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Ning L, Zanella S, Tomov ML, Amoli MS, Jin L, Hwang B, Saadeh M, Chen H, Neelakantan S, Dasi LP, Avazmohammadi R, Mahmoudi M, Bauser‐Heaton HD, Serpooshan V. Targeted Rapamycin Delivery via Magnetic Nanoparticles to Address Stenosis in a 3D Bioprinted in Vitro Model of Pulmonary Veins. ADVANCED SCIENCE (WEINHEIM, BADEN-WURTTEMBERG, GERMANY) 2024; 11:e2400476. [PMID: 38696618 PMCID: PMC11234432 DOI: 10.1002/advs.202400476] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/12/2024] [Revised: 04/09/2024] [Indexed: 05/04/2024]
Abstract
Vascular cell overgrowth and lumen size reduction in pulmonary vein stenosis (PVS) can result in elevated PV pressure, pulmonary hypertension, cardiac failure, and death. Administration of chemotherapies such as rapamycin have shown promise by inhibiting the vascular cell proliferation; yet clinical success is limited due to complications such as restenosis and off-target effects. The lack of in vitro models to recapitulate the complex pathophysiology of PVS has hindered the identification of disease mechanisms and therapies. This study integrated 3D bioprinting, functional nanoparticles, and perfusion bioreactors to develop a novel in vitro model of PVS. Bioprinted bifurcated PV constructs are seeded with endothelial cells (ECs) and perfused, demonstrating the formation of a uniform and viable endothelium. Computational modeling identified the bifurcation point at high risk of EC overgrowth. Application of an external magnetic field enabled targeting of the rapamycin-loaded superparamagnetic iron oxide nanoparticles at the bifurcation site, leading to a significant reduction in EC proliferation with no adverse side effects. These results establish a 3D bioprinted in vitro model to study PV homeostasis and diseases, offering the potential for increased throughput, tunability, and patient specificity, to test new or more effective therapies for PVS and other vascular diseases.
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Affiliation(s)
- Liqun Ning
- Wallace H. Coulter Department of Biomedical EngineeringEmory University School of Medicine and Georgia Institute of TechnologyAtlantaGA30322USA
- Department of Mechanical EngineeringCleveland State UniversityClevelandOH44115USA
| | - Stefano Zanella
- Wallace H. Coulter Department of Biomedical EngineeringEmory University School of Medicine and Georgia Institute of TechnologyAtlantaGA30322USA
| | - Martin L. Tomov
- Wallace H. Coulter Department of Biomedical EngineeringEmory University School of Medicine and Georgia Institute of TechnologyAtlantaGA30322USA
| | - Mehdi Salar Amoli
- Wallace H. Coulter Department of Biomedical EngineeringEmory University School of Medicine and Georgia Institute of TechnologyAtlantaGA30322USA
| | - Linqi Jin
- Wallace H. Coulter Department of Biomedical EngineeringEmory University School of Medicine and Georgia Institute of TechnologyAtlantaGA30322USA
| | - Boeun Hwang
- Wallace H. Coulter Department of Biomedical EngineeringEmory University School of Medicine and Georgia Institute of TechnologyAtlantaGA30322USA
| | - Maher Saadeh
- Wallace H. Coulter Department of Biomedical EngineeringEmory University School of Medicine and Georgia Institute of TechnologyAtlantaGA30322USA
| | - Huang Chen
- Wallace H. Coulter Department of Biomedical EngineeringEmory University School of Medicine and Georgia Institute of TechnologyAtlantaGA30322USA
| | - Sunder Neelakantan
- Department of Biomedical EngineeringTexas A&M UniversityCollege StationTX77843USA
| | - Lakshmi Prasad Dasi
- Wallace H. Coulter Department of Biomedical EngineeringEmory University School of Medicine and Georgia Institute of TechnologyAtlantaGA30322USA
| | - Reza Avazmohammadi
- Department of Biomedical EngineeringTexas A&M UniversityCollege StationTX77843USA
- J. Mike Walker ’66 Department of Mechanical EngineeringTexas A&M UniversityCollege StationTX77840USA
| | - Morteza Mahmoudi
- Department of Radiology and Precision Health ProgramMichigan State UniversityEast LandingMI48824USA
| | - Holly D. Bauser‐Heaton
- Wallace H. Coulter Department of Biomedical EngineeringEmory University School of Medicine and Georgia Institute of TechnologyAtlantaGA30322USA
- Department of PediatricsEmory University School of MedicineAtlantaGA30322USA
- Children's Healthcare of AtlantaAtlantaGA30322USA
- Sibley Heart Center at Children's Healthcare of AtlantaAtlantaGA30322USA
| | - Vahid Serpooshan
- Wallace H. Coulter Department of Biomedical EngineeringEmory University School of Medicine and Georgia Institute of TechnologyAtlantaGA30322USA
- Department of PediatricsEmory University School of MedicineAtlantaGA30322USA
- Children's Healthcare of AtlantaAtlantaGA30322USA
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Li D, Qiu L, Hong H, Chen H, Zhao P, Xiao Y, Zhang H, Sun Q, Ye L. A neonatal rat model of pulmonary vein stenosis. Cell Biosci 2023; 13:112. [PMID: 37337290 DOI: 10.1186/s13578-023-01058-8] [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: 02/06/2023] [Accepted: 05/23/2023] [Indexed: 06/21/2023] Open
Abstract
OBJECTIVES Pulmonary vein stenosis (PVS), one of the most challenging clinical problems in congenital heart disease, leads to secondary pulmonary arterial hypertension (PAH) and right ventricular (RV) hypertrophy. Due to the lack of a rodent model, the mechanisms underlying PVS and its associated secondary effects are largely unknown, and treatments are minimally successful. This study developed a neonatal rat PVS model with the aim of increasing our understanding of the mechanisms and developing possible treatments for PVS. METHODS PVS was created at postnatal day 1 (P1) by banding pulmonary veins that receive blood from the right anterior and mid lobes. The condition was confirmed using echocardiography, computed tomography (CT), gross anatomic examination, hematoxylin and eosin (H&E) staining, fibrosis staining, and immunofluorescence. Lung and RV remodeling under the condition of PVS were evaluated using H&E staining, fibrosis staining, and immunofluorescence. RESULTS At P21, echocardiography revealed a change in wave form and a decrease in pulmonary artery acceleration time-indicators of PAH-at the transpulmonary valve site in the PVS group. CT at P21 showed a decrease in pulmonary vein diameter in the PVS group. At P30 in the PVS group, gross anatomic examination showed pulmonary congestion, H&E staining showed wall thickening and lumen narrowing in the upstream pulmonary veins, and immunofluorescence showed an increase in the smooth muscle layers in the upstream pulmonary veins. In addition, at P30 in the PVS group, lung remodeling was evidenced by hyperemia, thickening of pulmonary small vessel walls and smooth muscle layers, and reduction of the number of alveoli. RV remodeling was evidenced by an increase in RV free wall thickness. CONCLUSIONS A neonatal rat model of PVS was successfully established, showing secondary lung and RV remodeling. This model may serve as a useful platform for understanding the mechanisms and treatments for PVS.
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Affiliation(s)
- Debao Li
- Department of Thoracic and Cardiovascular Surgery, School of Medicine, Shanghai Children's Medical Center, Shanghai Jiao Tong University, 1678 Dongfang Road, Shanghai, 200127, China
| | - Lisheng Qiu
- Department of Thoracic and Cardiovascular Surgery, School of Medicine, Shanghai Children's Medical Center, Shanghai Jiao Tong University, 1678 Dongfang Road, Shanghai, 200127, China
| | - Haifa Hong
- Department of Thoracic and Cardiovascular Surgery, School of Medicine, Shanghai Children's Hospital, Shanghai Jiao Tong University, Shanghai, China
| | - Hao Chen
- Department of Thoracic and Cardiovascular Surgery, School of Medicine, Shanghai Children's Medical Center, Shanghai Jiao Tong University, 1678 Dongfang Road, Shanghai, 200127, China
| | - Peibin Zhao
- Institute of Cardiovascular Development and Translational Medicine, Children's Heart Center, The Second Affiliated Hospital and Yuying Children's Hospital, Wenzhou Medical University, Wenzhou, 325027, China
| | - Yingying Xiao
- Department of Thoracic and Cardiovascular Surgery, School of Medicine, Shanghai Children's Hospital, Shanghai Jiao Tong University, Shanghai, China
| | - Hao Zhang
- Institute of Cardiovascular Development and Translational Medicine, Children's Heart Center, The Second Affiliated Hospital and Yuying Children's Hospital, Wenzhou Medical University, Wenzhou, 325027, China.
- Shanghai Institute for Pediatric Congenital Heart Disease, Shanghai Children's Medical Center, Shanghai Jiao Tong University School of Medicine, 1678 Dongfang Road, Shanghai, 200127, China.
| | - Qi Sun
- Department of Thoracic and Cardiovascular Surgery, School of Medicine, Shanghai Children's Medical Center, Shanghai Jiao Tong University, 1678 Dongfang Road, Shanghai, 200127, China.
| | - Lincai Ye
- Department of Thoracic and Cardiovascular Surgery, School of Medicine, Shanghai Children's Medical Center, Shanghai Jiao Tong University, 1678 Dongfang Road, Shanghai, 200127, China.
- Department of Thoracic and Cardiovascular Surgery, School of Medicine, Shanghai Children's Hospital, Shanghai Jiao Tong University, Shanghai, China.
- Shanghai Institute for Pediatric Congenital Heart Disease, Shanghai Children's Medical Center, Shanghai Jiao Tong University School of Medicine, 1678 Dongfang Road, Shanghai, 200127, China.
- Institute of Pediatric Translational Medicine, School of Medicine, Shanghai Children's Medical Center, Shanghai Jiao Tong University, Shanghai, China.
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Management of Complex Pulmonary Vein Stenosis at Altitude Combining Comprehensive Percutaneous Interventional Treatment with Sirolimus, Pulmonary Hypertension Medications and Intraluminal Imaging with Optical Coherence Tomography. Pediatr Cardiol 2023; 44:1125-1134. [PMID: 36723625 DOI: 10.1007/s00246-023-03102-3] [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: 11/24/2022] [Accepted: 01/10/2023] [Indexed: 02/02/2023]
Abstract
BACKGROUND Pulmonary vein stenosis (PVS) is a growing problem for the pediatric congenital heart population. Sirolimus has previously been shown to improve survival and slow down the progression of in-stent stenosis in patients with PVS. We evaluated patients before and after initiation of sirolimus to evaluate its effects on re-intervention and vessel patency utilizing Optical Coherence Tomography (OCT). METHODS We performed a retrospective study, reviewing the charts of patients with PVS, who had been prescribed sirolimus between October 2020 and December 2021. OCT was performed in the pulmonary vein of interest as per our published protocol. Angiographic and OCT imaging was retrospectively reviewed. Statistical analysis was performed using Chi square and Wilcoxon signed-rank test to compare pre-and post-sirolimus data. RESULTS Ten patients had been started and followed on sirolimus. Median age at sirolimus initiation was 25 months with median weight of 10.6 kg and average follow-up of 1 year. Median total catheterizations were 7 for patients prior to starting sirolimus and 2 after starting treatment (p = 0.014). Comparing pre- and post-sirolimus, patients were catheterized every 3 months vs every 11 months (p = 0.011), median procedure time was 203 min vs 145 min (p = 0.036) and fluoroscopy time, 80 min vs 57.2 min (p = 0.036). 23 veins had severe in-stent tissue ingrowth prior to SST (luminal diameter < 30% of stent diameter). Post-sirolimus, 23 pulmonary veins had moderate to severe in-stent tissue ingrowth that responded to non-compliant balloon inflation only with stent luminal improvement of > 75%. CONCLUSION Our study suggests that the addition of sirolimus in patients with moderate-severe PVS helps to decrease disease progression with decrease frequency of interventions. Reaching therapeutic levels for sirolimus is critical and medication interactions and side-effects need careful consideration. OCT continues to be important for evaluation and treatment guidance in this patient population.
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Vo NH, Shashi KK, Winant AJ, Liszewski MC, Lee EY. Imaging evaluation of the pediatric mediastinum: new International Thymic Malignancy Interest Group classification system for children. Pediatr Radiol 2022; 52:1948-1962. [PMID: 35476071 DOI: 10.1007/s00247-022-05361-3] [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: 11/01/2021] [Revised: 02/07/2022] [Accepted: 03/18/2022] [Indexed: 10/18/2022]
Abstract
Mediastinal masses are commonly identified in the pediatric population with cross-sectional imaging central to the diagnosis and management of these lesions. With greater anatomical definition afforded by cross-sectional imaging, classification of mediastinal masses into the traditional anterior, middle and posterior mediastinal compartments - as based on the lateral chest radiograph - has diminishing application. In recent years, the International Thymic Malignancy Interest Group (ITMIG) classification system of mediastinal masses, which is cross-sectionally based, has garnered acceptance by multiple thoracic societies and been applied in adults. Therefore, there is a need for pediatric radiologists to clearly understand the ITMIG classification system and how it applies to the pediatric population. The main purpose of this article is to provide an updated review of common pediatric mediastinal masses and mediastinal manifestations of systemic disease processes in the pediatric population based on the new ITMIG classification system.
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Affiliation(s)
- Nhi H Vo
- Department of Radiology, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, MA, USA
| | - Kumar K Shashi
- Department of Radiology, Boston Children's Hospital and Harvard Medical School, 300 Longwood Ave., Boston, MA, 02115, USA
| | - Abbey J Winant
- Department of Radiology, Boston Children's Hospital and Harvard Medical School, 300 Longwood Ave., Boston, MA, 02115, USA
| | - Mark C Liszewski
- Department of Radiology and Pediatrics, The Children's Hospital at Montefiore, Albert Einstein College of Medicine, Bronx, NY, USA
| | - Edward Y Lee
- Department of Radiology, Boston Children's Hospital and Harvard Medical School, 300 Longwood Ave., Boston, MA, 02115, USA.
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Callahan R, Morray BH, Hirsch R, Petit CJ. Management of Pediatric Pulmonary Vein Stenosis. JOURNAL OF THE SOCIETY FOR CARDIOVASCULAR ANGIOGRAPHY & INTERVENTIONS 2022; 1:100391. [PMID: 39131478 PMCID: PMC11307749 DOI: 10.1016/j.jscai.2022.100391] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 02/14/2022] [Revised: 04/27/2022] [Accepted: 06/01/2022] [Indexed: 08/13/2024]
Abstract
Pediatric intraluminal pulmonary vein stenosis has evolved into a chronic illness, with improving survival. Although significant knowledge gaps remain, medical providers have found success in the management of patients with pulmonary vein stenosis using a comprehensive multimodality treatment strategy. This review discusses the core principles employed by 4 centers dedicated to improving pulmonary vein stenosis outcomes, including how to make the diagnosis, educating the family, treatment strategy, the importance of surveillance, and the management of symptoms and comorbidities.
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Affiliation(s)
- Ryan Callahan
- Department of Cardiology, Boston Children’s Hospital and Harvard Medical School, Boston, Massachusetts
| | - Brian H. Morray
- Division of Pediatric Cardiology, Seattle Children’s Hospital and University of Washington School of Medicine, Seattle, Washington
| | - Russel Hirsch
- Heart Institute, Cincinnati Children’s Hospital and University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - Christopher J. Petit
- Division of Pediatric Cardiology, Morgan Stanley Children’s Hospital, NewYork-Presbyterian Hospital and Columbia University Vagelos College of Physicians and Surgeons, New York, New York
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Patel JD, Mandhani M, Gray R, Pettus J, McCracken CE, Thomas A, Bauser-Heaton H, Kim DW, Petit CJ. Transcatheter Recanalization of Atretic Pulmonary Veins in Infants and Children. Circ Cardiovasc Interv 2022; 15:e011351. [PMID: 35727880 DOI: 10.1161/circinterventions.121.011351] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Pulmonary vein stenosis is a progressive disease associated with a high rate of mortality in children. If left untreated, myofibroblastic proliferation can lead to pulmonary vein atresia (PVA). In our experience, transcatheter recanalization has emerged as a favorable interventional option. We sought to determine the acute success rate of recanalization of atretic pulmonary veins and mid-term outcomes of individual veins after recanalization. METHODS We reviewed all patients with PVA at our institution between 2008 and 2020 diagnosed by either catheterization or cardiac computed tomography. All veins with successful recanalization were reviewed and procedural success rate and patency rate were noted. Competing risk analysis was performed to demonstrate outcomes of individual atretic veins longitudinally. RESULTS Between 2008 and 2020, our institution diagnosed and treated 131 patients with pulmonary vein stenosis. Of these, 61 patients developed atresia of at least one pulmonary vein. In total, there were 97 atretic pulmonary veins within this group. Successful recanalization was accomplished in 47/97 (48.5%) atretic veins. No atretic pulmonary veins were successfully recanalized before 2012. The majority of veins were recanalized between 2017 and 2020-39/56 (70%). The most common intervention after recanalization was drug-eluting stent placement. At 2-year follow-up 42.6% of recanalized veins (20.6% of all atretic veins) remained patent with a median of 4 reinterventions per person. CONCLUSIONS Transcatheter recanalization of PVA can result in successful reestablishment of flow to affected pulmonary veins in many cases. Drug-eluting stent implantation was the most common intervention performed immediately post-recanalization. Vein patency was maintained in 42.6% of patients at 2-year follow-up from recanalization with appropriate surveillance and reintervention. Overall, only a small portion of atretic pulmonary veins underwent successful recanalization with maintained vessel patency at follow-up. Irrespective of successful recanalization, there was no detectable survival difference between the more recently treated PVA cohort and non-PVA cohort.
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Affiliation(s)
- Jay D Patel
- Division of Cardiology, Department of Pediatrics, Emory University, Children's Healthcare of Atlanta, GA (J.D.P., M.M., R.G., J.P., C.E.M., A.T., H.B.-H., D.W.K., C.J.P.)
| | - Mansi Mandhani
- Division of Cardiology, Department of Pediatrics, Emory University, Children's Healthcare of Atlanta, GA (J.D.P., M.M., R.G., J.P., C.E.M., A.T., H.B.-H., D.W.K., C.J.P.)
| | - Rosemary Gray
- Division of Cardiology, Department of Pediatrics, Emory University, Children's Healthcare of Atlanta, GA (J.D.P., M.M., R.G., J.P., C.E.M., A.T., H.B.-H., D.W.K., C.J.P.)
| | - Joelle Pettus
- Division of Cardiology, Department of Pediatrics, Emory University, Children's Healthcare of Atlanta, GA (J.D.P., M.M., R.G., J.P., C.E.M., A.T., H.B.-H., D.W.K., C.J.P.)
| | - Courtney E McCracken
- Division of Cardiology, Department of Pediatrics, Emory University, Children's Healthcare of Atlanta, GA (J.D.P., M.M., R.G., J.P., C.E.M., A.T., H.B.-H., D.W.K., C.J.P.)
| | - Amanda Thomas
- Division of Cardiology, Department of Pediatrics, Emory University, Children's Healthcare of Atlanta, GA (J.D.P., M.M., R.G., J.P., C.E.M., A.T., H.B.-H., D.W.K., C.J.P.)
| | - Holly Bauser-Heaton
- Division of Cardiology, Department of Pediatrics, Emory University, Children's Healthcare of Atlanta, GA (J.D.P., M.M., R.G., J.P., C.E.M., A.T., H.B.-H., D.W.K., C.J.P.)
| | - Dennis W Kim
- Division of Cardiology, Department of Pediatrics, Emory University, Children's Healthcare of Atlanta, GA (J.D.P., M.M., R.G., J.P., C.E.M., A.T., H.B.-H., D.W.K., C.J.P.)
| | - Christopher J Petit
- Division of Cardiology, Department of Pediatrics, Emory University, Children's Healthcare of Atlanta, GA (J.D.P., M.M., R.G., J.P., C.E.M., A.T., H.B.-H., D.W.K., C.J.P.)
- Division of Cardiology, Department of Pediatrics, Columbia University Vagelos College of Physicians and Surgeons, NewYork-Presbyterian Morgan Stanley Children's Hospital (C.J.P.)
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Zablah JE, O'Callaghan B, Shorofsky M, Ivy D, Morgan GJ. Technical Feasibility on the Use of Optical Coherence Tomography in the Evaluation of Pediatric Pulmonary Venous Stenosis. Pediatr Cardiol 2022; 43:1054-1063. [PMID: 35037988 DOI: 10.1007/s00246-022-02824-0] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/13/2021] [Accepted: 01/07/2022] [Indexed: 11/26/2022]
Abstract
Pulmonary vein stenosis (PVS) in children is a morbid disease and limited progress has been made in improving outcomes for this heterogenous group of patients. Evaluation is currently limited to imaging techniques that fail to provide an adequate overview of the intraluminal and luminal pathology perpetuating our limited understanding of this condition. Optical coherence tomography (OCT) is an imaging modality which provides intraluminal profiling with microstructural detail through optical reflective technology. We sought to evaluate whether its use was technically feasible in pediatric PVS and whether the imaging data provided potentially useful outputs for clinical utility. Eleven patients were prospectively selected from our cardiac catheterization for OCT evaluation of their pulmonary veins (PV) during elective catheterization for PVS. Measurements were taken both pre and post intervention using both manual and automated tools. Stent morphology was characterized. Eleven patients had evaluation of 34 pulmonary veins, with 7 patients having more than one assessment, for a total of 25 overall catheterizations. Most patients were female (75%). Median age at cardiac catheterization was 35 months (range 5-45 months). Median weight of subjects was 10.6 kg (3.7-14.2) with a median BSA documented at 0.505 m2 (0.21-0.57). Median number of pulmonary veins involved was 3, (range 1-5 veins) and median contrast volume of 2.9 mL/kg (0.7-3.7) given. Median radiation dose (DAP) was 6095 µGy·cm2 (1670-12,400). Median number of previous cardiac catheterizations was 7 (range 1-11). All of the vessels with a diameter < 5 mm were adequately visualized. Of all the OCT images acquired, in 15 vessels (44%) contrast was used to clear the vessels from blood as an angiogram was required at the time, in the other 19 vessels (56%), saline was used with adequate imaging. There were no complications related to OCT. OCT is technically feasible to use in pediatric patients without any directly related complications. It provides intraluminal anatomy in children with both native and treated pulmonary venous stenosis when vessel size is less than 5 mm.
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Affiliation(s)
- Jenny E Zablah
- The Heart Institute, Children's Hospital Colorado, University of Colorado School of Medicine, Anschutz Medical Campus, Aurora, Colorado, USA.
| | - Barry O'Callaghan
- The Heart Institute, Children's Hospital Colorado, University of Colorado School of Medicine, Anschutz Medical Campus, Aurora, Colorado, USA
| | - Michael Shorofsky
- The Heart Institute, Children's Hospital Colorado, University of Colorado School of Medicine, Anschutz Medical Campus, Aurora, Colorado, USA
| | - Dunbar Ivy
- The Heart Institute, Children's Hospital Colorado, University of Colorado School of Medicine, Anschutz Medical Campus, Aurora, Colorado, USA
| | - Gareth J Morgan
- The Heart Institute, Children's Hospital Colorado, University of Colorado School of Medicine, Anschutz Medical Campus, Aurora, Colorado, USA
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8
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Jenkins KJ, Fineman JR. Progress in Pulmonary Vein Stenosis: Lessons from Success in Treating Pulmonary Arterial Hypertension. CHILDREN 2022; 9:children9060799. [PMID: 35740736 PMCID: PMC9222029 DOI: 10.3390/children9060799] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 04/27/2022] [Revised: 05/26/2022] [Accepted: 05/27/2022] [Indexed: 11/30/2022]
Abstract
Pulmonary vein stenosis (PVS) is a rare and poorly understood condition that can be classified as primary, acquired, status-post surgical repair of PVS, and/or associated with developmental lung disease. Immunohistochemical studies demonstrate that obstruction of the large (extrapulmonary) pulmonary veins is associated with the neointimal proliferation of myofibroblasts. This rare disorder is likely multifactorial with a spectrum of pathobiology. Treatments have been historically surgical, with an increasing repetitive interventional approach. Understanding the biology of these disorders is in its infancy; thus, medical management has lagged behind. Throughout medical history, an increased understanding of the underlying biology of a disorder has led to significant improvements in care and outcomes. One example is the treatment of pulmonary arterial hypertension (PAH). PAH shares several common themes with PVS. These include the spectrum of disease and biological alterations, such as vascular remodeling and vasoconstriction. Over the past two decades, an exponential increase in the understanding of the pathobiology of PAH has led to a dramatic increase in medical therapies that have changed the landscape of the disease. We believe that a similar approach to PVS can generate novel medical therapeutic targets that will markedly improve the outcome of these vulnerable patients.
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Affiliation(s)
- Kathy J. Jenkins
- Department of Cardiology, Boston Children’s Hospital, Boston, MA 02115, USA;
| | - Jeffrey R. Fineman
- Department of Pediatrics, University of California, San Francisco, CA 94143, USA
- Correspondence:
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9
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Winant AJ, Vargas SO, Jenkins KJ, Callahan R, Rameh V, Krone KA, Johnston PR, Keochakian ML, Lee EY. Pleuropulmonary MDCT Findings: Comparison between Children with Pulmonary Vein Stenosis and Prematurity-Related Lung Disease. CHILDREN (BASEL, SWITZERLAND) 2022; 9:children9030355. [PMID: 35327727 PMCID: PMC8947577 DOI: 10.3390/children9030355] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/09/2021] [Revised: 02/02/2022] [Accepted: 02/18/2022] [Indexed: 01/27/2023]
Abstract
Purpose: To retrospectively compare the pleuropulmonary MDCT findings in children with pulmonary vein stenosis (PVS) and prematurity-related lung disease (PLD). Materials and Methods: All consecutive infants and young children (≤18 years old) who underwent thoracic MDCT studies from July 2004 to November 2021 were categorized into two groups—children with PVS (Group 1) and children with PLD without PVS (Group 2). Two pediatric radiologists independently evaluated thoracic MDCT studies for the presence of pleuropulmonary abnormalities as follows—(1) in the lung (ground-glass opacity (GGO), triangular/linear plaque-like opacity (TLO), consolidation, nodule, mass, cyst(s), interlobular septal thickening, and fibrosis); (2) in the airway (bronchial wall thickening and bronchiectasis); and (3) in the pleura (thickening, effusion, and pneumothorax). Interobserver agreement between the two reviewers was evaluated with the Kappa statistic. Results: There were a total of 103 pediatric patients (60 males (58.3%) and 43 females (41.7%); mean age, 1.7 years; range, 2 days−7 years). Among these 103 patients, 49 patients (47.6%) comprised Group 1 and the remaining 54 patients (52.4%) comprised Group 2. In Group 1, the observed pleuropulmonary MDCT abnormalities were—pleural thickening (44/49; 90%), GGO (39/49; 80%), septal thickening (39/49; 80%), consolidation (4/49; 8%), and pleural effusion (1/49; 2%). The pleuropulmonary MDCT abnormalities seen in Group 2 were—GGO (45/54; 83%), TLO (43/54; 80%), bronchial wall thickening (33/54; 61%), bronchiectasis (30/54; 56%), cyst(s) (5/54; 9%), pleural thickening (2/54; 4%), and pleural effusion (2/54; 4%). Septal thickening and pleural thickening were significantly more common in pediatric patients with PVS (Group 1) (p < 0.001). TLO, bronchial wall thickening, and bronchiectasis were significantly more frequent in pediatric patients with PLD without PVS (Group 2) (p < 0.001). There was high interobserver kappa agreement between the two independent reviewers for detecting pleuropulmonary abnormalities on thoracic MDCT angiography studies (k = 0.99). Conclusion: Pleuropulmonary abnormalities seen on thoracic MDCT can be helpful for distinguishing PVS from PLD in children. Specifically, the presence of septal thickening and pleural thickening raises the possibility of PVS, whereas the presence of TLO, bronchial wall thickening and bronchiectasis suggests PLD in the pediatric population.
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Affiliation(s)
- Abbey J. Winant
- Department of Radiology, Boston Children’s Hospital, Harvard Medical School, 300 Longwood Avenue, Boston, MA 02115, USA; (A.J.W.); (V.R.); (P.R.J.)
| | - Sara O. Vargas
- Department of Pathology, Boston Children’s Hospital, Harvard Medical School, 300 Longwood Avenue, Boston, MA 02115, USA;
| | - Kathy J. Jenkins
- Department of Cardiology, Boston Children’s Hospital, Harvard Medical School, 300 Longwood Avenue, Boston, MA 02115, USA; (K.J.J.); (R.C.); (M.L.K.)
| | - Ryan Callahan
- Department of Cardiology, Boston Children’s Hospital, Harvard Medical School, 300 Longwood Avenue, Boston, MA 02115, USA; (K.J.J.); (R.C.); (M.L.K.)
| | - Vanessa Rameh
- Department of Radiology, Boston Children’s Hospital, Harvard Medical School, 300 Longwood Avenue, Boston, MA 02115, USA; (A.J.W.); (V.R.); (P.R.J.)
| | - Katie A. Krone
- Division of Pulmonary Medicine, Boston Children’s Hospital, Harvard Medical School, 300 Longwood Avenue, Boston, MA 02115, USA;
| | - Patrick R. Johnston
- Department of Radiology, Boston Children’s Hospital, Harvard Medical School, 300 Longwood Avenue, Boston, MA 02115, USA; (A.J.W.); (V.R.); (P.R.J.)
| | - Mirjam L. Keochakian
- Department of Cardiology, Boston Children’s Hospital, Harvard Medical School, 300 Longwood Avenue, Boston, MA 02115, USA; (K.J.J.); (R.C.); (M.L.K.)
| | - Edward Y. Lee
- Department of Radiology, Boston Children’s Hospital, Harvard Medical School, 300 Longwood Avenue, Boston, MA 02115, USA; (A.J.W.); (V.R.); (P.R.J.)
- Correspondence: ; Tel.: +1-617-935-9997
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10
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Niccum M, Callahan R, Gauvreau K, Jenkins KJ. Aspiration Is Associated with Poor Treatment Response in Pediatric Pulmonary Vein Stenosis. CHILDREN (BASEL, SWITZERLAND) 2021; 8:783. [PMID: 34572215 PMCID: PMC8471903 DOI: 10.3390/children8090783] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/16/2021] [Revised: 08/31/2021] [Accepted: 08/31/2021] [Indexed: 12/02/2022]
Abstract
Intraluminal pulmonary vein stenosis is a disease with significant morbidity and mortality, though recent progress has been made using multimodal therapy with antiproliferative agents. The aim of this study was to evaluate the association between aspiration and poor treatment response in patients with intraluminal pulmonary vein stenosis. A retrospective, single-center cohort analysis was performed of patients treated with a combination of imatinib mesylate and multimodal anatomic relief between March 2009 and November 2019. Analysis focused on 2-ventricle patients due to small numbers and clinical heterogeneity of single ventricle patients. Among the 84 patients included, 15 had single ventricle physiology and 69 had 2-ventricle physiology. Among the 2-ventricle group, multivariable analysis revealed that patients with clinical aspiration had nearly five times higher odds of poor treatment response than patients without aspiration (OR 4.85, 95% CI [1.37, 17.2], p = 0.014). Furthermore, male patients had higher odds of poor treatment response than their female counterparts (OR 3.67, 95% CI [1.04, 12.9], p = 0.043). Aspiration is a novel, potentially modifiable risk factor for poor treatment response in pediatric multi-vessel intraluminal pulmonary vein stenosis in patients with 2-ventricle physiology.
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Affiliation(s)
- Maria Niccum
- Department of Pediatrics, Boston Children’s Hospital and Harvard Medical School, 300 Longwood Avenue, Boston, MA 02115, USA;
| | - Ryan Callahan
- Department of Cardiology, Boston Children’s Hospital and Harvard Medical School, 300 Longwood Avenue, Boston, MA 02115, USA; (R.C.); (K.G.)
| | - Kimberlee Gauvreau
- Department of Cardiology, Boston Children’s Hospital and Harvard Medical School, 300 Longwood Avenue, Boston, MA 02115, USA; (R.C.); (K.G.)
| | - Kathy J. Jenkins
- Department of Cardiology, Boston Children’s Hospital and Harvard Medical School, 300 Longwood Avenue, Boston, MA 02115, USA; (R.C.); (K.G.)
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11
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Lee EY, Jenkins KJ, Vargas SO, Callahan R, Park HJ, Gauthier Z, Winant AJ. Thoracic Multidetector Computed Tomography Angiography of Primary Pulmonary Vein Stenosis in Children: Evaluation of Characteristic Extravascular Findings. J Thorac Imaging 2021; 36:318-325. [PMID: 33999569 DOI: 10.1097/rti.0000000000000590] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE The purpose of this study was to investigate the extravascular thoracic multidetector computed tomography (MDCT) angiography findings of pediatric primary pulmonary vein stenosis (PVS) by comparing extravascular thoracic MDCT angiography findings in children with and without PVS. MATERIALS AND METHODS All pediatric patients (age 18 y and below) with a known diagnosis of primary PVS, confirmed by echocardiogram and/or conventional angiography, who underwent thoracic MDCT angiography studies from July 2006 to December 2020 were included. A comparison group, comprised of age-matched and sex-matched pediatric patients without PVS who underwent thoracic MDCT angiography studies during the same study period, was also generated. Two pediatric radiologists independently evaluated thoracic MDCT angiography studies for the presence of extravascular thoracic abnormalities in the lung (ground-glass opacity [GGO], consolidation, pulmonary nodule, mass, cyst, septal thickening, fibrosis, and bronchiectasis), pleura (pleural thickening, pleural effusion and pneumothorax), and mediastinum (lymphadenopathy and mass). When a thoracic abnormality was identified, the location and distribution of the abnormality (in relation to the location of PVS) were also evaluated. Extravascular thoracic MDCT angiography findings of pediatric patients with and without primary PVS were compared. Interobserver agreement between the 2 independent reviewers was evaluated with κ statistics. RESULTS The study group consisted of 15 thoracic MDCT angiography studies from 15 individual pediatric patients with primary PVS (8 males [53%] and 7 females [47%]; mean age: 10.9 mo; SD: 11.7 mo; range: 1 to 48 mo). The comparison group consisted of 15 thoracic MDCT angiography studies from 15 individual pediatric patients without PVS (8 males [53%] and 7 females [47%]; mean age: 10.2 mo; SD: 11.5 mo; range: 1 to 48 mo). In children with primary PVS, the characteristic extravascular thoracic MDCT angiography findings were GGO (14/15; 93%), septal thickening (5/15; 33%), pleural thickening (14/15; 93%), and ill-defined, mildly heterogeneously enhancing, noncalcified soft tissue mass (14/15; 93%) following the contours of PVS in the mediastinum. There was excellent interobserver κ agreement between 2 independent reviewers for detecting extravascular abnormalities on thoracic MDCT angiography studies (κ=0.99 for the study group and κ=0.98 for the comparison group). CONCLUSIONS Children with primary PVS have characteristic extravascular thoracic MDCT angiography findings. In the lungs and pleura, GGO, septal thickening, and pleural thickening are common findings. Importantly, in the mediastinum, the presence of a mildly heterogeneously enhancing, noncalcified soft tissue mass in the distribution of PVS is a novel characteristic thoracic MDCT angiography finding unique to pediatric primary PVS. When this constellation of extravascular thoracic MDCT angiography findings is detected, although rare, primary PVS should be considered as a possible underlying diagnosis, especially in symptomatic children.
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Affiliation(s)
| | | | - Sara O Vargas
- Pathology, Boston Children's Hospital and Harvard Medical School, Boston, MA
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12
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The Role of Elevated Wall Shear Stress in Progression of Pulmonary Vein Stenosis: Evidence from Two Case Studies. CHILDREN-BASEL 2021; 8:children8090729. [PMID: 34572161 PMCID: PMC8470228 DOI: 10.3390/children8090729] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/30/2021] [Revised: 08/21/2021] [Accepted: 08/24/2021] [Indexed: 12/03/2022]
Abstract
Pulmonary vein stenosis is a serious condition characterized by restriction or blockage due to fibrotic tissue ingrowth that develops in the pulmonary veins of infants or children. It is often progressive and can lead to severe pulmonary hypertension and death. Efforts to halt or reverse disease progression include surgery and catheter-based balloon dilation and stent implantation. Its cause and mechanism of progression are unknown. In this pilot study, we propose and explore the hypothesis that elevated wall shear stress at discrete pulmonary venous sites triggers stenosis. To assess this theory, we retrospectively analyzed cardiac catheterization, lung scan, and X-ray computed tomography data to estimate wall shear stress in the pulmonary veins at multiple time points during disease progression in two patients. Results are consistent with the existence of a level of elevated wall shear stress above which the disease is progressive and below which progression is halted. The analysis also suggests the possibility of predicting the target lumen size necessary in a given vein to reduce wall shear stress to normal levels and remove the trigger for stenosis progression.
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13
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Extravascular MDCT Findings of Pulmonary Vein Stenosis in Children with Cardiac Septal Defect. CHILDREN-BASEL 2021; 8:children8080667. [PMID: 34438558 PMCID: PMC8394993 DOI: 10.3390/children8080667] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/09/2021] [Revised: 07/14/2021] [Accepted: 07/22/2021] [Indexed: 01/01/2023]
Abstract
Purpose: To retrospectively investigate the extravascular thoracic MDCT angiography findings of pulmonary vein stenosis (PVS) in children with a cardiac septal defect. Materials and Methods: Pediatric patients (age ≤ 18 years) with cardiac septal defect and PVS, confirmed by echocardiogram and/or conventional angiography, who underwent thoracic MDCT angiography studies from April 2009 to April 2021 were included. Two pediatric radiologists independently evaluated thoracic MDCT angiography studies for the presence of extravascular thoracic abnormalities in: (1) lung and airway (ground-glass opacity (GGO), consolidation, pulmonary nodule, mass, cyst, septal thickening, fibrosis, and bronchiectasis); (2) pleura (pleural thickening, pleural effusion, and pneumothorax); and (3) mediastinum (mass and lymphadenopathy). Interobserver agreement between the two independent pediatric radiology reviewers was evaluated with kappa statistics. Results: The final study group consisted of 20 thoracic MDCT angiography studies from 20 consecutive individual pediatric patients (13 males (65%) and 7 females (35%); mean age: 7.5 months; SD: 12.7; range: 2 days to 7 months) with cardiac septal defect and PVS. The characteristic extravascular thoracic MDCT angiography findings were GGO (18/20; 90%), septal thickening (9/20; 45%), pleural thickening (16/20; 80%), and ill-defined, mildly heterogeneously enhancing, non-calcified soft tissue mass (9/20; 45%) following the contours of PVS in the mediastinum. There was a high interobserver kappa agreement between two independent reviewers for detecting extravascular abnormalities on thoracic MDCT angiography studies (k = 0.99). Conclusion: PVS in children with a cardiac septal defect has a characteristic extravascular thoracic MDCT angiography finding. In the lungs and pleura, GGO, septal thickening, and pleural thickening are frequently seen in children with cardiac septal defect and PVS. In the mediastinum, a mildly heterogeneously enhancing, non-calcified soft tissue mass in the distribution of PVS in the mediastinum is seen in close to half of the pediatric patients with cardiac septal defect and PVS.
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14
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Feins EN, Callahan R, Baird CW. Pulmonary Vein Stenosis-Evolving Surgical Management of a Challenging Disease. CHILDREN (BASEL, SWITZERLAND) 2021; 8:631. [PMID: 34438522 PMCID: PMC8392559 DOI: 10.3390/children8080631] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/29/2021] [Revised: 06/27/2021] [Accepted: 07/20/2021] [Indexed: 11/18/2022]
Abstract
Pulmonary vein stenosis (PVS) is an extremely challenging clinical problem in congenital heart disease. It has traditionally required multimodal therapy given its complex underlying pathophysiology. As with other modalities, surgical therapy has undergone tremendous evolution since the 1950s. These evolving strategies have been based upon an improved understanding of the substrates that cause PVS and recurrent vein obstruction. More recent anatomic-based surgical strategies have focused on the pulmonary vein course, and how adjacent mediastinal structures can create a fulcrum effect on the pulmonary veins as they pass from the lung parenchyma to the left atrium. The consequent angulation of pulmonary veins creates altered wall shear stress and likely serves as a nidus for recurrent PVS. Encouraging early results suggest that eliminating pulmonary vein angulation and shortening/straightening the pulmonary vein course may prove effective in surgically managing PVS.
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Affiliation(s)
- Eric N. Feins
- Department of Cardiac Surgery, Boston Children’s Hospital and Harvard Medical School, Boston, MA 02115, USA;
| | - Ryan Callahan
- Department of Cardiology, Boston Children’s Hospital and Harvard Medical School, Boston, MA 02115, USA;
| | - Christopher W. Baird
- Department of Cardiac Surgery, Boston Children’s Hospital and Harvard Medical School, Boston, MA 02115, USA;
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15
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Patient and Family-Centered Care for Pediatric Intraluminal Pulmonary Vein Stenosis: Case of a 3 Year Old Patient with Focus on Nurse Practitioner Role. CHILDREN-BASEL 2021; 8:children8070567. [PMID: 34356546 PMCID: PMC8305435 DOI: 10.3390/children8070567] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/01/2021] [Revised: 06/13/2021] [Accepted: 06/23/2021] [Indexed: 11/17/2022]
Abstract
A nurse practitioner’s experience in managing children with intraluminal pulmonary vein stenosis. A case study of a 3-year-old patient with multi–vessel intraluminal pulmonary vein stenosis.
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16
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Frank DB, Levy PT, Stiver CA, Boe BA, Baird CW, Callahan RM, Smith CV, Vanderlaan RD, Backes CH. Primary pulmonary vein stenosis during infancy: state of the art review. J Perinatol 2021; 41:1528-1539. [PMID: 33674714 DOI: 10.1038/s41372-021-01008-7] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/19/2020] [Revised: 01/13/2021] [Accepted: 02/11/2021] [Indexed: 12/15/2022]
Abstract
Primary pulmonary vein stenosis (PPVS) is an emerging problem among infants. In contrast to acquired disease, PPVS is the development of stenosis in the absence of preceding intervention. While optimal care approaches remain poorly characterized, over the past decade, understanding of potential pathophysiological mechanisms and development of novel therapeutic strategies are increasing. A multidisciplinary team of health care providers was assembled to review the available evidence and provide a common framework for the diagnosis, management, and treatment of PPVS during infancy. To address knowledge gaps, institutional and multi-institutional approaches must be employed to generate knowledge specific to ex-premature infants with PPVS. Within individual institutions, creation of a team comprised of dedicated health care providers from diverse backgrounds is critical to accelerate clinical learning and provide care for infants with PPVS. Multi-institutional collaborations, such as the PVS Network, provide the infrastructure and statistical power to advance knowledge for this rare disease.
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Affiliation(s)
- David B Frank
- Division of Cardiology, Children's Hospital of Philadelphia, Philadelphia, PA, USA
- Department of Pediatrics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Philip T Levy
- Division of Newborn Medicine, Boston Children's Hospital, Boston, MA, USA
- Department of Pediatrics, Harvard Medical School, Boston, MA, USA
| | - Corey A Stiver
- The Heart Center, Nationwide Children's Hospital, Columbus, OH, USA
- Department of Pediatrics, The Ohio State University College of Medicine, Columbus, OH, USA
| | - Brian A Boe
- The Heart Center, Nationwide Children's Hospital, Columbus, OH, USA
- Department of Pediatrics, The Ohio State University College of Medicine, Columbus, OH, USA
| | - Christopher W Baird
- Department of Pediatrics, Harvard Medical School, Boston, MA, USA
- Department of Cardiac Surgery, Boston Children's Hospital, Boston, MA, USA
| | - Ryan M Callahan
- Department of Pediatrics, Harvard Medical School, Boston, MA, USA
- Department of Cardiology, Boston Children's Hospital, Boston, MA, USA
| | - Charles V Smith
- Center for Developmental Therapeutics, Seattle Children's Research Institute, University of Washington School of Medicine, Seattle, WA, USA
| | - Rachel D Vanderlaan
- Department of Thoracic Surgery, New York Presbyterian Morgan Stanley Children's Hospital, New York, NY, USA
| | - Carl H Backes
- The Heart Center, Nationwide Children's Hospital, Columbus, OH, USA.
- Department of Pediatrics, The Ohio State University College of Medicine, Columbus, OH, USA.
- Division of Neonatology, The Ohio State University Wexner Medical Center, Columbus, OH, USA.
- Center for Perinatal Research, The Abigail Wexner Research Institute, Nationwide Children's Hospital, Columbus, OH, USA.
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17
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Vanderlaan RD, Caldarone CA. Pulmonary Vein Stenosis: Incremental Knowledge Gains to Improve Outcomes. CHILDREN-BASEL 2021; 8:children8060481. [PMID: 34200142 PMCID: PMC8229191 DOI: 10.3390/children8060481] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/11/2021] [Revised: 05/28/2021] [Accepted: 06/04/2021] [Indexed: 11/16/2022]
Abstract
Pulmonary vein stenosis remains a considerable clinical challenge, with high mortality still present in children with progressive disease. In this review, we discuss the clinical spectrum of pulmonary vein stenosis and what is known about the etiology and potential modifying and contributing factors in progressive pulmonary vein stenosis.
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Affiliation(s)
- Rachel D. Vanderlaan
- Division of Cardiovascular Surgery, Hospital for Sick Children, Toronto, ON M5G 1X8, Canada
- Correspondence: ; Tel.: +1-416-813-1500
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18
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Pulmonary vein stenosis: Treatment and challenges. J Thorac Cardiovasc Surg 2021; 161:2169-2176. [DOI: 10.1016/j.jtcvs.2020.05.117] [Citation(s) in RCA: 21] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/13/2020] [Revised: 05/19/2020] [Accepted: 05/23/2020] [Indexed: 11/15/2022]
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19
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Prieto LR. In Search of the Holy Grail for Pediatric Pulmonary Vein Stenosis. J Am Coll Cardiol 2021; 77:2819-2821. [PMID: 34082912 DOI: 10.1016/j.jacc.2021.04.029] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/13/2021] [Accepted: 04/15/2021] [Indexed: 11/19/2022]
Affiliation(s)
- Lourdes R Prieto
- Heart Institute, Nicklaus Children's Hospital, Miami, Florida, USA.
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20
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Systemic Sirolimus Therapy for Infants and Children With Pulmonary Vein Stenosis. J Am Coll Cardiol 2021; 77:2807-2818. [PMID: 34082911 DOI: 10.1016/j.jacc.2021.04.013] [Citation(s) in RCA: 23] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/01/2021] [Revised: 04/01/2021] [Accepted: 04/02/2021] [Indexed: 01/10/2023]
Abstract
BACKGROUND Anatomic interventions for pulmonary vein stenosis (PVS) in infants and children have been met with limited success. Sirolimus, a mammalian target of rapamycin inhibitor, has demonstrated promise as a primary medical therapy for PVS, but the impact on patient survival is unknown. OBJECTIVES The authors sought to investigate whether mTOR inhibition with sirolimus as a primary medical therapy would improve outcomes in high-risk infants and children with PVS. METHODS In this single-center study, patients with severe PVS were considered for systemic sirolimus therapy (SST) following a strict protocol while receiving standardized surveillance and anatomic therapies. The SST cohort was compared with a contemporary control group. The primary endpoint for this study was survival. The primary safety endpoint was adverse events (AEs) related to SST. RESULTS Between 2015 and 2020, our PVS program diagnosed and treated 67 patients with ≥moderate PVS. Of these, 15 patients were treated with sirolimus, whereas the remaining patients represent the control group. There was 100% survival in the SST group compared with 45% survival in the control group (log-rank p = 0.004). A sensitivity analysis was completed to address survival bias using median time from diagnosis of PVS to SST. A survival advantage persisted (log-rank p = 0.027). Two patients on sirolimus developed treatable AEs. Patients in the SST group underwent frequent transcatheter interventions with 3.7 catheterizations per person-year (25th to 75th percentile: 2.7 to 4.4 person-years). Median follow up time was 2.2 years (25th to 75th percentile: 1.2 to 2.9 years) in the SST group versus 0.9 years (25th to 75th percentile: 0.5 to 2.7 years) in the control group. CONCLUSIONS The authors found a survival benefit associated with SST in infants and children with moderate-to-severe PVS. This survival benefit persisted after adjusting the analysis for survival bias. There were 2 mild AEs associated with SST during the study period; both patients were able to resume therapy without recurrence.
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21
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Outcomes in Establishing Individual Vessel Patency for Pediatric Pulmonary Vein Stenosis. CHILDREN-BASEL 2021; 8:children8030210. [PMID: 33802089 PMCID: PMC8000090 DOI: 10.3390/children8030210] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/31/2021] [Revised: 03/05/2021] [Accepted: 03/07/2021] [Indexed: 02/06/2023]
Abstract
The purpose of this study was to determine what patient and pulmonary vein characteristics at the diagnosis of intraluminal pulmonary vein stenosis (PVS) are predictive of individual vein outcomes. A retrospective, single-center, cohort sub-analysis of individual pulmonary veins of patients enrolled in the clinical trial NCT00891527 using imatinib mesylate +/− bevacizumab as adjunct therapy for the treatment of multi-vessel pediatric PVS between March 2009 and December 2014 was performed. The 72-week outcomes of the individual veins are reported. Among the 48 enrolled patients, 46 patients and 182 pulmonary veins were included in the study. Multivariable analysis demonstrated that patients with veins without distal disease at baseline (odds ratio, OR 3.69, 95% confidence interval, CI [1.52, 8.94], p = 0.004), location other than left upper vein (OR 2.58, 95% CI [1.07, 6.19], p = 0.034), or veins in patients ≥ 1 y/o (OR 5.59, 95% CI [1.81, 17.3], p = 0.003) were at higher odds of having minimal disease at the end of the study. Veins in patients who received a higher percentage of eligible drug doses required fewer reinterventions (IRR 0.76, 95% CI [0.68, 0.85], p < 0.001). The success of a multi-modal treatment approach to aggressive PVS depends on the vein location, disease severity, and drug dose intensity.
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22
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Schramm J, Sivalingam S, Moreno GE, Thanh DQL, Gauvreau K, Doherty-Schmeck K, Jenkins KJ. Pulmonary Vein Stenosis: A Rare Disease with a Global Reach. CHILDREN-BASEL 2021; 8:children8030198. [PMID: 33800765 PMCID: PMC8000109 DOI: 10.3390/children8030198] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/31/2021] [Revised: 02/26/2021] [Accepted: 03/03/2021] [Indexed: 11/16/2022]
Abstract
Pulmonary vein stenosis (PVS) is a rare, but high mortality and resource intensive disease caused by mechanical obstruction or intraluminal myofibroproliferation, which can be post-surgical or idiopathic. There are increasing options for management including medications, cardiac catheterization procedures, and surgery. We queried the International Quality Improvement Collaborative for Congenital Heart Disease (IQIC) database for cases of PVS and described the cohort including additional congenital lesions and surgeries as well as infectious and mortality outcomes. IQIC is a quality improvement project in low-middle-income countries with the goal of reducing mortality after congenital heart surgery. Three cases were described in detail with relevant images. We identified 57 cases of PVS surgery, with similar mortality to higher income countries. PVS should be recognized as a global disease. More research and collaboration are needed to understand the disease, treatments, and outcomes, and to devise treatment approaches for low resource environments.
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Affiliation(s)
- Jennifer Schramm
- Department of Cardiology, Children’s National Hospital, Washington, DC 20010, USA;
| | - Sivakumar Sivalingam
- Department of Cardiothoracic Surgery, National Heart Institute, 50400 Kuala Lumpur, Malaysia;
| | - Guillermo E. Moreno
- Department of Cardiac Intensive Care, Hospital de Pediatría “Professor Dr. Juan P. Garrahan”, 412-6000 Ciudad de Buenos Aires, Argentina;
| | - Dinh Quang Le Thanh
- Department of Cardiac Surgery, Children’s Hospital 1, 700000 Ho Chi Minh City, Vietnam;
| | - Kimberlee Gauvreau
- Center for Applied Pediatric Quality Analytics, Department of Cardiology, Boston Children’s Hospital, Boston, MA 02115, USA; (K.G.); (K.D.-S.)
| | - Kaitlin Doherty-Schmeck
- Center for Applied Pediatric Quality Analytics, Department of Cardiology, Boston Children’s Hospital, Boston, MA 02115, USA; (K.G.); (K.D.-S.)
| | - Kathy J. Jenkins
- Center for Applied Pediatric Quality Analytics, Department of Cardiology, Boston Children’s Hospital, Boston, MA 02115, USA; (K.G.); (K.D.-S.)
- Correspondence:
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23
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Callahan R, Gauthier Z, Toba S, Sanders SP, Porras D, Vargas SO. Correlation of Intravascular Ultrasound with Histology in Pediatric Pulmonary Vein Stenosis. CHILDREN-BASEL 2021; 8:children8030193. [PMID: 33806479 PMCID: PMC7999454 DOI: 10.3390/children8030193] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/21/2021] [Revised: 02/16/2021] [Accepted: 03/01/2021] [Indexed: 11/16/2022]
Abstract
Preliminary intravascular ultrasound (IVUS) images of suspected pediatric intraluminal pulmonary vein stenosis (PVS) demonstrate wall thickening. It is unclear how the IVUS-delineated constituents of wall thickening correlate with the histology. We analyzed six postmortem formalin-fixed heart/lung specimens and four live patients with PVS as well as control pulmonary veins using IVUS and light microscopic examination. In PVS veins, IVUS demonstrated wall thickening with up to two layers of variable echogenicity, often with indistinct borders. Histologically, the veins showed fibroblastic proliferation with areas rich in myxoid matrix as well as areas with abundant collagen and elastic fibers. Discrete vein layers were obscured by scarring and elastic degeneration. A lower reflective periluminal layer by IVUS corresponded with hyperplasia of myofibroblast-like cells in abundant myxoid matrix. The hyper-reflective layer by IVUS extended to the outer edge of the vessel and corresponded to a less myxoid area with more collagen, smooth muscle and elastic fibers. The outer less reflective edge of the IVUS image correlated with a gradual transition into adventitia. Normal veins had a thin wall, correlating with histologically normal cellular and extracellular components, without intimal proliferation. IVUS may provide further understanding of the anatomy and mechanisms of pediatric pulmonary vein obstruction.
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Affiliation(s)
- Ryan Callahan
- Department of Cardiology, Boston Children’s Hospital and Harvard Medical School, Boston, MA 02115, USA; (Z.G.); (S.T.); (S.P.S.); (D.P.)
- Correspondence:
| | - Zachary Gauthier
- Department of Cardiology, Boston Children’s Hospital and Harvard Medical School, Boston, MA 02115, USA; (Z.G.); (S.T.); (S.P.S.); (D.P.)
| | - Shuhei Toba
- Department of Cardiology, Boston Children’s Hospital and Harvard Medical School, Boston, MA 02115, USA; (Z.G.); (S.T.); (S.P.S.); (D.P.)
- Department of Pathology, Boston Children’s Hospital and Harvard Medical School, Boston, MA 02115, USA;
| | - Stephen P. Sanders
- Department of Cardiology, Boston Children’s Hospital and Harvard Medical School, Boston, MA 02115, USA; (Z.G.); (S.T.); (S.P.S.); (D.P.)
- Department of Pathology, Boston Children’s Hospital and Harvard Medical School, Boston, MA 02115, USA;
| | - Diego Porras
- Department of Cardiology, Boston Children’s Hospital and Harvard Medical School, Boston, MA 02115, USA; (Z.G.); (S.T.); (S.P.S.); (D.P.)
| | - Sara O. Vargas
- Department of Pathology, Boston Children’s Hospital and Harvard Medical School, Boston, MA 02115, USA;
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24
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Humpl T, Fineman J, Qureshi AM. The many faces and outcomes of pulmonary vein stenosis in early childhood. Pediatr Pulmonol 2021; 56:649-655. [PMID: 32506838 DOI: 10.1002/ppul.24848] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/23/2019] [Revised: 04/22/2020] [Accepted: 05/11/2020] [Indexed: 11/10/2022]
Abstract
Pulmonary vein stenosis is a rare and poorly understood condition causing obstruction of the large pulmonary veins and of blood flow from the lungs to the left atrium. This results in elevated pulmonary venous pressure and pulmonary edema, pulmonary hypertension, potentially cardiac failure, and death. Clinical signs of the disease include failure to thrive, increasingly severe dyspnea, hemoptysis, respiratory difficulty, recurrent respiratory tract infections/pneumonia, cyanosis, and subcostal retractions. On chest radiograph, the most frequent finding is increased interstitial, ground-glass and/or reticular opacity. Transthoracic echocardiography with pulsed Doppler delineates the stenosis, magnetic resonance imaging and multislice computerized tomography are used for further evaluation. Interventional cardiac catherization, surgical techniques, and medical therapies have been used with varying success as treatment options.
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Affiliation(s)
- Tilman Humpl
- Division of Pediatric Intensive Care, University Children's Hospital Berne, Inselspital, Berne, Switzerland
| | - Jeffrey Fineman
- Department of Pediatrics, Pediatric Critical Care University of California, San Francisco, California
| | - Athar M Qureshi
- The Lillie Frank Abercrombie Section of Cardiology, Texas Children's Hospital, Baylor College of Medicine, Houston, Texas
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25
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Masaki N, Mizumoto M, Adachi O, Sai S. Histopathology of anastomotic stenosis after total anomalous pulmonary vein connection. Interact Cardiovasc Thorac Surg 2021; 32:998-1000. [PMID: 33532846 DOI: 10.1093/icvts/ivab007] [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: 11/06/2020] [Revised: 12/12/2020] [Accepted: 01/01/2021] [Indexed: 11/12/2022] Open
Abstract
We report a case of a 10-month-old girl who was diagnosed with pulmonary vein stenosis after total anomalous pulmonary vein connection repair and underwent release of an anastomotic stenosis. Histopathological examinations of the resected anastomotic tissue revealed intimal hyperplasia at the anastomotic site. Predominant lesion cells were identified as myofibroblasts and had the characteristics of fibroblasts and synthetic smooth muscle cells. These cells could be a useful target for preventing anastomotic stenosis after total anomalous pulmonary vein connection repair.
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Affiliation(s)
- Naoki Masaki
- Department of Cardiovascular Surgery, Miyagi Children's Hospital, Sendai, Japan
| | - Masahiro Mizumoto
- Department of Cardiovascular Surgery, Miyagi Children's Hospital, Sendai, Japan
| | - Osamu Adachi
- Department of Cardiovascular Surgery, Miyagi Children's Hospital, Sendai, Japan
| | - Sadahiro Sai
- Department of Cardiovascular Surgery, Miyagi Children's Hospital, Sendai, Japan
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26
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Abstract
PURPOSE OF REVIEW Pulmonary vein stenosis (PVS) is a rare entity that until the last 2 decades was seen primarily in infants and children. Percutaneous and surgical interventions have limited success due to relentless restenosis, and mortality remains high. In adults, acquired PVS following ablation for atrial fibrillation has emerged as a new syndrome. This work will review these two entities with emphasis on current treatment. RECENT FINDINGS Greater emphasis on understanding and addressing the mechanism of restenosis for congenital PVS has led to the use of drug-eluting stents (DES) and systemic drug therapy to target neo-intimal growth. Frequent reinterventions are positively affecting outcomes. Longer-term outcomes of percutaneous treatment for acquired PVS are emerging. Treatment of congenital PVS continues to be plagued by restenosis. DES show promise, but frequent reinterventions are required. Larger upstream vein diameter predicts success for congenital and acquired PVS interventions. Efforts to induce/maintain vessel growth are important for future treatment strategies.
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Affiliation(s)
- Patcharapong Suntharos
- Division of Pediatric Cardiology, Nicklaus Children's Hospital, 3100 SW 62nd Avenue, Miami, FL, 33155, USA
| | - Lourdes R Prieto
- Division of Pediatric Cardiology, Nicklaus Children's Hospital, 3100 SW 62nd Avenue, Miami, FL, 33155, USA.
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27
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Callahan R, Jenkins KJ, Gauthier Z, Gauvreau K, Porras D. Preliminary findings on the use of intravascular ultrasound in the assessment of pediatric pulmonary vein stenosis. Catheter Cardiovasc Interv 2020; 97:E362-E370. [PMID: 32936535 DOI: 10.1002/ccd.29264] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/21/2020] [Revised: 08/24/2020] [Accepted: 08/31/2020] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Determine the feasibility of performing intravascular ultrasound (IVUS) in pediatric pulmonary vein stenosis (PVS) and investigate whether IVUS can delineate the mechanism of PVS. BACKGROUND The use of IVUS in pediatric patients with PVS has not been reported. METHODS Retrospective, single center, cohort analysis of all patients who underwent IVUS of pulmonary veins from August 2016 to December 2019. RESULTS IVUS was performed on 81 pulmonary veins in 50 pediatric patients (median age = 1.7 years [0.9, 3.1], median weight = 8.6 kg [7.3, 11.8]). All veins accepted the IVUS catheter (.014 or .018), with adequate visualization in 88% (71/81) of imaged veins, and improvement in visualization in the more recent period (23/24; 96%). Veins were categorized as having presumed intimal thickening (PIT) with luminal narrowing (n = 36), ostial narrowing without PIT (n = 14), distortion/compression (n = 6), normal (n = 2), and stent with (n = 9) or without in-stent stenosis (n = 4). In veins with at least 6 months of follow up, (re)intervention occurred more commonly in veins with PIT (14/19; 74%) versus veins without PIT (3/13; 23%; p = 0.01). There were no IVUS related adverse events. CONCLUSION IVUS can be used safely in pediatric patients and can reliably demonstrate vein lumen and wall architecture. With further refinement, IVUS has the potential to differentiate intimal neo-proliferation from other mechanisms of obstruction. The exact role of IVUS in the assessment of pediatric PVS is yet to be determined.
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Affiliation(s)
- Ryan Callahan
- Department of Cardiology, Boston Children's Hospital and Harvard Medical School, Boston, Massachusetts
| | - Kathy J Jenkins
- Department of Cardiology, Boston Children's Hospital and Harvard Medical School, Boston, Massachusetts
| | - Zachary Gauthier
- Department of Cardiology, Boston Children's Hospital and Harvard Medical School, Boston, Massachusetts
| | - Kimberlee Gauvreau
- Department of Cardiology, Boston Children's Hospital and Harvard Medical School, Boston, Massachusetts
| | - Diego Porras
- Department of Cardiology, Boston Children's Hospital and Harvard Medical School, Boston, Massachusetts
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28
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Shi G, Zhu F, Wen C, Qiu L, Zhang H, Zhu Z, Chen H. Single-institution outcomes of surgical repair of infracardiac total anomalous pulmonary venous connection. J Thorac Cardiovasc Surg 2020; 161:1408-1417.e2. [PMID: 32739162 DOI: 10.1016/j.jtcvs.2020.06.023] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/14/2019] [Revised: 06/08/2020] [Accepted: 06/09/2020] [Indexed: 01/08/2023]
Abstract
OBJECTIVE This contemporary study sought to describe the outcomes of patients undergoing biventricular repair of infracardiac total anomalous pulmonary venous connection. METHODS A retrospective study was performed on patients with infracardiac total anomalous pulmonary venous connection who underwent sutureless technique or conventional repair between 2006 and 2018. Risk factors for survival and post-repair pulmonary vein stenosis (PVS) were assessed with Cox regression model. Time-to-event analysis was conducted using Kaplan-Meier estimates. RESULTS This study included 82 consecutive patients with the median age of 21 days (interquartile range, 9-40 days). The median follow-up was 29 months (interquartile range, 12.5-59 months) and was available in 95% of the survivors at the end of the study period in 2019. Overall, 8 deaths (8.5%) occurred in the conventional repair group. There was a trend of higher mortality in the conventional repair group, although it did not reach a statistical difference (P = .2). Postrepair PVS occurred at a median of 2 months (interquartile range, 1.2-3.6 months) postoperatively and all occurred in the conventional repair group. Time-to-event analysis with the event of postrepair PVS showed significantly higher freedom from restenosis in the sutureless technique group (P = .0004). Adjusted hazard ratios from time-dependent Cox model described the association between postrepair PVS and pulmonary venous confluence of antler configuration (hazard ratio, 2.14; 95% confidence interval, 1.03-5.47; P = .002) and the use of sutureless technique (hazard ratio, 0.72; 95% confidence interval, 0.39-0.97; P = .003). CONCLUSIONS Sutureless technique is associated with a lower risk of postrepair PVS in patients with infracardiac total anomalous pulmonary venous connection. pulmonary venous confluence configuration of antler appearance appears to be associated with restenosis and mortality.
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Affiliation(s)
- Guocheng Shi
- Department of Cardiothoracic Surgery, Congenital Heart Center, Shanghai Children's Medical Center, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Fang Zhu
- Department of Cardiothoracic Surgery, Congenital Heart Center, Shanghai Children's Medical Center, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Chen Wen
- Department of Cardiothoracic Surgery, Congenital Heart Center, Shanghai Children's Medical Center, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Lisheng Qiu
- Department of Cardiothoracic Surgery, Congenital Heart Center, Shanghai Children's Medical Center, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Haibo Zhang
- Department of Cardiothoracic Surgery, Congenital Heart Center, Shanghai Children's Medical Center, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Zhongqun Zhu
- Department of Cardiothoracic Surgery, Congenital Heart Center, Shanghai Children's Medical Center, Shanghai Jiao Tong University School of Medicine, Shanghai, China.
| | - Huiwen Chen
- Department of Cardiothoracic Surgery, Congenital Heart Center, Shanghai Children's Medical Center, Shanghai Jiao Tong University School of Medicine, Shanghai, China.
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Systemic Sirolimus to Prevent In-Stent Stenosis in Pediatric Pulmonary Vein Stenosis. Pediatr Cardiol 2020; 41:282-289. [PMID: 31720783 DOI: 10.1007/s00246-019-02253-6] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/13/2019] [Accepted: 11/05/2019] [Indexed: 10/25/2022]
Abstract
Evaluate the efficacy of systemic sirolimus (rapamycin) in preventing in-stent stenosis (ISS) in pediatric intraluminal pulmonary vein stenosis (PVS). Report the adverse events related to sirolimus therapy. There is a high incidence of ISS following stent implantation in PVS. The use of sirolimus in preventing ISS has not been reported. Retrospective review of all patients who received sirolimus (8 week course) for treatment of ISS for PVS between January 2013 and June 2018. Forty stents (37 bare metal, 3 drug-eluting) in 20 patients were treated with sirolimus; 20 at the time of implantation (primary prevention [1P]) and 20 following documented ISS requiring transcatheter reintervention (secondary prevention [2P]). Treated patients were young (median 2 y/o [0.7-5.7]) and most had PVS associated with congenital heart disease (75%, 15/20; 4/15 with TAPVC). In the 1P group, 85% (17/20) of stents were without significant (< 50%) ISS at median of 102 days (range 56-527); the growth rate of ISS in this group was 7.5 ± 7.1%/month. In the 2P group, most stents had a slower growth rate of ISS after sirolimus therapy compared to pre-treatment (median 3.7 [- 0.2 to 13.1] vs. 10.4 [1.3 to 19.5] %/month; p < 0.001). One patient developed pneumonia on drug while concurrently taking another immunosuppressive agent. No other serious adverse events were related to sirolimus therapy. Systemic sirolimus slows the growth rate of ISS following stent implantation in PVS compared to pre-treatment rates and was administered safely in a small number of pediatric patients with complex heart disease.
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Nasr VG, Callahan R, Wichner Z, Odegard KC, DiNardo JA. Intraluminal Pulmonary Vein Stenosis in Children. Anesth Analg 2019; 129:27-40. [DOI: 10.1213/ane.0000000000003924] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
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31
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Sokoliuk V, DiNardo JA, Brown ML. Never Say Never: The Use of Nitric Oxide in Patients With Obstructed Pulmonary Veins: A Case Report. A A Pract 2019; 12:205-207. [PMID: 30247162 DOI: 10.1213/xaa.0000000000000885] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Pulmonary vein stenosis (PVS) is a progressive disease with pulmonary hypertension (PH) as a major cause of morbidity and mortality. Traditional management of PH with inhaled nitric oxide (iNO) is typically avoided in PVS patients because, while iNO may reduce pulmonary vascular resistance, PH persists as pulmonary blood flow increases in the presence of a downstream resistive lesion. We report 3 cases with primary PVS and PH in which iNO was used to successfully decrease mean pulmonary artery pressures with clinical improvement. Based on this experience, we suggest that iNO can be used to treat PH in select patients with PVS.
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Affiliation(s)
- Victoria Sokoliuk
- From the Department of Cardiac Anesthesia, Boston Children's Hospital, Boston, Massachusetts
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32
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Metakaryotic cells linked to pediatric pulmonary vein stenosis. Cardiovasc Pathol 2018; 39:51-53. [PMID: 30660022 DOI: 10.1016/j.carpath.2018.12.005] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/25/2018] [Revised: 12/14/2018] [Accepted: 12/14/2018] [Indexed: 12/27/2022] Open
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33
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Yoon JK, Kim GB, Song MK, Bae EJ, Kim WH, Kwak JG, Lee JR. Hybrid Pulmonary Vein Stenting in Infants with Refractory to Surgical Pulmonary Vein Stenosis Repair. Pediatr Cardiol 2018; 39:1642-1649. [PMID: 30105463 DOI: 10.1007/s00246-018-1944-2] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/22/2018] [Accepted: 07/28/2018] [Indexed: 11/27/2022]
Abstract
Pulmonary vein stenosis (PVS) is still a frustrating disease with extremely high mortality, especially in children with multiple severe PVS. Hybrid pulmonary vein stenting (HPVS) is a rescue treatment for recurrent and malignant PVS. The aim of this study is to share our successful experience with intraoperative HPVS for recurrent PVS after total anomalous pulmonary venous connection (TAPVC) repair in infant. Six patients were identified between 2013 and January 2018, who were diagnosed with recurrent PVS and underwent HPVS in the operating room. The mean age at the time of the HPVS was 10.3 ± 2.7 months (range 7-14 months) and the mean body weight was 7.9 ± 2.6 kg (range 4.1-10.5 kg). Prior pulmonary vein surgery had been performed on average 2.7 times (range 2-3) in all patients. We used a bare-metal stent (BMS) of 6-8 mm diameter in 15 veins of five patients and a drug-eluting coronary stent (DES) in two veins of one patient. All patients had undergone several elective further pulmonary vein in-stent balloon dilatations or another stent insertion after HPVS. Over a mean follow-up of 17.3 ± 13.7 months (range 6-44 months), all patients maintained patency of stents although two patients died due to respiratory failure not associated with PVS. HPVS is a useful treatment modality for recurrent PVS patient that could save the life and achieve longer freedom from restenosis than repetitive surgical pulmonary vein widening only. Even though the prognosis of severe multiple PVS is very poor, planned HPVS could be a good palliation in this patients group.
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Affiliation(s)
- Ja Kyoung Yoon
- Department of Pediatrics, Seoul National University Children's Hospital, Seoul, South Korea
- Department of Pediatrics, Sejong General Hospital, Bucheon, South Korea
| | - Gi Beom Kim
- Department of Pediatrics, Seoul National University Children's Hospital, Seoul, South Korea.
- Department of Pediatrics, Seoul National University Children's Hospital, Seoul National University College of Medicine, 101 Daehak-ro, Jongno-gu, Seoul, 03080, South Korea.
| | - Mi Kyoung Song
- Department of Pediatrics, Seoul National University Children's Hospital, Seoul, South Korea
| | - Eun Jung Bae
- Department of Pediatrics, Seoul National University Children's Hospital, Seoul, South Korea
| | - Woong Han Kim
- Department of Thoracic and Cardiovascular Surgery, Seoul National University Children's Hospital, Seoul, South Korea
| | - Jae Gun Kwak
- Department of Thoracic and Cardiovascular Surgery, Seoul National University Children's Hospital, Seoul, South Korea
| | - Jeong Ryul Lee
- Department of Thoracic and Cardiovascular Surgery, Seoul National University Children's Hospital, Seoul, South Korea
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34
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Kanaan UB, Mahle WT. New Paradigms for Pulmonary Vein Stenosis Treatment: When Surgery and Transcatheter Therapy Aren't Good Enough. J Pediatr 2018; 198:12-13. [PMID: 29551312 DOI: 10.1016/j.jpeds.2018.01.082] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/23/2018] [Accepted: 01/31/2018] [Indexed: 11/24/2022]
Affiliation(s)
- Usama B Kanaan
- Children's Healthcare of Atlanta Emory University School of Medicine Atlanta, Georgia
| | - William T Mahle
- Children's Healthcare of Atlanta Emory University School of Medicine Atlanta, Georgia.
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35
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Callahan R, Kieran MW, Baird CW, Colan SD, Gauvreau K, Ireland CM, Marshall AC, Sena LM, Vargas SO, Jenkins KJ. Adjunct Targeted Biologic Inhibition Agents to Treat Aggressive Multivessel Intraluminal Pediatric Pulmonary Vein Stenosis. J Pediatr 2018; 198:29-35.e5. [PMID: 29576325 DOI: 10.1016/j.jpeds.2018.01.029] [Citation(s) in RCA: 51] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/29/2017] [Revised: 12/28/2017] [Accepted: 01/10/2018] [Indexed: 10/17/2022]
Abstract
OBJECTIVE To evaluate the use of imatinib mesylate with or without bevacizumab targeting neoproliferative myofibroblast-like cells with tyrosine kinase receptor expression, as adjuncts to modern interventional therapies for the treatment of multivessel intraluminal pulmonary vein stenosis (PVS). We describe the 48- and 72-week outcomes among patients receiving imatinib mesylate with or without bevacizumab for multivessel intraluminal PVS. STUDY DESIGN This single-arm, prospective, open-label US Food and Drug Administration approved trial enrolled patients with ≥2 affected pulmonary veins after surgical or catheter-based relief of obstruction between March 2009 and December 2014. Drug therapy was discontinued at 48 weeks, or after 24 weeks of stabilization, whichever occurred later. RESULTS Among 48 enrolled patients, 5 had isolated PVS, 26 congenital heart disease, 5 lung disease, and 12 both. After the 72-week follow-up, 16 patients had stabilized, 27 had recurred locally without stabilization, and 5 had progressed. Stabilization was associated with the absence of lung disease (P = .03), a higher percentage of eligible drug doses received (P = .03), and was not associated with age, diagnosis, disease laterality, or number of veins involved. Survival to 72 weeks was 77% (37 of 48). Adverse events were common (n = 1489 total), but only 16 were definitely related to drug treatment, none of which were serious. CONCLUSION Survival to 72 weeks was 77% in a referral population with multivessel intraluminal PVS undergoing multimodal treatment, including antiproliferative tyrosine kinase blockade. Toxicity specific to tyrosine kinase blockade was minimal.
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Affiliation(s)
- Ryan Callahan
- Department of Cardiology, Boston Children's Hospital and Harvard Medical School, Boston, MA.
| | - Mark W Kieran
- Division of Pediatric Medical Neuro-Oncology, Dana-Farber Cancer Institute, Boston Children's Hospital and Harvard Medical School, Boston, MA; Department of Hematology/Oncology, Boston Children's Hospital and Harvard Medical School, Boston, MA
| | - Christopher W Baird
- Department of Cardiac Surgery, Boston Children's Hospital and Harvard Medical School, Boston, MA
| | - Steven D Colan
- Department of Cardiology, Boston Children's Hospital and Harvard Medical School, Boston, MA
| | - Kimberlee Gauvreau
- Department of Cardiology, Boston Children's Hospital and Harvard Medical School, Boston, MA
| | - Christina M Ireland
- Department of Cardiology, Boston Children's Hospital and Harvard Medical School, Boston, MA
| | - Audrey C Marshall
- Department of Cardiology, Floating Hospital for Children at Tufts Medical Center, Boston, MA
| | - Laureen M Sena
- Department of Radiology, UMass Memorial Medical Center, Boston, MA
| | - Sara O Vargas
- Department of Pathology, Boston Children's Hospital and Harvard Medical School, Boston, MA
| | - Kathy J Jenkins
- Department of Cardiology, Boston Children's Hospital and Harvard Medical School, Boston, MA
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