger
- Pediatric Cardiovascular Surgery, Pediatric Heart Center, Department of Surgery, University Children’s Hospital Zurich, Zurich, Switzerland
- Children’s Research Center, University Children’s Hospital Zurich, Zurich, Switzerland
| | - Anna Valencia
- Pediatric Cardiovascular Surgery, Pediatric Heart Center, Department of Surgery, University Children’s Hospital Zurich, Zurich, Switzerland
- Children’s Research Center, University Children’s Hospital Zurich, Zurich, Switzerland
| | - Daniel Quandt
- Children’s Research Center, University Children’s Hospital Zurich, Zurich, Switzerland
- Pediatric Cardiology, Pediatric Heart Center, Department of Surgery, University Children’s Hospital Zurich, Zurich, Switzerland
| | - Hitendu Dave
- Pediatric Cardiovascular Surgery, Pediatric Heart Center, Department of Surgery, University Children’s Hospital Zurich, Zurich, Switzerland
- Children’s Research Center, University Children’s Hospital Zurich, Zurich, Switzerland
| | - Oliver Kretschmar
- Children’s Research Center, University Children’s Hospital Zurich, Zurich, Switzerland
- Pediatric Cardiology, Pediatric Heart Center, Department of Surgery, University Children’s Hospital Zurich, Zurich, Switzerland
| | - Michael Hübler
- Pediatric Cardiovascular Surgery, Pediatric Heart Center, Department of Surgery, University Children’s Hospital Zurich, Zurich, Switzerland
- Children’s Research Center, University Children’s Hospital Zurich, Zurich, Switzerland
| | - Martin Schweiger
- Pediatric Cardiovascular Surgery, Pediatric Heart Center, Department of Surgery, University Children’s Hospital Zurich, Zurich, Switzerland
- Children’s Research Center, University Children’s Hospital Zurich, Zurich, Switzerland
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14
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Oh J, Song IK, Cho J, Yun TJ, Park CS, Choi JM, Gwak M, Shin WJ. Acute Change in Ventricular Contractility-Load Coupling After Corrective Surgery for Congenital Heart Defect: A Retrospective Cohort Study. Pediatr Cardiol 2019; 40:1618-1626. [PMID: 31482237 PMCID: PMC6848039 DOI: 10.1007/s00246-019-02195-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/28/2019] [Accepted: 08/23/2019] [Indexed: 11/29/2022]
Abstract
Ventricular performance and its loading condition change drastically after surgical correction of congenital heart defect. Pressure-volume loops analysis can provide quantitative information about ventriculo-arterial coupling (VAC) indicating the interaction between ventricular contractility and loading condition. Therefore, we investigated changes in VAC after corrective surgery for ventricular septal defect (VSD)/tetralogy of Fallot (TOF), and implication of ventriculo-arterial decoupling as a prognostic factor of post-operative outcomes. In children with VSD/TOF, pre- and post-operative arterial elastance (Ea), end-systolic ventricular elastance (Ees) and VAC (Ea/Ees) were non-invasively estimated using echocardiographic parameters. Post-operative outcomes included maximum vasoactive-inotropic score, the duration of mechanical ventilation and hospital stay. Preoperatively, patients with VSD had significantly lower Ea and Ees than patients with TOF; however, VAC were preserved in both. In patients with VSD, post-operative Ea increased disproportionately to change in Ees, resulting in increased VAC. Post-operative higher VAC in patients with VSD was independently associated with maximum vasoactive-inotropic score (odds ratio [OR] 63.9; 95% Confidence Interval [CI] 4.0-553.0; P = 0.003), prolonged mechanical ventilation (OR 6.3; 95% CI 1.1-37.8; P = 0.044) and longer hospitalization (OR 17.6; 95% CI 1.6-187.0; P = 0.018). In patients with TOF, Ea and Ees reduced post-operatively; however, VAC remained unchanged and was not associated with post-operative outcomes. Despite of different loading condition, preoperative VAC maintained in both of VSD and TOF. However, particularly in VSD patients, abrupt increase in post-operative loading state induces contractility-load decoupling, which leads to worse post-operative outcomes.
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Affiliation(s)
- Jimi Oh
- Department of Anesthesiology and Pain Medicine, Asan Medical Center, University of Ulsan College of Medicine, 88 Olympic-ro 43-gil, Songpa-gu, 05505 Seoul, Republic of Korea
| | - In-Kyung Song
- Department of Anesthesiology and Pain Medicine, Laboratory for Cardiovascular Dynamics, Asan Medical Center, University of Ulsan College of Medicine, 88 Olympic-ro 43-gil, Songpa-gu, 05505 Seoul, Republic of Korea
| | - Junki Cho
- Department of Anesthesiology and Pain Medicine, Asan Medical Center, University of Ulsan College of Medicine, 88 Olympic-ro 43-gil, Songpa-gu, 05505 Seoul, Republic of Korea
| | - Tae-Jin Yun
- Department of Pediatric Cardiac Surgery, Asan Medical Center, University of Ulsan College of Medicine, 88 Olympic-ro 43-gil, Songpa-gu, 05505 Seoul, Republic of Korea
| | - Chun Soo Park
- Department of Pediatric Cardiac Surgery, Asan Medical Center, University of Ulsan College of Medicine, 88 Olympic-ro 43-gil, Songpa-gu, 05505 Seoul, Republic of Korea
| | - Jae Moon Choi
- Department of Anesthesiology and Pain Medicine, Asan Medical Center, University of Ulsan College of Medicine, 88 Olympic-ro 43-gil, Songpa-gu, 05505 Seoul, Republic of Korea
| | - Mijeung Gwak
- Department of Anesthesiology and Pain Medicine, Asan Medical Center, University of Ulsan College of Medicine, 88 Olympic-ro 43-gil, Songpa-gu, 05505 Seoul, Republic of Korea
| | - Won-Jung Shin
- Department of Anesthesiology and Pain Medicine, Laboratory for Cardiovascular Dynamics, Asan Medical Center, University of Ulsan College of Medicine, 88 Olympic-ro 43-gil, Songpa-gu, 05505, Seoul, Republic of Korea.
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15
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Di Molfetta A, Iacobelli R, Guccione P, Di Chiara L, Rocchi M, Cobianchi Belisari F, Campanale M, Gagliardi MG, Filippelli S, Ferrari G, Amodeo A. Evolution of Ventricular Energetics in the Different Stages of Palliation of Hypoplastic Left Heart Syndrome: A Retrospective Clinical Study. Pediatr Cardiol 2017; 38:1613-1619. [PMID: 28831530 DOI: 10.1007/s00246-017-1704-8] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/05/2017] [Accepted: 07/28/2017] [Indexed: 11/27/2022]
Abstract
Hyperplastic left heart syndrome (HLHS) patients are palliated by creating a Fontan-type circulation passing from different surgical stages. The aim of this work is to describe the evolution of ventricular energetics parameters in HLHS patients during the different stages of palliation including the hybrid, the Norwood, the bidirectional Glenn (BDG), and the Fontan procedures. We conducted a retrospective clinical study enrolling all HLHS patients surgically treated with hybrid procedure and/or Norwood and/or BDG and/or Fontan operation from 2011 to 2016 collecting echocardiographic and hemodynamic data. Measured data were used to calculate energetic variables such as ventricular elastances, external and internal work, ventriculo-arterial coupling and cardiac mechanical efficiency. From 2010 to 2016, a total of 29 HLHS patients undergoing cardiac catheterization after hybrid (n = 7) or Norwood (n = 6) or Glenn (n = 8) or Fontan (n = 8) procedure were retrospectively enrolled. Ventricular volumes were significantly higher in the Norwood circulation than in the hybrid circulation (p = 0.03) with a progressive decrement from the first stage to the Fontan completion. Ventricular elastances were lower in the Norwood circulation than in the hybrid circulation and progressively increased passing from the first stage to the Fontan completion. The arterial elastance and Rtot increased in the Fontan circulation. The ventricular work progressively increased. Finally, the ventricular efficiency improves passing from the first to the last stage of palliation. The use of ventricular energetic parameters could lead to a more complete evaluation of such complex patients to better understand their adaptation to different pathophysiological conditions.
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Affiliation(s)
- A Di Molfetta
- Department of Pediatric Cardiology and Cardiac Surgery, Pediatric Hospital Bambino Gesù, Piazza Sant'Onofrio, 4, 00165, Rome, RM, Italy.
| | - R Iacobelli
- Department of Pediatric Cardiology and Cardiac Surgery, Pediatric Hospital Bambino Gesù, Piazza Sant'Onofrio, 4, 00165, Rome, RM, Italy
| | - P Guccione
- Department of Pediatric Cardiology and Cardiac Surgery, Pediatric Hospital Bambino Gesù, Piazza Sant'Onofrio, 4, 00165, Rome, RM, Italy
| | - L Di Chiara
- Department of Pediatric Cardiology and Cardiac Surgery, Pediatric Hospital Bambino Gesù, Piazza Sant'Onofrio, 4, 00165, Rome, RM, Italy
| | - M Rocchi
- Faculty of Biomedical Engineer, Rome University Campus Bio-medico, Via Álvaro del Portillo, 21, Rome, RM, Italy
| | - F Cobianchi Belisari
- Department of Cardiology, Catholic University of Rome, Largo A. Gemelli, 1, 20123, Milan, MI, Italy
| | - M Campanale
- Department of Pediatric Cardiology and Cardiac Surgery, Pediatric Hospital Bambino Gesù, Piazza Sant'Onofrio, 4, 00165, Rome, RM, Italy
| | - M G Gagliardi
- Department of Pediatric Cardiology and Cardiac Surgery, Pediatric Hospital Bambino Gesù, Piazza Sant'Onofrio, 4, 00165, Rome, RM, Italy
| | - S Filippelli
- Department of Pediatric Cardiology and Cardiac Surgery, Pediatric Hospital Bambino Gesù, Piazza Sant'Onofrio, 4, 00165, Rome, RM, Italy
| | - G Ferrari
- Nalecz Institute of Technology, IBBE-PAS, Warsaw, Poland
| | - A Amodeo
- Department of Pediatric Cardiology and Cardiac Surgery, Pediatric Hospital Bambino Gesù, Piazza Sant'Onofrio, 4, 00165, Rome, RM, Italy
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16
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Häcker AL, Reiner B, Oberhoffer R, Hager A, Ewert P, Müller J. Increased arterial stiffness in children with congenital heart disease. Eur J Prev Cardiol 2017; 25:103-109. [PMID: 29058952 DOI: 10.1177/2047487317737174] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
Objective Central systolic blood pressure (SBP) is a measure of arterial stiffness and strongly associated with atherosclerosis and end-organ damage. It is a stronger predictor of cardiovascular events and all-cause mortality than peripheral SBP. In particular, for children with congenital heart disease, a higher central SBP might impose a greater threat of cardiac damage. The aim of the study was to analyse and compare central SBP in children with congenital heart disease and in healthy counterparts. Patients and methods Central SBP was measured using an oscillometric method in 417 children (38.9% girls, 13.0 ± 3.2 years) with various congenital heart diseases between July 2014 and February 2017. The test results were compared with a recent healthy reference cohort of 1466 children (49.5% girls, 12.9 ± 2.5 years). Results After correction for several covariates in a general linear model, central SBP of children with congenital heart disease was significantly increased (congenital heart disease: 102.1 ± 10.2 vs. healthy reference cohort: 100.4 ± 8.6, p < .001). The analysis of congenital heart disease subgroups revealed higher central SBP in children with left heart obstructions (mean difference: 3.6 mmHg, p < .001), transpositions of the great arteries after arterial switch (mean difference: 2.2 mmHg, p = .017) and univentricular hearts after total cavopulmonary connection (mean difference: 2.1 mmHg, p = .015) compared with the reference. Conclusion Children with congenital heart disease have significantly higher central SBP compared with healthy peers, predisposing them to premature heart failure. Screening and long-term observations of central SBP in children with congenital heart disease seems warranted in order to evaluate the need for treatment.
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Affiliation(s)
- Anna-Luisa Häcker
- 1 Department of Paediatric Cardiology and Congenital Heart Disease, Deutsches Herzzentrum München, Technische Universität München, Germany.,2 Institute of Preventive Paediatrics, Technische Universität München, Germany
| | - Barbara Reiner
- 1 Department of Paediatric Cardiology and Congenital Heart Disease, Deutsches Herzzentrum München, Technische Universität München, Germany.,2 Institute of Preventive Paediatrics, Technische Universität München, Germany
| | - Renate Oberhoffer
- 1 Department of Paediatric Cardiology and Congenital Heart Disease, Deutsches Herzzentrum München, Technische Universität München, Germany.,2 Institute of Preventive Paediatrics, Technische Universität München, Germany
| | - Alfred Hager
- 1 Department of Paediatric Cardiology and Congenital Heart Disease, Deutsches Herzzentrum München, Technische Universität München, Germany
| | - Peter Ewert
- 1 Department of Paediatric Cardiology and Congenital Heart Disease, Deutsches Herzzentrum München, Technische Universität München, Germany
| | - Jan Müller
- 1 Department of Paediatric Cardiology and Congenital Heart Disease, Deutsches Herzzentrum München, Technische Universität München, Germany.,2 Institute of Preventive Paediatrics, Technische Universität München, Germany
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17
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Veldtman GR, Opotowsky AR, Wittekind SG, Rychik J, Penny DJ, Fogel M, Marino BS, Gewillig M. Cardiovascular adaptation to the Fontan circulation. CONGENIT HEART DIS 2017; 12:699-710. [DOI: 10.1111/chd.12526] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/30/2017] [Accepted: 07/17/2017] [Indexed: 11/28/2022]
Affiliation(s)
- Gruschen R. Veldtman
- Adolescent and Adult Congenital Program; Heart Institute, Cincinnati Children's Hospital Medical Centre; Cincinnati Ohio, USA
| | | | - Samuel G. Wittekind
- Adolescent and Adult Congenital Program; Heart Institute, Cincinnati Children's Hospital Medical Centre; Cincinnati Ohio, USA
| | - Jack Rychik
- The Cardiac Center at The Children's Hospital of Philadelphia, Professor of Pediatrics, Perelman School of Medicine at the University of Pennsylvania; Philadelphia Pennsylvania, USA
| | - Daniel J. Penny
- Department of Cardiology; Texas Children's Hospital and Department of Pediatrics, Baylor College of Medicine; Houston Texas, USA
| | - Mark Fogel
- The Cardiac Center at The Children's Hospital of Philadelphia, Professor of Pediatrics, Perelman School of Medicine at the University of Pennsylvania; Philadelphia Pennsylvania, USA
| | - Bradley S. Marino
- Ann & Robert H. Lurie Children's Hospital of Chicago; Chicago Illinois, USA
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18
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Martin AS, Abraham DM, Hershberger KA, Bhatt DP, Mao L, Cui H, Liu J, Liu X, Muehlbauer MJ, Grimsrud PA, Locasale JW, Payne RM, Hirschey MD. Nicotinamide mononucleotide requires SIRT3 to improve cardiac function and bioenergetics in a Friedreich's ataxia cardiomyopathy model. JCI Insight 2017; 2:93885. [PMID: 28724806 DOI: 10.1172/jci.insight.93885] [Citation(s) in RCA: 88] [Impact Index Per Article: 12.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2017] [Accepted: 06/06/2017] [Indexed: 12/23/2022] Open
Abstract
Increasing NAD+ levels by supplementing with the precursor nicotinamide mononucleotide (NMN) improves cardiac function in multiple mouse models of disease. While NMN influences several aspects of mitochondrial metabolism, the molecular mechanisms by which increased NAD+ enhances cardiac function are poorly understood. A putative mechanism of NAD+ therapeutic action exists via activation of the mitochondrial NAD+-dependent protein deacetylase sirtuin 3 (SIRT3). We assessed the therapeutic efficacy of NMN and the role of SIRT3 in the Friedreich's ataxia cardiomyopathy mouse model (FXN-KO). At baseline, the FXN-KO heart has mitochondrial protein hyperacetylation, reduced Sirt3 mRNA expression, and evidence of increased NAD+ salvage. Remarkably, NMN administered to FXN-KO mice restores cardiac function to near-normal levels. To determine whether SIRT3 is required for NMN therapeutic efficacy, we generated SIRT3-KO and SIRT3-KO/FXN-KO (double KO [dKO]) models. The improvement in cardiac function upon NMN treatment in the FXN-KO is lost in the dKO model, demonstrating that the effects of NMN are dependent upon cardiac SIRT3. Coupled with cardio-protection, SIRT3 mediates NMN-induced improvements in both cardiac and extracardiac metabolic function and energy metabolism. Taken together, these results serve as important preclinical data for NMN supplementation or SIRT3 activator therapy in Friedreich's ataxia patients.
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Affiliation(s)
- Angelical S Martin
- Duke Molecular Physiology Institute and Sarah W. Stedman Nutrition and Metabolism Center.,Department of Pharmacology and Cancer Biology
| | - Dennis M Abraham
- Department of Medicine, Division of Cardiology and Duke Cardiovascular Physiology Core, Duke University Medical Center, Durham, North Carolina, USA
| | - Kathleen A Hershberger
- Duke Molecular Physiology Institute and Sarah W. Stedman Nutrition and Metabolism Center.,Department of Pharmacology and Cancer Biology
| | - Dhaval P Bhatt
- Duke Molecular Physiology Institute and Sarah W. Stedman Nutrition and Metabolism Center
| | - Lan Mao
- Department of Medicine, Division of Cardiology and Duke Cardiovascular Physiology Core, Duke University Medical Center, Durham, North Carolina, USA
| | - Huaxia Cui
- Duke Molecular Physiology Institute and Sarah W. Stedman Nutrition and Metabolism Center
| | - Juan Liu
- Department of Pharmacology and Cancer Biology
| | | | - Michael J Muehlbauer
- Duke Molecular Physiology Institute and Sarah W. Stedman Nutrition and Metabolism Center
| | - Paul A Grimsrud
- Duke Molecular Physiology Institute and Sarah W. Stedman Nutrition and Metabolism Center
| | - Jason W Locasale
- Duke Molecular Physiology Institute and Sarah W. Stedman Nutrition and Metabolism Center.,Department of Pharmacology and Cancer Biology
| | - R Mark Payne
- Department of Medicine, Division of Pediatrics, Indiana University, Indianapolis, Indiana, USA
| | - Matthew D Hirschey
- Duke Molecular Physiology Institute and Sarah W. Stedman Nutrition and Metabolism Center.,Department of Pharmacology and Cancer Biology.,Department of Medicine, Division of Endocrinology, Metabolism, & Nutrition, Duke University Medical Center, Durham, North Carolina, USA
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19
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Watrous RL, Chin AJ. Model-Based Comparison of the Normal and Fontan Circulatory Systems-Part III. World J Pediatr Congenit Heart Surg 2017; 8:148-160. [PMID: 28329460 DOI: 10.1177/2150135116679831] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND For patients with the Fontan circulatory arrangement, angiotensin-converting enzyme inhibition, guanylate cyclase activation, phosphodiesterase 5 inhibition, and endothelin receptor antagonism have so far resulted in little or no improvement in [Formula: see text] or peak cardiac index (CI), suggesting that our understanding of the factors that most impact the exercise hemodynamics is incomplete. METHODS To facilitate comparisons with clinical reports of the exercise performance of preadolescent Fontan patients, we rescaled our previously reported computational models of a two-year-old normal child and similarly aged Fontan patient, extended our Fontan model to capture the nonlinear relationship between flow and resistance quantified from previous computational fluid dynamic analyses of the total cavopulmonary connection (TCPC), and added respiration as well as skeletal muscle contraction. RESULTS (1) Without respiration, the computational model for both the normal and the Fontan cannot attain the values for CI at peak exercise reported in the clinical literature, (2) because flow through the TCPC is much greater during inspiration than during expiration, the effect on the CI of the dynamic (flow-related) TCPC resistance is much more dramatic during exercise than it is in breath-hold mode at rest, and (3) coupling breathing with skeletal muscle contraction leads to the highest augmentation of cardiac output, that is, the skeletal muscle pump is most effective when the intrathoracic pressure is at a minimum-at peak inspiration. CONCLUSIONS Novel insights emerge when a Fontan model incorporating dynamic TCPC resistance, full respiration, and skeletal muscle contraction can be compared to the model of the normal.
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Affiliation(s)
- Raymond L Watrous
- 1 Division of Cardiology, Children's Hospital of Philadelphia, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Alvin J Chin
- 1 Division of Cardiology, Children's Hospital of Philadelphia, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA.,2 Department of Pediatrics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
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20
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Ohuchi H, Hayama Y, Negishi J, Noritake K, Miyazaki A, Yamada O, Shiraishi I. Determinants of Aortic Size and Stiffness and the Impact on Exercise Physiology in Patients After the Fontan Operation. Int Heart J 2017; 58:73-80. [DOI: 10.1536/ihj.16-183] [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: 11/18/2022]
Affiliation(s)
- Hideo Ohuchi
- Department of Pediatric Cardiology, National Cerebral and Cardiovascular Center
- Department of Adult Congenital Heart Disease, National Cerebral and Cardiovascular Center
| | - Yosuke Hayama
- Department of Pediatric Cardiology, National Cerebral and Cardiovascular Center
| | - Jun Negishi
- Department of Pediatric Cardiology, National Cerebral and Cardiovascular Center
| | - Kanae Noritake
- Department of Pediatric Cardiology, National Cerebral and Cardiovascular Center
| | - Aya Miyazaki
- Department of Pediatric Cardiology, National Cerebral and Cardiovascular Center
| | - Osamu Yamada
- Department of Pediatric Cardiology, National Cerebral and Cardiovascular Center
| | - Isao Shiraishi
- Department of Pediatric Cardiology, National Cerebral and Cardiovascular Center
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21
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Saiki H, Eidem BW, Ohtani T, Grogan MA, Redfield MM. Ventricular-Arterial Function and Coupling in the Adult Fontan Circulation. J Am Heart Assoc 2016; 5:JAHA.116.003887. [PMID: 27663413 PMCID: PMC5079039 DOI: 10.1161/jaha.116.003887] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
Abstract
Background In adult Fontan patients, ventricular or arterial dysfunction may impact homeostasis of the Fontan circulation and predispose to heart failure. We sought to characterize ventricular‐arterial (VA) properties in adult Fontan patients. Methods and Results Adult Fontan patients (n=170), including those with right (SRV, n=57) and left (SLV, n=113) dominant ventricular morphology, were compared to age, sex, and body size matched controls (n=170). Arterial function, load‐insensitive measures of contractility, VA coupling, diastolic function, and ventricular efficiency were assessed. Compared to controls, Fontan patients had similar arterial (Ea), but lower end‐systolic ventricular (Ees), elastance, preload recruitable stroke work and peak power index, impaired VA coupling, eccentric remodeling, reduced ventricular efficiency and increased diastolic stiffness (P<0.05 for all). Ventricular efficiency declined steeply with higher heart rate in Fontan, but not control, patients. Among Fontan patients (n=123) and controls (n=162) with preserved cardiac index (CI; ≥2.5 L/min per m2), Fontan patients had worse contractility than controls, but CI was preserved owing to relative tachycardia, lower afterload, and eccentric remodeling. However, 25% of Fontan patients had reduced CI and were distinguished from those with preserved CI by less‐eccentric remodeling and worse diastolic function, rather than more‐impaired contractility. Conclusions Adult Fontan patients have contractile and diastolic dysfunction with normal afterload, impaired VA coupling, and reduced ventricular efficiency with heightened sensitivity to heart rate. Maintenance of CI is dependent on lower afterload, eccentric remodeling, and relative preservation of diastolic function. These data contribute to our understanding of circulatory physiology in adult Fontan patients.
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Affiliation(s)
- Hirofumi Saiki
- Department of Cardiovascular Disease, Mayo Clinic, Rochester, MN
| | | | - Tomohito Ohtani
- Department of Cardiovascular Disease, Mayo Clinic, Rochester, MN
| | - Martha A Grogan
- Department of Cardiovascular Disease, Mayo Clinic, Rochester, MN
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22
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Clinical-Physiological Considerations in Patients Undergoing Staged Palliation for a Functionally Single Ventricle. Pediatr Crit Care Med 2016; 17:S347-55. [PMID: 27490622 DOI: 10.1097/pcc.0000000000000821] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES The objectives of this review are to discuss the pathophysiology of the circulation with a functionally univentricular heart, with a focus on the unique physiologic characteristics, which provide the underpinnings for the management of these complex patients. DATA SOURCE MEDLINE and PubMed. CONCLUSIONS The circulation of the patient with a functionally univentricular heart displays unique physiologic characteristics, which are quite different from those of the normal biventricular circulation. There are profound differences within the heart itself in terms of ventricular function, interventricular interactions, and myocardial architecture, which are likely to have significant implications for the efficiency of ventricular ejection and metabolism. The coupling between the systemic ventricle and the aorta also displays unique features. The 3D orientation of the Fontan anastomosis itself can profoundly impact cardiac output, although the "portal" pulmonary arterial bed is a crucial determinant of overall cardiovascular function. As a result, disease-specific approaches to improve cardiovascular function are required at all stages during the care of these complex patients.
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Latus H, Gerstner B, Kerst G, Moysich A, Gummel K, Apitz C, Bauer J, Schranz D. Effect of Inhaled Nitric Oxide on Blood Flow Dynamics in Patients After the Fontan Procedure Using Cardiovascular Magnetic Resonance Flow Measurements. Pediatr Cardiol 2016; 37:504-11. [PMID: 26547436 DOI: 10.1007/s00246-015-1307-1] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/29/2015] [Accepted: 11/02/2015] [Indexed: 10/22/2022]
Abstract
Invasive hemodynamic studies have shown that nitric oxide (NO), a selective pulmonary vasodilator, can lower pulmonary vascular resistance in Fontan patients. Because oximetry-derived flow quantification may be unreliable, we sought to detect changes in blood flow within the Fontan circulation after inhalation of NO using cardiovascular magnetic resonance (CMR). Thirty-three patients (mean age 12.8 ± 7.0 years) after the Fontan procedure underwent CMR as part of their routine clinical assessment. Standard two-dimensional blood flow measurements were performed in the Fontan tunnel, superior vena cava (SVC) and ascending aorta (AAO) before and after inhalation of 40 ppm NO for 8-10 min. Systemic-to-pulmonary collateral (SPC) flow was calculated as AAO - (SVC + tunnel). Heart rate (82 ± 18 to 81 ± 18 bpm; p = 0.31) and transcutaneous oxygen saturations (93 ± 4 to 94 ± 3 %; p = 0.13) did not change under NO inhalation. AAO flow (3.23 ± 0.72 to 3.12 ± 0.79 l/min/m(2); p = 0.08) decreased, tunnel flow (1.58 ± 0.40 to 1.65 ± 0.46 l/min/m(2); p = 0.032) increased, and SVC flow (1.01 ± 0.39 to 1.02 ± 0.40 l/min/m(2); p = 0.50) remained unchanged resulting in higher total caval flow (Qs) (2.59 ± 0.58 to 2.67 ± 0.68 l/min/m(2); p = 0.038). SPC flow decreased significantly from 0.64 ± 0.52 to 0.45 ± 0.51 l/min/m(2) (p = 0.002) and resulted in a significant decrement of the Qp/Qs ratio (1.23 ± 0.23 to 1.15 ± 0.23; p = 0.001). Inhalation of NO in Fontan patients results in significant changes in pulmonary and systemic blood flow. The reduction in SPC flow is accompanied by a net increase in effective systemic blood flow suggesting beneficial effects of pulmonary vasodilators on cardiac output, tissue perfusion and exercise capacity.
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Affiliation(s)
- Heiner Latus
- Pediatric Heart Center, Justus-Liebig-University of Giessen, Feulgenstr. 12, 35392, Giessen, Germany.
| | - Bettina Gerstner
- Pediatric Heart Center, Justus-Liebig-University of Giessen, Feulgenstr. 12, 35392, Giessen, Germany
| | - Gunter Kerst
- Pediatric Heart Center, Justus-Liebig-University of Giessen, Feulgenstr. 12, 35392, Giessen, Germany
| | - Axel Moysich
- Pediatric Heart Center, Justus-Liebig-University of Giessen, Feulgenstr. 12, 35392, Giessen, Germany
| | - Kerstin Gummel
- Pediatric Heart Center, Justus-Liebig-University of Giessen, Feulgenstr. 12, 35392, Giessen, Germany
| | - Christian Apitz
- Pediatric Heart Center, Justus-Liebig-University of Giessen, Feulgenstr. 12, 35392, Giessen, Germany
| | - Juergen Bauer
- Pediatric Heart Center, Justus-Liebig-University of Giessen, Feulgenstr. 12, 35392, Giessen, Germany
| | - Dietmar Schranz
- Pediatric Heart Center, Justus-Liebig-University of Giessen, Feulgenstr. 12, 35392, Giessen, Germany
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Stout KK, Broberg CS, Book WM, Cecchin F, Chen JM, Dimopoulos K, Everitt MD, Gatzoulis M, Harris L, Hsu DT, Kuvin JT, Law Y, Martin CM, Murphy AM, Ross HJ, Singh G, Spray TL. Chronic Heart Failure in Congenital Heart Disease. Circulation 2016; 133:770-801. [DOI: 10.1161/cir.0000000000000352] [Citation(s) in RCA: 219] [Impact Index Per Article: 27.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
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Auswirkung des totalen Aortenbogenersatzes auf die ventrikuloarterielle Kopplung. ZEITSCHRIFT FUR HERZ THORAX UND GEFASSCHIRURGIE 2014. [DOI: 10.1007/s00398-014-1104-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Liang F, Senzaki H, Kurishima C, Sughimoto K, Inuzuka R, Liu H. Hemodynamic performance of the Fontan circulation compared with a normal biventricular circulation: a computational model study. Am J Physiol Heart Circ Physiol 2014; 307:H1056-72. [DOI: 10.1152/ajpheart.00245.2014] [Citation(s) in RCA: 42] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
The physiological limitations of the Fontan circulation have been extensively addressed in the literature. Many studies emphasized the importance of pulmonary vascular resistance in determining cardiac output (CO) but gave little attention to other cardiovascular properties that may play considerable roles as well. The present study was aimed to systemically investigate the effects of various cardiovascular properties on clinically relevant hemodynamic variables (e.g., CO and central venous pressure). To this aim, a computational modeling method was employed. The constructed models provided a useful tool for quantifying the hemodynamic effects of any cardiovascular property of interest by varying the corresponding model parameters in model-based simulations. Herein, the Fontan circulation was studied compared with a normal biventricular circulation so as to highlight the unique characteristics of the Fontan circulation. Based on a series of numerical experiments, it was found that 1) pulmonary vascular resistance, ventricular diastolic function, and systemic vascular compliance play a major role, while heart rate, ventricular contractility, and systemic vascular resistance play a secondary role in the regulation of CO in the Fontan circulation; 2) CO is nonlinearly related to any single cardiovascular property, with their relationship being simultaneously influenced by other cardiovascular properties; and 3) the stability of central venous pressure is significantly reduced in the Fontan circulation. The findings suggest that the hemodynamic performance of the Fontan circulation is codetermined by various cardiovascular properties and hence a full understanding of patient-specific cardiovascular conditions is necessary to optimize the treatment of Fontan patients.
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Affiliation(s)
- Fuyou Liang
- Shanghai Jiao Tong University-Chiba University International Cooperative Research Center, School of Naval Architecture, Ocean and Civil Engineering, Shanghai Jiao Tong University, Shanghai, China
| | - Hideaki Senzaki
- Department of Pediatrics and Pediatric Cardiology, Saitama Medical Center, Saitama Medical University, Kamoda, Kawagoe, Saitama, Japan
| | - Clara Kurishima
- Department of Pediatrics and Pediatric Cardiology, Saitama Medical Center, Saitama Medical University, Kamoda, Kawagoe, Saitama, Japan
| | - Koichi Sughimoto
- Department of Cardiac Surgery, Royal Children's Hospital, Parkville, Victoria, Australia
| | - Ryo Inuzuka
- Pediatrics, University Hospital University of Tokyo, Tokyo, Japan; and
| | - Hao Liu
- Shanghai Jiao Tong University-Chiba University International Cooperative Research Center, School of Naval Architecture, Ocean and Civil Engineering, Shanghai Jiao Tong University, Shanghai, China
- Graduate School of Engineering, Chiba University, Inage, Chiba, Japan
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Kung E, Perry JC, Davis C, Migliavacca F, Pennati G, Giardini A, Hsia TY, Marsden A. Computational modeling of pathophysiologic responses to exercise in Fontan patients. Ann Biomed Eng 2014; 43:1335-47. [PMID: 25260878 DOI: 10.1007/s10439-014-1131-4] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2014] [Accepted: 09/19/2014] [Indexed: 11/29/2022]
Abstract
Reduced exercise capacity is nearly universal among Fontan patients. Although many factors have emerged as possible contributors, the degree to which each impacts the overall hemodynamics is largely unknown. Computational modeling provides a means to test hypotheses of causes of exercise intolerance via precisely controlled virtual experiments and measurements. We quantified the physiological impacts of commonly encountered, clinically relevant dysfunctions introduced to the exercising Fontan system via a previously developed lumped-parameter model of Fontan exercise. Elevated pulmonary arterial pressure was observed in all cases of dysfunction, correlated with lowered cardiac output (CO), and often mediated by elevated atrial pressure. Pulmonary vascular resistance was not the most significant factor affecting exercise performance as measured by CO. In the absence of other dysfunctions, atrioventricular valve insufficiency alone had significant physiological impact, especially under exercise demands. The impact of isolated dysfunctions can be linearly summed to approximate the combined impact of several dysfunctions occurring in the same system. A single dominant cause of exercise intolerance was not identified, though several hypothesized dysfunctions each led to variable decreases in performance. Computational predictions of performance improvement associated with various interventions should be weighed against procedural risks and potential complications, contributing to improvements in routine patient management protocol.
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Affiliation(s)
- Ethan Kung
- Mechanical Engineering Department, Clemson University, Clemson, SC, 29634, USA
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Weymann A, Radovits T, Schmack B, Korkmaz S, Li S, Chaimow N, Pätzold I, Becher PM, Hartyánszky I, Soós P, Merkely G, Németh BT, Istók R, Veres G, Merkely B, Terytze K, Karck M, Szabó G. Total aortic arch replacement: superior ventriculo-arterial coupling with decellularized allografts compared with conventional prostheses. PLoS One 2014; 9:e103588. [PMID: 25079587 PMCID: PMC4117632 DOI: 10.1371/journal.pone.0103588] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2014] [Accepted: 06/30/2014] [Indexed: 11/18/2022] Open
Abstract
Background To date, no experimental or clinical study provides detailed analysis of vascular impedance changes after total aortic arch replacement. This study investigated ventriculoarterial coupling and vascular impedance after replacement of the aortic arch with conventional prostheses vs. decellularized allografts. Methods After preparing decellularized aortic arch allografts, their mechanical, histological and biochemical properties were evaluated and compared to native aortic arches and conventional prostheses in vitro. In open-chest dogs, total aortic arch replacement was performed with conventional prostheses and compared to decellularized allografts (n = 5/group). Aortic flow and pressure were recorded continuously, left ventricular pressure-volume relations were measured by using a pressure-conductance catheter. From the hemodynamic variables end-systolic elastance (Ees), arterial elastance (Ea) and ventriculoarterial coupling were calculated. Characteristic impedance (Z) was assessed by Fourier analysis. Results While Ees did not differ between the groups and over time (4.1±1.19 vs. 4.58±1.39 mmHg/mL and 3.21±0.97 vs. 3.96±1.16 mmHg/mL), Ea showed a higher increase in the prosthesis group (4.01±0.67 vs. 6.18±0.20 mmHg/mL, P<0.05) in comparison to decellularized allografts (5.03±0.35 vs. 5.99±1.09 mmHg/mL). This led to impaired ventriculoarterial coupling in the prosthesis group, while it remained unchanged in the allograft group (62.5±50.9 vs. 3.9±23.4%). Z showed a strong increasing tendency in the prosthesis group and it was markedly higher after replacement when compared to decellularized allografts (44.6±8.3dyn·sec·cm−5 vs. 32.4±2.0dyn·sec·cm−5, P<0.05). Conclusions Total aortic arch replacement leads to contractility-afterload mismatch by means of increased impedance and invert ventriculoarterial coupling ratio after implantation of conventional prostheses. Implantation of decellularized allografts preserves vascular impedance thereby improving ventriculoarterial mechanoenergetics after aortic arch replacement.
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Affiliation(s)
- Alexander Weymann
- Department of Cardiac Surgery, Heart and Marfan Center, University of Heidelberg, Heidelberg, Germany
- * E-mail:
| | - Tamás Radovits
- Heart and Vascular Center, Semmelweis University, Budapest, Hungary
| | - Bastian Schmack
- Department of Cardiac Surgery, Heart and Marfan Center, University of Heidelberg, Heidelberg, Germany
| | - Sevil Korkmaz
- Department of Cardiac Surgery, Heart and Marfan Center, University of Heidelberg, Heidelberg, Germany
| | - Shiliang Li
- Department of Cardiac Surgery, Heart and Marfan Center, University of Heidelberg, Heidelberg, Germany
| | - Nicole Chaimow
- Department of Cardiac Surgery, Heart and Marfan Center, University of Heidelberg, Heidelberg, Germany
| | - Ines Pätzold
- Department of Cardiac Surgery, Heart and Marfan Center, University of Heidelberg, Heidelberg, Germany
| | - Peter Moritz Becher
- Department of General and Interventional Cardiology, University Heart Center Hamburg Eppendorf, Hamburg, Germany
| | | | - Pál Soós
- Department of Cardiac Surgery, Heart and Marfan Center, University of Heidelberg, Heidelberg, Germany
- Heart and Vascular Center, Semmelweis University, Budapest, Hungary
| | - Gergő Merkely
- Heart and Vascular Center, Semmelweis University, Budapest, Hungary
| | | | - Roland Istók
- 2 Department of Pathology, Semmelweis University, Budapest, Hungary
| | - Gábor Veres
- Department of Cardiac Surgery, Heart and Marfan Center, University of Heidelberg, Heidelberg, Germany
- Heart and Vascular Center, Semmelweis University, Budapest, Hungary
| | - Béla Merkely
- Heart and Vascular Center, Semmelweis University, Budapest, Hungary
| | - Konstantin Terytze
- Federal Environment Agency, Dessau-Roβlau, Germany
- Department of Earth Science, Free University Berlin, Berlin, Germany
| | - Matthias Karck
- Department of Cardiac Surgery, Heart and Marfan Center, University of Heidelberg, Heidelberg, Germany
| | - Gábor Szabó
- Department of Cardiac Surgery, Heart and Marfan Center, University of Heidelberg, Heidelberg, Germany
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Bossers SSM, Helbing WA, Duppen N, Kuipers IM, Schokking M, Hazekamp MG, Bogers AJJC, Ten Harkel ADJ, Takken T. Exercise capacity in children after total cavopulmonary connection: lateral tunnel versus extracardiac conduit technique. J Thorac Cardiovasc Surg 2014; 148:1490-7. [PMID: 24521957 DOI: 10.1016/j.jtcvs.2013.12.046] [Citation(s) in RCA: 36] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/01/2013] [Revised: 12/20/2013] [Accepted: 12/24/2013] [Indexed: 11/24/2022]
Abstract
OBJECTIVES In patients with univentricular heart disease, the total cavopulmonary connection (TCPC) is the preferred treatment. TCPC can be performed using the intra-atrial lateral tunnel (ILT) or extracardiac conduit (ECC) technique. The purpose of the present study was to evaluate exercise capacity in contemporary TCPC patients and compare the results between the 2 techniques. METHODS A total of 101 TCPC patients (ILT, n=42; ECC, n=59; age, 12.2±2.6 years; age at TCPC completion, 3.2±1.1 years) underwent cardiopulmonary exercise testing. The patients were recruited prospectively from 5 tertiary referral centers. RESULTS For the entire group, the mean peak oxygen uptake was 74%±14%, peak heart rate was 90%±8%, peak workload was 62%±13%, and slope of ventilation versus carbon dioxide elimination (VE/VCO2 slope) was 127%±30% of the predicted value. For the ILT and ECC groups, patient age, age at TCPC completion, body surface area, peak workload, and peak heart rate were comparable. The percentage of predicted peak oxygen uptake was lower in the ILT group (70%±12% vs 77%±15%; P=.040), and the percentage of predicted VE/VCO2 slope was greater in the ILT group (123%±36% vs 108%±14%; P=.015). In a subgroup analysis that excluded ILT patients with baffle leak, these differences were not statistically significant. CONCLUSIONS Common exercise parameters were impaired in contemporary Fontan patients. Chronotropic incompetence was uncommon. The peak oxygen uptake and VE/VCO2 slope were less favorable in ILT patients, likely related to baffle leaks in some ILT patients. These results have shown that a reduced exercise capacity in Fontan patients remains an important issue in contemporary cohorts. The ECC had a more favorable exercise outcome at medium-term follow-up.
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Affiliation(s)
- Sjoerd S M Bossers
- Department of Pediatric Cardiology, Erasmus Medical Centre - Sophia Children's Hospital, Rotterdam, The Netherlands
| | - Willem A Helbing
- Department of Pediatric Cardiology, Erasmus Medical Centre - Sophia Children's Hospital, Rotterdam, The Netherlands.
| | - Nienke Duppen
- Department of Pediatric Cardiology, Erasmus Medical Centre - Sophia Children's Hospital, Rotterdam, The Netherlands
| | - Irene M Kuipers
- Department of Pediatric Cardiology, Academic Medical Centre - Emma Children's Hospital, Amsterdam, The Netherlands
| | - Michiel Schokking
- Department of Pediatric Cardiology, Radboud University Medical Centre - Radboud University Medical Centre Children's Hospital, Nijmegen, The Netherlands
| | - Mark G Hazekamp
- Department of Cardiothoracic Surgery, Leiden University Medical Centre, Leiden, The Netherlands
| | - Ad J J C Bogers
- Department of Cardiothoracic Surgery, Erasmus Medical Centre, Rotterdam, The Netherlands
| | - Arend D J Ten Harkel
- Department of Pediatric Cardiology, Leiden University Medical Centre - Willem-Alexander Child and Youth Centre, Leiden, The Netherlands
| | - Tim Takken
- Child Development and Exercise Centre, Department of Pediatric Cardiology, University Medical Centre Utrecht - Wilhelmina Children's Hospital, Utrecht, The Netherlands
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Contractility-afterload mismatch in patients with protein-losing enteropathy after the Fontan operation. Pediatr Cardiol 2014; 35:1225-31. [PMID: 24827079 PMCID: PMC4164859 DOI: 10.1007/s00246-014-0920-8] [Citation(s) in RCA: 8] [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: 12/19/2013] [Accepted: 04/25/2014] [Indexed: 11/23/2022]
Abstract
This study aimed to clarify the relationship between onset of protein-losing enteropathy (PLE) and Fontan circulation, with special reference to the development of contractility-afterload mismatch. The PLE group comprised 9 patients who experienced PLE after undergoing the Fontan operation, and the control group consisted of 32 patients had did not experienced PLE more than 10 years after the Fontan operation. The study compared the pre- and postoperative values of arterial elastance (Ea), end-systolic elastance (Ees), and contractility-afterload mismatch (Ea/Ees). Furthermore, the variations in the values were examined during the preoperative, postoperative, and midterm postoperative periods in seven PLE patients who underwent cardiac catheterization at the onset of PLE and during the pre- and postintervention periods in three PLE patients who underwent surgical intervention to improve the Fontan circulation after the onset of PLE. Comparison of the values obtained before and after Fontan operations showed that the Ea values increased significantly in the PLE group. However, the pre- and postoperative Ees values did not differ in the two groups. During the postoperative period, Ea/Ees increased significantly, and the Ea and Ea/Ees values increased continuously until the onset of PLE in the PLE group. In the patients who underwent surgical intervention to improve the Fontan circulation after the onset of PLE, the Ea/Ees decreased significantly, and the serum albumin levels improved after the intervention. Contractility-afterload mismatch, mainly caused by the increase in the afterload of the systemic ventricle, may have an important role in the development of PLE after the Fontan operation.
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Latus H, Gummel K, Diederichs T, Bauer A, Rupp S, Kerst G, Jux C, Akintuerk H, Schranz D, Apitz C. Aortopulmonary collateral flow is related to pulmonary artery size and affects ventricular dimensions in patients after the fontan procedure. PLoS One 2013; 8:e81684. [PMID: 24303064 PMCID: PMC3841134 DOI: 10.1371/journal.pone.0081684] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2013] [Accepted: 10/15/2013] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Aortopulmonary collaterals (APCs) are frequently found in patients with a single-ventricle (SV) circulation. However, knowledge about the clinical significance of the systemic-to-pulmonary shunt flow in patients after the modified Fontan procedure and its potential causes is limited. Accordingly, the aim of our study was to detect and quantify APC flow using cardiovascular magnetic resonance (CMR) and assess its impact on SV volume and function as well as to evaluate the role of the size of the pulmonary arteries in regard to the development of APCs. METHODS 60 patients (mean age 13.3 ± 6.8 years) after the Fontan procedure without patent tunnel fenestration underwent CMR as part of their routine clinical assessment that included ventricular functional analysis and flow measurements in the inferior vena cava (IVC), superior vena cava (SVC) and ascending aorta (Ao). APC flow was quantified using the systemic flow estimator: (Ao) - (IVC + SVC). Pulmonary artery index (Nakata index) was calculated as RPA + LPA area/body surface area using contrast enhanced MR angiography. The patient cohort was divided into two groups according to the median APC flow: group 1 < 0.495 l/min/m(2) and group 2 > 0.495 l/min/m(2). RESULTS Group 1 patients had significant smaller SV enddiastolic (71 ± 16 vs 87 ± 25 ml/m(2); p=0.004) and endsystolic volumes (29 ± 11 vs 40 ± 21 ml/m(2); p=0.02) whereas ejection fraction (59 ± 9 vs 56 ± 13%; p=0.38) differed not significantly. Interestingly, pulmonary artery size showed a significant inverse correlation with APC flow (r=-0.50, p=0.002). CONCLUSIONS Volume load due to APC flow in Fontan patients affected SV dimensions, but did not result in an impairment of SV function. APC flow was related to small pulmonary artery size, suggesting that small pulmonary arteries represent a potential stimulus for the development of APCs.
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Affiliation(s)
- Heiner Latus
- Pediatric Heart Center, Justus-Liebig University Clinic, Giessen, Germany
- * E-mail:
| | - Kerstin Gummel
- Pediatric Heart Center, Justus-Liebig University Clinic, Giessen, Germany
| | - Tristan Diederichs
- Pediatric Heart Center, Justus-Liebig University Clinic, Giessen, Germany
| | - Anna Bauer
- Pediatric Heart Center, Justus-Liebig University Clinic, Giessen, Germany
| | - Stefan Rupp
- Pediatric Heart Center, Justus-Liebig University Clinic, Giessen, Germany
| | - Gunter Kerst
- Pediatric Heart Center, Justus-Liebig University Clinic, Giessen, Germany
| | - Christian Jux
- Department of Pediatric Cardiology, University Children’s Hospital Muenster, Muenster, Germany
| | - Hakan Akintuerk
- Pediatric Heart Center, Justus-Liebig University Clinic, Giessen, Germany
| | - Dietmar Schranz
- Pediatric Heart Center, Justus-Liebig University Clinic, Giessen, Germany
| | - Christian Apitz
- Pediatric Heart Center, Justus-Liebig University Clinic, Giessen, Germany
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Myers KA, Leung MT, Terri Potts M, Potts JE, Sandor GG. Noninvasive Assessment of Vascular Function and Hydraulic Power and Efficiency in Pediatric Fontan Patients. J Am Soc Echocardiogr 2013; 26:1221-1227. [DOI: 10.1016/j.echo.2013.06.013] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/07/2012] [Indexed: 10/26/2022]
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Heart Failure in Adults who had the Fontan Procedure: Natural History, Evaluation, and Management. CURRENT TREATMENT OPTIONS IN CARDIOVASCULAR MEDICINE 2013; 15:587-601. [DOI: 10.1007/s11936-013-0257-2] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
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35
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Lambert E, d'Udekem Y, Cheung M, Sari CI, Inman J, Ahimastos A, Eikelis N, Pathak A, King I, Grigg L, Schlaich M, Lambert G. Sympathetic and vascular dysfunction in adult patients with Fontan circulation. Int J Cardiol 2013; 167:1333-8. [DOI: 10.1016/j.ijcard.2012.04.015] [Citation(s) in RCA: 44] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/02/2012] [Accepted: 04/01/2012] [Indexed: 01/21/2023]
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36
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Kanakis M, Lioulias A, Samanidis G, Loukas C, Mitropoulos F. Evolution in Experimental Fontan Circulation: A Review. Ann Thorac Cardiovasc Surg 2013; 19:177-85. [PMID: 23698375 DOI: 10.5761/atcs.ra.13-00017] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Affiliation(s)
- Meletios Kanakis
- Department of Pediatric and Congenital Heart Surgery, Onassis Cardiac Surgery Center, Athens, Greece
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Shabanian R, Shahbaznejad L, Razaghian A, Kiani A, Rahimzadeh M, Seifirad S, Kocharian A, Gilani JS, Navabi MA. Sildenafil and ventriculo-arterial coupling in Fontan-palliated patients: a noninvasive echocardiographic assessment. Pediatr Cardiol 2013; 34:129-34. [PMID: 22864675 DOI: 10.1007/s00246-012-0400-y] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/22/2012] [Accepted: 05/17/2012] [Indexed: 11/29/2022]
Abstract
The fundamental role of pulmonary vascular resistance in the Fontan circulation is obvious. Medications decreasing this resistance may have an impact on the fate of this population. Hence, we assessed noninvasively the effect of oral sildenafil on the ventriculo-arterial coupling in patients with Fontan circulation. In a single-center, prospective case series study, 23 patients with fenestrated extracardiac total cavopulmonary connection age 12-31 years were enrolled in this study. Clinical characteristics and echocardiographic examination were performed before and after a 1 week course of sildenafil at 0.5 mg/kg every 8 h. Sildenafil had no effect on heart rate and blood pressure. However, oxygen saturation was significantly increased with sildenafil (87.6 ± 4.3 vs. 90.1 ± 3.6; P < 0.0001). The calculated noninvasive ventricular end-systolic elastance (Ees) was greater after sildenafil compared with the pre-sildenafil values (1.59 ± 0.17 vs. 1.72 ± 0.27 mm Hg/ml; P = 0.001). Moreover, significant decreases in arterial elastance (Ea) (1.62 ± 0.53 vs. 1.36 ± 0.43 mm Hg/ml; P < 0.0001), ventricular end-diastolic elastance (Eed) (0.05 ± 0.021 vs. 0.04 ± 0.013; P = 0.002), and, finally, ventriculo-arterial coupling index (0.99 ± 0.26 vs. 0.76 ± 0.15; P < 0.0001) were found after sildenafil administration. The intolerable side effects that led to stopping the sildenafil occurred only in one (4 %) patient. Sildenafil has increased ventricular systolic elastance and improved ventriculo-arterial coupling in patients palliated with Fontan circulation. Short-term sildenafil was well tolerated in most of the patients with only minor side effects.
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Affiliation(s)
- Reza Shabanian
- Department of Pediatric Cardiology, Children's Medical Center, Tehran University of Medical Sciences, 14194 Tehran, Iran.
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Biglino G, Schievano S, Steeden JA, Ntsinjana H, Baker C, Khambadkone S, de Leval MR, Hsia TY, Taylor AM, Giardini A. Reduced ascending aorta distensibility relates to adverse ventricular mechanics in patients with hypoplastic left heart syndrome: noninvasive study using wave intensity analysis. J Thorac Cardiovasc Surg 2012; 144:1307-13; discussion 1313-4. [PMID: 23031685 DOI: 10.1016/j.jtcvs.2012.08.028] [Citation(s) in RCA: 42] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/11/2012] [Revised: 08/01/2012] [Accepted: 08/07/2012] [Indexed: 11/16/2022]
Abstract
OBJECTIVE To evaluate the aortic arch elastic properties and ventriculoarterial coupling efficiency in patients with single ventricle physiology, with and without a surgically reconstructed arch. METHODS We studied 21 children with single ventricle physiology after bidirectional superior cavopulmonary surgery: 10 with hypoplastic left heart syndrome, who underwent surgical arch reconstruction, and 11 with other types of single ventricle physiology but without arch reconstruction. All children underwent pre-Fontan magnetic resonance imaging. No patient exhibited aortic recoarctation. Data on aortic wave speed, aortic distensibility and wave intensity profiles were all extracted from the magnetic resonance imaging studies using an in-house-written plug-in for the Digital Imaging and Communications in Medicine viewer OsiriX. RESULTS Children with hypoplastic left heart syndrome had significantly greater wave speed (P = .002), and both stiffer (P = .004) and larger (P < .0001) ascending aortas than the patients with a nonreconstructed arch. Aortic distensibility was not influenced by ventricular stroke volume but depended on a combination of increased aortic diameter and abnormal wall mechanical properties. Those with hypoplastic left heart syndrome had a lower peak wave intensity and reduced energy carried by the forward compression and the forward expansion waves, even after correction for stroke volume, suggesting an abnormal systolic and diastolic function. Lower wave energy was associated with an increased aortic diameter. CONCLUSIONS Using a novel, noninvasive technique based on image analysis, we have demonstrated that aortic arch reconstruction in children with hypoplastic left heart syndrome is associated with reduced aortic distensibility and unfavorable ventricular-vascular coupling compared with those with single ventricle physiology without aortic arch reconstruction.
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Affiliation(s)
- Giovanni Biglino
- Centre for Cardiovascular Imaging, UCL Institute of Cardiovascular Science, London, United Kingdom
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Iwai S, Kawata H, Ozawa H, Yamauchi S, Kishimoto H. Use of the Damus-Kaye-Stansel procedure prevents increased ventricular strain in Fontan candidates. Eur J Cardiothorac Surg 2012; 43:150-4. [PMID: 22518038 DOI: 10.1093/ejcts/ezs142] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
OBJECTIVES In Fontan candidates, we have recently been aggressively performing the Damus-Kaye-Stansel procedure (DKS) to prevent increased afterload on the systemic ventricle. The present study investigated the efficacy of the DKS procedure in terms of the ventricular function following a Fontan operation. METHODS Patients undergoing a Fontan operation were divided into three groups: DKS performed at the time of the bidirectional Glenn or Fontan operation (DKS group, n = 25); DKS not performed at any stage due to mild pulmonary stenosis (PS) (PS group, n = 23) and DKS not performed due to pulmonary atresia (PA) or severe PS (PA group, n = 24). Ventricular function, afterload on the systemic ventricle and atrioventricular valve regurgitation were compared between groups. RESULTS Cardiac catheterization before a Glenn or Fontan operation and at 1-year following the Fontan revealed significantly decreased ventricular end-diastolic pressure in the DKS group. The ventricular ejection fraction was significantly deteriorated in the PS group. Effective arterial elastance, as an index of total ventricular afterload, was increased after a Fontan in all groups, with a substantial increase in the PS group. As an index of ventricular mechanical efficiency, ventriculoarterial coupling was significantly increased only in the PS group. Cardiac ultrasonography revealed atrioventricular valve regurgitation above grade 3 persisting in many patients from the PS group. Semilunar valve function after DKS operation did not progress to moderate or worse in any patients. CONCLUSIONS The proactive performance of the DKS procedure prevents increased ventricular afterload, avoiding deterioration of cardiac function and contributing to improved long-term results following a Fontan operation.
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Affiliation(s)
- Shigemitsu Iwai
- Department of Cardiovascular Surgery, Osaka Medical Center and Research Institute for Maternal and Child Health, Osaka, Japan.
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Ciliberti P, Schulze-Neick I, Giardini A. Modulation of pulmonary vascular resistance as a target for therapeutic interventions in Fontan patients: focus on phosphodiesterase inhibitors. Future Cardiol 2012; 8:271-84. [DOI: 10.2217/fca.12.16] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
Despite advancements in surgical techniques over the past 20 years, Fontan patients have decreased exercise capacity as a consequence of an inherent inability to adequately increase cardiac output during exercise. They are also affected by several complications that are associated with considerable morbidity and mortality. As the systemic and pulmonary circulations are placed in series without a subpulmonary ventricle propelling blood through the pulmonary vasculature, the systemic venous pressure and the respiratory mechanics are the only forces driving pulmonary blood flow. In Fontan circulation, pulmonary vascular resistance is the single most important factor involved in the limitation of cardiac output and treatments able to decrease pulmonary vascular resistance might conversely improve cardiac output and exercise capacity. In this article we discuss the initial experience with the use of sildenafil in Fontan patients and we discuss the possible mechanisms through which sildenafil might positively act in Fontan circulation.
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Affiliation(s)
- Paolo Ciliberti
- Cardiorespiratory Unit, Great Ormond Street Hospital for Children, Great Ormond Street, London WC1N 3JH, UK
| | - Ingram Schulze-Neick
- Cardiorespiratory Unit, Great Ormond Street Hospital for Children, Great Ormond Street, London WC1N 3JH, UK
| | - Alessandro Giardini
- Cardiorespiratory Unit, Great Ormond Street Hospital for Children, Great Ormond Street, London WC1N 3JH, UK
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Cua CL, Feltes TF. Echocardiographic evaluation of the single right ventricle in congenital heart disease: results of new techniques. Circ J 2011; 76:22-31. [PMID: 22139360 DOI: 10.1253/circj.cj-11-1267] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
Right ventricular (RV) function is increasingly recognized as having prognostic significance in various disease processes. The current gold standard for noninvasive measurement of RV function is cardiac magnetic resonance imaging; however, because of practical considerations, echocardiography remains the most often used modality for evaluating the RV. In the past, because of its complex morphology, echocardiographic assessment of the RV was usually qualitative in nature. Current advances in echocardiographic techniques have been able to overcome some of the previous limitations and thus quantification of RV function is increasingly being performed. In addition, recent echocardiographic guidelines for evaluating the RV have been published to aid in standardizing practice. The evaluation of RV function almost certainly has no greater importance than in the congenital heart population, especially in those patients that have a single RV acting as the systemic ventricle. As this complex population continues to increase in number, accurate and precise evaluation of RV function will be a major issue in determining clinical care.
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Affiliation(s)
- Clifford L Cua
- Heart Center, Nationwide Children's Hospital, Columbus, OH 43205, USA.
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Kanakis MA, Mitropoulos FA, Katsimpoulas M, Dimitriou C, Peroulis M, Kostomitsopoulos N, Lioulias A, Kostakis A. Experimentally modified Fontan circulation in an adolescent pig model without the use of cardiopulmonary bypass. Med Sci Monit 2011; 17:BR10-15. [PMID: 21169902 PMCID: PMC3524685 DOI: 10.12659/msm.881319] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Background The feasibility and the hemodynamic outcome of Fontan circulation, without the use of cardiopulmonary bypass, were studied on a beating heart of an adolescent pig model, using a modified total cavopulmonary connection. Material/Methods Eight open-chest anesthetized pigs underwent a successful total cavopulmonary connection with the use of an appropriate Y-shaped Dacron-type conduit. Through a median sternotomy, the distal part of the superior vena cava was anastomosed end-to-end to one side of the conduit. The other side of the graft was anastomosed end-to-side to the main pulmonary artery. The conduit was tailored to an appropriate length and anastomosed end-to-end to the inferior vena cava. The hemodynamic status of the animals was recorded before and after the establishment of the total cavopulmonary connection. Results Forty-five minutes after completion of total cavopulmonary connection, and for a total of 1 hour, hemodynamic measurements showed a decrease in mean arterial and mean pulmonary artery pressures, heart rate and cardiac output. The inferior vena caval pressure and total pulmonary vascular resistance were increased. Conclusions A total cavopulmonary connection, performed on a beating heart, without extracorporeal circulation or other means of temporary bypass, although it is technically demanding, is feasible.
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Affiliation(s)
- Meletios A Kanakis
- Department of Thoracic Surgery, Sismanoglio General Hospital, Athens, Greece.
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Abstract
The long-term outcome of patients with congenitally malformed hearts involving abnormal right ventricular morphology and haemodynamics is variable. In most instances, the patients are at risk for right ventricular failure, in part due to morphological differences between the right and left ventricles and their response to chronic volume and pressure overload. In patients after repair of tetralogy of Fallot, and after balloon valvotomy for valvar pulmonary stenosis, pulmonary regurgitation is the most significant risk factor for right ventricular dysfunction. In patients with a dominant right ventricle after Fontan palliation, and in those with systemic right ventricles in association with surgically or congenitally corrected transposition, the right ventricle is not morphologically capable of dealing with chronic exposure to the high afterload of the systemic circulation. In patients with Ebstein's malformation of the tricuspid valve, the degree of atrialisation of the right ventricle determines how well the right ventricle will function as the pump for the pulmonary vascular bed.
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Abstract
Choussat's "Ten Commandments," which describes the components of an ideal Fontan candidate, was first published in 1977. Despite the wisdom in these commandments, it is clear from a historic perspective that total compliance with all criteria does not necessarily portend excellent long-term survival. I believe the end point of the original commandments should be modified to include improvement in long-term survival. I suggest the following single commandment: "Thou Shalt Be Perfect."
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Shimizu S, Shishido T, Une D, Kamiya A, Kawada T, Sano S, Sugimachi M. Right ventricular stiffness constant as a predictor of postoperative hemodynamics in patients with hypoplastic right ventricle: a theoretical analysis. J Physiol Sci 2010; 60:205-12. [PMID: 20131025 PMCID: PMC10717266 DOI: 10.1007/s12576-010-0086-y] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2009] [Accepted: 01/10/2010] [Indexed: 11/29/2022]
Abstract
One and a half ventricle repair (1.5VR) is a surgical option for hypoplastic right ventricle (RV). The benefits of this procedure compared to biventricular repair (2VR) or Fontan operation remain unsettled. To compare postoperative hemodynamics, we performed a theoretical analysis using a computational model based on lumped-parameter state-variable equations. We varied the RV stiffness constant (B (RV)) to simulate the various RV hypoplasia, and estimated hemodynamics for a given B (RV). With B (RV) < 150% of normal, cardiac output was the largest in 2VR. With B (RV) > 150%, cardiac output became larger in 1.5VR than in 2VR. With B (RV) > 250%, RV end-diastolic volume was almost the same between 1.5VR and 2VR, and a rapid increase in atrial pressure precluded the use of 1.5VR. These results indicate that the beneficial effect of 1.5VR depends on the RV stiffness constant. Determination of management strategy should not only be based on the morphologic parameters but also on the physiological properties of RV.
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Affiliation(s)
- Shuji Shimizu
- Department of Cardiovascular Dynamics, Advanced Medical Engineering Center, National Cardiovascular Center Research Institute, 5-7-1 Fujishiro-dai, Suita, Osaka, Japan.
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Rychik J, Goldberg D, Dodds K. Long-term results and consequences of single ventricle palliation. PROGRESS IN PEDIATRIC CARDIOLOGY 2010. [DOI: 10.1016/j.ppedcard.2010.02.001] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
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Leyvi G, Wasnick JD. Single-Ventricle Patient: Pathophysiology and Anesthetic Management. J Cardiothorac Vasc Anesth 2010; 24:121-30. [DOI: 10.1053/j.jvca.2009.07.018] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/18/2008] [Indexed: 11/11/2022]
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Gaitan BD, Ramakrishna H, DiNardo JA, Cannesson M. Case 1—2010 Pulmonary Thrombectomy in an Adult With Fontan Circulation. J Cardiothorac Vasc Anesth 2010; 24:173-82. [DOI: 10.1053/j.jvca.2009.11.003] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/06/2009] [Indexed: 11/11/2022]
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Krishnan US, Taneja I, Gewitz M, Young R, Stewart J. Peripheral vascular adaptation and orthostatic tolerance in Fontan physiology. Circulation 2009; 120:1775-83. [PMID: 19841302 DOI: 10.1161/circulationaha.109.854331] [Citation(s) in RCA: 43] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
BACKGROUND The Fontan circulation is critically dependent on elevated venous pressures to sustain effective venous return. We hypothesized that chronically increased systemic venous pressures lead to adaptive changes in regional and peripheral vessels to maintain cardiac output, especially when patients are upright. METHODS AND RESULTS Nine post-Fontan procedure patients (aged 13 to 24 years) and 6 age- and sex-matched controls were compared with techniques to measure circulatory responses (peripheral and compartmental blood flow, venous capacity, and microvascular filtration). Parameters studied included strain-gauge plethysmography measures of peripheral circulatory function, regional blood volume distribution by impedance plethysmography, and head-up tilt testing. Important differences between Fontan patients and controls were seen in several vascular compartments: (1) Calf capacitance was lower (median, 3.5 versus 5.5 mL/100 mL tissue; P=0.005), and resting venous pressure was higher (13.0 versus 10.5 mm Hg; P=0.004); (2) higher leg arterial resistance was observed (32.1 versus 22.2; P=0.03); (3) microvascular filtration pressures and threshold for edema were elevated; and (4) with head-up tilt testing, splanchnic flow was not reduced in Fontan patients versus controls (fractional change, +4% versus -32%; P=0.004), and splanchnic arterial resistance did not increase as expected (fractional change, +8% versus +79%; P=0.003). CONCLUSIONS Reduced venous compliance and increased filtration thresholds may act as adaptive mechanisms in maintaining venous return in Fontan circulation. Well-compensated Fontan subjects demonstrate superior orthostatic tolerance resulting from decreased compartmental fluid shifts in response to head-up tilt and higher vascular resistance. This results from increased venous stiffness and decreased splanchnic capacitance and may also be an adaptive mechanism to maintain venous return in these patients while standing.
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Affiliation(s)
- Usha S Krishnan
- Department of Pediatric Cardiology, New York Medical College, Valhalla, NY 10595, USA.
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Clinical outcome 5 to 18 years after the Fontan operation performed on children younger than 5 years. J Thorac Cardiovasc Surg 2009; 138:89-95. [DOI: 10.1016/j.jtcvs.2008.12.027] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/15/2008] [Revised: 12/11/2008] [Accepted: 12/25/2008] [Indexed: 11/22/2022]
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