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Smith CL, Krishnamurthy G, Srinivasan A, Dori Y. Lymphatic interventions in congenital heart disease. Semin Pediatr Surg 2024; 33:151419. [PMID: 38830312 DOI: 10.1016/j.sempedsurg.2024.151419] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/05/2024]
Abstract
Congenital heart disease affects 1/100 live births and is one of the most common congenital abnormalities. The relationship between congenital heart disease and lymphatic abnormalities and/or dysfunction is well documented and can be grossly divided into syndromic and non-syndromic etiologies. In patients with genetic syndromes (as examples listed above), there are known primary abnormal lymphatic development leading to a large pleiotropic manifestation of lymphatic dysfunction. Non-syndromic patients, or those without clear genetic etiologies for their lymphatic dysfunction, are often thought to be secondary to physiologic abnormalities as sequelae of congenital heart disease and palliative surgeries. Patients with congenital heart disease and lymphatic dysfunction have a wide variety of clinical manifestations for which there were not many therapeutic interventions available. The development of new imaging techniques allows us to understand better the pathophysiology of these problems and to develop different percutaneous interventions aiming to restore normal lymphatic function.
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Affiliation(s)
- Christopher L Smith
- Division of Cardiology The Children's Hospital of Philadelphia and Department of Pediatrics Perelman School of Medicine at The University of Pennsylvania, Philadelphia PA.
| | - Ganesh Krishnamurthy
- Department of Radiology The Children's Hospital of Philadelphia and Perelman School of Medicine at The University of Pennsylvania, Philadelphia PA
| | - Abhay Srinivasan
- Department of Radiology The Children's Hospital of Philadelphia and Perelman School of Medicine at The University of Pennsylvania, Philadelphia PA
| | - Yoav Dori
- Division of Cardiology The Children's Hospital of Philadelphia and Department of Pediatrics Perelman School of Medicine at The University of Pennsylvania, Philadelphia PA
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Abdulkarim A, Shaji S, Elfituri M, Gunsaulus M, Zafar MA, Zaidi AN, Pass RH, Feingold B, Kurland G, Kreutzer J, Ghassemzadeh R, Goldstein B, West S, Alsaied T. Pulmonary Complications in Patients With Fontan Circulation: JACC Review Topic of the Week. J Am Coll Cardiol 2023; 81:2434-2444. [PMID: 37344046 DOI: 10.1016/j.jacc.2023.04.036] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/07/2023] [Revised: 04/03/2023] [Accepted: 04/10/2023] [Indexed: 06/23/2023]
Abstract
The Fontan operation has resulted in significant improvement in survival of patients with single ventricle physiology. As a result, there is a growing population of individuals with Fontan physiology reaching adolescence and adulthood. Despite the improved survival, there are long-term morbidities associated with the Fontan operation. Pulmonary complications are common and may contribute to both circulatory and pulmonary insufficiency, leading ultimately to Fontan failure. These complications include restrictive lung disease, sleep abnormalities, plastic bronchitis, and cyanosis. Cyanosis post-Fontan procedure can be attributed to multiple causes including systemic to pulmonary venous collateral channels and pulmonary arteriovenous malformations. This review presents the unique cardiopulmonary interactions in the Fontan circulation. Understanding the cardiopulmonary interactions along with improved recognition and treatment of pulmonary abnormalities may improve the long-term outcomes in this growing patient population. Interventions focused on improving pulmonary function including inspiratory muscle training and endurance training have shown a promising effect post-Fontan procedure.
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Affiliation(s)
- Ali Abdulkarim
- Department of Pediatrics, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Shawn Shaji
- Heart Institute, University of Pittsburgh Medical Center, Children's Hospital of Pittsburgh, Pittsburgh, Pennsylvania, USA; Division of Pediatric Cardiology, Department of Pediatrics, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Mahmud Elfituri
- Department of Pediatrics, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Megan Gunsaulus
- Heart Institute, University of Pittsburgh Medical Center, Children's Hospital of Pittsburgh, Pittsburgh, Pennsylvania, USA; Division of Pediatric Cardiology, Department of Pediatrics, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Muhammad A Zafar
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
| | - Ali N Zaidi
- Mount Sinai Heart, Mount Sinai Kravis Children's Heart Center, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Robert H Pass
- Department of Pediatrics, Icahn School of Medicine at Mount Sinai, Division of Pediatric Cardiology and Mount Sinai Kravis Children's Heart Center, New York, New York, USA
| | - Brian Feingold
- Heart Institute, University of Pittsburgh Medical Center, Children's Hospital of Pittsburgh, Pittsburgh, Pennsylvania, USA; Division of Pediatric Cardiology, Department of Pediatrics, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Geoffrey Kurland
- University of Pittsburgh Medical Center, Children's Hospital of Pittsburgh, Pittsburgh, Pennsylvania, USA; Division of Pediatric Pulmonology, Department of Pediatrics, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Jacqueline Kreutzer
- Heart Institute, University of Pittsburgh Medical Center, Children's Hospital of Pittsburgh, Pittsburgh, Pennsylvania, USA; Division of Pediatric Cardiology, Department of Pediatrics, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Rod Ghassemzadeh
- University of Pittsburgh Medical Center, Children's Hospital of Pittsburgh, Department of Critical Care, Pittsburgh, Pennsylvania, USA
| | - Bryan Goldstein
- Heart Institute, University of Pittsburgh Medical Center, Children's Hospital of Pittsburgh, Pittsburgh, Pennsylvania, USA; Division of Pediatric Cardiology, Department of Pediatrics, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Shawn West
- Heart Institute, University of Pittsburgh Medical Center, Children's Hospital of Pittsburgh, Pittsburgh, Pennsylvania, USA; Division of Pediatric Cardiology, Department of Pediatrics, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Tarek Alsaied
- Heart Institute, University of Pittsburgh Medical Center, Children's Hospital of Pittsburgh, Pittsburgh, Pennsylvania, USA; Division of Pediatric Cardiology, Department of Pediatrics, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA.
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Bauer C, Dori Y, Scala M, Tulzer A, Tulzer G. Current diagnostic and therapeutic strategies for the management of lymphatic insufficiency in patients with hypoplastic left heart syndrome. Front Pediatr 2023; 11:1058567. [PMID: 36911024 PMCID: PMC9999027 DOI: 10.3389/fped.2023.1058567] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/30/2022] [Accepted: 01/31/2023] [Indexed: 03/14/2023] Open
Abstract
Children with hypoplastic left heart syndrome share unique hemodynamic features that alter lymphatic integrity at all stages of palliation. Lymphatic congestion is almost universal in this patient group to some extent. It may lead to reversal of lymphatic flow, the development of abnormal lymphatic channels and ultimately decompression and loss of protein rich lymphatic fluid into extra lymphatic compartments in prone individuals. Some of the most devastating complications that are associated with single ventricle physiology, notably plastic bronchitis and protein losing enteropathy, have now been proven to be lymphatic in origin. Based on the new pathophysiologic concept new diagnostic and therapeutic strategies have recently been developed. Dynamic contrast magnetic resonance lymphangiography is now mainstay in diagnosis of lymphatic insufficiency and allows a thorough assessment of anatomy and function of the main lymphatic compartments through intranodal, intrahepatic and intramesenteric lymphatic imaging. Contrast enhanced ultrasound can evaluate thoracic duct patency and conventional fluoroscopic lymphangiography has been refined for evaluation of patients where magnetic resonance imaging cannot be performed. Novel lymphatic interventional techniques, such as thoracic duct embolization, selective lymphatic duct embolization and liver lymphatic embolization allow to seal abnormal lymphatic networks minimally invasive and have shown to resolve symptoms. Innominate vein turn-down procedures, whether surgical or interventional, have been designed to reduce lymphatic afterload and increase systemic preload effectively in the failing Fontan circulation. Outflow obstruction can now be managed with new microsurgical techniques that create lympho-venous anastomosis. Short term results for all of these new approaches are overall promising but evidence is sparse and long-term outcome still has to be defined. This review article aims to summarize current concepts of lymphatic flow disorders in single ventricle patients, discuss new emerging diagnostic and therapeutic strategies and point out lacks in evidence and needs for further research on this rapidly growing topic.
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Affiliation(s)
- Christoph Bauer
- Department of Paediatric Cardiology, Kepler University Hospital GmbH, Linz, Austria.,Johannes Kepler University Linz, Linz, Austria
| | - Yoav Dori
- Department of Cardiology, Jill and Mark Fishman Center for Lymphatic Disorders, Children's Hospital of Philadelphia, Philadelphia, PA, United States
| | - Mario Scala
- Johannes Kepler University Linz, Linz, Austria.,Central Radiology Institute, Kepler University Hospital GmbH, Linz, Austria
| | - Andreas Tulzer
- Department of Paediatric Cardiology, Kepler University Hospital GmbH, Linz, Austria.,Johannes Kepler University Linz, Linz, Austria
| | - Gerald Tulzer
- Department of Paediatric Cardiology, Kepler University Hospital GmbH, Linz, Austria.,Johannes Kepler University Linz, Linz, Austria
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Matsuo K, Hirose M, Aoki H, Kayatani F. Transconduit approach for pulmonary vein stenting in an extracardiac Fontan and plastic bronchitis case. BMJ Case Rep 2022; 15:e250565. [PMID: 35985750 PMCID: PMC9396155 DOI: 10.1136/bcr-2022-250565] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/07/2022] [Indexed: 11/03/2022] Open
Abstract
Plastic bronchitis (PB) is a rare but severe complication in patients following the Fontan operation, the final palliative procedure for single ventricle heart disease. PB is characterised by the formation of rubbery casts of the tracheobronchial tree that may cause cough, wheezing, dyspnoea and hypoxia. Progressive airway obstruction may lead to asphyxia and death, and the overall mortality rate is 15.2%. Most patients receive a combination therapy from three different treatment strategies, that is, therapy for relief of airway obstruction, anti-inflammatory treatment and treatment to improve haemodynamics of the Fontan physiology. Therapy improving haemodynamics consists of optimising the Fontan circulation or cardiac function, antiarrhythmic therapy, inhibition of lymph leakage/production, decompression of the Fontan circulation and heart transplantation.We present the case of a child with PB after extracardiac Fontan operation, who was refractory to balloon angioplasty and surgical release for pulmonary vein (PV) stenosis. We decided to perform stent implantation for the right PVs through transconduit puncture instead of fenestration because the position of fenestration was too high to access the PVs. After PV stenting via the transconduit approach, she experienced improvement in cough, wheezing and breathlessness, and a significant reduction in airway cast formation.
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Affiliation(s)
- Kumiyo Matsuo
- Pediatric Cardiology, Osaka Women's and Children's Hospital, Izumi, Japan
| | - Masaki Hirose
- Pediatric Cardiology, Osaka Women's and Children's Hospital, Izumi, Japan
| | - Hisaaki Aoki
- Pediatric Cardiology, Osaka Women's and Children's Hospital, Izumi, Japan
| | - Futoshi Kayatani
- Pediatric Cardiology, Osaka Women's and Children's Hospital, Izumi, Japan
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