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Roy P, Sah V, Deb N, Jaiswal V. Navigating the path of TOF- A Literature review unveiling maternal-fetal dynamics, treatment strategies and psychological dimensions. Dis Mon 2024; 70:101659. [PMID: 37951837 DOI: 10.1016/j.disamonth.2023.101659] [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: 11/14/2023]
Abstract
Tetralogy of Fallot (TOF) is a complex congenital heart defect that poses unique challenges for both mothers and their unborn children. This comprehensive review, aims to provide a holistic exploration of the maternal-fetal dynamics, treatment strategies, and psychological dimensions involved in navigating the path of TOF during pregnancy. It delves into the physiological changes that occur during pregnancy in TOF patients, including pulmonary regurgitation, right ventricular hypertrophy, and the overriding aorta. By understanding these dynamics, healthcare professionals can tailor treatment strategies to optimize maternal and fetal outcomes. The review further investigates the treatment strategies employed in managing TOF during pregnancy, encompassing medical interventions, cardiac monitoring, and multidisciplinary care. It explores the role of advanced imaging techniques, such as echocardiography and cardiac magnetic resonance imaging, in assessing TOF severity and guiding treatment decisions. The psychological factors influencing maternal adaptation, coping strategies, and the long-term implications on the child's psychological development are also examined. The integration of multidisciplinary approaches, including cardiac care, psychosocial support, and mental health interventions, can orchestrate a harmonious symphony of maternal-fetal well-being in the challenging journey of TOF pregnancies. Future research endeavours should continue to explore these dimensions, further refining treatment strategies and enhancing the understanding of TOF pregnancies for improved outcomes.
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Affiliation(s)
- Poulami Roy
- Department of Medicine, North Bengal Medical College and Hospital, India
| | - Viraj Sah
- Seth Gordhandas Sunderdas Medical College and King Edward Memorial Hospital, Mumbai
| | - Novonil Deb
- Department of Medicine, North Bengal Medical College and Hospital, India.
| | - Vikash Jaiswal
- Department of Cardiovascular Research, Larkin Community Hospital, South Miami, FL, USA
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2
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Abbaszadeh R, Askari-Moghadam R, Moradian M, Mortazaeian H, Qomi MRS, Omidi N, Khalili Y, Tahouri T. The Nakata index and McGoon ratio: correlation with the severity of pulmonary regurgitation after the repair of paediatric tetralogy of Fallot. Egypt Heart J 2023; 75:95. [PMID: 38017289 PMCID: PMC10684472 DOI: 10.1186/s43044-023-00423-9] [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: 09/01/2023] [Accepted: 11/22/2023] [Indexed: 11/30/2023] Open
Abstract
BACKGROUND Pulmonary regurgitation is the most common complication after the complete repair of tetralogy of Fallot, and severe pulmonary regurgitation after surgery requires pulmonary valve replacement. In this retrospective observational, cross-sectional study, we included a total of 56 children aged 6 years or younger who underwent complete repair of TOF at Shahid Rajaei Cardiovascular Medical and Research Center in Tehran, Iran. Preoperative dual-source computed tomography was used to measure the McGoon ratio and Nakata index. The patients were divided into two groups based on the severity of postoperative pulmonary regurgitation, as estimated by trans-thoracic echocardiography: the severe pulmonary regurgitation group and the non-severe pulmonary regurgitation group. The McGoon ratio and Nakata index were then compared between the two groups. RESULTS When comparing the two groups, we found that the corrected right pulmonary artery diameter, main pulmonary artery diameter, and McGoon ratio in the non-severe pulmonary regurgitation group were higher than in the severe pulmonary regurgitation group. However, none of these differences were statistically significant. Additionally, other variables, including the corrected left pulmonary artery diameter and Nakata index, showed higher measurements in children with severe pulmonary regurgitation, but again, the differences were not statistically significant. CONCLUSIONS This study indicates that pulmonary arteries diameter, Nakata index, and McGoon ratio were not significantly correlated with the severity of pulmonary regurgitation after the complete repair of tetralogy of Fallot.
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Affiliation(s)
- Reza Abbaszadeh
- Rajaei Cardiovascular Medical and Research Center, Iran University of Medical Sciences, Tehran, Iran
| | - Raheleh Askari-Moghadam
- Rajaei Cardiovascular Medical and Research Center, Iran University of Medical Sciences, Tehran, Iran
| | - Maryam Moradian
- Rajaei Cardiovascular Medical and Research Center, Iran University of Medical Sciences, Tehran, Iran
| | - Hojat Mortazaeian
- Rajaei Cardiovascular Medical and Research Center, Iran University of Medical Sciences, Tehran, Iran
| | | | - Negar Omidi
- Cardiac primary Prevention Research Center, Cardiovascular Disease Research Institute, Tehran Heart Center, Tehran University of Medical Sciences, Tehran, Iran
| | - Yasaman Khalili
- Rajaei Cardiovascular Medical and Research Center, Iran University of Medical Sciences, Tehran, Iran
| | - Tahmineh Tahouri
- Shahid Modarres Educational Hospital, Faculty of Medicine, Shahid Beheshti University of Medical Sciences, Tehran, Iran.
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3
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Krishnamurthy R, Suman G, Chan SS, Kirsch J, Iyer RS, Bolen MA, Brown RKJ, El-Sherief AH, Galizia MS, Hanneman K, Hsu JY, de Rosen VL, Rajiah PS, Renapurkar RD, Russell RR, Samyn M, Shen J, Villines TC, Wall JJ, Rigsby CK, Abbara S. ACR Appropriateness Criteria® Congenital or Acquired Heart Disease. J Am Coll Radiol 2023; 20:S351-S381. [PMID: 38040460 DOI: 10.1016/j.jacr.2023.08.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2023] [Accepted: 08/22/2023] [Indexed: 12/03/2023]
Abstract
Pediatric heart disease is a large and diverse field with an overall prevalence estimated at 6 to 13 per 1,000 live births. This document discusses appropriateness of advanced imaging for a broad range of variants. Diseases covered include tetralogy of Fallot, transposition of great arteries, congenital or acquired pediatric coronary artery abnormality, single ventricle, aortopathy, anomalous pulmonary venous return, aortopathy and aortic coarctation, with indications for advanced imaging spanning the entire natural history of the disease in children and adults, including initial diagnosis, treatment planning, treatment monitoring, and early detection of complications. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision process support the systematic analysis of the medical literature from peer reviewed journals. Established methodology principles such as Grading of Recommendations Assessment, Development, and Evaluation or GRADE are adapted to evaluate the evidence. The RAND/UCLA Appropriateness Method User Manual provides the methodology to determine the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where peer reviewed literature is lacking or equivocal, experts may be the primary evidentiary source available to formulate a recommendation.
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Affiliation(s)
| | - Garima Suman
- Research Author, Mayo Clinic, Rochester, Minnesota
| | | | - Jacobo Kirsch
- Panel Chair, Cleveland Clinic Florida, Weston, Florida
| | - Ramesh S Iyer
- Panel Chair, Seattle Children's Hospital, Seattle, Washington
| | | | - Richard K J Brown
- University of Utah, Department of Radiology and Imaging Sciences, Salt Lake City, Utah; Commission on Nuclear Medicine and Molecular Imaging
| | | | | | - Kate Hanneman
- Toronto General Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Joe Y Hsu
- Kaiser Permanente, Los Angeles, California
| | | | | | | | - Raymond R Russell
- The Warren Alpert School of Medicine at Brown University, Providence, Rhode Island; American Society of Nuclear Cardiology
| | - Margaret Samyn
- Children's Hospital of Wisconsin, Milwaukee, Wisconsin; Society for Cardiovascular Magnetic Resonance
| | - Jody Shen
- Stanford University, Stanford, California
| | - Todd C Villines
- University of Virginia Health System, Charlottesville, Virginia; Society of Cardiovascular Computed Tomography
| | - Jessica J Wall
- University of Washington, Seattle, Washington; American College of Emergency Physicians
| | - Cynthia K Rigsby
- Specialty Chair, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois
| | - Suhny Abbara
- Specialty Chair, University of Texas Southwestern Medical Center, Dallas, Texas
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4
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Ligon RA, Latson LA, Ruzmetov MM, Hernandez LE. Right ventricular outflow tract landing zone perimeter / circularised diameter - new imaging standards in pulmonary valve replacement reporting. Cardiol Young 2023; 33:1840-1845. [PMID: 36259096 DOI: 10.1017/s1047951122003286] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
BACKGROUND Right ventricular outflow tract intervention spans transcatheter, surgical, or hybrid pulmonary valve replacement methodologies. Standardised pre-procedure workup includes cardiac MRI to identify an intended valve site (landing zone). Our institutional practice includes measurement of the right ventricular outflow tract perimeter (circumference) of this site in end-systole. Our primary aim was to compare patients by their perimeter values to the palliative interventions performed (transcatheter versus surgical/hybrid methodologies). METHODS Retrospective review of patients undergoing pulmonary valve replacement from January 2017 to 2021. We performed perimeter measurements at the intended valve site on advanced imaging; the outcomes of interventions were outlined via descriptive and statistical analyses. RESULTS A total of 37 patients underwent pulmonary valve replacement that met study criteria - 21 transcatheter, 7 surgical, and 9 hybrid. Median age at intervention was 26 years (range 8-70). The mean end-systolic perimeter of the transcatheter cohort was 88.9 ± 8.7 mm and in the surgical/hybrid cohort measured 106.6 ± 7.5 mm. For the transcatheter cohort, the median "circularised" diameter derived from the perimeter measurement (divided by π) was 27.7 mm (range 24.3-32.4). Notably, this correlated (r = 0.93, p < 0.01) with the median diameter of the narrowest region during actual transcatheter right ventricular outflow tract balloon sizing (lateral imaging) of 27.1 mm (range 23.2-30.1). CONCLUSIONS Right ventricular outflow tract perimeter measurement to determine circularised diameter is useful in planning pulmonary valve replacement in terms of candidacy of transcatheter versus the need for a surgical/hybrid approach. The circularised diameter correlates with transcatheter right ventricular outflow tract balloon sizing.
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Affiliation(s)
- R Allen Ligon
- Division of Pediatric and Adult Congenital Cardiology, The Pediatric Heart Institute, Joe DiMaggio Children's Hospital, 1150 North 35 Avenue, Suite 490, Hollywood, FL, USA
| | - Larry A Latson
- Division of Pediatric and Adult Congenital Cardiology, The Pediatric Heart Institute, Joe DiMaggio Children's Hospital, 1150 North 35 Avenue, Suite 490, Hollywood, FL, USA
| | - Mark M Ruzmetov
- Division of Pediatric and Adult Congenital Cardiology, The Pediatric Heart Institute, Joe DiMaggio Children's Hospital, 1150 North 35 Avenue, Suite 490, Hollywood, FL, USA
| | - Lazaro E Hernandez
- Division of Pediatric and Adult Congenital Cardiology, The Pediatric Heart Institute, Joe DiMaggio Children's Hospital, 1150 North 35 Avenue, Suite 490, Hollywood, FL, USA
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Baessato F, Ewert P, Meierhofer C. CMR and Percutaneous Treatment of Pulmonary Regurgitation: Outreach the Search for the Best Candidate. Life (Basel) 2023; 13:life13051127. [PMID: 37240773 DOI: 10.3390/life13051127] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2023] [Revised: 04/30/2023] [Accepted: 05/03/2023] [Indexed: 05/28/2023] Open
Abstract
Performance of cardiovascular magnetic resonance (CMR) in the planning phase of percutaneous pulmonary valve implantation (PPVI) is needed for the accurate delineation of the right ventricular outflow tract (RVOT), coronary anatomy and the quantification of right ventricular (RV) volume overload in patients with significant pulmonary regurgitation (PR). This helps to find the correct timings for the intervention and prevention of PPVI-related complications such as coronary artery compression, device embolization and stent fractures. A defined CMR study protocol should be set for all PPVI candidates to reduce acquisition times and acquire essential sequences that are determinants for PPVI success. For correct RVOT sizing, contrast-free whole-heart sequences, preferably at end-systole, should be adopted in the pediatric population thanks to their high reproducibility and concordance with invasive angiographic data. When CMR is not feasible or contraindicated, cardiac computed tomography (CCT) may be performed for high-resolution cardiac imaging and eventually the acquisition of complementary functional data. The aim of this review is to underline the role of CMR and advanced multimodality imaging in the context of pre-procedural planning of PPVI concerning its current and potential future applications.
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Affiliation(s)
- Francesca Baessato
- Department of Cardiology, Regional Hospital S. Maurizio, 39100 Bolzano, Italy
- Congenital Heart Disease and Pediatric Cardiology, German Heart Center Munich, 80636 Munich, Germany
| | - Peter Ewert
- Congenital Heart Disease and Pediatric Cardiology, German Heart Center Munich, 80636 Munich, Germany
| | - Christian Meierhofer
- Congenital Heart Disease and Pediatric Cardiology, German Heart Center Munich, 80636 Munich, Germany
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6
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Liu T, Jackson AC, Menahem S. Adolescents and Adults With Congenital Heart Disease: Why Are They Lost to Follow-Up? World J Pediatr Congenit Heart Surg 2023; 14:357-363. [PMID: 36823988 DOI: 10.1177/21501351221149897] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/25/2023]
Abstract
Almost 90% of infants with congenital heart disease (CHD) now reach adulthood but require long-term surveillance to recognize and manage residual and/or evolving lesions. Yet many are lost to follow-up. A scoping review identified four specific domains that pose barriers to consistent follow-up. There are multiple issues associated with transition from pediatric to adult care which included-the lack of a seamless transfer, the establishment of a new trusting relationship, promoting the right balance of patient autonomy and addressing knowledge gaps. Additional issues related to logistic problems of time, distance, cost, and the availability of specialized care, are further compounded by the psychosocial factors and the heterogeneity of the cardiac abnormality affecting our patients. Further study of all these issues is warranted to improve ongoing engagement.
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Affiliation(s)
- Tianwei Liu
- Department of Medical Education, University of Melbourne, Melbourne, Australia
| | - Alun C Jackson
- Melbourne Graduate School of Education, University of Melbourne, Melbourne, Australia.,Australian Centre for Heart Health, Melbourne, Australia
| | - Samuel Menahem
- Australian Centre for Heart Health, Melbourne, Australia.,Department of Paediatrics and School of Clinical Sciences, Monash University, Clayton, Australia.,Murdoch Children's Research Institute, University of Melbourne, Melbourne, Australia
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7
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Siddiqi U, Adewale A, Pena E, Schulz K, Ilbawi M, El-Zein C, Vricella L, Hibino N. Preserving the pulmonary valve in Tetralogy of Fallot repair: Reconsidering the indication for valve-sparing. J Card Surg 2022; 37:5144-5152. [PMID: 36378940 PMCID: PMC10100041 DOI: 10.1111/jocs.17156] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2022] [Revised: 10/31/2022] [Accepted: 11/01/2022] [Indexed: 11/16/2022]
Abstract
BACKGROUND Tetralogy of Fallot (TOF) repair is a frequent procedure, and although valve-sparing (VS) repair is preferred, determining which patients can successfully undergo this operation remains controversial. We sought to identify parameters to determine a selective, accurate indication for VS repair. METHODS We reviewed 71 patients (82%) undergoing VS repair. We analyzed hemodynamic data, intraoperative reports, and follow-up echocardiography results to identify acceptable indications. Patients requiring pulmonary valve (PV) reintervention versus no reintervention were compared. RESULTS PV annulus size at repair was z-score of -2.0 (-5.3, 1.3). Approximately half (51%) had a z-score less than -2. Cox regression results showed this was not a risk factor for reintervention (p = .59). Overall, 1-, 3-, 5-, and 10-year freedom from PV reintervention rates were 95.8%, 92.8%, 91% and 77.8%, respectively. Residual pulmonary stenosis (PS) at initial repair was relatively higher in the reintervention group compared with no reintervention group (40 [28, 51] mmHg vs. 30 [22, 37] mmHg; p = .08). For patients with residual PS, pressure gradient (PG) was consistent over time across both groups (PV reintervention: -3 [-15, 8] mmHg vs. no reintervention: 0 [-9, 8] mmHg). The risk of PV reintervention is 3.7-fold higher when the PG from intraoperative TEE is greater than 45 mmHg (p = .04). CONCLUSIONS Our review of the midterm outcomes of expanded indication for VS suggests intraoperative decision to convert to transannular patch is warranted if intraoperative postprocedure TEE PG is greater than 45 mmHg or RV pressure is higher than half of systemic pressure to prevent reintervention.
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Affiliation(s)
- Umar Siddiqi
- Comer Children's Hospital, University of Chicago, Chicago, Illinois, USA
| | - Adedotun Adewale
- Advocate Children's Hospital, Advocate Children's Heart Institute, Oak Lawn, Illinois, USA
| | - Emily Pena
- Advocate Children's Hospital, Advocate Children's Heart Institute, Oak Lawn, Illinois, USA
| | - Kelci Schulz
- Advocate Children's Hospital, Advocate Children's Heart Institute, Oak Lawn, Illinois, USA
| | - Michel Ilbawi
- Advocate Children's Hospital, Advocate Children's Heart Institute, Oak Lawn, Illinois, USA
| | - Chawki El-Zein
- Advocate Children's Hospital, Advocate Children's Heart Institute, Oak Lawn, Illinois, USA
| | - Luca Vricella
- Comer Children's Hospital, University of Chicago, Chicago, Illinois, USA.,Advocate Children's Hospital, Advocate Children's Heart Institute, Oak Lawn, Illinois, USA
| | - Narutoshi Hibino
- Comer Children's Hospital, University of Chicago, Chicago, Illinois, USA
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8
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Arya N, Schievano S, Caputo M, Taylor AM, Biglino G. Relationship between Pulmonary Regurgitation and Ventriculo-Arterial Interactions in Patients with Post-Early Repair of Tetralogy of Fallot: Insights from Wave-Intensity Analysis. J Clin Med 2022; 11:6186. [PMID: 36294505 PMCID: PMC9604580 DOI: 10.3390/jcm11206186] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2022] [Revised: 10/07/2022] [Accepted: 10/18/2022] [Indexed: 11/16/2022] Open
Abstract
This study aimed to investigate the effect of pulmonary regurgitation (PR) on left ventricular ventriculo-arterial (VA) coupling in patients with repaired tetralogy of Fallot (ToF). It was hypothesised that increasing PR severity results in a smaller forward compression wave (FCW) peak in the aortic wave intensity, because of right-to-left ventricular interactions. The use of cardiovascular magnetic resonance (CMR)-derived wave-intensity analysis provided a non-invasive comparison between patients with varying PR degrees. A total of n = 201 patients were studied and both hemodynamic and wave-intensity data were compared. Wave-intensity peaks and areas of the forward compression and forward expansion waves were calculated as surrogates of ventricular function. Any extent of PR resulted in a significant reduction in the FCW peak. A correlation was found between aortic distensibility and the FCW peak, suggesting unfavourable (VA) coupling in patients that also present stiffer ascending aortas. Data suggest that VA coupling is affected by increased impedance.
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Affiliation(s)
- Nikesh Arya
- Faculty of Mathematical and Physical Sciences, University College London, London WC1E 6BT, UK
| | - Silvia Schievano
- Institute of Cardiovascular Science, University College London, London WC1E 6BT, UK
- Centre for Cardiovascular Imaging, Great Ormond Street Hospital for Children NHS Foundation Trust, London WC1N 3HJ, UK
| | - Massimo Caputo
- Bristol Medical School, Faculty of Health Sciences, University of Bristol, Bristol BS8 1TH, UK
- Bristol Heart Institute, University Hospitals Bristol & Weston NHS Foundation Trust, Bristol, BS2 8HW, UK
| | - Andrew M. Taylor
- Institute of Cardiovascular Science, University College London, London WC1E 6BT, UK
- Centre for Cardiovascular Imaging, Great Ormond Street Hospital for Children NHS Foundation Trust, London WC1N 3HJ, UK
| | - Giovanni Biglino
- Bristol Medical School, Faculty of Health Sciences, University of Bristol, Bristol BS8 1TH, UK
- National Heart and Lung Institute, Imperial College London, London SW7 2BX, UK
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9
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Carlson Hanse L, Tjørnild MJ, Sørensen SG, Johansen P, Lugones I, Hjortdal VE. Trileaflet semilunar valve reconstruction: pulsatile in vitro evaluation. Interact Cardiovasc Thorac Surg 2022; 35:6692721. [PMID: 36066430 PMCID: PMC9462423 DOI: 10.1093/icvts/ivac227] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2022] [Revised: 07/11/2022] [Accepted: 09/05/2022] [Indexed: 11/14/2022] Open
Abstract
Abstract
OBJECTIVES
Residual regurgitation is common after congenital surgery for right ventricular outflow tract malformation. It is accepted as there is no competent valve solution in a growing child. We investigated a new surgical technique of trileaflet semilunar valve reconstruction possessing the potential of remaining sufficient and allowing for some growth with the child. In this proof-of-concept study, our aim was to evaluate if it is achievable as a functional pulmonary valve reconstruction in vitro.
METHODS
Explanted pulmonary trunks from porcine hearts were evaluated in a pulsatile flow-loop model. First, the native pulmonary trunk was investigated, after which the native leaflets were explanted. Then, trileaflet semilunar valve reconstruction was performed and investigated. All valves were initially investigated at a flow output of 4 l/min and subsequently at 7 l/min. The characterization was based on hydrodynamic pressure and echocardiographic measurements.
RESULTS
Eight pulmonary trunks were evaluated. All valves are competent on colour Doppler. There is no difference in mean pulmonary systolic artery pressure gradient at 4 l/min (P = 0.32) and at 7 l/min (P = 0.20). Coaptation length is increased in the neo-valve at 4 l/min (P < 0.001, P < 0.001, P = 0.008) and at 7 l/min (P < 0.001, P = 0.006, P = 0.006). A windmill shape is observed in all neo-valves.
CONCLUSIONS
Trileaflet semilunar valve reconstruction is sufficient and non-stenotic. It resulted in an increased coaptation length and a windmill shape, which is speculated to decrease with the growth of the patient, yet remains sufficient as a transitional procedure until a long-term solution is feasible. Further in vivo investigations are warranted.
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Affiliation(s)
- Lisa Carlson Hanse
- Department of Cardiothoracic and Vascular Surgery, Aarhus University Hospital , Aarhus, Denmark
- Department of Clinical Medicine, Aarhus University Hospital , Aarhus, Denmark
| | - Marcell J Tjørnild
- Department of Cardiothoracic and Vascular Surgery, Aarhus University Hospital , Aarhus, Denmark
- Department of Clinical Medicine, Aarhus University Hospital , Aarhus, Denmark
| | - Simon G Sørensen
- Department of Clinical Medicine, Aarhus University Hospital , Aarhus, Denmark
- Department of Molecular Medicine (MOMA), Aarhus University Hospital , Aarhus, Denmark
| | - Peter Johansen
- Department of Engineering, Aarhus University , Aarhus, Denmark
| | - Ignacio Lugones
- Department of Congenital Heart Surgery in Hospital General de Niños “Pedro de Elizalde” , Buenos Aires, Argentina
| | - Vibeke E Hjortdal
- Department of Cardiothoracic Surgery , Rigshospitalet, Copenhagen, Denmark
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10
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Mitova E, Wittnich C. Cardiac Structures in Marine Animals Provide Insight on Potential Directions for Interventions for Pediatric Congenital Heart Defects. Am J Physiol Heart Circ Physiol 2021; 322:H1-H7. [PMID: 34652986 DOI: 10.1152/ajpheart.00451.2021] [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] [Indexed: 11/22/2022]
Abstract
Despite recent advances in pediatric diagnosis and surgical intervention, mortality and morbidity continue to be a prevalent issue in both Tetralogy of Fallot (ToF) and Hypoplastic Left Heart Syndrome (HLHS). Therefore, novel approaches to studying both of these conditions is warranted. Investigating cardiac anatomical features of different species in the animal kingdom similar to the defects and complications present in ToF and HLHS (as well as others) could serve as a new avenue for improving the management of congenital heart diseases (CHD). This review reveals that although structures found in HLHS and ToF are pathological, similar structures are found in diving mammals and reptiles that are adaptive. Pathologic aortic dilation in CHD resembles the aortic bulb present in diving mammals, but the latter is more elastic and distensible compared to the former. The unrepaired HLHS heart resembles the univentricular heart of non-crocodilian reptiles. Right ventricle hypertrophy is pathological in HLHS and ToF, but adaptive in crocodilians and diving mammals. Lastly, the increased pulmonary resistance due to pulmonary stenosis in ToF is comparable to increased pulmonary resistance in crocodilians due to the presence of an active valve proximal to the pulmonary valve. Some of these anatomical structures could potentially be adapted for palliative surgery in children with HLHS or ToF. Moreover, further investigating the underlying molecular signals responsible for the adaptive tissue responses seen in other species may also be useful for developing novel strategies for preventing some of the complications that occur after surgical repair in both of these CHDs.
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Affiliation(s)
- Emilia Mitova
- Department of Physiology, University of Toronto, Toronto, Ontario, Canada
| | - Carin Wittnich
- Department of Physiology, University of Toronto, Toronto, Ontario, Canada.,Department of Surgery, University of Toronto, Toronto, Ontario, Canada
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11
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Saef JM, Ghobrial J. Valvular heart disease in congenital heart disease: a narrative review. Cardiovasc Diagn Ther 2021; 11:818-839. [PMID: 34295708 DOI: 10.21037/cdt-19-693-b] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2019] [Accepted: 01/29/2021] [Indexed: 12/29/2022]
Abstract
Patients with congenital heart disease (CHD) are one of the fastest growing populations in cardiology, and valvular pathology is at the center of many congenital lesions. Derangements in valvular embryology lead to several anomalies prone to dysfunction, each with hemodynamic effects that require appropriate surveillance and management. Surgical innovation has provided new treatments that have improved survival in this population, though has also contributed to esotericism in patients who already have unique anatomic and physiologic considerations. Conduit and prosthesis durability are often monitored collaboratively with general and specialized congenital-focused cardiologists. As such, general cardiologists must become familiar with valvular disease with CHD for appropriate care and referral practices. In this review, we summarize the embryology of the semilunar and atrioventricular (AV) valves as a foundation for understanding the origins of valvular CHD and describe the mechanisms that account for heterogeneity in disease. We then highlight the categories of pathology from the simple (e.g., bicuspid aortic valve, isolated pulmonic stenosis) to the more complex (e.g., Ebstein's anomaly, AV valvular disease in single ventricle circulations) with details on natural history, diagnosis, and contemporary therapeutic approaches. Care for CHD patients requires collaborative effort between providers, both CHD-specialized and not, to achieve optimal patient outcomes.
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Affiliation(s)
- Joshua M Saef
- Division of Cardiology, Heart and Vascular Institute, Cleveland Clinic Foundation, Cleveland, OH, USA
| | - Joanna Ghobrial
- Division of Cardiology, Heart and Vascular Institute, Cleveland Clinic Foundation, Cleveland, OH, USA
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12
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Van den Eynde J, Sá MPBO, Vervoort D, Roever L, Meyns B, Budts W, Gewillig M, Ruhparwar A, Zhigalov K, Weymann A. Pulmonary Valve Replacement in Tetralogy of Fallot: An Updated Meta-Analysis. Ann Thorac Surg 2020; 113:1036-1046. [PMID: 33378694 DOI: 10.1016/j.athoracsur.2020.11.040] [Citation(s) in RCA: 26] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/14/2020] [Revised: 10/23/2020] [Accepted: 11/16/2020] [Indexed: 11/01/2022]
Abstract
BACKGROUND The benefits of pulmonary valve replacement (PVR) for pulmonary insufficiency in patients with repaired tetralogy of Fallot are still incompletely understood, and optimal timing remains challenging. METHODS We systematically reviewed databases (PubMed/MEDLINE, Embase, Cochrane Central Register of Controlled Trials /Cochrane Controlled Trials Register, ClinicalTrials.gov, Scientific Electronic Library Online, Literatura Latino Americana em Ciências da Saúde, and Google Scholar) and reference lists of relevant articles for studies about PVR in repaired tetralogy of Fallot patients that reported any of the following outcomes: mortality and redo PVR rates, right ventricular (RV) and left ventricular measures, QRS duration, cardiopulmonary exercise test results, or brain natriuretic peptide. In addition to calculating the pooled treatment effects using a random-effects meta-analysis, we evaluated the effect of preoperative measures on PVR outcomes using meta-regressions. RESULTS Eighty-four studies involving 7544 patients met the eligibility criteria. Pooled mortality at 30 days, 5 years, and 10 years after PVR was 0.87% (63 of 7253 patients, 80 studies), 2.7% (132 of 4952 patients, 37 studies), and 6.2% (510 of 2765 patients, 15 studies), respectively. Pooled 5- and 10-year redo PVR rates were 3.7% (141 of 3755 patients, 23 studies) and 16.8% (172 of 3035 patients, 16 studies), respectively. The results of the previous meta-analysis could be confirmed. In addition, we demonstrated that after PVR (1) QRS duration, cardiopulmonary exercise test results, and RV and left ventricular measures longitudinal strain do not significantly change; (2) brain natriuretic peptide decreases; and (3) greater indexed RV end-diastolic and end-systolic volumes are associated with lower chances of RV volume normalization after PVR. CONCLUSIONS This updated meta-analysis provides evidence about the benefits of PVR.
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Affiliation(s)
- Jef Van den Eynde
- Unit of Cardiac Surgery, Department of Cardiovascular Diseases, University Hospitals Leuven, Leuven, Belgium.
| | - Michel Pompeu B O Sá
- Division of Cardiovascular Surgery of Pronto Socorro Cardiológico de Pernambuco, PROCAPE, University of Pernambuco, Recife, Pernambuco, Brazil
| | | | - Leonardo Roever
- Department of Clinical Research, Federal University of Uberlândia, Minas Gerais, Uberlândia, Brazil
| | - Bart Meyns
- Unit of Cardiac Surgery, Department of Cardiovascular Diseases, University Hospitals Leuven, Leuven, Belgium
| | - Werner Budts
- Congenital and Structural Cardiology University Hospitals Leuven and Department of Cardiovascular Sciences, Catholic University Leuven, Leuven, Belgium
| | - Marc Gewillig
- Pediatric Cardiology, University Hospitals Leuven, Leuven, Belgium
| | - Arjang Ruhparwar
- Department of Thoracic and Cardiovascular Surgery, West German Heart and Vascular Center, Essen, Germany
| | - Konstantin Zhigalov
- Department of Thoracic and Cardiovascular Surgery, West German Heart and Vascular Center, Essen, Germany
| | - Alexander Weymann
- Department of Thoracic and Cardiovascular Surgery, West German Heart and Vascular Center, Essen, Germany
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13
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CMR in Evaluating Valvular Heart Disease: Diagnosis, Severity, and Outcomes. JACC Cardiovasc Imaging 2020; 14:2020-2032. [PMID: 33248967 DOI: 10.1016/j.jcmg.2020.09.029] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/30/2020] [Revised: 09/04/2020] [Accepted: 09/14/2020] [Indexed: 01/20/2023]
Abstract
Cardiac magnetic resonance (CMR) is a versatile imaging tool that brings much to the assessment of valvular heart disease. Although it is best known for myocardial imaging (even in valve disease), it provides excellent assessment of all 4 heart valves, with some distinct advantages, including a free choice of image planes and accurate flow and volumetric quantification. These allow the severity of each valve lesion to be characterized, in addition to optimal visualization of the surrounding outflow tracts and vessels, to deliver a comprehensive package. It can assess each valve lesion separately (in multiple valve disease) and is not affected by hemodynamic status. The accurate quantitation of regurgitant lesions and the ability to characterize myocardial changes also provides an ability to predict future clinical outcomes in asymptomatic patients. This review outlines how CMR can be used in cardiac valve disease to compliment echocardiography and enhance the patient assessment. It covers the main CMR methods used, their strengths and limitations, and the optimal way to apply them to evaluate valve disease.
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14
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Liu H, Liu S, Zaki A, Wang X, Zhu K, Lu Y, Yang Y, Hamidi R, Wei L, Wang C. Pulmonary valve replacement in primary repair of tetralogy of Fallot in adult patients. J Thorac Dis 2020; 12:4833-4841. [PMID: 33145056 PMCID: PMC7578467 DOI: 10.21037/jtd-20-1475] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
Background Adults with unrepaired tetralogy of Fallot (ToF) are common in developing countries. Long-term overload of the right ventricle places adult patients at risk for postoperative right heart failure after primary repair, which contributes to morbidity and mortality. The effect of pulmonary valve replacement (PVR) in reducing postoperative morbidity and mortality in adults has never been validated. Methods We conducted a retrospective cohort study in adults (age ≥18 years) with ToF undergoing primary repair from January 2014 to December 2019 at our institution. Patients were divided into three groups according to techniques used to enlarge the right ventricle outflow tract (RVOT). Baseline variables and perioperative outcomes were collected. The primary endpoint was operative mortality. Secondary endpoints were incidences of right heart failure and stage 3 acute kidney injury (AKI). Results A total of 56 patients were enrolled (mean age 41.5±11.7 years, 30 females, 53.6%). They were divided into three groups designated as the following: TA-PVR group for trans-annular patch enlargement with PVR; TA group for trans-annulus patch enlargement without PVR; and group AP for annulus preservation. Four patients (7.1%) died postoperatively, all due to right heart failure. All twelve patients in the TA-PVR group survived. There was no significant difference in mortalities among groups. Ten patients (17.9%) developed right heart failure after surgery with no significant difference among groups. Three patients (5.4%) developed stage 3 AKI after surgery, none belonging to the TA-PVR group, however, not statistically significant. Conclusions Right heart failure is a common complication after primary repair of adult ToF. Trans-annulus patch enlargement should be cautiously selected in this population. PVR with trans-annulus patch enlargement may be a promising technique to protect against postoperative right heart failure and mortality when annulus preservation is not feasible.
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Affiliation(s)
- Huan Liu
- Department of Cardiovascular Surgery, Zhongshan Hospital, Shanghai Cardiovascular Institution, Fudan University, Shanghai, China
| | - Shun Liu
- Department of Cardiovascular Surgery, Zhongshan Hospital, Shanghai Cardiovascular Institution, Fudan University, Shanghai, China
| | - Anthony Zaki
- Department of Thoracic and Cardiovascular Surgery, Cleveland Clinic, Cleveland, OH, USA
| | - Xiuwen Wang
- Department of Cardiovascular Surgery, Zhongshan Hospital, Shanghai Cardiovascular Institution, Fudan University, Shanghai, China
| | - Kai Zhu
- School of Clinical Medicine, Jiujiang University, Jiujiang, China
| | - Yuntao Lu
- Department of Cardiovascular Surgery, Zhongshan Hospital, Shanghai Cardiovascular Institution, Fudan University, Shanghai, China
| | - Ye Yang
- Department of Cardiovascular Surgery, Zhongshan Hospital, Shanghai Cardiovascular Institution, Fudan University, Shanghai, China
| | - Rafi Hamidi
- Department of Cardiovascular Surgery, Zhongshan Hospital, Shanghai Cardiovascular Institution, Fudan University, Shanghai, China
| | - Lai Wei
- Department of Cardiovascular Surgery, Zhongshan Hospital, Shanghai Cardiovascular Institution, Fudan University, Shanghai, China
| | - Chunsheng Wang
- Department of Cardiovascular Surgery, Zhongshan Hospital, Shanghai Cardiovascular Institution, Fudan University, Shanghai, China
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15
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Sanchez AM, Lozier MR, Alvardo HR, Sarkar A, Smith JM, Molina S, Llanos A, Roth T, Bhatt A. When "Blue Babies" Grow Up: Complications After Surgical Repair of Tetralogy of Fallot. JACC Case Rep 2020; 2:1723-1729. [PMID: 34317044 PMCID: PMC8312140 DOI: 10.1016/j.jaccas.2020.06.023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2019] [Revised: 05/18/2020] [Accepted: 06/23/2020] [Indexed: 11/17/2022]
Abstract
Tetralogy of Fallot (TOF) is a complex congenital cardiac defect. Surgical correction is well established as the treatment of choice and has resulted in a rapidly growing group of adults living with TOF. We describe potential complications of patients who have undergone TOF repair and were lost to follow-up. (Level of Difficulty: Intermediate.)
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Affiliation(s)
- Alexandra M Sanchez
- University of Miami Miller School of Medicine, Holy Cross Hospital, Fort Lauderdale, Florida
| | - Matthew R Lozier
- University of Miami Miller School of Medicine, Holy Cross Hospital, Fort Lauderdale, Florida
| | - Humberto Rovira Alvardo
- University of Miami Miller School of Medicine, Holy Cross Hospital, Fort Lauderdale, Florida
| | - Abdullah Sarkar
- University of Miami Miller School of Medicine, Holy Cross Hospital, Fort Lauderdale, Florida
| | - Jillian M Smith
- Department of Cardiology, Holy Cross Hospital Jim Moran Heart and Vascular Research Institute, Fort Lauderdale, Florida
| | - Samantha Molina
- Department of Cardiology, Holy Cross Hospital Jim Moran Heart and Vascular Research Institute, Fort Lauderdale, Florida
| | - Alexander Llanos
- Department of Cardiology, Holy Cross Hospital Jim Moran Heart and Vascular Research Institute, Fort Lauderdale, Florida
| | - Todd Roth
- Adult Congenital Heart Center, Memorial Healthcare System, Hollywood, Florida
| | - Ami Bhatt
- Adult Congenital Heart Disease Program, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
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16
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Tran CT, Halicek M, Dormer JD, Tandon A, Hussain T, Fei B. Fully automated segmentation of the right ventricle in patients with repaired Tetralogy of Fallot using U-Net. PROCEEDINGS OF SPIE--THE INTERNATIONAL SOCIETY FOR OPTICAL ENGINEERING 2020; 11317. [PMID: 32476706 DOI: 10.1117/12.2549052] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
Cardiac magnetic resonance (CMR) imaging is considered the standard imaging modality for volumetric analysis of the right ventricle (RV), an especially important practice in the evaluation of heart structure and function in patients with repaired Tetralogy of Fallot (rTOF). In clinical practice, however, this requires time-consuming manual delineation of the RV endocardium in multiple 2-dimensional (2D) slices at multiple phases of the cardiac cycle. In this work, we employed a U-Net based 2D convolutional neural network (CNN) classifier in the fully automatic segmentation of the RV blood pool. Our dataset was comprised of 5,729 short-axis cine CMR slices taken from 100 individuals with rTOF. Training of our CNN model was performed on images from 50 individuals while validation was performed on images from 10 individuals. Segmentation results were evaluated by Dice similarity coefficient (DSC) and Hausdorff distance (HD). Use of the CNN model on our testing group of 40 individuals yielded a median DSC of 90% and a median 95th percentile HD of 5.1 mm, demonstrating good performance in these metrics when compared to literature results. Our preliminary results suggest that our deep learning-based method can be effective in automating RV segmentation.
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Affiliation(s)
- Christopher T Tran
- University of Texas at Dallas, Department of Bioengineering, Richardson, TX, USA
| | - Martin Halicek
- University of Texas at Dallas, Department of Bioengineering, Richardson, TX, USA.,Georgia Inst. of Tech. and Emory Univ., Dept. of Biomedical Engineering, Atlanta, GA
| | - James D Dormer
- Georgia Inst. of Tech. and Emory Univ., Dept. of Biomedical Engineering, Atlanta, GA
| | - Animesh Tandon
- Dept. of Radiology, Univ. of Texas Southwestern Medical Center, Dallas, TX.,Department of Pediatrics, Univ. of Texas Southwestern Medical Center, Dallas, TX
| | - Tarique Hussain
- Dept. of Radiology, Univ. of Texas Southwestern Medical Center, Dallas, TX.,Department of Pediatrics, Univ. of Texas Southwestern Medical Center, Dallas, TX
| | - Baowei Fei
- University of Texas at Dallas, Department of Bioengineering, Richardson, TX, USA.,Advanced Imaging Research Center, Univ. of Texas Southwestern Medical Center, Dallas, TX.,Dept. of Radiology, Univ. of Texas Southwestern Medical Center, Dallas, TX
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17
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Abstract
Approximately 50 million adults worldwide have known congenital heart disease (CHD). Among the most common types of CHD defects in adults are atrial septal defects and ventricular septal defects followed by complex congenital heart lesions such as tetralogy of Fallot. Adults with CHDs are more likely to have hypertension, cerebral vascular disease, diabetes and chronic kidney disease than age-matched controls without CHD. Moreover, by the age of 50, adults with CHD are at a greater than 10% risk of experiencing cardiac dysrhythmias and approximately 4% experience sudden death. Consequently, adults with CHD require healthcare that is two- to four-times greater than adults without CHD. This paper discusses the diagnosis and treatment of adults with atrial septal defects, ventricular septal defects and tetralogy of Fallot.
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Affiliation(s)
- Robert J Henning
- School of Public Health, University of South Florida, Tampa, FL 33612, USA
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18
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Cochran CD, Yu S, Gakenheimer-Smith L, Lowery R, Lu JC, Mahani MG, Agarwal PP, Dorfman AL. Identifying Risk Factors for Massive Right Ventricular Dilation in Patients With Repaired Tetralogy of Fallot. Am J Cardiol 2020; 125:970-976. [PMID: 31964501 DOI: 10.1016/j.amjcard.2019.12.016] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/27/2019] [Revised: 12/03/2019] [Accepted: 12/09/2019] [Indexed: 12/28/2022]
Abstract
In repaired tetralogy of Fallot (rTOF), pulmonary insufficiency results in varying degrees of right ventricle (RV) dilation. A subset of patients is diagnosed at initial cardiac magnetic resonance imaging (CMR) with a massively dilated RV, far beyond pulmonary valve replacement (PVR) criteria, which is unlikely to return to normal size after PVR. This study aimed to identify risk factors for massive RV dilation at initial CMR. This nested case-control study included all patients at our institution with rTOF and massive RV dilation (indexed RV end-diastolic volume [RVEDVi] ≥200 ml/m2) on initial CMR. Patients were matched by age at first CMR, gender, and type of repair with rTOF controls with RVEDVi<200 ml/m2. In 39 cases (median RVEDVi 227 ml/m2, interquartile range [IQR] 213 to 250) and 73 controls (median RVEDVi 155 ml/m2, IQR 130 to 169), repair at >6 months of age, longer QRS duration, and non-Caucasian race were significantly associated with massive RV dilation on univariate analysis. In multivariate analysis, repair at >6 months of age (adjusted odds ratio [AOR] 2.90, 95% confidence interval [CI] 1.12 to 7.55, p = 0.03), longer QRS duration (AOR = 1.03, 95% CI 1.01 to 1.05, p = 0.005), and non-Caucasian race (AOR = 7.84, 95% CI 1.76 to 34.8, p = 0.01) remained independently associated with massive RV dilation. Era of repair, history of systemic to pulmonary shunt palliation, genetic anomaly, and additional cardiac lesions did not differ between groups. In conclusion, these risk factors identify a subset of patients who may benefit from earlier CMR evaluation to avoid massive irreversible RV dilation.
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Affiliation(s)
- Clinton D Cochran
- Division of Pediatric Cardiology, Department of Pediatrics, University of Michigan, Ann Arbor, Michigan.
| | - Sunkyung Yu
- Division of Pediatric Cardiology, Department of Pediatrics, University of Michigan, Ann Arbor, Michigan
| | | | - Ray Lowery
- Division of Pediatric Cardiology, Department of Pediatrics, University of Michigan, Ann Arbor, Michigan
| | - Jimmy C Lu
- Division of Pediatric Cardiology, Department of Pediatrics, University of Michigan, Ann Arbor, Michigan
| | - Maryam Ghadimi Mahani
- Section of Cardiothoracic Radiology, Section of Pediatric Radiology, Department of Radiology, University of Michigan, Ann Arbor, Michigan
| | - Prachi P Agarwal
- Section of Cardiothoracic Radiology, Department of Radiology, University of Michigan, Ann Arbor, Michigan
| | - Adam L Dorfman
- Division of Pediatric Cardiology, Department of Pediatrics, University of Michigan, Ann Arbor, Michigan
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19
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Zegelbone PM, Ringel RE, Coulson JD, Nies MK, Stabler ME, Brown JR, Everett AD. Heart failure biomarker levels correlate with invasive haemodynamics in pulmonary valve replacement. Cardiol Young 2020; 30:50-54. [PMID: 31771681 DOI: 10.1017/s1047951119002737] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
BACKGROUND Although widely used in cardiology, relation of heart failure biomarkers to cardiac haemodynamics in patients with CHD (and in particular with pulmonary insufficiency undergoing pulmonary valve replacement) remains unclear. We hypothesised that the cardiac function biomarkers N-terminal pro-brain natriuretic peptide (NT-proBNP), soluble suppressor of tumorigenicity 2, and galectin-3 would have significant associations to right ventricular haemodynamic derangements. METHODS Consecutive patients ( n = 16) undergoing cardiac catheterisation for transcatheter pulmonary valve replacement were studied. NT-proBNP, soluble suppressor of tumorigenicity 2, and galectin-3 levels were measured using a multiplex enzyme-linked immunosorbent assay from a pre-intervention blood sample obtained after sheath placement. Spearman correlation was used to identify significant correlations (p ≤ 0.05) of biomarkers with baseline cardiac haemodynamics. Cardiac MRI data (indexed right ventricular and left ventricular end-diastolic volumes and ejection fraction) prior to device placement were also compared to biomarker levels. RESULTS NT-proBNP and soluble suppressor of tumorigenicity 2 were significantly correlated (p < 0.01) with baseline mean right atrial pressure and right ventricular end-diastolic pressure. Only NT-proBNP was significantly correlated with age. Galectin-3 did not have significant associations in this cohort. Cardiac MRI measures of right ventricular function and volume were not correlated to biomarker levels or right heart haemodynamics. CONCLUSIONS NT-proBNP and soluble suppressor of tumorigenicity 2, biomarkers of myocardial strain, significantly correlated to invasive pressure haemodynamics in transcatheter pulmonary valve replacement patients. Serial determination of soluble suppressor of tumorigenicity 2, as it was not associated with age, may be superior to serial measurement of NT-proBNP as an indicator for timing of pulmonary valve replacement.
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Affiliation(s)
| | - Richard E Ringel
- Division of Pediatric Cardiology, Johns Hopkins Children's Center, Baltimore, MD, USA
| | - John D Coulson
- Division of Pediatric Cardiology, Johns Hopkins Children's Center, Baltimore, MD, USA
| | - Melanie K Nies
- Division of Pediatric Cardiology, Johns Hopkins Children's Center, Baltimore, MD, USA
| | - Meagan E Stabler
- Department of Epidemiology, Geisel School of Medicine, Lebanon, NH, USA
| | - Jeremiah R Brown
- Department for Biomedical Data Science, Geisel School of Medicine, Lebanon, NH, USA
| | - Allen D Everett
- Division of Pediatric Cardiology, Johns Hopkins Children's Center, Baltimore, MD, USA
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20
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Mkalaluh S, Mashhour A, Szczechowicz M, Zhigalov K, Ennker J, Easo J, Weymann A. Surgical Pulmonary Valve Replacement Due to Failed Percutaneous Pulmonary Valve Intervention in a Patient After Correction of Fallot's Tetralogy: Surgery Remains the Standard. AMERICAN JOURNAL OF CASE REPORTS 2019; 20:478-481. [PMID: 30956275 PMCID: PMC6474213 DOI: 10.12659/ajcr.914639] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
Patient: Male, 26 Final Diagnosis: Pulmonary valve replacement Symptoms: No symptom Medication: — Clinical Procedure: — Specialty: Surgery
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Affiliation(s)
- Sabreen Mkalaluh
- Department of Cardiac Surgery, European Medical School Oldenburg-Groningen, Carl von Ossietzky University Oldenburg, Oldenburg, Germany
| | - Ahmed Mashhour
- Department of Cardiac Surgery, European Medical School Oldenburg-Groningen, Carl von Ossietzky University Oldenburg, Oldenburg, Germany
| | - Marcin Szczechowicz
- Department of Cardiac Surgery, European Medical School Oldenburg-Groningen, Carl von Ossietzky University Oldenburg, Oldenburg, Germany
| | - Konstantin Zhigalov
- Department of Cardiac Surgery, European Medical School Oldenburg-Groningen, Carl von Ossietzky University Oldenburg, Oldenburg, Germany
| | - Jürgen Ennker
- Department of Cardiac Surgery, European Medical School Oldenburg-Groningen, Carl von Ossietzky University Oldenburg, Oldenburg, Germany
| | - Jerry Easo
- Department of Cardiac Surgery, European Medical School Oldenburg-Groningen, Carl von Ossietzky University Oldenburg, Oldenburg, Germany
| | - Alexander Weymann
- Department of Cardiac Surgery, European Medical School Oldenburg-Groningen, Carl von Ossietzky University Oldenburg, Oldenburg, Germany
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21
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Bedair R, Iriart X. EDUCATIONAL SERIES IN CONGENITAL HEART DISEASE: Tetralogy of Fallot: diagnosis to long-term follow-up. Echo Res Pract 2019; 6:R9-R23. [PMID: 30557849 PMCID: PMC6301192 DOI: 10.1530/erp-18-0049] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2018] [Accepted: 11/07/2018] [Indexed: 11/17/2022] Open
Abstract
Tetralogy of Fallot (TOF) is the most common cyanotic congenital heart defect, affecting 3 in 10,000 live births. Surgical correction in early childhood is associated with good outcomes, but lifelong follow-up is necessary to identify the long-term sequelae that may occur. This article will cover the diagnosis of TOF in childhood, the objectives of surveillance through adulthood and the value of multi-modality imaging in identifying and guiding timely surgical and percutaneous interventions.
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Affiliation(s)
- R Bedair
- Department of Adult Congenital Cardiology, Bristol Heart Institute - University Hospitals Bristol NHS Foundation Trust, Bristol, UK
| | - X Iriart
- Department of Pediatric and Adult Congenital Cardiology, Hôpital Cardiologique du Haut-Lévêque, CHU de Bordeaux, Pessac, France
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22
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23
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Singh NM, Loomba RS, Gudausky TM, Mitchell ME. Monocusp valve placement in children with tetralogy of Fallot undergoing repair with transannular patch: A functioning pulmonary valve does not improve immediate postsurgical outcomes. CONGENIT HEART DIS 2018; 13:935-943. [PMID: 30260077 DOI: 10.1111/chd.12670] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/13/2018] [Revised: 08/05/2018] [Accepted: 08/07/2018] [Indexed: 11/28/2022]
Abstract
INTRODUCTION In patients with tetralogy of Fallot (TOF), use of transannular patch (TAP) may be required in order to relieve significant right ventricular outflow tract obstruction, subsequently resulting in pulmonary insufficiency (PI). The monocusp valve has been used to temporarily reduce insufficiency in hopes to improve short and midterm outcomes. The purpose of this study was to assess for potential benefits of the monocusp valve in this subset of patients. DESIGN Between 2005 and 2016, 119 patients with TOF with pulmonary stenosis who underwent repair with TAP were analyzed, 43 (36.1%) had a monocusp valve placed. Immediate outcomes were assessed by postoperative echocardiograms, ICU data including time to extubation, chest tube duration, reintervention, length of stay, and mortality. RESULTS Median age of repair was similar for monocusp group at 143.5 days and nonmonocusp at 137.0 days (P = .93). Peak preoperative right ventricular outflow tract obstruction was higher in the monocusp group (80 mm Hg vs. 70 mm Hg, P ≤ .01). Patients who had monocusp placed had longer bypass time. There was less PI for monocusp group immediately after repair and at discharge (P ≤ .01). There was no difference in days of intubation, chest tube duration, length of hospitalization, reintervention rates, or mortality. CONCLUSION Decreasing the degree of PI with a monocusp valve in patients undergoing repair for TOF repair with TAP does not improve clinical outcomes in the immediate postoperative period.
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Affiliation(s)
- Nikki M Singh
- Division of Pediatric Cardiology, Medical College of Wisconsin, Herma Heart Institute at Children's Hospital of Wisconsin, Milwaukee, Wisconsin
| | - Rohit S Loomba
- Advocate Children's Heart Institute, Advocate Children's Hospital, Oak Lawn, Illinois
| | - Todd M Gudausky
- Division of Pediatric Cardiology, Medical College of Wisconsin, Herma Heart Institute at Children's Hospital of Wisconsin, Milwaukee, Wisconsin
| | - Michael E Mitchell
- Division of Pediatric Cardiothoracic Surgery, Medical College of Wisconsin, Herma Heart Institute at Children's Hospital of Wisconsin, Milwaukee, Wisconsin
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24
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Warnes CA. Adult congenital heart disease: the challenges of a lifetime. Eur Heart J 2018; 38:2041-2047. [PMID: 28011704 DOI: 10.1093/eurheartj/ehw529] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/16/2016] [Accepted: 10/18/2016] [Indexed: 11/13/2022] Open
Abstract
The growing population of adults with congenital heart disease (CHD) poses challenges for cardiac surgeons, general cardiologists and CHD sub specialists. The patients themselves, often believing themselves to be 'totally corrected' following operative repair, also face challenges with re-operations and lifelong cardiac problems. This review examines the challenges of the past, present and future for both medical providers and patients.
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Affiliation(s)
- Carole A Warnes
- Department of Cardiovascular Diseases, Mayo Clinic, 200 First Street SW, Rochester, MN 55905, USA
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25
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Gulsin GS, Singh A, McCann GP. Cardiovascular magnetic resonance in the evaluation of heart valve disease. BMC Med Imaging 2017; 17:67. [PMID: 29284450 PMCID: PMC5747097 DOI: 10.1186/s12880-017-0238-0] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2017] [Accepted: 12/13/2017] [Indexed: 01/18/2023] Open
Abstract
BACKGROUND Over the last 25 years, cardiovascular magnetic resonance imaging (CMR) has emerged as an alternative to echocardiography for assessment of valvular heart disease (VHD). Although echo remains the first-line imaging modality for the assessment of patients with VHD, CMR can now provide a comprehensive assessment in many instances. Using a combination of techniques, CMR provides information on valve anatomy and enables quantitative analysis of the severity of the valve lesion. MAIN TEXT In this review, the fundamentals of CMR in assessment of VHD are described, together with its strengths and weaknesses. We detail the utility of CMR for studying all aspects of VHD, including valve anatomy, flow quantification as well as ventricular volumes and function. The optimisation of CMR for evaluating the commonest valve lesions (aortic stenosis, aortic regurgitation, mitral regurgitation, mitral stenosis) as well as in right-sided VHD and prosthetic valves is summarised. The focus of this review is to enable the reader to optimise the use of CMR in his or her own evaluation of heart valve lesions in clinical practice. CONCLUSIONS CMR can be used for the comprehensive evaluation of VHD. This exciting, non-invasive imaging modality is likely to have increasing utility in the clinical evaluation of patients with VHD.
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Affiliation(s)
- G. S. Gulsin
- Department of Cardiovascular Sciences, University of Leicester and the NIHR Biomedical Research Centre, Glenfield Hospital, Groby Road, Leicester, UK
| | - A. Singh
- Department of Cardiovascular Sciences, University of Leicester and the NIHR Biomedical Research Centre, Glenfield Hospital, Groby Road, Leicester, UK
| | - G. P. McCann
- Department of Cardiovascular Sciences, University of Leicester and the NIHR Biomedical Research Centre, Glenfield Hospital, Groby Road, Leicester, UK
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26
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Abstract
PURPOSE OF REVIEW Our review is intended to provide readers with an overview of disease processes involving the pulmonic valve, highlighting recent outcome studies and guideline-based recommendations; with focus on the two most common interventions for treating pulmonic valve disease, balloon pulmonary valvuloplasty and pulmonic valve replacement. RECENT FINDINGS The main long-term sequelae of balloon pulmonary valvuloplasty, the gold standard treatment for pulmonic stenosis, remain pulmonic regurgitation and valvular restenosis. The balloon:annulus ratio is a major contributor to both, with high ratios resulting in greater degrees of regurgitation, and small ratios increasing risk for restenosis. Recent studies suggest that a ratio of approximately 1.2 may provide the most optimal results. Pulmonic valve replacement is currently the procedure of choice for patients with severe pulmonic regurgitation and hemodynamic sequelae or symptoms, yet it remains uncertain how it impacts long-term survival. Transcatheter pulmonic valve replacement is a rapidly evolving field and recent outcome studies suggest short and mid-term results at least equivalent to surgery. The Melody valve® was FDA approved for failing pulmonary surgical conduits in 2010 and for failing bioprosthetic surgical pulmonic valves in 2017 and has been extensively studied, whereas the Sapien XT valve®, offering larger diameters, was approved for failing pulmonary conduits in 2016 and has been less extensively studied. Patients with pulmonic valve disease deserve lifelong surveillance for complications. Transcatheter pulmonic valve replacement is a novel and attractive therapeutic option, but is currently only FDA approved for patients with failing pulmonary conduits or dysfunctional surgical bioprosthetic valves. New advances will undoubtedly increase the utilization of this rapidly expanding technology.
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Effect of balloon annulus ratio on the outcome post balloon pulmonary valvuloplasty in children. PROGRESS IN PEDIATRIC CARDIOLOGY 2017. [DOI: 10.1016/j.ppedcard.2017.05.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
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Earlier Pulmonary Valve Replacement in Down Syndrome Patients Following Tetralogy of Fallot Repair. Pediatr Cardiol 2017; 38:1251-1256. [PMID: 28616649 DOI: 10.1007/s00246-017-1653-2] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/14/2017] [Accepted: 06/08/2017] [Indexed: 10/19/2022]
Abstract
The association between Down syndrome and pulmonary hypertension could contribute to more severe pulmonary regurgitation after tetralogy of Fallot repair and possibly earlier pulmonary valve replacement. We compared cardiac magnetic resonance measures of pulmonary regurgitation and right ventricular dilation as well as timing of pulmonary valve replacement between those with and without Down syndrome after tetralogy of Fallot repair. Review of our surgical database from 2000 to 2015 identified patients with tetralogy of Fallot with pulmonary stenosis. Those with Down syndrome were compared to those without. The primary outcome of interest was time from repair to pulmonary valve replacement. Secondary outcomes included pulmonary regurgitation and indexed right ventricular volume on cardiac magnetic resonance imaging. The cohort of 284 patients included 35 (12%) with Down syndrome. Transannular patch repair was performed in 210 (74%). Down syndrome showed greater degree of pulmonary regurgitation (55 ± 14 vs. 37 ± 16%, p = 0.01) without a significantly greater rate of right ventricular dilation (p = 0.09). In multivariable analysis, Down syndrome (HR 2.3, 95% CI 1.2-4.5, p = 0.02) and transannular patch repair (HR 5.5, 95% CI 1.7-17.6, p = 0.004) were significant risk factors for valve replacement. Those with Down syndrome had significantly lower freedom from valve replacement (p = 0.03). Down syndrome is associated with an increased degree of pulmonary regurgitation and earlier pulmonary valve replacement after tetralogy of Fallot repair. These patients require earlier assessment by cardiac magnetic resonance imaging to determine timing of pulmonary valve replacement and evaluation for and treatment of preventable causes of pulmonary hypertension.
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Wijesekera VA, Raju R, Precious B, Berger AJ, Kiess MC, Leipsic JA, Grewal J. Sequential Right and Left Ventricular Assessment in Posttetralogy of Fallot Patients with Significant Pulmonary Regurgitation. CONGENIT HEART DIS 2016; 11:606-614. [DOI: 10.1111/chd.12354] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
Affiliation(s)
- Vishva A. Wijesekera
- Pacific Adult Congenital Heart Service, Division of Cardiology, St. Paul's Hospital; University of British Columbia; Vancouver Canada
| | - Rekha Raju
- Department of Cardiac Imaging; St. Paul's Hospital, University of British Columbia; Vancouver Canada
| | - Bruce Precious
- Department of Cardiac Imaging; St. Paul's Hospital, University of British Columbia; Vancouver Canada
| | - Adam J. Berger
- Department of Cardiac Imaging; St. Paul's Hospital, University of British Columbia; Vancouver Canada
| | - Marla C. Kiess
- Pacific Adult Congenital Heart Service, Division of Cardiology, St. Paul's Hospital; University of British Columbia; Vancouver Canada
| | - Jonathon A. Leipsic
- Department of Cardiac Imaging; St. Paul's Hospital, University of British Columbia; Vancouver Canada
| | - Jasmine Grewal
- Pacific Adult Congenital Heart Service, Division of Cardiology, St. Paul's Hospital; University of British Columbia; Vancouver Canada
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Pathak SJ, Pockett CR, Moore JW, El-Said HG. Effect of Balloon:Annulus Ratio on Incidence of Pulmonary Insufficiency Following Valvuloplasty. CONGENIT HEART DIS 2016; 11:415-419. [DOI: 10.1111/chd.12327] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 11/22/2015] [Indexed: 11/29/2022]
Affiliation(s)
- Sagar J. Pathak
- Department of Pediatric Cardiology; University of California, San Diego & Rady Children's Hospital-San Diego; San Diego, Cal. USA
| | - Charissa R. Pockett
- Department of Pediatric Cardiology; University of California, San Diego & Rady Children's Hospital-San Diego; San Diego, Cal. USA
| | - John W. Moore
- Department of Pediatric Cardiology; University of California, San Diego & Rady Children's Hospital-San Diego; San Diego, Cal. USA
| | - Howaida G. El-Said
- Department of Pediatric Cardiology; University of California, San Diego & Rady Children's Hospital-San Diego; San Diego, Cal. USA
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Riveros R, Riveros-Perez E. Perioperative Considerations for Children With Right Ventricular Dysfunction and Failing Fontan. Semin Cardiothorac Vasc Anesth 2015; 19:187-202. [PMID: 26287019 DOI: 10.1177/1089253215593178] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
The survival of patients with congenital heart diseases (CHD) has increased in the past decades, resulting in the identification of new characteristics of chronic comorbidities observed in pediatric and adults with CHD. Patients with CHD can present with a broad clinical spectrum of manifestations of congestive heart failure (CHF) at any point throughout their lives that may be related to anatomical or surgical variables. This article focuses on the perioperative assessment of patients with CHD and CHF, with an emphasis on pathophysiologic, diagnostic, and therapeutic alternatives in patients with right ventricular failure and failing Fontan circulation. We also provide descriptions of the effects of sedatives and anesthetics commonly used in this population in diagnostic or invasive procedures.
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Ho JG, Schamberger MS, Hurwitz RA, Johnson TR, Sterrett LE, Ebenroth ES. The Effects of Pulmonary Valve Replacement for Severe Pulmonary Regurgitation on Exercise Capacity and Cardiac Function. Pediatr Cardiol 2015; 36:1194-203. [PMID: 25753686 DOI: 10.1007/s00246-015-1143-3] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/03/2014] [Accepted: 03/04/2015] [Indexed: 11/25/2022]
Abstract
Patients may develop hemodynamic abnormalities after right ventricular outflow tract (RVOT) repair. Re-intervention timing remains a dilemma. This study evaluates exercise capacity and RV function before and after intervention using age-related comparisons. Twenty-six patients with severe pulmonary regurgitation (PR) after initial repair scheduled for pulmonary valve replacement (PVR) were enrolled. Metabolic treadmill testing (EST) and MRI were obtained before and after surgery. EST results were compared with matched controls. Preoperative exercise time and peak oxygen consumption (VO2 max) were significantly diminished compared with controls but were not significantly different postoperatively. The patients were then split into age-related cohorts. When comparing pre-PVR and post-PVR exercise time and VO2 max among themselves, neither cohort showed significant differences. However, patients younger than 25 years had better postoperative results, an age-related difference not seen in the controls. Preoperative MRI showed significantly dilated RV, PR, and low normal function. After PVR, the right to left ventricular end-diastolic volume ratio (RVEDV:LVEDV) and pulmonary artery regurgitant fraction (RF) significantly decreased. There was no change in ventricular ejection fractions (EF). Severe PR, decreased RVEF, and RV dilation can significantly diminish exercise capacity. PVR improves RVEDV:LVEDV and RF, but not EF. Younger patients had better exercise capacity that was maintained postoperatively. This age-related difference was not seen in the controls, indicating that earlier intervention may preserve exercise capacity. Serial ESTs in patients with severe PR following RVOT repair may identify deteriorating exercise capacity as an early indicator for the need for PVR.
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Affiliation(s)
- Jason G Ho
- Section of Cardiology, Department of Pediatrics, Riley Hospital for Children at Indiana University Health, Indiana University School of Medicine, 699 Riley Hospital Drive, RR 127, Indianapolis, IN, 46202, USA,
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Abstract
Pulmonary valve replacement in patients with congenital cardiac disease is now being performed with more liberal indications in light of the data that chronic pulmonary insufficiency is not a benign lesion. The beneficial effects of valve replacement with low operative mortality and morbidity support this approach. Many options exist for a pulmonary valve prosthesis, which underscores the fact that there is no ideal valve available. Our efforts are focussed around a synthetic valve that avoids the bio-degeneration of a bio-prosthesis and avoids the need for life-long coumadin. We developed a bicuspid (bileaflet) polytetrafluoroethylene valve design, which has now gone through three major revisions in >200 patients over 14 years. We began the experience utilising a polytetrafluoroethylene hand-sewn bicuspid valve in the right ventricular outflow tract, initially using 0.6 mm and more recently 0.1 mm polytetrafluoroethylene. The 0.1 mm thickness material functions well as a leaflet, maintaining a relatively thin and flexible nature. It does not calcify or initiate thromboses at least for the first several years. We identified issues with dehiscence of the leaflet from the right ventricular outflow tract muscle, especially in the larger, potentially expansive right ventricular outflow tracts, and this prompted our latest design change to place the valve within a polytetrafluoroethylene tube. This current version of the polytetrafluoroethylene valve conduit has excellent short-to-intermediate-term function. Further follow-up is necessary to determine late durability and life-long valve-related procedural risk for our patients.
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Abstract
Despite tremendous advances in surgical treatment of tetralogy of Fallot, augmenting the small right ventricular outflow tract remains a challenge. Transannular patch augmentation revolutionised surgical management, but did so at the expense of rendering patients with pulmonary insufficiency and the resulting problems associated therewith. Recent surgical efforts have focused on pulmonary valve preservation at initial correction and pulmonary valve restoration after transannular patching, with favourable results. In this manuscript, we review methods of pulmonary valve preservation and restoration.
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Yamasaki Y, Nagao M, Yamamura K, Yonezawa M, Matsuo Y, Kawanami S, Kamitani T, Higuchi K, Sakamoto I, Shiokawa Y, Yabuuchi H, Honda H. Quantitative assessment of right ventricular function and pulmonary regurgitation in surgically repaired tetralogy of Fallot using 256-slice CT: comparison with 3-Tesla MRI. Eur Radiol 2014; 24:3289-99. [DOI: 10.1007/s00330-014-3344-1] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2014] [Revised: 06/24/2014] [Accepted: 07/11/2014] [Indexed: 10/24/2022]
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Zdradzinski MJ, Qureshi AM, Stewart R, Pettersson G, Krasuski RA. Comparison of long-term postoperative sequelae in patients with tetralogy of Fallot versus isolated pulmonic stenosis. Am J Cardiol 2014; 114:300-4. [PMID: 24878128 DOI: 10.1016/j.amjcard.2014.04.041] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/14/2014] [Revised: 04/24/2014] [Accepted: 04/24/2014] [Indexed: 01/18/2023]
Abstract
Patients with tetralogy of Fallot (TOF) after complete repair and pulmonic stenosis (PS) after surgical valvotomy often develop significant pulmonic regurgitation (PR) that eventually requires valve replacement. Although criteria exist for the timing of pulmonary valve replacement in TOF, it remains less clear when to intervene in valvotomy patients and whether TOF recommendations can be applied. Our aim was to compare the structural and functional sequelae of valvotomy for PS with complete repair for TOF. We compared the clinical characteristics, electrocardiograms, echocardiograms, cardiac magnetic resonance imaging (MRI), and invasive hemodynamics of 109 adults (34 PS and 75 TOF) newly referred to a congenital heart disease center for evaluation of PR between 2005 and 2012. Both cohorts were similar in terms of baseline demographics and presenting New York Heart Association function class. Valvotomy patients had a slightly greater degree of PR by echocardiogram, although it was similar by cardiac MRI. Electrocardiography QRS width was greater in patients with TOF (114±27 vs 150±28 ms, p<0.001). MRI right ventricular ejection fraction (49±8 vs 41±11%, p=0.001) and left ventricular ejection fraction (59±7 vs 52±10%, p=0.002) were lower in patients with TOF. Pacemaker or defibrillator implantation was significantly greater in patients with TOF (3% vs 23%, p=0.011). In conclusion, patients postvalvotomy and complete repair present with similar degrees of PR and severity of symptoms. Biventricular systolic function and electrocardiography QRS width appear less affected, suggesting morphologic changes in TOF and its repair that extend beyond the effects of PR. These findings suggest the need for developing disease-specific guidelines for patients with PR postvalvotomy.
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Abstract
Tetralogy of Fallot is the most common form of cyanotic congenital cardiac disease. Patients with previously repaired tetralogy of Fallot are the most common patients seen in the Program for Adults with Congenital Heart Disease at The Johns Hopkins All Children's Heart Institute. Guidelines for the management of these patients are available from multiple sources including The American College of Cardiology (ACC) and The American Heart Association (AHA), The Canadian Cardiovascular Society, and The European Society of Cardiology (ESC). These guidelines describe multiple components related to the care for these patients including strategies for medical follow-up, the management of arrhythmias and electrophysiological diseases, and the treatment of chronic pulmonary insufficiency and stenosis. Several new strategies are available for replacement of the pulmonary valve including transcatheter replacement of the pulmonary valve and replacement of the pulmonary valve with a self-manufactured bicuspid polytetrafluoroethylene pulmonary valve.
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Han BK, Lesser JR. CT imaging in congenital heart disease: An approach to imaging and interpreting complex lesions after surgical intervention for tetralogy of Fallot, transposition of the great arteries, and single ventricle heart disease. J Cardiovasc Comput Tomogr 2013; 7:338-53. [DOI: 10.1016/j.jcct.2013.10.003] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/16/2013] [Revised: 10/16/2013] [Accepted: 10/30/2013] [Indexed: 01/25/2023]
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Mavroudis C, Mavroudis CD, Frost J. Native Pulmonary Valve Restoration After Remote Tetralogy of Fallot Repair. World J Pediatr Congenit Heart Surg 2013; 4:422-6. [DOI: 10.1177/2150135113505296] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Methods to repair tetralogy of Fallot have evolved from large ventriculotomy, large transannular patch placement techniques to smaller, transatrial approaches with valve-sparing strategies in select patients. Despite these advances, there continue to be patients in whom transannular patch is inevitable, and the management of the resulting pulmonary insufficiency that develops from this has been the source of considerable discussion. Techniques aimed at restoring pulmonary valve competence utilizing the remaining valve leaflets after transannular patch placement have recently been proposed for very select patient populations. We review the technical aspects of the operation including removal of the transannular patch and bicuspidization of a formerly tricuspid pulmonary valve, which results in a competent, nonstenotic valve. This report confirms the feasibility of these operative details and highlights the importance of planning before initial repair of tetralogy of Fallot as a way to prepare for a future valve restoration procedure and therefore avoid prosthetic valve placement.
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Affiliation(s)
- Constantine Mavroudis
- Johns Hopkins Children’s Heart Surgery, Florida Hospital for Children, Orlando, FL, USA
| | | | - Jennifer Frost
- Johns Hopkins Children’s Heart Surgery, Florida Hospital for Children, Orlando, FL, USA
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Hart SA, Devendra GP, Kim YY, Flamm SD, Kalahasti V, Arruda J, Walker E, Boonyasirinant T, Bolen M, Setser R, Krasuski RA. PINOT NOIR: pulmonic insufficiency improvement with nitric oxide inhalational response. J Cardiovasc Magn Reson 2013; 15:75. [PMID: 24006858 PMCID: PMC3844630 DOI: 10.1186/1532-429x-15-75] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2013] [Accepted: 08/22/2013] [Indexed: 12/02/2022] Open
Abstract
BACKGROUND Tetralogy of Fallot (TOF) repair and pulmonary valvotomy for pulmonary stenosis (PS) lead to progressive pulmonary insufficiency (PI), right ventricular enlargement and dysfunction. This study assessed whether pulmonary regurgitant fraction measured by cardiovascular magnetic resonance (CMR) could be reduced with inhaled nitric oxide (iNO). METHODS Patients with at least moderate PI by echocardiography undergoing clinically indicated CMR were prospectively enrolled. Patients with residual hemodynamic lesions were excluded. Ventricular volume and blood flow sequences were obtained at baseline and during administration of 40 ppm iNO. RESULTS Sixteen patients (11 with repaired TOF and 5 with repaired PS) completed the protocol with adequate data for analysis. The median age [range] was 35 [19-46] years, BMI was 26 ± 5 kg/m(2) (mean ± SD), 50% were women and 75% were in NYHA class I. Right ventricular end diastolic volume index for the cohort was 157 ± 33 mL/m(2), end systolic volume index was 93 ± 20 mL/m(2) and right ventricular ejection fraction was 40 ± 6%. Baseline pulmonary regurgitant volume was 45 ± 25 mL/beat and regurgitant fraction was 35 ± 16%. During administration of iNO, regurgitant volume was reduced by an average of 6 ± 9% (p=0.01) and regurgitant fraction was reduced by an average of 5 ± 8% (p=0.02). No significant changes were observed in ventricular indices for either the left or right ventricle. CONCLUSION iNO was successfully administered during CMR acquisition and appears to reduce regurgitant fraction in patients with at least moderate PI suggesting a potential role for selective pulmonary vasodilator therapy in these patients. TRIALS REGISTRATION ClinicalTrials.gov, NCT00543933.
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Affiliation(s)
- Stephen A Hart
- Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland, USA
| | - Ganesh P Devendra
- Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland, USA
| | - Yuli Y Kim
- Hospital of the University of Pennsylvania and Children’s Hospital of Philadelphia, Philadelphia, USA
| | - Scott D Flamm
- Cleveland Clinic Imaging Institute, Cardiovascular Imaging, Cleveland, USA
- Cleveland Clinic Pediatric Institute, Pediatric Cardiology, Cleveland, USA
- Cleveland Clinic Heart and Vascular Institute, Cardiovascular Medicine, Cleveland, USA
| | | | - Janine Arruda
- Cleveland Clinic Pediatric Institute, Pediatric Cardiology, Cleveland, USA
| | - Esteban Walker
- Cleveland Clinic Quantitative Health Sciences, Cleveland, USA
| | | | - Michael Bolen
- Cleveland Clinic Imaging Institute, Cardiovascular Imaging, Cleveland, USA
- Cleveland Clinic Heart and Vascular Institute, Cardiovascular Medicine, Cleveland, USA
| | - Randolph Setser
- Cleveland Clinic Imaging Institute, Cardiovascular Imaging, Cleveland, USA
| | - Richard A Krasuski
- Cleveland Clinic Heart and Vascular Institute, Cardiovascular Medicine, Cleveland, USA
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Pandya B, Quail MA, Cullen S. Clinical Issues and Outcomes in Adults Following Repair of Tetralogy of Fallot. CURRENT TREATMENT OPTIONS IN CARDIOVASCULAR MEDICINE 2013; 15:602-14. [DOI: 10.1007/s11936-013-0264-3] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Nour S, Dai G, Wang Q, Wang F, Chachques JC, Wu G. Forgotten driving forces in right heart failure (Part II): experimental study. Asian Cardiovasc Thorac Ann 2013; 20:646-57. [PMID: 23284105 DOI: 10.1177/0218492312440567] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Cardiac-assist devices for right ventricular failure remain controversial with poor results. This study evaluated a pulsatile cardiac-assist device in an acute right ventricular failure model vs. current therapies. MATERIALS AND METHODS Pulmonary regurgitation was created in 12 piglets by valve avulsion and external transfixation of 2 pulmonary artery cusps suspended to the pulmonary arterial wall. The piglets were divided into 2 treatment groups: a pulsatile group P and a non-pulsatile group NP. Management started when severe right ventricular failure was observed (48.1 ± 24.5 min). In group P, pulsatile trousers driven by a pneumatic generator were pulsated intermittently at 40 beats min(-1). Group NP was treated with oral tadalafil 1 mg kg(-1), intravenous fluids, and adrenaline 0.3 μg kg(-1). After 1 h of therapy, cardiac output was significantly better in group P than group NP (1 ± 0.2 vs. 0.7 ± 0.2 L min(-1)). Mean right ventricular pressure (16 ± 6 vs. 24 ± 2 mm Hg) and pulmonary arterial pressure (22 ± 1 vs. 31 ± 2 mm Hg) were lower in group P. Vascular resistances indices were lower in group P than group NP: pulmonary resistance index was 174 ± 60 vs. 352 ± 118 dyne sec cm(-5)kg(-1); systemic resistance index was 611 ± 70 vs. 1215 ± 315 dyne sec cm(-5)kg(-1). Western-blot analysis showed higher endogenous NO synthase expression in group P pulmonary arteries. CONCLUSIONS The pulsatile suit can be used safely as a noninvasive cardiac-assist device in acute right ventricular failure. This represents a cost-effective nearly physiological method, suitable for adults and children.
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Affiliation(s)
- Sayed Nour
- Laboratory of Biosurgical Research, Pompidou Hospital, University Paris Descartes, Paris, France.
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Han BK, Lesser JR. Cardiac CT in the Diagnosis and Postoperative Assessment of Congenital Heart Disease. CURRENT CARDIOVASCULAR IMAGING REPORTS 2013. [DOI: 10.1007/s12410-013-9195-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
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Reddy S, Zhao M, Hu DQ, Fajardo G, Katznelson E, Punn R, Spin JM, Chan FP, Bernstein D. Physiologic and molecular characterization of a murine model of right ventricular volume overload. Am J Physiol Heart Circ Physiol 2013; 304:H1314-27. [PMID: 23504182 DOI: 10.1152/ajpheart.00776.2012] [Citation(s) in RCA: 60] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
Pulmonary insufficiency (PI) is a common long-term sequel after repair of tetralogy of Fallot, causing progressive right ventricular (RV) dilation and failure. We describe the physiologic and molecular characteristics of the first murine model of RV volume overload. PI was created by entrapping the pulmonary valve leaflets with sutures. Imaging, catheterization, and exercise testing were performed at 1, 3, and 6 mo and compared with sham controls. RNA from the RV free wall was hybridized to Agilent whole genome oligonucleotide microarrays. Volume overload resulted in RV enlargement, decreased RV outflow tract shortening fraction at 1 mo followed by normalization at 3 and 6 mo (39 ± 2, 44 ± 2, and 41 ± 2 vs. 46 ± 3% in sham), early reversal of early and late diastolic filling velocities (E/A ratio) followed by pseudonormalization (0.87 ± 0.08, 0.82 ± 0.08, and 0.96 ± 0.08 vs. 1.04 ± 0.03; P < 0.05), elevated end-diastolic pressure (7.6 ± 0.7, 6.9 ± 0.8, and 7 ± 0.5 vs. 2.7 ± 0.2 mmHg; P < 0.05), and decreased exercise duration (26 ± 0.4, 26 ± 1, and 22 ± 1.3 vs. 30 ± 1.1 min; P < 0.05). Subendocardial RV fibrosis was evident by 1 mo. At 1 mo, 372 genes were significantly downregulated. Mitochondrial pathways and G protein-coupled receptor signaling were the most represented categories. At 3 mo, 434 genes were upregulated and 307 downregulated. While many of the same pathways continued to be downregulated, TNF-α, transforming growth factor-β(1) (TGF-β(1)), p53-signaling, and extracellular matrix (ECM) remodeling transitioned from down- to upregulated. We describe a novel murine model of chronic RV volume overload recapitulating aspects of the clinical disease with gene expression changes suggesting early mitochondrial bioenergetic dysfunction, enhanced TGF-β signaling, ECM remodeling, and apoptosis.
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Affiliation(s)
- Sushma Reddy
- Department of Pediatrics, Stanford University School of Medicine, Stanford, CA 94305, USA.
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Senthilnathan S, Dragulescu A, Mertens L. Pulmonary Regurgitation after Tetralogy of Fallot Repair: A Diagnostic and Therapeutic Challenge. J Cardiovasc Echogr 2013; 23:1-9. [PMID: 28465877 PMCID: PMC5353440 DOI: 10.4103/2211-4122.117975] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Pulmonary regurgitation is the key hemodynamically significant lesion in repaired tetralogy of Fallot contributing to progressive right ventricular (RV) dilatation and biventricular dysfunction. The timing for pulmonary valve replacement remains a controversial topic, and the decision to intervene depends on assessment of RV size and RV function. OBJECTIVES This review aims to discuss the echocardiographic techniques that can be used to assess patients with pulmonary regurgitation after the repair of tetralogy of Fallot defect. While cardiac magnetic resonance (CMR) imaging is the clinical reference method, there is an important role of echocardiography in identifying patients with significant pulmonary regurgitation and assessing the RV size and function. The different echocardiographic techniques that can be used in this context are discussed. Newer techniques for assessing RV size and function include three-dimensional (3D) echocardiography, tissue Doppler and strain imaging. 3D RV volumetric reconstruction based on two-dimensional imaging is a promising new technique that could potentially replace CMR for RV volumetric assessment. CONCLUSIONS Developments in echocardiographic techniques provide new insights into the impact of pulmonary regurgitation on RV structure and function. Echocardiography and CMR are complementary modalities and further research is required to define the optimal use of both techniques for this indication.
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Affiliation(s)
- Selvi Senthilnathan
- The Labatt Family Heart Center, the Hospital for Sick Children, University of Toronto. Toronto, ON, Canada
| | - Andreea Dragulescu
- The Labatt Family Heart Center, the Hospital for Sick Children, University of Toronto. Toronto, ON, Canada
| | - Luc Mertens
- The Labatt Family Heart Center, the Hospital for Sick Children, University of Toronto. Toronto, ON, Canada
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Menon SC, Kaza AK, Puchalski MD. Effect of ventricular size and function on exercise performance and the electrocardiogram in repaired tetralogy of Fallot with pure pulmonary regurgitation. Ann Pediatr Cardiol 2012; 5:151-5. [PMID: 23129904 PMCID: PMC3487203 DOI: 10.4103/0974-2069.99617] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
Background: In repaired tetralogy of Fallot (TOF), exercise test parameters like peak oxygen uptake and ventilatory efficiency predict mortality. Studies have also suggested cardiac magnetic resonance (CMR)-derived right ventricular (RV) size threshold values for pulmonary valve replacement in repaired TOF. However, effects of proposed RV size on exercise capacity and morbidity are not known. Methods: The relationship between CMR-derived ventricular size, function, and pulmonary regurgitation (PR) and NYHA class, exercise performance, and electrocardiogram (ECG) was studied in patients of repaired TOF with pure PR in a retrospective review of records. Results: 46 patients (22 females), mean age 14 years (8–30.8), were studied. There was no relationship between CMR-derived ventricular size, function, or PR and exercise test parameters, or NYHA class. RV end systolic and end diastolic volume correlated positively with the degree of PR. QRS duration on ECG correlated positively with RV end-diastolic volume (P < 0.01, r2 = 0.34) and PR (P < 0.01, r2 = 0.52). Conclusions: In repaired TOF and pure PR, there is no correlation between ventricular size or function and exercise performance. RV size increases with increasing PR. Timing of pulmonary valve replacement in TOF with pure PR needs further prospective evaluation for its effect on morbidity and mortality.
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Affiliation(s)
- Shaji C Menon
- Division of Pediatric Cardiology, University of Utah, Salt Lake City, UT, USA
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Karl TR. Tetralogy of fallot: a surgical perspective. THE KOREAN JOURNAL OF THORACIC AND CARDIOVASCULAR SURGERY 2012; 45:213-24. [PMID: 22880165 PMCID: PMC3413825 DOI: 10.5090/kjtcs.2012.45.4.213] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/18/2012] [Revised: 06/11/2012] [Accepted: 06/12/2012] [Indexed: 11/19/2022]
Abstract
Tetralogy of Fallot (TOF) is an index lesion for all paediatric and congenital heart surgeons. In designing an appropriate operation for children with TOF, the predicted postoperative physiology must be taken into account, both for the short and long term. A favourable balance between pulmonary stenosis (PS) and pulmonary insufficiency (PI) may be critical for preservation of biventricular function. A unified repair strategy to limit both residual PS and PI is presented, along with supportive experimental evidence. A strategy for dealing with coronary anomalies and some comments regarding best timing of operation are also included.
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Affiliation(s)
- Tom R Karl
- Cardiac Surgical Unit, Mater Children's Hospital, Queensland Paediatric Cardiac Service, Australia
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Margey R, Inglessis-Azuaje I. Percutaneous Therapies in the Treatment of Valvular Pulmonary Stenosis. Interv Cardiol Clin 2012; 1:101-119. [PMID: 28582060 DOI: 10.1016/j.iccl.2011.12.001] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
Transcatheter balloon pulmonary valvuloplasty (BPV) is the standard of care in managing symptomatic patients with moderate-to-severe pulmonary valvular stenosis, or asymptomatic patients with severe pulmonary valvular stenosis or with moderate pulmonary stenosis and evidence of objective exercise intolerance or right ventricular dysfunction. This article discusses the incidence, causes, and pathophysiology of valvular pulmonary stenosis in adolescents and adults; its natural history and noninvasive evaluation; the current guideline-recommended indications for BPV; the technical aspects of performing BPV; the immediate and long-term outcomes after valvuloplasty; and the complications and safety of the procedure. Also discussed is the role of this procedure in neonatal critical pulmonary stenosis and in percutaneous pulmonary valve replacement for patients with prior pulmonic valve interventions or degenerated right ventricular pulmonary artery conduits.
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Affiliation(s)
- Ronan Margey
- Structural Heart Disease and Interventional Cardiology, Division of Cardiology, Massachusetts General Hospital and Harvard Medical School, 55 Fruit Street, Boston, MA 02114, USA.
| | - Ignacio Inglessis-Azuaje
- Adult Congenital Heart Disease Intervention, Division of Cardiology, Massachusetts General Hospital and Harvard Medical School, 55 Fruit Street, Boston, MA 02114, USA
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